Research priorities in regional anaesthesia: an international Delphi study.

BACKGROUND: Regional anaesthesia use is growing worldwide, and there is an increasing emphasis on research in regional anaesthesia to improve patient outcomes. However, priorities for future study remain unclear. We therefore conducted an international research prioritisation exercise, setting the agenda for future investigators and funding bodies. METHODS: We invited members of specialist regional anaesthesia societies from six continents to propose research questions that they felt were unanswered. These were consolidated into representative indicative questions, and a literature review was undertaken to determine if any indicative questions were already answered by published work. Unanswered indicative questions entered a three-round modified Delphi process, whereby 29 experts in regional anaesthesia (representing all participating specialist societies) rated each indicative question for inclusion on a final high priority shortlist. If ≥75% of participants rated an indicative question as 'definitely' include in any round, it was accepted. Indicative questions rated as 'definitely' or 'probably' by <50% of participants in any round were excluded. Retained indicative questions were further ranked based on the rating score in the final Delphi round. The final research priorities were ratified by the Delphi expert group. RESULTS: There were 1318 responses from 516 people in the initial survey, from which 71 indicative questions were formed, of which 68 entered the modified Delphi process. Eleven 'highest priority' research questions were short listed, covering themes of pain management; training and assessment; clinical practice and efficacy; technology and equipment. CONCLUSIONS: We prioritised unanswered research questions in regional anaesthesia. These will inform a coordinated global research strategy for regional anaesthesia and direct investigators to address high-priority areas.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations.

PURPOSE: Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways. SOURCE: We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature. PRINCIPAL FINDINGS: Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen. CONCLUSION: Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

RéSUMé: OBJECTIF: L'arthroplastie par prothèse totale (APT), en particulier de la hanche et du genou, constitue l'une des interventions chirurgicales les plus couramment pratiquées. L'avancement et l'évolution des techniques chirurgicales et d'anesthésie ont permis de réaliser une APT en ambulatoire/sur la base d'un congé le jour même. Dans ce module de développement professionnel continu, nous proposons une synthèse des données probantes périopératoires qui pourraient contribuer à l'élaboration de trajectoires réussies pour l'APT en ambulatoire. SOURCES: Nous avons réalisé des recherches dans MEDLINE, Embase, CENTRAL et dans la base de données Cochrane des revues systématiques à la recherche d'articles sur les APT ambulatoires ou accélérées. En l'absence de données probantes directes dans un contexte ambulatoire, nous avons extrapolé les données probantes à partir de la littérature sur les APT en milieu hospitalier. CONSTATATIONS PRINCIPALES: La sélection des patient·es englobant les facteurs patient·es, médicaux et sociaux est fondamentale pour un congé réussi le jour même après une APT. Les données probantes portant sur le type d'anesthésie peropératoire privilégient la technique neuraxiale pour respecter les critères de congé le jour même et réduire les complications périopératoires. La disponibilité d'un anesthésique local à courte durée d'action pour l'anesthésie neuraxiale affecterait le choix de l'anesthésique. Néanmoins, dans une population bien sélectionnée, l'anesthésie générale moderne avec analgésie multimodale et antithrombotiques peut être envisagée. L'analgésie régionale fait partie intégrante d'un régime d'analgésie multimodale visant à réduire la consommation d'opioïdes et à faciliter le congé de l'hôpital le jour même, ce qui réduit le nombre de réadmissions. En ce qui concerne l'arthroplastie totale du genou en ambulatoire, la combinaison d'un bloc du canal des adducteurs et d'une infiltration périarticulaire d'anesthésique local constitue un régime approprié d'analgésie régionale. CONCLUSION: L'anesthésie pour les APT a évolué de telle sorte que le congé le jour même deviendra la norme pour certain·es patient·es. Il est essentiel d'établir des trajectoires de congé précoce afin de prévenir les effets indésirables et la réadmission dans cette population. Au fur et à mesure que davantage de données seront générées à partir d'un volume accru d'APT en ambulatoire, des données probantes plus solides émergeront pour appuyer les composantes idéales de l'anesthésie pour optimiser les devenirs.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks.

BACKGROUND: There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques. METHODS: We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement. RESULTS: Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified. CONCLUSIONS: Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process.

In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.

Wrong-site nerve blocks: evidence-review and prevention strategies.

PURPOSE OF REVIEW: There has been increasing attention to wrong site medical procedures over the last 20 years. This review aims to provide a summary of the current understanding and recommendations for the prevention of wrong-site nerve blocks (WSNB). RECENT FINDINGS: Various procedural, patient, practitioner, and organizational factors have been associated with the risk of WSNB. Recent findings have suggested that the use of a checklist is likely to reduce the incidence of WSNB. However, despite the widespread use of preprocedural checklists, WSNB continue to occur at significant frequency. This may be due to the inability of practitioners and teams to implement checklists correctly or the cognitive errors that prevent checklists from being executed as designed. SUMMARY: Though the evidence is limited, it is recommended that a combination of multiple strategies should be employed to prevent WSNB. These include the use of preprocedural markings, well constructed checklists, time-out/stop-moments, and cognitive/physical aids. Effective implementation requires team education and engagement that empowers all team members to speak up as part of a culture of safety.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process.

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

Surgically positioned paravertebral catheters and postoperative analgesia after open abdominal aortic aneurysm repair.

OBJECTIVE: To compare postoperative morphine equivalent intake after open abdominal aortic aneurysm (AAA) repair among analgesic modalities: systemic analgesia (SA) only with no regional anesthesia, surgically positioned paravertebral catheter (PVC), and thoracic epidural analgesia (TEA). METHODS: This retrospective cohort study included patients undergoing elective open AAA at the Queen Elizabeth II Health Science Center, Halifax, Nova Scotia. Demographics, morphine equivalents, methods of analgesia administration, and outcomes data were collected on all patients from 2005 to 2016. Total morphine equivalent (MEQ) on postoperative days (PODs) 1, 2, and 3 were compared among patients with SA, PVC, and TEA. A multivariable zero-inflated log-linear regression was used to determine the association between analgesic modality and MEQ. Multivariable logistic regression models were used to determine associations between analgesic modality and postoperative pain, rates of discharge from intensive care within 1 day and opioid-related adverse events. RESULTS: The study cohort included 355 patients: 177 retroperitoneal and 178 transperitoneal repairs; 173 patients underwent SA, 117 PVC, and 65 TEA. On POD1, median MEQs were 984 (interquartile range [IQR], 342-1525) for SA, 89 (33-246) for PVC, and 49 (0-90) for TEA. On POD2, the median MEQs were 105 (IQR, 57-210) for SA, 45 (15-99) for PVC, and 30 (0-64) for TEA. On POD3, the median MEQs were 45 (IQR, 15-120) for SA, 30 (0-60) for PVC, and 10 (0-45) for TEA. On multivariable log-linear regression, compared with SA, PVC and TEA were associated with increased odds of receiving no opioids on POD1 (odds ratio [OR], 66.85; 95% confidence interval [CI], 17.49-255.57; and OR, 214.68; 95% CI, 60.20-766.38; respectively), POD 2 (OR, 6.97; 95% CI, 3.61-13.46; and OR, 28.73; 95% CI, 15.68-52.62; respectively), and POD 3 (OR, 3.93; 95% CI, 2.72-5.67; and OR, 4.68; 95% CI, 3.20-6.86; respectively). If patients did receive opioids, compared with SA, PVC and TEA were associated with decreased consumption on POD1 (RR, 0.22; 95% CI, 0.18-0.27; and RR, 0.16; 95% CI, 0.12-0.20; respectively), POD2 (RR, 0.50; 95% CI, 0.42-0.58; and RR, 0.46; 95% CI, 0.37-0.56; respectively), and POD3 (RR, 0.78; 95% CI, 0.66-0.93; and RR, 0.76; 95% CI, 0.63-0.93; respectively). Compared with SA, PVC was associated with earlier discharge from intensive care (OR, 2.75; 95% CI, 1.17-6.45) and TEA was not (OR, 1.12; 95% CI, 0.56-2.2). Compared with TEA, PVC was not associated with increased rate of opioid-related adverse events (OR, 0.44; 95% CI, 0.08-2.44). CONCLUSIONS: PVC and TEA are associated with decreased MEQ compared with SA. PVC is associated with earlier discharge from intensive care compared with SA and similar rates of opioid-related adverse events compared with TEA. Paravertebral analgesia appears to be a safe and effective analgesic modality in patients undergoing retroperitoneal approach for abdominal aneurysm repair.

Incidence of sub-perineural injection using a targeted intracluster supraclavicular ultrasound-guided approach in cadavers.

BACKGROUND: Multi-injection targeted intracluster injection ultrasound-guided supraclavicular brachial plexus block has been advocated to provide a faster onset of anaesthesia compared with a double injection technique. By placing the needle within clusters of hypoechoic structures, corresponding to neural tissue, this technique may increase needle trauma and the incidence of nerve injury. This study assessed the rate of sub-perineural needle placement with a single intracluster brachial plexus injection in the supraclavicular fossa of human cadavers. METHODS: A single ultrasound-guided intracluster brachial plexus injection was performed bilaterally at the supraclavicular fossa on 21 lightly embalmed clinical grade cadavers. Using an in-plane technique, an echogenic needle was positioned to target the middle or lower trunk 'cluster', where 0.2 ml black India ink was injected. An effort was taken to avoid the hypoechoic structures with the needle tip. Tissue samples were assessed histologically by two experienced reviewers. RESULTS: All 42 injections were sonographically assessed to be within the 'main cluster'. Ink was extra-epineural in 13/41 (32%), sub-epineural but outside perineurium in 18/41 (44%), and sub-perineural in 10/41 sections (24%; 95% confidence interval, 13-41%). The histology from one injection was uninterpretable. Of the 10 sub-perineural deposits, the ink was intrafascicular in nine sections. CONCLUSIONS: We observed a high rate of sub-perineural injection with a single intracluster injection. Thus the targeted intracluster injection supraclavicular block cannot be recommended until further evidence is available regarding the safety of this technique.

Intraoperative insertion of paravertebral catheter for postoperative analgesia in retroperitoneal aortic aneurysm repair.

Paravertebral catheters are a well-established analgesic modality in thoracic surgery but have not been described in abdominal aortic surgery. We describe a simple, safe, and effective technique of paravertebral catheter insertion by the operative surgeon after a retroperitoneal abdominal aortic aneurysm repair. Once the aneurysm repair is complete, an extrapleural plane between the parietal pleura and the twelfth rib is created through blunt dissection. A catheter is advanced into the space percutaneously under direct vision, and a continuous infusion of local anesthetic is administered. Paravertebral catheters typically remain in place for 3 to 5 days and provide excellent postoperative non-narcotic analgesia.

Continuous interscalene block in patients having outpatient rotator cuff repair surgery: a prospective randomized trial.

BACKGROUND: We performed this randomized trial to compare the recovery profile of patients receiving single injection (SISB) and continuous interscalene brachial plexus block (CISB) or general anesthesia (GA) for arthroscopic rotator cuff repair surgery through the first postoperative week. Our primary hypothesis was that the highest pain numeric rating scale (NRS) (worst pain score) at the end of the study week would be lower for patients in the CISB group than for patients in the SISB or GA groups. METHODS: Seventy-one patients scheduled for elective outpatient arthroscopic rotator cuff repair were enrolled. CISB patients received 20 mL of 0.5% ropivacaine as a bolus through a catheter, whereas SISB patients received the same injection volume through a needle. CISB patients received an infusion of 0.2% ropivacaine at 5 mL/h with a patient-controlled bolus of 5 mL hourly for 48 hours. GA-only patients received a standardized general anesthetic. Postoperative highest NRS pain scores through the first postoperative week, time-to-first pain, analgesic consumption, fast-tracked postoperative anesthesia care unit (PACU) bypass rate, length of PACU stay, time-to-discharge home, total hours of sleep, and related adverse effects were recorded in the PACU and at home on postoperative days 1, 2, 3, and 7. RESULTS: No patient in the CISB or SISB groups reported a NRS ≥1 or required analgesics while in the PACU. While most patients in the CISB and SISB groups were fast-tracked to PACU discharge, no patient in the GA group was fast-tracked (Χ P = 0.003). Length of stay in the PACU was significantly shorter for the CISB and SISB groups than for the GA group (20 ± 31, 30 ± 42, and 165 ± 118 minutes, respectively (CISB vs GA, P < 0.001; SISB vs GA, P <0.001), and time-to-discharge home was significantly shorter when compared with the GA group. Time to first pain report was longer in the CISB group. Mean NRS scores were lower for patients in the CISB group than in the SISB and GA groups on postoperative days 1 and 2, and use of narcotics (doses ≥1) was lower until postoperative day 3. Patients who received CISB slept significantly longer than patients who received SISB or GA (P < 0.01) during the first 48 hours postoperatively. By the end of the study week, 26% of patients in the CISB group, 83% in the SISB group, and 58% of GA patients reported NRS ≥4 (both P-values ≤ 0.05). CONCLUSION: The analgesic benefits of CISB found in the PACU and immediately after discharge extend through the intermediate recovery period ending on postoperative day 7.

Standard approaches for upper extremity nerve blocks with an emphasis on outpatient surgery.

PURPOSE OF REVIEW: Currently, no standards exist with regard to the techniques and administration of ultrasound-guided peripheral nerve blocks. Consequently, the techniques and teaching substantially vary among practitioners and institutions. The purpose of this review is to propose a set of standard US-guided techniques for upper extremity nerve blocks. RECENT FINDINGS: On the basis of the synthesis of information in available literature and the consensus of an internationally recognized collaborative panel of regional anaesthesia experts, the review recommends a standardized approach to common upper extremity nerve blocks using ultrasound guidance. SUMMARY: A set of structured recommendations and approaches are suggested to help standardize clinical practice and teaching of ultrasound-guided upper extremity nerve blocks. Additional emphasis is placed on the discussion of nerve blocks in outpatient surgery.

Fascia lliaca block for analgesia after hip arthroplasty: a randomized double-blind, placebo-controlled trial.

BACKGROUND AND OBJECTIVES: Fascia iliaca block (FIB) is often used to treat pain after total hip arthroplasty (THA), despite a lack of randomized trials to evaluate its efficacy for this indication. The objective of this study was to assess the analgesic benefit of FIB after THA. Our primary hypothesis was administration of FIB decreases the intensity of postoperative pain (numeric rating scale [NRS-11] score) compared with sham block (SB) in patients after THA. METHODS: After institutional review board approval and informed consent, 32 eligible patients having THA were recruited. In the postoperative care unit, although all patients received intravenous morphine sulfate patient-controlled analgesia, patients reporting pain of 3 or greater on the NRS-11 scale were randomized to receive ultrasound-guided fascia iliaca (30 mL 0.5% ropivacaine) or SB (30 mL 0.9% NaCl) using identical technique, below fascia iliaca. The primary outcome was pain intensity (NRS-11) after FIB. RESULTS: Thirty-two patients (16 in each group) completed the study; all patients received an FIB. There was no difference in pain intensity (NRS-11 = 5.0 ± 0.6 vs 4.7 ± 0.6, respectively) after FIB versus SB or in opioid consumption (8.97 ± 1.6 vs 5.7 ± 1.6 mg morphine, respectively) between the groups at 1 hour. The morphine consumption after 24 hours was similar in both groups (49.0 ± 29.9 vs 50.4 ± 34.5 mg, P = 0.88, respectively). CONCLUSIONS: The evidence in these data suggests that the difference in average pain intensity after FIB versus SB was not significant (95% confidence interval, -2.2-1.4 NRS units).