Impact of the type of anesthesia on adverse events during transcarotid artery revascularization.

OBJECTIVE: The use of local or regional anesthesia (LRA) is encouraged during transcarotid artery revascularization (TCAR) because the procedure is performed through a small incision. LRA permits neurologic evaluation during the procedure and may reduce periprocedural cardiac morbidity compared with general anesthesia (GA). There is limited and conflicting information regarding the preferred anesthesia to use during TCAR. We compared periprocedural clinical and technical complications, and intraprocedural performance metrics of TCAR performed under GA vs LRA. METHODS: Patient, lesion, physician, and procedural information was collected in a worldwide quality assurance program of consecutive TCAR procedures. A composite clinical adverse event rate (death, stroke, transient ischemic attack, myocardial infarction) and a composite technical adverse event rate (aborted procedure, conversion to carotid endarterectomy, bleeding, dissection, cranial-nerve injury, device failure) in the periprocedural period were computed. Four intraprocedural performance measures (flow-reversal time, fluoroscopy time, contrast volume, and skin-to-skin time) were recorded. Deidentified data were analyzed independently at the Center for Vascular Research, University of Maryland. Poisson regressions were used to assess the impact of anesthesia type on adverse event rates. Linear regressions were used to compare performance measures. RESULTS: A total of 27,043 TCARs were performed by 1456 physicians between 2012 and 2021. A majority of patients (83%) received GA, and this proportion increased over time (R2 = 0.74; P < .0001). Some physicians (33.4%) used LRA in some of their procedures; only 2.7% used LRA in all of their procedures. Clinical risk factors were more common in the LRA group (P < .0001) and anatomic risk factors in the GA group (P < .0001); these differences were adjusted for in subsequent analyses. LRA was more likely to be used by vascular surgeons and by physicians with higher prior transfemoral carotid stenting experience (P < .0001). When comparing GA vs LRA, clinical adverse events (1.49%; 95% confidence interval [CI], 1.3-1.8 vs 1.55%; 95% CI, 1.2-2.0; P = .78), technical adverse events (5.6%; 95% CI, 5.2-6.2 vs 5.3%; 95% CI, 4.5-6.3; P = .47), and intraprocedural performance measures did not differ by type of anesthesia. CONCLUSIONS: Almost two-thirds of physicians performed TCAR exclusively under GA, and the overall proportion of procedures performed under GA increased over time. A larger fraction of patients with severe medical risk factors received LRA vs GA, whereas a larger fraction of patients with anatomic risk-factors received GA. Periprocedural clinical and technical adverse events did not differ by type of anesthesia. Intraprocedural performance metrics that drive procedural cost were similar between groups; potential differences in procedural cost driven by anesthetic choice require further study.

Vein distensibility is superior to vein diameter for predicting unassisted maturation of arteriovenous fistulae.

BACKGROUND: A mature arteriovenous fistula (AVF) is the preferred hemodialysis access owing to its durability and lower risk of complications. Various factors have been implicated as predictors for maturation, including vein diameter and access type. Vein distensibility, which refers to the ability of the vein to dilate in response to changes in blood flow and pressure, has been proposed as a potential predictor for maturation, but its utility remains poorly studied. METHODS: This is a single-institution retrospective study of AVFs performed under regional anesthesia. Vein distensibility was defined as the absolute and relative difference in target vein diameter (TVD) between the preoperative ultrasound vein mapping performed with tourniquet and a repeat ultrasound examination after a regional block before AVF creation and without a tourniquet. RESULTS: Forty-six patients underwent first-time AVF surgery with distensibility recorded in a prospectively maintained database. The mean initial preoperative TVD was 2.7 mm, and after the block 3.4 mm. The unassisted maturation rate for the entire cohort was 76%. In patients with an absolute change of TVD of <0.5 mm (Δ<0.5), the unassisted maturation rate was 63% (12/19), even though 95% of the group had a preoperative TVD of >3 mm. In those with ≥0.5 mm, the unassisted maturation rate was 85% (23/27; P = .08), even though the preoperative vein map TVD was 2.3 mm and 75% had a vein map TVD of <3 mm. For radiocephalic AVFs (n = 26), the unassisted maturation rate was 75% for Δ<0.5 vs 94% for Δ≥0.5 (P = .16), despite a preoperative vein map TVD of >3 mm in 92% vs 75%, respectively. The receiver operatring characteristic area under the curve for unassisted maturation with a Δ≥0.5 mm was 0.68 (P = .26). CONCLUSIONS: Quality in dialysis access surgery requires optimizing the unassisted maturation rate. A physiological measure that accounts for the dynamic process of maturation may be more informative than anatomic measurements alone. The results shown here demonstrate that vein distensibility may be a better predictor than absolute vein diameter on standard vein mapping ultrasound examinations.

Association of anesthetic modality and other variables on 1-year functional patency of cephalic-based arteriovenous fistulae.

OBJECTIVE: Some studies suggest that regional anesthesia provides better patency for arteriovenous fistula (AVF) for hemodialysis access as compared to local and general anesthesia. This study evaluates the impact of anesthetic modality on long term fistula function at 12 months. METHODS: A retrospective review of patients undergoing cephalic vein-based hemodialysis access in consecutive cases between 2014 and 2019 was conducted from five safety net hospitals. The primary endpoint was functional patency at 12 months. Subset analysis individually evaluated cephalic-based lower forearm and wrist vs upper arm AVFs. Bivariate and multivariate logistic regression models evaluated the relationship between anesthetic modality and fistula function at 12 months. RESULTS: There were 818 cephalic-based fistulas created during the study period. The overall 12-month functional patency rate was 78.7%, including an 81.3% patency for upper arm AVF and 73.3% for wrist AVF (P = .009). There was no statistically significant difference among patients with functional and nonfunctional AVFs at 12 months with respect to anesthetic modality when comparing regional, local, and general anesthesia (P = .343). Multivariate regression analysis identified that history of AVF/arteriovenous graft (odds ratio [OR], 0.24; P = .007), receiving intraoperative systemic anticoagulation (OR, 2.49; P < .001), and vein diameter (OR, 1.85; P = .039) as independently associated with AVF functional patency at 12 months. CONCLUSIONS: There was no association between anesthetic modality and functional patency of cephalic-based AVFs at 12 months. Further studies are needed to better define which patients may benefit from regional anesthesia.

Endovascular revascularization of critical limb ischemia: the role of ultrasound-guided popliteal sciatic nerve block for the procedural pain management.

OBJECTIVES: To evaluate the impact of the ultrasound-guided popliteal sciatic nerve block (PSNB) for pain management during endovascular treatment of chronic limb-threatening ischemia (CLTI). MATERIAL AND METHODS: From November 2020 to January 2022, 111 CLTI patients that underwent endovascular procedures were prospectively enrolled in this prospective single-arm interventional study. Ultrasound-guided PSNB was used for procedural pain control. Pain intensity was evaluated throughout the procedure (baseline, 10 min after the block, pain peak, and at the end of the procedure) with the visual analog scale (VAS). RESULTS: Forty-six patients underwent above-the-knee revascularization (ATK), 20/111 below-the-knee (BTK) revascularization, 20/111 to both ATK and BTK revascularization. In 25 cases, no endovascular option was feasible at diagnostic angiography. The PSNB was effective in 96% of patients, with no need for further pain management with a statistically significant reduction (p < 0.0001) in the mean value of the VAS from 7.86 ± 1.81 (pre-procedural) to 2.04 ± 2.20 after 10 min from the block and up to 0.74 ± 1.43 at the end of the procedure (mean time 43 min). Only 1 complication related to the popliteal sciatic nerve block was registered (a temporary foot drop, completely resolved within 48 h). The time necessary to perform the block ranged between 4 and 10 min. CONCLUSION: Ultrasound-guided PSNB is a feasible and effective method to manage patients with rest pain and increase comfort and compliance during endovascular procedures. CLINICAL RELEVANCE STATEMENT: An ultrasound-guided popliteal sciatic nerve block is a safe, feasible, and effective technique to manage pain during endovascular treatment of chronic limb-threatening ischemia, especially in frail patients with multiple comorbidities who are poor candidates for deep sedoanalgesia or general anesthesia. KEY POINTS: Endovascular treatment of CTLI may require long revascularization sessions in patients with high levels of pain at rest, which could be exacerbated during the revascularization procedure. The PSNB is routinely used for anesthesia and analgesia during foot and ankle surgery, but the experience with lower limb revascularization procedures is very limited and not included in any international guideline. Ultrasound-guided PSNB is a feasible and effective regional anesthesia technique to relieve procedural and resting pain. Because of its safety and availability, every interventional radiologist should know how to perform this type of loco-regional anesthesia.

Utility of Quadratus Lumborum Blocks in Patients Who Undergo Liver Transplant: A Single-Center Retrospective Study.

BACKGROUND: Regional anesthesia is an alternative to opioids for pain in patients undergoing liver transplantation. Quadratus lumborum blocks may provide appropriate dermatomal coverage with an excellent safety profile. METHODS: Data were collected retrospectively on adult patients who underwent liver transplant at an academic medical center from 2019 to 2022 (n = 207). The primary outcome was opioid administration during the 48 h after transplant. RESULTS: Patient demographics did not differ between groups. No association was found between patients who received a block and postoperative opioid administration (p = 0.848). However, among patients extubated in the operating room, patients who received a block reported, on average, a 0.9-unit lower pain score than patients who received no block (p = 0.041). Patients who received a block were also more likely to be extubated in the operating room (87.8% block vs. 44.4% no block; p < 0.001). CONCLUSION: Patients who underwent liver transplantation had similar postoperative opioid use whether or not they received a quadratus lumborum block. Yet, when evaluating additional factors, such as extubation, pain scores were lower in patients who received a quadratus lumborum block. This important finding supports the idea that quadratus lumborum blocks may be a safe and valuable technique for controlling postoperative pain in adult patients who undergo liver transplantation.

Optimizing accrual to a large-scale, clinically integrated randomized trial in anesthesiology: A 2-year analysis of recruitment.

BACKGROUND: Performing large randomized trials in anesthesiology is often challenging and costly. The clinically integrated randomized trial is characterized by simplified logistics embedded into routine clinical practice, enabling ease and efficiency of recruitment, offering an opportunity for clinicians to conduct large, high-quality randomized trials under low cost. Our aims were to (1) demonstrate the feasibility of the clinically integrated trial design in a high-volume anesthesiology practice and (2) assess whether trial quality improvement interventions led to more balanced accrual among study arms and improved trial compliance over time. METHODS: This is an interim analysis of recruitment to a cluster-randomized trial investigating three nerve block approaches for mastectomy with immediate implant-based reconstruction: paravertebral block (arm 1), paravertebral plus interpectoral plane blocks (arm 2), and serratus anterior plane plus interpectoral plane blocks (arm 3). We monitored accrual and consent rates, clinician compliance with the randomized treatment, and availability of outcome data. Assessment after the initial year of implementation showed a slight imbalance in study arms suggesting areas for improvement in trial compliance. Specific improvement interventions included increasing the frequency of communication with the consenting staff and providing direct feedback to clinician investigators about their individual recruitment patterns. We assessed overall accrual rates and tested for differences in accrual, consent, and compliance rates pre- and post-improvement interventions. RESULTS: Overall recruitment was extremely high, accruing close to 90% of the eligible population. In the pre-intervention period, there was evidence of bias in the proportion of patients being accrued and receiving the monthly block, with higher rates in arm 3 (90%) compared to arms 1 (81%) and 2 (79%, p = 0.021). In contrast, in the post-intervention period, there was no statistically significant difference between groups (p = 0.8). Eligible for randomization rate increased from 89% in the pre-intervention period to 95% in the post-intervention period (difference 5.7%; 95% confidence interval = 2.2%-9.4%, p = 0.002). Consent rate increased from 95% to 98% (difference of 3.7%; 95% confidence interval = 1.1%-6.3%; p = 0.004). Compliance with the randomized nerve block approach was maintained at close to 100% and availability of primary outcome data was 100%. CONCLUSION: The clinically integrated randomized trial design enables rapid trial accrual with a high participant compliance rate in a high-volume anesthesiology practice. Continuous monitoring of accrual, consent, and compliance rates is necessary to maintain and improve trial conduct and reduce potential biases. This trial methodology serves as a template for the implementation of other large, low-cost randomized trials in anesthesiology.

Anterior quadratus lumborum catheters for elective cesarean section: A double-blind, randomized, placebo-controlled trial.

BACKGROUND: Optimizing pain management following cesarean section is crucial for the well-being of both mother and infant. Various types of quadratus lumborum blocks have exhibited reduced opioid consumption and pain scores after cesarean section. However, duration of block effect is relatively short. The aim of this study was to investigate the analgesic efficacy of the anterior quadratus lumborum catheters for cesarean section. METHODS: All 32 enrolled participants were allocated to postoperative bilateral ultrasound-guided anterior quadratus lumborum catheter placement with injection of 60 mL ropivacaine 0.375% after cesarean section. Randomization at 2 h resulted in either 60 mL ropivacaine 0.2% or 60 mL isotonic saline injected through the catheters, with subsequent 22-h infusion of either ropivacaine 0.2% or isotonic saline with an infusion rate of 4 mL h-1 per catheter. Participants in the active group received a total of 697 mg ropivacaine during the first 24 h. All participants received the standard postoperative multimodal pain regimen, and a final bilateral injection at 24-h post-catheter placement of 60 mL ropivacaine 0.375% in total. The primary outcome was time to first opioid administration. Secondary outcomes were pain scores, time to first ambulation, nausea and vomiting, accumulated opioid consumption, and catheter displacement rates. RESULTS: No significant intergroup differences were observed following the randomized intervention. Median time to first opioid (IQR) was (active vs. placebo) 414 (283, 597) vs. 428 (245, 552) minutes, with a median difference (CI) of -14 (-184 to 262) min, p = .32. CONCLUSION: Bilateral anterior quadratus lumborum catheters with continuous infusion did not prolong time to first opioid after elective cesarean section.

Nerve Blocks for Craniotomy.

PURPOSE OF REVIEW: Postcraniotomy headache (PCH) is a common adverse event and can lead to various complications and decreased quality of life. RECENT FINDINGS: To reduce postcraniotomy pain and associated complications, a multimodal pain therapy including analgesics, analgesic adjuncts, and regional anesthesia is essential. The use of opioids should be minimized to facilitate prompt postoperative neurosurgical assessment. Here, we provide an update on the latest evidence regarding the role of scalp nerve blocks in the pain management of patients undergoing craniotomy procedure. Nerve blocks are effective in alleviating postoperative pain after craniotomy. Scalp blocks contribute to lower pain levels and less opioid consumption in the first 48 h following surgery. Moreover, there is a significant decrease in patients suffering from PONV among patients who receive scalp block.

Use of Peripheral Nerve Blocks for Total hip Arthroplasty.

PURPOSE OF REVIEW: The purpose of this review is to summarize the recent literature regarding regional anesthesia (RA) techniques and outcomes for total hip arthroplasty (THA) in the face of changing surgical techniques and perioperative considerations. RECENT FINDINGS: Based on large meta-analyses, peripheral nerve blocks are indicated for THA. Each block has its own risks and benefits and data for outcomes for particular techniques are limited. New surgical techniques, improved use of multimodal analgesia, and improved ultrasound guided regional anesthetics lead to better pain control for patients undergoing THA with less associated risks. Block selection continues to be influenced by provider comfort, surgical approach, patient anatomy, and postoperative goals. Head-to-head studies of particular nerve blocks are warranted.

Nerve Injury Following Regional Nerve Block: A Literature Review of Its Etiologies, Risk Factors, and Prevention.

PURPOSE OF REVIEW: Postoperative nerve injury after nerve block is complex and multifactorial. The mechanisms, etiologies, and risk factors are explored. This review article conducts a literature search and summarizes current evidence and best practices in prevention of nerve injury. RECENT FINDINGS: Emerging technology such as ultrasound, injection pressure monitors, and nerve stimulators for peripheral nerve block have been incorporated into regular practice to reduce the rate of nerve injury. Studies show avoidance of intrafascicular injection, limiting concentrations/volumes of local anesthetic, and appropriate patient selection are the most significant controllable factors in limiting the negative consequences of nerve block. Peripheral nerve injury is an uncommon occurrence after nerve block and is obscured by surgical manipulation, positioning, and underlying neural integrity. Underlying neural integrity is not always evident despite an adequate history and physical exam. Surgical stress, independently of nerve block, may exacerbate these neurologic disease processes and make diagnosing a postoperative nerve injury more challenging. Prevention of nerve injury by surgical teams, care with positioning, and avoidance of intrafascicular injection with nerve block are the most evidence-based practices.

Analysis of Top 100 Articles Cited in Top Pain Journals: A Comprehensive Two Decade Bibliometric Analysis.

PURPOSE OF REVIEW: A bibliometric analysis was performed to analyze and compare the top 100 articles from the most well-known five pain journals: Pain, Pain Physician, Pain Medicine, Regional Anesthesia & Pain Medicine, and Journal of Pain. A query of the Scopus database was performed to filter the top 200 most cited articles from each journal. CY score was calculated for the top 200 articles from each journal by dividing the total number of citations by the number of years the article has been published. RECENT FINDINGS: All articles had a collective analysis of the top CY scores, the top 100 of which were further analyzed. The pain subtype, type of publication, country of origin, and senior author were extrapolated from these top 100 articles. Frequency tables were organized, revealing Pain Journal as the highest publishing journal out of the top 100 articles. Chronic pain was the most studied subtype of pain and narrative reviews were the most common type of evidence. Studies were also organized in five-year epochs to analyze the frequency of publications in these intervals. Results show that 2010-2014 had the highest frequency of articles published overall. Journal Impact Factor (JIF) is also an objective indicator of the average number of citations per published article from each journal. The journal with the highest JIF was Pain with an impact factor of 7.926. (6).

Treatment of shoulder pain with ultrasound-guided interfascial plane block: A case series.

BACKGROUND: Shoulder pain is a common presentation to the Emergency Department (ED). Despite an increasing volume of ED visits for shoulder pain, achieving adequate pain control can be challenging. Ultrasound-guided nerve blocks, such as the interscalene nerve block (ISB), are effective but can cause hemidiaphragmatic paresis and motor dysfunction. The interfascial plane block (IPB) is a simple and new regional anesthesia technique that spares the diaphragm, and most upper extremity motor function. CASE REPORT: Three patients presented to the ED with acute shoulder pain refractory to oral analgesics and were treated successfully with an ultrasound-guided IPB in the ED. CONCLUSION: The ultrasound-guided IPB is a simple, safe, and effective alternative approach to treating shoulder pain in the ED, especially in patients who may not tolerate ISB.

Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates.

OBJECTIVES: In the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time. METHODS: We conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021-June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends. RESULTS: The response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%-39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%-100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%-91%). Eighty-five percent (95% CI, 77%-92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%-85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%-23%) report an average of 1 complication annually. CONCLUSIONS: All programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.

Rectus sheath nerve block for analgesia & incarcerated hernia reduction in the emergency department.

BACKGROUND: Patients who present to the emergency department (ED) with incarcerated or strangulated ventral hernias are often in significant pain. Furthermore, even with procedural sedation, reduction itself also causes substantial pain. Hernias that cannot be reduced at the bedside with intravenous opioids or procedural sedation will require emergent surgery, which contributes to morbidity and mortality, especially in high-risk populations. CASE REPORT: We present the case of a 94-year-old man with an incarcerated ventral hernia that was reduced in the ED with the aid of a rectus sheath block, ultimately avoiding the need for emergent surgical intervention. IMPLICATIONS: Ultrasound can visualize and diagnose an incarcerated hernia, and a bilateral rectus sheath block can be performed in the ED to anesthetize the peritoneal wall, paralyze abdominal musculature, and achieve nearly painless hernia reduction.

Utility of the occipital nerve block in the emergency department: A case series.

INTRODUCTION: Tension headaches, as well as various scalp pathologies including lacerations and abscesses are commonly treated in the emergency department (ED). The occipital nerve block (ONB), previously described in anesthesia and neurology literature, offers analgesia of the posterior scalp on the side ipsilateral to the injection while maintaining a low adverse effect profile. CASE REPORT: We report three cases in which ONB was utilized for tension headache, scalp laceration repair, and incision and drainage of scalp abscess. These patients all reported significant pain improvement without any reported complications. CONCLUSION: The ONB is a landmark based technique that offers an opportunity to provide analgesia in the ED that is simple, effective, and without known significant risks that are associated with other modalities of treatment.

Ultrasound-guided rhomboid intercostal block (RIB) for acute scapula fracture in the emergency department.

INTRODUCTION: Proper pain in acute scapular fractures can be challenging to achieve due to their anatomy and location. While the current mainstay of treatment relies on opioids, the Rhomboid Intercostal Block (RIB) has been utilized for anesthesia to effectively treat pain for scapular fractures. However, it has not yet been utilized in the emergency department (ED). CASE REPORT: In this case report, we present the first documented use of RIB to treat pain safely and effectively in a 69-year-old male with a scapula fracture following a ground-level fall in the ED. The RIB was performed under ultrasound guidance, providing precise localization and administration of the nerve block. CONCLUSION: The RIB demonstrated successful pain management in the ED. Although hopeful, further research is needed to understand limitations, potential side effects, length of pain control, and overall clinical outcomes of the RIB in the ED.

Simulation-based ultrasound-guided regional anesthesia education: a national survey of Canadian anesthesiology residency training programs.

PURPOSE: Simulation-based education in ultrasound-guided regional anesthesia (UGRA) improves knowledge, skills, and patient outcomes. Nevertheless, it is not known how simulation-based UGRA education is used across Canada. We aimed to characterize the current use of simulation-based UGRA education in Canadian anesthesiology residency training programs. METHODS: We developed and distributed a structured national survey to simulation leads of all 17 Canadian anesthesiology residency training programs. The survey inquired about program demographics, simulation modalities, facilitators and barriers to simulation use, use for assessment, and beliefs around simulation-based UGRA education. We gathered data from August to November 2023 and summarized our findings descriptively. RESULTS: Fifteen programs (88%) responded to our survey. Eight programs (53%) used UGRA simulation for technical training and nine programs (60%) for nontechnical training. The most common simulators used were live model scanning (13 programs, 87%) and gel phantom models (7 programs, 47%). Five programs (33%) mandated simulation-based UGRA in their curriculum. We found that deliberate practice and improved patient safety were most valued in simulation training while lack of funding and faculty availability were the most common barriers to implementation. Most respondents agreed that formative simulation-based education would improve trainee skills and called for greater standardization. Nevertheless, there were mixed responses regarding summative UGRA simulation and the need for simulation proficiency before clinical practice. CONCLUSIONS: Our findings show significant variations in simulation implementation and views on UGRA simulation-based education among Canadian anesthesiology residency training programs. Future studies should explore avenues to overcome barriers and improve knowledge translation in UGRA.

RéSUMé: OBJECTIF: La formation basée sur la simulation en anesthésie régionale échoguidée améliore les connaissances, les compétences et les issues pour les patient·es. Néanmoins, on ne sait pas comment la formation en AR échoguidée basée sur la simulation est utilisée au Canada. Nous avons cherché à caractériser l'utilisation actuelle de l'enseignement de l'AR échoguidée basée sur la simulation dans les programmes canadiens de résidence en anesthésiologie. MéTHODE: Nous avons élaboré et distribué un sondage national structuré aux responsables de la simulation des 17 programmes canadiens de résidence en anesthésiologie. L'enquête portait sur les données démographiques du programme, les modalités de simulation, les facilitateurs et les obstacles à l'utilisation de la simulation, son utilisation pour l'évaluation, et les croyances concernant l'éducation en AR échoguidée basée sur la simulation. Nous avons recueilli des données d'août à novembre 2023 et résumé nos résultats de manière descriptive. RéSULTATS: Quinze programmes (88 %) ont répondu à notre sondage. Huit programmes (53 %) utilisent la simulation en AR échoguidée pour la formation technique et neuf programmes (60 %) pour la formation non technique. Les simulateurs les plus couramment utilisés étaient le balayage sur modèles vivants (13 programmes, 87 %) et les modèles de fantômes en gel (7 programmes, 47 %). Cinq programmes (33 %) ont rendu obligatoire l'AR échoguidée basée sur la simulation dans leur programme. Nous avons constaté que la pratique délibérée et l'amélioration de la sécurité des patient·es étaient les plus appréciées dans la formation par simulation, tandis que le manque de financement et la disponibilité du corps professoral étaient les obstacles les plus courants à la mise en œuvre. La plupart des répondant·es ont convenu que l'éducation formative basée sur la simulation améliorerait les compétences des stagiaires et ont appelé à une plus grande standardisation. Néanmoins, les réponses étaient mitigées concernant la simulation sommative en AR échoguidée et la nécessité d'une maîtrise de la simulation avant la pratique clinique. CONCLUSION: Nos résultats montrent des variations significatives dans la mise en œuvre de la simulation et les points de vue sur l'éducation basée sur la simulation en AR échoguidée parmi les programmes canadiens de résidence en anesthésiologie. Les études futures devraient explorer les moyens de surmonter les obstacles et d'améliorer l'application des connaissances à l'anesthésie régionale échoguidée.

Practice and challenges related to regional anesthesia in Amhara regional hospitals, Northwest-Ethiopia: a web-based survey study.

BACKGROUND: Regional anesthesia (RA) can improve patient outcomes and reduce perioperative complications including deaths. Despite its benefits, RA is less utilised in low-resource settings. The purpose of this study was to assess practice and challenges related to RA in Amhara Regional Hospitals, Northwest-Ethiopia. METHODS: A web- based survey was distributed among 360 anesthetists working in Amhara Regional Hospitals, Northwest-Ethiopia from November 15 - January 30, 2023. An English, semi-structure, self-administered questionnaire was disseminated by email and telegram following ethical clearance. The survey included questions about the use of RA, socio-demographic characteristics of anesthetist, types of practiced regional blocks, and barriers to perform RA. All volunteer respondents who filled online questionnaire during study period were included. The data were coded and analyzed using statistical package for social Sciences (SPSS) software-version 20. Both inferential and descriptive statistics were used to describe the results. RESULTS: The overall response rate was 63.3% (223 out of 360 completed surveys). A total of 132 respondents (36.7%) did not provide a response, and 5 respondents (1.4%) submitted incomplete) surveys. The most frequently self-reported barriers to performing peripheral nerve blocks were a lack of equipment (regional procedure kit including block needle, ultrasound, nerve stimulator, or epidural set) 185 (82.9%), lack of knowledge 171(76.7%), lack of practical skills 112 (50.2%), and lack of drugs/medication 50 (22.4%). CONCLUSIONS: The principal findings indicate that all respondents perform spinal anaesthesia, while the practice of peripheral RA varies. Reported barriers to performing RA are related to knowledge and training, as well as a lack of equipment (there aren't enough regional procedure kits available that include an epidural set, block needle, nerve stimulator, and ultrasound). A more stringent approach with specific requirements, distinguishing between neuraxial and peripheral blocks, enhance training opportunities for peripheral nerve blocks are required in Ethiopia.

Anesthesia practice for Cesarean delivery in Japan: a retrospective cohort study.

PURPOSE: General anesthesia for Cesarean delivery affects maternal and neonatal outcomes. We aimed to evaluate temporal trends in anesthesia management for Cesarean deliveries over 16 years and analyze interinstitutional variations in general anesthesia use in Japan. METHODS: In this retrospective cohort study, we obtained patient data from the nationwide health insurance claims database containing data for ten million individuals. We included patients who underwent Cesarean delivery between 1 January 2005 and 31 August 2021. The primary outcome was the use of general anesthesia. We evaluated institutional variations in general anesthesia use in medical facilities using two-level hierarchical logistic regression analyses with median odds ratios and intraclass correlation coefficients. RESULTS: The cohort included 86,793 patients who underwent 102,617 Cesarean deliveries at 2,496 institutions. General anesthesia was used in 3.7% (95% confidence interval [CI], 3.6 to 3.9) of all Cesarean deliveries. The temporal trend in the use of general anesthesia decreased gradually from 10.8% in 2005 to 2.9% in 2021 (P for trend < 0.001). The adjusted median odds ratio for medical facilities was 6.1 (95% CI, 5.9 to 6.7), and the intraclass correlation coefficient was 0.52 (95% CI, 0.51 to 0.55). CONCLUSION: Although the rate of general anesthesia use for Cesarean delivery in Japan decreased gradually from 2005 to 2021, general anesthesia was used in 3.7% of all Cesarean deliveries. The use of general anesthesia varied significantly across institutions, and 52% of the overall variations in general anesthesia practice can be explained by differences between facilities.

RéSUMé: OBJECTIF: L'anesthésie générale pour l'accouchement par césarienne affecte les issues maternelles et néonatales. Notre objectif était d'évaluer les tendances temporelles de la prise en charge anesthésique pour les accouchements par césarienne sur 16 ans et d'analyser les variations interinstitutionnelles dans l'utilisation de l'anesthésie générale au Japon. MéTHODE: Dans cette étude de cohorte rétrospective, nous avons obtenu des données sur les patient·es à partir de la base de données nationale des réclamations d'assurance maladie contenant des données pour dix millions de personnes. Nous avons inclus les personnes ayant bénéficié d'un accouchement par césarienne entre le 1er janvier 2005 et le 31 août 2021. Le critère d'évaluation principal était le taux d'utilisation de l'anesthésie générale. Nous avons évalué les variations institutionnelles dans l'utilisation de l'anesthésie générale dans les établissements médicaux à l'aide d'analyses de régression logistique hiérarchique à deux niveaux avec des rapports de cotes médians et des coefficients de corrélation intraclasse. RéSULTATS: La cohorte comprenait 86 793 patient·es ayant bénéficié de 102 617 accouchements par césarienne dans 2496 établissements. L'anesthésie générale a été utilisée dans 3,7 % (intervalle de confiance [IC] à 95 %, 3,6 à 3,9) de tous les accouchements par césarienne. La tendance temporelle de l'utilisation de l'anesthésie générale a diminué graduellement, passant de 10,8 % en 2005 à 2,9 % en 2021 (P pour la tendance < 0,001). Le rapport de cotes médian ajusté pour les établissements médicaux était de 6,1 (IC 95 %, 5,9 à 6,7), et le coefficient de corrélation intraclasse était de 0,52 (IC 95 %, 0,51 à 0,55).

Evaluation of the Erector spinae plane block for postoperative analgesia in laparoscopic ventral hernia repair: a randomized placebo controlled trial.

BACKGROUND: The Erector spinae plane block (ESPB) reduces postoperative pain after several types of abdominal laparoscopic surgeries. There is sparse data on the effect of ESPB in laparoscopic ventral hernia repair. The purpose of this study was to test the postoperative analgesic efficacy of an ESPB for this procedure. METHODS: In this prospective, double-blind, randomized controlled study, adult patients undergoing laparoscopic ventral hernia repair were randomly assigned to either bilateral preoperative ESPB with catheters at the level of Th7 (2 × 30 ml of either 2.5 mg/ml ropivacaine or saline), with postoperative catheter top ups every 6 h for 24 h. The primary outcome was rescue opioid consumption during the first hour postoperatively. Secondary outcomes were total opioid consumption at 4 h and 24 h, pain scores, nausea, sedation, as well as Quality of Recovery 15 (QoR-15) and the EuroQol-5 Dimensions (EQ-5D-5L) during the first week. RESULTS: In total, 64 patients were included in the primary outcome measure. There was no significant difference in rescue opioid consumption (oral morphine equivalents (OME)) at one hour postoperatively, with the ESPB group 26.9 ± 17.1 mg versus 32.4 ± 24.3 mg (mean ± SD) in the placebo group (p= 0.27). There were no significant differences concerning the secondary outcomes during the seven-day observation period. Seven patients received a rescue block postoperatively, providing analgesia in five patients. CONCLUSION: We found no difference in measured outcomes between ESPB and placebo in laparoscopic ventral hernia repair. Future studies may evaluate whether a block performed using higher concentration and/or at a different thoracic level provides more analgesic efficacy. TRIAL REGISTRATION: NCT04438369 ; 18/06/2020. .