Superior Trunk Block Catheter and 2% Chloroprocaine as a Phrenic Sparing Approach for Awake Arthroscopic Acromioclavicular Joint Surgery: A Case Report.

Regional anaesthesia for shoulder surgery remains challenging in patients with pre-existing respiratory comorbidities. Various alternative phrenic sparing techniques have been described in the literature, but to our knowledge, none have explored the benefits of using short-acting local anaesthetics in combination to achieve surgical anaesthesia for awake surgery. This case report describes the successful use of the superior trunk block catheter, a relative phrenic sparing shoulder nerve block, and 2% chloroprocaine, a short-acting local anaesthetic, to provide surgical anaesthesia for awake shoulder surgery in a patient with severe respiratory disease.

Ultrasound guided quadro-iliac plane block: Another novel fascial plane block.

STUDY OBJECTIVE: We report a novel block technique aimed to provide lumbosacral, abdominal and hip analgesia: The Quadro-iliac plane (QIP) block. DESIGN: A cadaveric examination that evaluates the spread of QIP block. SETTING: Cadaver laboratory. PATIENTS: One unembalmed cadaver. INTERVENTIONS: Bilateral ultrasound-guided QIP blocks on cadavers with 40 mL of methylene blue %0.5 each side. MEASUREMENTS: Dye spread in cadaver. MAIN RESULTS: There was staining in the deep interfascial plane of the erector spinae muscles. Extensive staining of the interfascial plane corresponding to the posterior aspect of the quadratus lumborum muscle (QLM) was observed. There was extensive staining on the anterior surface of the QLM. There was spread of dye traversing along the transversalis fascia and significantly infiltrating retroperitoneal fat tissue. Bilateral staining of the ilioinguinal and iliohypogastric nerves was observed. On the right, there was minimal staining over the subcostal nerve. There was dye present bilaterally within the deep regions of the transverse processes. The lumbar plexus was stained on both sides. CONCLUSION: The local anesthetic applied from a place where the QLM reaches its largest volume and the fascial plane creates a closed gap in the caudal area may exhibit a more rounded and extensive spread.Quadro-iliac plane block, involves the administration of local anesthetic to the posterior aspect of the QLM at its origin from the iliac crest. According to our cadaver study, this technique may be a promising option for alleviating acute and chronic pain in the lumbosacral, lower abdominal, and hip regions.

Patient Satisfaction and Quality of Recovery With Ambulatory Serratus Plane Catheter After Mastectomy: A Service Evaluation.

Background Acute moderate to severe pain after mastectomy is common and impedes patient recovery. Ambulatory serratus plane catheter with infusion pump (ASPIP) is a novel method to provide continuous delivery of local anaesthetic agents in the immediate postoperative period for extended analgesia, early mobility, and return to function after mastectomy. The aim of this project was to evaluate the introduction of ASPIP service and its effect on postoperative pain, opioid use, hospital stay, and recovery. Methods This was a service evaluation project. Eligible mastectomy patients were included over six months. All patients provided consent for intraoperative catheter insertion and ASPIP use. The numerical rating scale (NRS) and the Quality of Recovery-15 (QoR-15) tool were used to assess postoperative pain and the quality of recovery, respectively. Overall satisfaction, sleep quality, and recommendations for the catheter were collected. Day-case rates of mastectomy with or without reconstruction were also measured. Data were presented using descriptive statistics. Mean (SD) and median (quartiles) were used for the continuous variables with percentages to report rates. Approval of the institution's Audit & Quality Improvement Department was obtained. Results Thirty-two consecutive mastectomy patients were included over six months. The mean age was 60 years and the mean BMI was 25.8. Mean pain NRS (10 maximum) at rest and on movement were 1.88 vs. 2.56, 2.03 vs. 2.84, and 1.85 vs. 2.3 out of 10 on postoperative day (POD) one, two, and three, respectively. Six patients required opioids on POD one, four patients on POD two, and none on the third day. Sleep disturbance was observed in three, five, and three patients in the first three days, respectively. The mean overall satisfaction was 9.25/10 (SD: 1.18). All patients recommended ASPIP to other patients. QoR-15 scores reported as median (quartiles) were 143 (136, 147) preoperatively and 135 (126.5, 143) postoperatively, with a median difference of -3 (95% CI: -6 to 0). The day-case rate for mastectomy +/- reconstruction was 66% and 39%, respectively. There were no major complications from the catheter with minor issues in four patients. Conclusion The ASPIP is an effective and safe method of managing postoperative pain after mastectomy with positive patient experience and reduced opioid requirement. As part of an enhanced recovery pathway, it can also increase mastectomy day-case rates, including immediate implant reconstruction.

The Shining Star of the Last Decade in Regional Anesthesia Part-II: Interfascial Plane Blocks for Cardiac, Abdominal, and Spine Surgery.

The sine qua non of enhanced recovery after surgery protocols designed to improve the perioperative experiences and outcomes of patients is to determine the most appropriate analgesia management. Although many regional techniques have been tried over the years in this purpose, interfacial plane blocks have become more popular with the introduction of ultrasound technology into daily practice and they have great potential to support effective postoperative pain management in many surgeries. The current article focuses on the benefits, techniques, indications, and complications of interfascial plane blocks applied in cardiac, abdominal, and spine surgeries.

Ultrasound Guidance Pulsed Radiofrequency Ablation of the Medial Antebrachial Cutaneous Nerve for Palliation of Chronic Pain after Burn Injury: A Case Report.

Chronic burn pain persists for 6 months or longer after the wound has healed, affecting the patient's quality of life and daily activities. Pharmacological treatments are essential in the treatment of chronic pain after burns, but interventional methods come to the fore in cases where there is no response to pharmacological treatments. Radiofrequency ablation is known as a safe, effective, and minimally invasive treatment for patients with intractable chronic pain. Various pain syndromes can be successfully treated with radiofrequency ablation however, there is no publication of chronic pain management associated with burn injury. Here, we first describe the successful management of chronic burn pain using radiofrequency ablation of the medial antebrachial cutaneous nerve.

Recommendations for anatomical structures to identify on ultrasound for the performance of intermediate and advanced blocks in ultrasound-guided regional anesthesia.

Recent recommendations describe a set of core anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia (UGRA). This project aimed to generate consensus recommendations for core structures to identify during the performance of intermediate and advanced blocks. An initial longlist of structures was refined by an international panel of key opinion leaders in UGRA over a three-round Delphi process. All rounds were conducted virtually and anonymously. Blocks were considered twice in each round: for "orientation scanning" (the dynamic process of acquiring the final view) and for "block view" (which visualizes the block site and is maintained for needle insertion/injection). A "strong recommendation" was made if ≥75% of participants rated any structure as "definitely include" in any round. A "weak recommendation" was made if >50% of participants rated it as "definitely include" or "probably include" for all rounds, but the criterion for strong recommendation was never met. Structures which did not meet either criterion were excluded. Forty-one participants were invited and 40 accepted; 38 completed all three rounds. Participants considered the ultrasound scanning for 19 peripheral nerve blocks across all three rounds. Two hundred and seventy-four structures were reviewed for both orientation scanning and block view; a "strong recommendation" was made for 60 structures on orientation scanning and 44 on the block view. A "weak recommendation" was made for 107 and 62 structures, respectively. These recommendations are intended to help standardize teaching and research in UGRA and support widespread and consistent practice.

International consensus on anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia.

There is no universally agreed set of anatomical structures that must be identified on ultrasound for the performance of ultrasound-guided regional anesthesia (UGRA) techniques. This study aimed to produce standardized recommendations for core (minimum) structures to identify during seven basic blocks. An international consensus was sought through a modified Delphi process. A long-list of anatomical structures was refined through serial review by key opinion leaders in UGRA. All rounds were conducted remotely and anonymously to facilitate equal contribution of each participant. Blocks were considered twice in each round: for "orientation scanning" (the dynamic process of acquiring the final view) and for the "block view" (which visualizes the block site and is maintained for needle insertion/injection). Strong recommendations for inclusion were made if ≥75% of participants rated a structure as "definitely include" in any round. Weak recommendations were made if >50% of participants rated a structure as "definitely include" or "probably include" for all rounds (but the criterion for "strong recommendation" was never met). Thirty-six participants (94.7%) completed all rounds. 128 structures were reviewed; a "strong recommendation" is made for 35 structures on orientation scanning and 28 for the block view. A "weak recommendation" is made for 36 and 20 structures, respectively. This study provides recommendations on the core (minimum) set of anatomical structures to identify during ultrasound scanning for seven basic blocks in UGRA. They are intended to support consistent practice, empower non-experts using basic UGRA techniques, and standardize teaching and research.

The Shining Star of the Last Decade in Regional Anesthesia Part-I: Interfascial Plane Blocks for Breast, Thoracic, and Orthopedic Surgery.

Regional anesthesia has benefits beyond just treating acute postoperative pain. Interfascial plane blocks, which have been very popular with ultrasound in recent years, function primarily by administering a high volume of a local anesthetic to the fascial plane. Contrary to traditional peripheral nerve blocks, the targeted nerve or structure in interfacial plane blocks is not fully defined, and the indications have not been fully revealed yet. Anatomical, cadaveric, and radiological studies show how effective the interfascial plane blocks play a role. This review focuses on the benefits, techniques, indications, and complications of interfascial plane blocks in the context of breast, thoracic, and orthopedic surgery.

Does proning on NIV improve oxygenation?

Proning intubated patients with acute respiratory distress syndrome (ARDS) is an established practice to improve oxygenation temporarily. We present two cases of patients on our intensive care unit with ARDS, on non-invasive ventilation (NIV), in whom proning improved oxygenation at a stage when intubation was the next step. We discuss the mechanisms by which proning improves oxygenation as well as the potential risks proning on NIV brings, for which we make specific recommendations.

AVPR1A and SLC6A4 polymorphisms in choral singers and non-musicians: a gene association study.

Amateur choral singing is a common pastime and worthy of study, possibly conferring benefits to health and social behaviour. Participants might be expected to possess musical ability and share some behavioural characteristics. Polymorphisms in genes concerned with serotonergic neurotransmission are associated with both behaviour and musical aptitude. Those investigated previously include the variable number tandem repeats RS1, RS3 and AVR in the AVPR1A (arginine vasopressin receptor 1a) gene and STin2 in the SLC6A4 (solute carrier family 6 [neurotransmitter transporter, serotonin], member 4) gene, as well as the SLC6A4 promoter region polymorphism, 5-HTTLPR. We conducted a genetic association study on 523 participants to establish whether alleles at these polymorphisms occur more commonly in choral singers than in those not regularly participating in organised musical activity (non-musicians). We also analysed tagging single nucleotide polymorphisms (SNPs) for AVPR1A and SLC6A4 to determine whether other variants in these genes were associated with singer/non-musician status. At the STin2 polymorphism, overall association with singer/non-musician status was evident at P = 0.006. The 9-repeat (P = 0.04) and 12-repeat (P = 0.04) alleles were more common in singers and the 10-repeat allele less so (P = 0.009). Odds ratios were 0.73 (95% CI 0.57-0.94) for the 10-repeat allele and 2.47 (95% CI 0.88-6.94) for the rarer 9-repeat allele. No overall association was detected at P<0.05 between any other polymorphism and singer/non-musician status. Our null findings with respect to RS3, RS1 and AVR, polymorphisms associated with musical ability by other authors, suggest that choir membership may depend partly on factors other than musical ability. In a related musical project involving one participating choir, a new 40-part unaccompanied choral work, "Allele", was composed and broadcast on national radio. In the piece, each singer's part incorporated their personal RS3 genotype.