Regional anaesthesia for district hospitals and clinics.

Pain is a common reason that patients seek care in the emergency department (ED). Regional anaesthesia in the form of nerve blocks provides an excellent alternative to traditional forms of analgesia, and may be superior in managing musculoskeletal pain compared to opioids. Adequate pain management improves patient satisfaction, facilitates examination and minor procedures, and allows for earlier and safe discharge. In low resource settings this modality is underutilised due to lack of trained providers and/or support from specialised services, shortages of equipment, and lack of context-sensitive guidelines. Advances in ultrasound guided regional anaesthesia has the potential to improve access to safe and reliable anaesthesia. It is often not accessible or an active part of training even for emergency physicians. There are, however, a number of nerve blocks that are easy to learn, don't require specialised equipment, and can be readily applied in EDs for minor procedures and longer acting forms of analgesia. Nerve blocks more applicable in the operating theatre or best done under ultrasound guidance are mentioned but not discussed in this article. This continuous professional development (CPD) article aims to provide guidance with respect to several key areas related to more commonly used types of regional anaesthesia in district level services. We discuss the importance of good clinical practice including thorough preparation of equipment and the patient to avoid common complications, clinical indications for regional blocks in the ED, local anaesthetic agents, different techniques for some common regional blocks, potential complications, and the need for a trained interprofessional team.

[Regional Anaesthesia in the Prehospital Setting]. / Regionalanästhesie in der präklinischen Notfallmedizin.

Pain is often the main symptom in trauma patients. Although peripheral nerve blocks (PNB) provide fast, safe, and adequate analgesia, they are currently only rarely used outside the perioperative setting. In Germany, intravenous analgesia with non-opioid analgesics (NOPA) and strong opioids is the main treatment concept for prehospital pain. However, the use of highly potent opioids can be associated with significant side effects, especially in emergency patients. Therefore, PNBs are used in many hospitals for the treatment of perioperative pain. As with perioperative use, the advantages of early PNB in the prehospital analgesic treatment of trauma patients are obvious, especially for elderly and multimorbid patients. Early prehospital PNB can also facilitate the reduction of dislocated fractures or dislocated joints as well as the technical rescue of trauma patients. Common geriatric fractures, such as proximal femur or humerus fractures, can be treated appropriately and adequately with PNB.In this article, we show which PNB procedures can be useful in prehospital patient care and which requirements should be met for their safe use. We also present a concept for assessing whether and to what extent the prehospital use of PNB is indicated and appropriate. The aim of this article is to draw attention to PNB as a possible part of prehospital care concepts for trauma patients and to discuss its prehospital use.

Research priorities in regional anaesthesia: where should we focus?

Using a modified Delphi technique, an international group of regional anaesthetists generated a list of top research priorities in regional anaesthesia. The list of unanswered research questions was created from a questionnaire completed by >500 anaesthetists and distilled into 11 priorities grouped into four themes: clinical practice and efficacy, pain management, technology and equipment, and training and assessment.

Regional Anesthesia in the Elite Athlete.

Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.

Regional Anesthesia for Athletes Undergoing Upper Extremity Procedures: Techniques and Considerations.

Upper extremity injuries are frequent in athletes which may require surgeries. Regional anesthesia for postoperative analgesia is important to aid recovery, and peripheral nerve blocks for surgical anesthesia enable surgeries to be performed without general anesthetics and their associated adverse effects. The relevant nerve block approaches to anesthetize the brachial plexus for elbow, wrist and hand surgeries are discussed in this article. There is very limited margin for error when performing nerve blocks and multimodal monitoring approach to reduce harm are outlined. Lastly, the importance of obtaining informed consent prior to nerve block procedures should not be overlooked.

Latest Advances in Regional Anaesthesia.

Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.

Development of ultrasound guided regional anaesthesia in the emergency department, Hospital Kuala Lumpur.

Ultrasound guided regional anaesthesia is a fast-rising acute pain management modality in emergency departments worldwide. It is a safe and effective alternative to opioid based systemic analgesia. Establishing a standardised and efficient protocol requires a multidisciplinary approach namely involving collaborations between anaesthesiology and emergency medicine counterparts. In this article, we outline our approach in establishing an end-to-end service which is both patient-centred and sustainable.

Regional Anesthesia Complications and Contraindications.

Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.

Regional Anesthesia for Hip Arthroscopy.

Pain after hip arthroscopy can be severe, yet we lack a consensus method for non-narcotic analgesia. Here we describe anatomic elements of hip arthroscopy and our current understanding of the relevant sensory innervation as a prelude to the evaluation of locoregional analgesic techniques. Many regional nerve blocks and local anesthetic infiltration techniques are reviewed, including 2 newer ultrasound fascial plane blocks. Further study of targeted, motor-sparing approaches, either ultrasound-guided or under direct surgical visualization is needed.

Regional anesthesia in neonates with cleft lip and palate: Retrospective study.

BACKGROUND: Orofacial clefts are the most common congenital abnormalities. Cleft lip reconstruction is performed mostly in 3 months of life including the neonatal period. The consumption of opioids during anesthesia is one of the monitored parameters of anesthesia safety. We investigated the effect of using an infraorbital nerve block for reducing opioid consumption during cleft lip surgery in neonates. PATIENTS/METHODS: Overall, 100 patients who underwent primary cleft lip surgery in neonatal age between 2018 and 2021 were included in the study. The primary outcome was to compare opioid requirements during cleft lip surgery with and without using regional anesthesia. Secondary outcomes included a first oral intake from surgery between neonates with and without regional anesthesia and complications rate of infraorbital nerve block. RESULTS: Data from 100 patients (46 patients with and 64 without regional anesthesia) were retrospectively analyzed and classified into two groups according to whether regional anesthesia during neonatal cleft lip surgery had been performed or not. The use of infraorbital block was found to be positively correlated with lower doses of opioids used during the general anesthesia for the surgery (mean 0.48 µg/kg vs 0.29 µg/kg, p < 0.05). The postoperative course was evaluated based on the interval from surgery to first oral intake which was statistically insignificant shorter (p = 0.16) in the group of patients using regional anesthesia. No complications were recorded in the group of patients with regional anesthesia. CONCLUSIONS: Regional anesthesia is associated with reduced opioid consumption during anesthesia thereby increasing the safety of anesthesia in neonates. GOV IDENTIFIER: NCT06067854https://clinicaltrials.gov/study/NCT06067854?cond=NCT06067854&rank=1.

Locoregional Anesthesia Has Lower Risks of Cardiac Complications Than General Anesthesia After Prolonged Endovascular Repair of Abdominal Aortic Aneurysms.

OBJECTIVES: Although general anesthesia is the primary anesthesia in endovascular aneurysm repair (EVAR), some studies suggest locoregional anesthesia could be a feasible alternative for eligible patients. However, most evidence was from retrospective studies and was subjected to an inherent selection bias that general anesthesia is often chosen for more complex and prolonged cases. To mitigate this selection bias, this study aimed to compare 30-day outcomes of prolonged, nonemergent, intact, infrarenal EVAR in patients undergoing locoregional or general anesthesia. In addition, risk factors associated with prolonged operative time in EVAR were identified. DESIGN: Retrospective large-scale national registry study. SETTING: American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2022. PARTICIPANTS: A total of 4,075 out of 16,438 patients (24.79%) had prolonged EVAR. Among patients with prolonged EVAR, 324 patients (7.95%) were under locoregional anesthesia. There were 3,751 patients (92.05%) under general anesthesia, and 955 of them were matched to the locoregional anesthesia cohort. INTERVENTIONS: Patients undergoing infrarenal EVAR were included. Exclusion criteria included age <18 years, emergency cases, ruptured abdominal aortic aneurysm, and acute intraoperative conversion to open. Only cases with prolonged operative times (>157 minutes) were selected. A 1:3 propensity-score matching was used to address demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were assessed. Moreover, factors associated with prolonged EVAR were identified by multivariate logistic regression. MEASUREMENTS AND MAIN RESULTS: Except for general anesthesia contraindications, patients undergoing locoregional or general anesthesia exhibited largely similar preoperative characteristics. After propensity-score matching, patients under locoregional and general anesthesia had a lower risk of myocardial infarction (0.93% v 2.83%, p = 0.04), but comparable 30-day mortality (3.72% v 2.72%, p = 0.35) and other complications. Specific concomitant procedures, aneurysm anatomy, and comorbidities associated with prolonged EVAR were identified. CONCLUSIONS: Locoregional anesthesia can be a safe and effective alternative to general anesthesia, particularly in EVAR cases with anticipated complexity and prolonged operative times, as it offers the potential benefit of reduced cardiac complications. Risk factors associated with prolonged EVAR can aid in preoperative risk stratification and inform the decision-making process regarding anesthesia choice.

Is Tourniquet Pain the Result of Increased Compartment Pressure in the Forearm?

ABSTRACT: The pneumatic tourniquet has been a mainstay in upper extremity surgery by allowing the surgeon to operate in a blood-free field. Many upper extremity surgical procedures are done under local anesthesia or minimal sedation, and the problem of tourniquet pain is a vexing one. The question is posed: Is tourniquet pain the result of increased compartment pressure in the forearm? This study measured compartment pressures of the volar forearm in 10 healthy normotensive volunteers before inflation of a pneumatic tourniquet and compared it with pressure measurements taken while the tourniquet was still inflated after 15 minutes. Compartment pressures were measured using a Stryker needle manometer; all measurements were taken in the volar forearm by the senior author (C.H.M.). There was no increase in the volar/flexor compartment pressure of the forearm after 15 minutes of tourniquet inflation. All subjects complained of pain of the forearm, characteristically what is commonly called "tourniquet pain." We therefore conclude that in the upper extremity, at least for relatively short operating times, appropriate inflation of a tourniquet does not induce the early onset of increased compartment pressure in the forearm.

Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis.

STUDY OBJECTIVE: Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. DESIGN: Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment. SETTING: Postoperative pain treatment. PATIENTS: Adult patients undergoing visceral cancer surgery. INTERVENTIONS: Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques. MEASUREMENTS: Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus. MAIN RESULTS: 59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA. CONCLUSIONS: Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.