An Evaluation of the Transfer of Skills and Knowledge from Two World Federation of Societies of Anaesthesiologists Fellowship Programs.

BACKGROUND: Subspecialist training is an important part of developing human resources for health and for some learners, may require taking place in another, higher-resourced country. Despite effective learning of skills and knowledge in a different, more highly resourced context, transfer of these skills and knowledge back to a more poorly resourced context can be a challenge. We aimed to evaluate the transfer of skills and knowledge in 2 World Federation of Societies of Anaesthesiologists (WFSA) fellowship programs. METHODS: This qualitative program evaluation study, guided by Guskey's evaluation framework, used in-depth interviews of both faculty and graduates of the 2 fellowship programs. Interviews were conducted remotely, transcribed verbatim, and analyzed using qualitative content and pattern analysis. RESULTS: We interviewed 2 administrators, 10 faculty members, 17 graduated fellows, and 3 graduated fellows now in the role of faculty member in that fellowship. Key themes were barriers and enablers to the transfer of skills, including workplace and staffing, resources, mentorship, the interprofessional team, and leadership. Graduated fellows were able to have an impact on returning home in the areas of practice and service development, research, and teaching. CONCLUSIONS: Our study found that the 2 fellowship programs had variable success in the transfer of learned skills and knowledge back to the fellows' "home" institutions. Contextual differences between the fellowship institution and the home institution were the main source of barriers to transfer, and fellows from different countries had diverse needs. Supporting the transfer of knowledge and skills should be an explicit goal of these fellowship programs, and as such, should be considered in the recruitment of fellows, curriculum development, and in how the success of a fellowship is evaluated. Curricula should not just focus on medical knowledge and skills, but also skills in leading change and in education.

Efficacy and Safety of Ultrasound Guided Inter-semispinal Plane Block for Postoperative Analgesia in Posterior Cervical Laminectomy - A Prospective Randomised Controlled Study.

STUDY DESIGN: Prospective, randomized controlled study. OBJECTIVE: To assess the safety and efficacy of an ultrasound-guided ISP block for postoperative analgesia in posterior cervical laminectomy. METHODS: 88 patients requiring posterior cervical laminectomy were randomized into two groups, those who underwent ISP block with multimodal analgesia (ISPB group) and those with only multimodal analgesia (control group). Demographic details, intraoperative parameters (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used), and postoperative parameters (numeric rating scale, satisfaction score, mobilization time, and complications) were recorded. RESULTS: The total opioid consumption (128.41 + 39.65vs 284.09 + 140.92mcg; P < .001), muscle relaxant usage (46.14 + 6.18 mg vs 59.32 + 3.97 mg; P < .001), surgical duration (128.61 + 26.08/160.23 + 30.99mins; P < .01), and intra-operative blood loss (233.18 + 66.08 mL vs 409.77 + 115.41 mL; P < .01) were significantly less in the ISPB group compared to the control. In the postoperative period, the control group's pain score was significantly higher (P < .001) in the initial 48 hours. The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores were significantly better in the ISPB compared to the control (P < .001). The mean time required to ambulate was statistically less in ISPB (4.30 + 1.64hours) when compared to controls (9.48 + 3.07hours) (P < .001). CONCLUSION: In patients undergoing posterior cervical laminectomy, ISP block is a safe and effective technique with better outcomes than standard multi-modal analgesia alone, in terms of reduced intra-operative opioid requirements and blood loss, better postoperative analgesia, and early mobilization.

Comparison Between Relative Efficacy of Erector Spinae Plane Block and Caudal Epidural Block for Postoperative Analgesia in Lumbar Fusion Surgery- A Prospective Randomized Controlled Study.

STUDY DESIGN: Prospective, randomized controlled double-blinded study. OBJECTIVE: To compare the relative efficacy of ultrasound-guided ESPB and CEB for postoperative analgesia after a single-level lumbar fusion surgery and compared it with conventional multimodal analgesia. METHODS: 81 patients requiring single-level lumbar fusion surgery were randomly allocated into 3 groups (ESPB group, CEB group, and the control group). Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization, and complications were recorded. RESULTS: The total opioid consumption in the first 24 hours was significantly lower in both the block groups than in the control group (103.70 ± 13.34 vs 105 ± 16.01 vs 142.59 ± 40.91mcg; P < .001). The total muscle relaxant consumption was also significantly less in block groups compared to controls (50.93 ± 1.98 vs 52.04 ± 3.47 vs 55.00 ± 5.29 mg; P < .001). The intraoperative blood loss was significantly less in both the block group (327.78 ± 40.03 mL, 380.74 ± 77.80 mL) than the control group (498.89 ± 71.22 mL) (P < .001). Among the block groups, the immediate postoperative pain relief was better in the CEB group, however, the ESPB group had a longer duration of postoperative pain relief. CONCLUSION: Both ESPB and CEB produce adequate postoperative analgesia after lumbar fusion however the duration of action was significantly longer in the ESPB group with relatively shorter surgical time and lesser blood loss compared to the CEB group.

Transient paraplegia in lumbar spine surgery-a potential complication following erector spinae plane block.

PURPOSE: Erector spinae plane block (ESPB) has gained popularity over recent years and is being increasingly used in spine surgery for pain management. To date, no major neurological complications have been reported. We present here two patients who developed transient postoperative paraplegia and discuss the possible causes of this phenomenon. METHODS: Patients, who underwent preoperative bilateral ESPB as an adjunct to general anesthesia for elective lumbar spine surgery at our institution between January 2017 and December 2020, were retrospectively identified. Among them, only patients who developed postoperative motor and sensory deficits were finally included. RESULTS: Overall, two patients [of 316 who underwent ESPB (0.6%)] developed complete motor and sensory deficits in bilateral lower limbs postoperatively. In both patients, the surgery was uncomplicated. Ninety minutes following recovery from general anesthesia, both patients showed gradual neurological recovery in a distal-to-proximal pattern, with complete motor recovery preceding the sensory improvement. Since the surgical procedure was performed at the cauda equine level, transient paraplegia in these patients could only attributed to ESPB. CONCLUSION: Transient paraplegia following ESPB (due to anterior spread of the local anesthetic agent into the epidural space) has never been reported, and both anesthetists and surgeons must be aware of this possible complication.

Clinical efficacy of ultrasound guided bilateral erector spinae block for single-level lumbar fusion surgery: a prospective, randomized, case-control study.

BACKGROUND CONTEXT: Postoperative experience plays a vital role in patient recovery and does not depend on the type and quality of the surgical procedure alone. Non-opioid therapies have become part of the multimodal analgesic regimen for better pain control and reduced opioid-related side effects. Most recently evolved among these are the regional anesthetic techniques, such as the thoracolumbar interfascial plane (TLIP) block and the erector spinae (ESP) block. PURPOSE: To assess the efficacy of ultrasound-guided (US) ESP block for postoperative analgesia after a single level lumbar spine fusion surgery compared with conventional (opioid-based) multimodal postoperative analgesia. STUDY DESIGN: A prospective, randomized, controlled, and double-blinded clinical trial. PATIENT SAMPLE: A 100 consecutive patients requiring single-level lumbar spinal fusion procedure were randomized into two groups- block (multimodal analgesia with US-ESP) and control (only multimodal analgesia) groups. OUTCOME MEASURES: Demographic and surgical data, intra-operative blood loss, duration of surgery, total opioid consumption (TOC) and amount of muscle relaxants used were assessed. Postoperatively, the Numeric pain Rating Scale(NRS), Modified Observer's assessment of Alertness and/or Sedation Scale (MOASS) and Patient satisfaction scores were recorded every 2 hours for the first 6 hours followed by every 6 hours for 24 hours. Continuous variables were analyzed using Student's t-test, and categorical variables were analyzed using either the Chi-square test or Fisher's exact test. p-value < .05 was considered statistically significant. METHODS: Patients in both groups underwent the identical protocol for pre-emptive analgesia and induction of anesthesia. Patients in the block group received the US-ESP block after induction and positioning, followed by the multimodal analgesia, while the control group received only the multimodal analgesia. RESULTS: Both groups had identical demographic backgrounds and surgical profile. TOC for 24 hours following induction was significantly lower in the block group than the control group (105.0 ± 15.15 vs 158.00 ± 23.38mcg; p < .001). The total muscle relaxant consumption during surgery was also significantly less in the block group than the control group (51.90 ± 3.17 vs 57.70 ± 5.90; p < .001). The intra-operative blood loss was significantly less (p < .001) in the block group (303.00 ± 86.55 ml) than the control group (437.00 ± 116.85 ml). Compared to the block group, the control group's pain score (NRS) was significantly higher in the first 48 hours following surgery. The MOASS score was significantly lower in the control group (4.46 ± 0.50 vs 3.82 ± 0.82; p < .001) in the immediate postoperative period. The satisfaction score was significantly higher in the block group than the control group (9.52 ± 0.65 vs 8.22 ± 0.79; p < .001). CONCLUSION: The employed US-ESP block for single-level lumbar fusion surgery is an effective component of multimodal analgesia for reducing blood loss, total opioid consumption, and related side effects with a significant reduction of postoperative pain and higher patient satisfaction.

Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective.

The COVID-19 outbreak is on the world. While many countries have imposed general lockdown, emergency services are continuing. Healthcare professionals have been infected with the virulent severe acute respiratory syndrome coronavirus-2 (SARS), which spreads by close contact and aerosols. The anesthesiologist is particularly vulnerable to aerosols while performing intubation and other airway related procedures. Regional anesthesia (RA) minimizes the need for airway manipulation and the risks of cross infection to other patients, and the healthcare personnel. In this context, for prioritizing RA over general anesthesia, wherever possible, a structured algorithmic approach is outlined. The role of percentage saturation of hemoglobin with oxygen (oxygen saturation), blood pressure and early use of point-of-care ultrasound in differential diagnosis and specific management is detailed. The perioperative anesthetic implications of multisystem manifestations of COVID-19, anesthetic management options, the scope of RA and considerations for its safe conduct in operating rooms is described. An outline for safe and rapid training of healthcare personnel, with an Entrustable Professional Activity framework for ascertaining the practice readiness among trained residents for RA in COVID-19, is suggested. These are the authors' experiences gained from the current pandemic and similar SARS, Middle East Respiratory Syndrome and influenza outbreaks in recent past faced by our authors in Singapore, India, Hong Kong and Canada.

A prospective randomized study to analyze the efficacy of balanced pre-emptive analgesia in spine surgery.

BACKGROUND CONTEXT: Surgical procedures involving the spine are known to cause moderate to severe postoperative pain. Inadequate management of acute pain in the postoperative period results in higher morbidity, and consequently may lead to chronic pain caused by central sensitization. The role of pre-emptive analgesia (PA) and intraoperative analgesia in management of postoperative pain has gained precedence over recent years. Pathophysiology of postoperative pain in spine surgery is unique, as it is a combination of nociceptive, inflammatory, and neuronal stimuli. Blockage of all three stimuli in the perioperative period by pre-emptively administrating a combination of paracetamol (P), ketorolac (K), and pregabalin (PR) might help in adequate management and alleviation of acute postoperative pain. PURPOSE: To evaluate the analgesic effect of a combination of P, K, and PR as pre-emptive multimodal analgesia, aimed to block or reduce acute postoperative pain after spine surgery. STUDY DESIGN: A prospective, randomized, controlled, and double-blinded clinical trial. PATIENT SAMPLE: After Institutional Review Board approval, 100 consecutive patients requiring single- or double level spinal fusion procedures were randomized into two groups-PA and control (C). METHODS: The PA group received P, K, and PR 4 hours before surgery, as PA. Both groups underwent identical anesthetic and postoperative pain management protocol. OUTCOME MEASURES: Demographic and surgical data, 4 hourly postoperative pain levels-Numeric Pain Rating scale (NRS), Ambulatory NRS scores; level of consciousness-Ramsay sedation scale, total amount of opioids consumed (TOC) through patient-controlled analgesia; functional levels-Oswestry Disability Index (ODI), surgical satisfaction index-North American Spine Society (NASS) satisfaction scale, duration of hospital stay, and all complications were recorded and analyzed. A research grant of 6,032 USD was obtained from AO Spine toward this work. There is no conflict to disclose. RESULTS: Both the groups had identical demographic backgrounds and surgical profiles. The average NRS score within the first 48-hour period in the PA group (2.7±0.79) was significantly less than the C group (3.4±0.98) and the differences were more in the first 12 hours following surgery. Similarly, Ambulatory NRS scores were significantly low in the PA group during the first and second postoperative days. The PA group individuals were found to be more physically motivated, as 95.7% were able to ambulate 50 m on the first postoperative day compared with 30% in the C group. The PA group had significantly low TOC (3.02±2.29 mg) in comparison to the C group (4.94±3.08 mg). The duration of hospital stay was 4.17±1.02 and 4.84±1.62 days in the PA and C groups (p=.017), respectively. No major complications occurred in either groups and were found to be similar in percentage between both the groups, except for nausea and vomiting which were more in C group. Dry mouth was the most common side effect noted irrespective of the groups. All patients had significant improvement in ODI with better results in PA group at first month follow up. The PA group (97.90%) was extremely satisfied compared with C group (72%, p=.002) according to NASS scale. CONCLUSIONS: Postoperative pain management in spine surgery is maximized if perioperative painful stimuli can be inhibited, which requires adequate blood levels of analgesic, anti-inflammatory, and neuropathic drugs intraoperatively. The employed strategy of preoperative administration of balanced analgesia with a combination of P, K, and PR, each having different mechanisms of action, resulted in lesser pain intensity, allowed better ambulation tolerance, improved functional outcomes and has also reduced the requirement of opioids and duration of hospital stay with no additional complications. Thus, this balanced analgesia administered preoperatively would address the complicated postsurgical pain.

Effectiveness and Safety of Batroxobin, Tranexamic Acid and a Combination in Reduction of Blood Loss in Lumbar Spinal Fusion Surgery.

STUDY DESIGN: A prospective randomized double blind placebo controlled trail. OBJECTIVE: To evaluate and compare the efficacy and safety of batroxobin (botropase), tranexamic acid (TXA), and their combination in reduction of perioperative blood loss in lumbar spine single level fusion surgeries. SUMMARY OF BACKGROUND DATA: Spinal surgeries are associated with significant blood loss leading to perioperative anemia and increased need for allogenic transfusion. TXA competitively inhibits plasmin and batroxobin converts fibrinogen to fibrin and theoretically their combination is synergistic. Though TXA is widely studied in controlling blood loss, there is little information on use of batroxobin and their combination. Thus, we aimed to study effect and safety of individual drugs and their combination in controlling blood loss in spinal surgery. METHODS: Hundred patients were randomized into four groups. Group B received batroxobin, group T received TXA, group BT received batroxobin and TXA and group P received placebo. Outcomes assessed are intraoperative and postoperative blood loss, hematocrit, allogenic blood transfusion, and deep vein thrombosis (DVT), postoperatively. RESULT: Mean intraoperative blood loss in Group B, T, BT, and P were 268.32 ±â€Š62.92 mL, 340.72 ±â€Š182.75 mL, 256.96 ±â€Š82.64 mL, and 448.44 ±â€Š205.86 mL, respectively. Postoperative surgical site drain collection in Group B, T, BT, and P were 218.00 ±â€Š100.54 mL, 260.40 ±â€Š100.85 mL, 191.00 ±â€Š87.84 mL, and 320.00 ±â€Š125.83 mL, respectively. Intraoperative blood loss of Group P was statistically higher than Groups B and BT (P < 0.001). Mean postoperative surgical site drain collection was statistically significant (P < 0.001). No statistically significant differences in fluid administration (P = 0.751), blood transfusion (P = 1.000), preoperative and postoperative hemoglobin (P = 0.090, P = 0.134, respectively), and deep vein thrombosis (P = 1.000). CONCLUSION: Batroxobin and combination of batroxobin with tranexamic acid significantly reduced perioperative blood loss when compared with placebo. LEVEL OF EVIDENCE: 2.