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BACKGROUND: As few anaesthetists provide lumbar erector spinae block for disc surgery, there is a need to provide training to enable a randomised controlled trial investigating analgesia after painful spinal surgery (NIHR153170). The primary objective of the study was to develop and measure the construct validity of a checklist for assessment of skills in performing lumbar and thoracic erector spinae fascial plane injection using soft-embalmed Thiel cadavers. METHODS: Twenty-four UK consultant regional anaesthetists completed two iterations of a Delphi questionnaire. The final checklist consisted of 11 steps conducive to best practice. Thereafter, we validated the checklist by comparing the performance of 12 experts with 12 novices, each performing lumbar and thoracic erector spinae plane injections or fascia iliaca, serrato-pectoral (PEC II) and serratus injections, randomly allocated to the left and right sides of six soft-embalmed Thiel cadavers. Six expert, trained raters blinded to operator and site of block examined 120 videos each. RESULTS: The mean (95% confidence interval) internal consistency of the 11-item checklist for erector spinae plane injection was 0.72 (0.63-0.79) and interclass correlation was 0.88 (0.82-0.93). The checklist showed construct validity for lumbar and thoracic erector spinae injection, experts vs novices {median (interquartile range [range]) 8.0 (7.0-10.0 [1-11]) vs 7.0 (5.0-9.0 [4-11]), difference 1.5 (1.0-2.5), P<0.001}. Global rating scales showed construct validity for lumbar and thoracic erector spinae injection, 28.0 (24.0-31.0 [7-35]) vs 21.0 (17.0-24.0 [7-35]), difference 7.5 (6.0-8.5), P<0.001. The most difficult items to perform were identifying the needle tip before advancing and always visualising the needle tip. Instrument handling and flow of procedure were the areas of greatest difficulty on the global rating scale (GRS). Checklists and GRS scores correlated. There was homogeneity of regression slopes controlling for status, type of injection, and rater. Generalisability analysis showed a high reliability using the checklist and GRS for all fascial plane blocks (Rho [ρ2] 0.93-0.96: Phi [Ï] 0.84-0.87). CONCLUSIONS: An 11-point checklist developed through a modified Delphi process to provide best practice guidance for fascial plane injection showed construct validity in performing lumbar and thoracic erector spinae fascial plane injection in soft-embalmed Thiel cadavers.
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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.
Subject(s)
Anesthesia, Conduction , Biomedical Research , Humans , Delphi Technique , Surveys and Questionnaires , Research DesignABSTRACT
To coincide with the annual scientific meeting of Regional Anaesthesia UK in London 2024, where there is a joint scientific session with the British Journal of Anaesthesia, a special regional anaesthesia edition of the journal has been produced. This editorial offers some highlights from the manuscripts contained within the special edition.
Subject(s)
Anesthesia, Conduction , Anesthesiology , Humans , LondonABSTRACT
Background: Adequate training of anaesthetists in regional anaesthesia is important to ensure optimal patient access to regional anaesthesia. Methods: We undertook a national survey of UK trainee anaesthetists and Royal College of Anaesthetists (RCoA) tutors to assess experiences of training in regional anaesthesia. We performed descriptive statistics for baseline characteristics, and logistic regression of training indices and tutor confidence that their hospital could provide regional anaesthesia training at all three stages of the RCoA 2021 curriculum. Results: A total of 492 trainees (19.2%) and 114 tutors (45.2%) completed the survey. Trainees were less likely to have received training in chest/abdominal wall compared with upper/lower limb blocks {erector spinae vs femoral block (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.16-0.39), P<0.001}, or achieved >20 chest/abdominal wall blocks by Stage 3 of training (chest vs lower limb block [OR 0.09, 95% CI 0.05-0.15, P<0.001]. There was a strong association between training received, number of blocks performed (>20 vs 0-5 blocks), and self-reported ability to perform blocks independently, OR 20.9 (95% CI 9.38-53.2). 24/182 (13%) and 10/182 (5.5%) of trainees had performed ≥50 non-obstetric lumbar and thoracic epidurals, respectively, by Stage 3 training. There was a positive association between having a lead clinician for regional anaesthesia, particularly those with paid sessions, and reported confidence to provide regional anaesthesia training at all stages of the curriculum (Stage 3 OR 7.27 [95% CI 2.64-22.0]). Conclusion: Our results confirm the importance of clinical experience and access to training in regional anaesthesia, and support the introduction of departmental regional anaesthesia leads to improve equity and quality in training opportunities.
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Introduction Needle tip visualisation is a key skill required for the safe practice of ultrasound-guided regional anaesthesia (UGRA). This exploratory study assesses the utility of a novel augmented reality device, NeedleTrainer™, to differentiate between anaesthetists with varying levels of UGRA experience in a simulated environment. Methods Four groups of five participants were recruited (n = 20): novice, early career, experienced anaesthetists, and UGRA experts. Each participant performed three simulated UGRA blocks using NeedleTrainer™ on healthy volunteers (n = 60). The primary aim was to determine whether there was a difference in needle tip visibility, as calculated by the device, between groups of anaesthetists with differing levels of UGRA experience. Secondary aims included the assessment of simulated block conduct by an expert assessor and subjective participant self-assessment. Results The percentage of time the simulated needle tip was maintained in view was higher in the UGRA expert group (57.1%) versus the other three groups (novice 41.8%, early career 44.5%, and experienced anaesthetists 43.6%), but did not reach statistical significance (p = 0.05). An expert assessor was able to differentiate between participants of different UGRA experience when assessing needle tip visibility (novice 3.3 out of 10, early career 5.1, experienced anaesthetists 5.9, UGRA expert group 8.7; p < 0.01) and final needle tip placement (novice 4.2 out of 10, early career 5.6, experienced anaesthetists 6.8, UGRA expert group 8.9; p < 0.01). Subjective self-assessment by participants did not differentiate UGRA experience when assessing needle tip visibility (p = 0.07) or final needle tip placement (p = 0.07). Discussion An expert assessor was able to differentiate between participants with different levels of UGRA experience in this simulated environment. Objective NeedleTrainer™ and subjective participant assessments did not reach statistical significance. The findings are novel as simulated needling using live human subjects has not been assessed before, and no previous studies have attempted to objectively quantify needle tip visibility during simulated UGRA techniques. Future research should include larger sample sizes to further assess the potential use of such technology.
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Introduction Needle insertion and visualisation skills needed for ultrasound (US)-guided procedures can be challenging to acquire. The novel NeedleTrainer device superimposes a digital holographic needle on a real-time US image display without puncturing a surface. The aim of this randomised control study was to compare the success of trainees performing a simulated central venous catheter insertion on a phantom either with or without prior NeedleTrainer device practice. Methods West of Scotland junior trainees who had not performed insertion of a central venous catheter were randomised into two groups (n=20). Participants undertook standardized online training through a pre-recorded video and training on how to handle a US probe. Group 1 had 10 minutes of supervised training with the NeedleTrainer device. Group 2 were a control group. Participants were assessed on needle insertion to a pre-defined target vein in a phantom. The outcome measures were the time taken for needle placement (secs), number of needle passes (n), operator confidence (0-10), assessor confidence (0-10), and NASA task load index score. Results The mean mental demand score in the control group was 7.65 (SD 3.5) compared to 12.8 (SD 2.2, p=0.005) in the NeedleTrainer group. There was no statistical difference between the groups in any of the other outcome measures. Discussion This was a small pilot study, and small participant numbers may have impacted the statistical significance. There is natural variation of skill within participants that could not have been controlled for. The difference in pressure needed using the NeedleTrainer compared to a real needle may impact the outcome measures.
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Enhanced recovery after total hip arthroplasty aims to facilitate return to function and early hospital discharge, but the role of novel fascial plane block techniques in such pathways is uncertain. A randomised trial by Kukreja and colleagues describes superior quality of recovery after hip arthroplasty in patients receiving a pericapsular nerve group (PENG) block. We discuss the trial findings in the context of ongoing uncertainty regarding best analgesic practice for this surgical procedure.
Subject(s)
Analgesia , Arthroplasty, Replacement, Hip , Nerve Block , Humans , Pain, Postoperative/drug therapy , Pain, Postoperative/prevention & control , Pain Management/methods , Analgesia/methods , Nerve Block/methods , Femoral NerveABSTRACT
BACKGROUND: Ultrasound-guided regional anaesthesia relies on the visualisation of key landmark, target, and safety structures on ultrasound. However, this can be challenging, particularly for inexperienced practitioners. Artificial intelligence (AI) is increasingly being applied to medical image interpretation, including ultrasound. In this exploratory study, we evaluated ultrasound scanning performance by non-experts in ultrasound-guided regional anaesthesia, with and without the use of an assistive AI device. METHODS: Twenty-one anaesthetists, all non-experts in ultrasound-guided regional anaesthesia, underwent a standardised teaching session in ultrasound scanning for six peripheral nerve blocks. All then performed a scan for each block; half of the scans were performed with AI assistance and half without. Experts assessed acquisition of the correct block view and correct identification of sono-anatomical structures on each view. Participants reported scan confidence, experts provided a global rating score of scan performance, and scans were timed. RESULTS: Experts assessed 126 ultrasound scans. Participants acquired the correct block view in 56/62 (90.3%) scans with the device compared with 47/62 (75.1%) without (P=0.031, two data points lost). Correct identification of sono-anatomical structures on the view was 188/212 (88.8%) with the device compared with 161/208 (77.4%) without (P=0.002). There was no significant overall difference in participant confidence, expert global performance score, or scan time. CONCLUSIONS: Use of an assistive AI device was associated with improved ultrasound image acquisition and interpretation. Such technology holds potential to augment performance of ultrasound scanning for regional anaesthesia by non-experts, potentially expanding patient access to these techniques. CLINICAL TRIAL REGISTRATION: NCT05156099.
Subject(s)
Anesthesia, Conduction , Nerve Block , Humans , Nerve Block/methods , Artificial Intelligence , Ultrasonography, Interventional/methods , Anesthesia, Conduction/methods , UltrasonographyABSTRACT
Recent recommendations describe a set of core anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia (UGRA). This project aimed to generate consensus recommendations for core structures to identify during the performance of intermediate and advanced blocks. An initial longlist of structures was refined by an international panel of key opinion leaders in UGRA over a three-round Delphi process. All rounds were conducted virtually and anonymously. Blocks were considered twice in each round: for "orientation scanning" (the dynamic process of acquiring the final view) and for "block view" (which visualizes the block site and is maintained for needle insertion/injection). A "strong recommendation" was made if ≥75% of participants rated any structure as "definitely include" in any round. A "weak recommendation" was made if >50% of participants rated it as "definitely include" or "probably include" for all rounds, but the criterion for strong recommendation was never met. Structures which did not meet either criterion were excluded. Forty-one participants were invited and 40 accepted; 38 completed all three rounds. Participants considered the ultrasound scanning for 19 peripheral nerve blocks across all three rounds. Two hundred and seventy-four structures were reviewed for both orientation scanning and block view; a "strong recommendation" was made for 60 structures on orientation scanning and 44 on the block view. A "weak recommendation" was made for 107 and 62 structures, respectively. These recommendations are intended to help standardize teaching and research in UGRA and support widespread and consistent practice.
Subject(s)
Anesthesia, Conduction , Ultrasonography, Interventional , Humans , Ultrasonography , Peripheral Nerves/diagnostic imagingABSTRACT
BACKGROUND/IMPORTANCE: There is heterogeneity among the outcomes used in regional anesthesia research. OBJECTIVE: We aimed to produce a core outcome set for regional anesthesia research. METHODS: We conducted a systematic review and Delphi study to develop this core outcome set. A systematic review of the literature from January 2015 to December 2019 was undertaken to generate a long list of potential outcomes to be included in the core outcome set. For each outcome found, the parameters such as the measurement scale, timing and definitions, were compiled. Regional anesthesia experts were then recruited to participate in a three-round electronic modified Delphi process with incremental thresholds to generate a core outcome set. Once the core outcomes were decided, a final Delphi survey and video conference vote was used to reach a consensus on the outcome parameters. RESULTS: Two hundred and six papers were generated following the systematic review, producing a long list of 224 unique outcomes. Twenty-one international regional anesthesia experts participated in the study. Ten core outcomes were selected after three Delphi survey rounds with 13 outcome parameters reaching consensus after a final Delphi survey and video conference. CONCLUSIONS: We present the first core outcome set for regional anesthesia derived by international expert consensus. These are proposed not to limit the outcomes examined in future studies, but rather to serve as a minimum core set. If adopted, this may increase the relevance of outcomes being studied, reduce selective reporting bias and increase the availability and suitability of data for meta-analysis in this area.
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BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.
Subject(s)
Anesthesia, Conduction , Consensus , Delphi Technique , Documentation , HumansABSTRACT
BACKGROUND: Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN: A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS: Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION: Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION: In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
Subject(s)
Anesthesia, Conduction , Pharmaceutical Preparations , Anticoagulants , Fibrinolytic Agents/therapeutic use , Hemorrhage/drug therapy , HumansABSTRACT
PURPOSE: To determine the preferences and attitudes of members of regional anesthesia societies during the COVID-19 pandemic. METHODS: We distributed an electronic survey to members of the American Society of Regional Anesthesia and Pain Medicine, Regional Anaesthesia-UK, and the European Society of Regional Anaesthesia & Pain Therapy. A questionnaire consisting of 19 questions was developed by a panel of experienced regional anesthesiologists and distributed by email to the participants. The survey covered the following domains: participant information, practice settings, preference for the type of anesthetic technique, the use of personal protective equipment, and oxygen therapy. RESULTS: The survey was completed by 729 participants from 73 different countries, with a response rate of 20.1% (729/3,630) for the number of emails opened and 8.5% (729/8,572) for the number of emails sent. Most respondents (87.7%) identified as anesthesia staff (faculty or consultant) and practiced obstetric and non-obstetric anesthesia (55.3%). The practice of regional anesthesia either expanded or remained the same, with only 2% of respondents decreasing their use compared with the pre-pandemic period. The top reasons for an increase in the use of regional anesthesia was to reduce the need for an aerosol-generating medical procedure and to reduce the risk of possible complications to patients. The most common reason for decreased use of regional anesthesia was the risk of urgent conversion to general anesthesia. Approximately 70% of the responders used airborne precautions when providing care to a patient under regional anesthesia. The most common oxygen delivery method was nasal prongs (cannula) with a surgical mask layered over it (61%). CONCLUSIONS: Given the perceived benefits of regional over general anesthesia, approximately half of the members of three regional anesthesia societies seem to have expanded their use of regional anesthesia techniques during the initial surge of the COVID-19 pandemic.
RéSUMé: OBJECTIF: Déterminer les préférences et les attitudes des membres des sociétés d'anesthésie régionale pendant la pandémie de COVID-19. MéTHODE: Nous avons distribué un sondage électronique aux membres de l'American Society of Regional Anesthesia and Pain Medicine, de Regional Anesthesia-UK et de l'European Society of Regional Anaesthesia & Pain Therapy. Un questionnaire composé de 19 questions a été élaboré par un panel d'anesthésiologistes régionaux d'expérience et distribué par courriel aux participants. Le sondage couvrait les domaines suivants : les renseignements sur les participants, les contextes de pratique, leur préférence quant au type de technique d'anesthésie, l'utilisation d'équipement de protection individuelle et l'oxygénothérapie RéSULTATS: Le sondage a été complété par 729 participants provenant de 73 pays différents, avec un taux de réponse de 20,1 % (729/3630) pour le nombre de courriels ouverts et de 8,5 % (729/8572) pour le nombre de courriels envoyés. La plupart des répondants (87,7 %) se sont identifiés comme anesthésiologistes (académique ou consultant) et pratiquaient l'anesthésie obstétricale et non obstétricale (55,3 %). Leur pratique de l'anesthésie régionale s'est étendue ou est demeurée inchangée, et seulement 2 % des répondants ont indiqué avoir diminué leur utilisation de cette pratique par rapport à la période pré-pandémique. Les principales raisons d'une augmentation de l'utilisation de l'anesthésie régionale étaient de réduire la nécessité d'une intervention médicale générant des aérosols et de réduire le risque de complications potentielles pour les patients. La raison la plus courante de diminution du recours à l'anesthésie régionale était le risque de conversion urgente à une anesthésie générale. Environ 70 % des intervenants ont utilisé des précautions en matière de propagation des aérosols lorsqu'ils procuraient des soins à un patient sous anesthésie régionale. La méthode d'administration d'oxygène la plus fréquemment utilisée était les canules nasales avec un masque chirurgical superposé (61 %). CONCLUSION: Compte tenu des avantages perçus de l'anesthésie régionale par rapport à l'anesthésie générale, environ la moitié des membres de trois sociétés d'anesthésie régionale semblent avoir élargi leur utilisation des techniques d'anesthésie régionale pendant la vague initiale de la pandémie de COVID-19.
Subject(s)
Anesthesia, Conduction , COVID-19 , Humans , Pandemics , SARS-CoV-2 , Surveys and Questionnaires , United StatesABSTRACT
There is no universally agreed set of anatomical structures that must be identified on ultrasound for the performance of ultrasound-guided regional anesthesia (UGRA) techniques. This study aimed to produce standardized recommendations for core (minimum) structures to identify during seven basic blocks. An international consensus was sought through a modified Delphi process. A long-list of anatomical structures was refined through serial review by key opinion leaders in UGRA. All rounds were conducted remotely and anonymously to facilitate equal contribution of each participant. Blocks were considered twice in each round: for "orientation scanning" (the dynamic process of acquiring the final view) and for the "block view" (which visualizes the block site and is maintained for needle insertion/injection). Strong recommendations for inclusion were made if ≥75% of participants rated a structure as "definitely include" in any round. Weak recommendations were made if >50% of participants rated a structure as "definitely include" or "probably include" for all rounds (but the criterion for "strong recommendation" was never met). Thirty-six participants (94.7%) completed all rounds. 128 structures were reviewed; a "strong recommendation" is made for 35 structures on orientation scanning and 28 for the block view. A "weak recommendation" is made for 36 and 20 structures, respectively. This study provides recommendations on the core (minimum) set of anatomical structures to identify during ultrasound scanning for seven basic blocks in UGRA. They are intended to support consistent practice, empower non-experts using basic UGRA techniques, and standardize teaching and research.
Subject(s)
Anesthesia, Conduction , Anesthesia, Conduction/methods , Consensus , Humans , Ultrasonography , Ultrasonography, Interventional/methodsABSTRACT
INTRODUCTION: Arteriovenous fistulae (AVF) are the 'gold standard' vascular access for haemodialysis. Universal usage is limited, however, by a high early failure rate. Several small, single-centre studies have demonstrated better early patency rates for AVF created under regional anaesthesia (RA) compared with local anaesthesia (LA). The mechanistic hypothesis is that the sympathetic blockade associated with RA causes vasodilatation and increased blood flow through the new AVF. Despite this, considerable variation in practice exists in the UK. A high-quality, adequately powered, multicentre randomised controlled trial (RCT) is required to definitively inform practice. METHODS AND ANALYSIS: The Anaesthesia Choice for Creation of Arteriovenous Fistula (ACCess) study is a multicentre, observer-blinded RCT comparing primary radiocephalic/brachiocephalic AVF created under regional versus LA. The primary outcome is primary unassisted AVF patency at 1 year. Access-specific (eg, stenosis/thrombosis), patient-specific (including health-related quality of life) and safety secondary outcomes will be evaluated. Health economic analysis will also be undertaken. ETHICS AND DISSEMINATION: The ACCess study has been approved by the West of Scotland Research and ethics committee number 3 (20/WS/0178). Results will be published in open-access peer-reviewed journals within 12 months of completion of the trial. We will also present our findings at key national and international renal and anaesthetic meetings, and support dissemination of trial outcomes via renal patient groups. TRIAL REGISTRATION NUMBER: ISRCTN14153938. SPONSOR: NHS Greater Glasgow and Clyde GN19RE456, Protocol V.1.3 (8 May 2021), REC/IRAS ID: 290482.
Subject(s)
Arteriovenous Fistula , Arteriovenous Shunt, Surgical , Kidney Failure, Chronic , Anesthesia, Local , Arteriovenous Fistula/surgery , Humans , Multicenter Studies as Topic , Randomized Controlled Trials as Topic , Renal Dialysis/methods , Retrospective Studies , Treatment Outcome , Vascular PatencyABSTRACT
OBJECTIVES: Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury. METHODS: A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included. RESULTS: Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83). CONCLUSION: This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce. LEVEL OF EVIDENCE: Systematic review, level II.
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BACKGROUND: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.
Subject(s)
Analgesia , Anesthesia, Conduction , Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Arthroplasty, Replacement, Hip/adverse effects , Arthroplasty, Replacement, Knee/adverse effects , Consensus , Humans , Pain, Postoperative , Peripheral NervesABSTRACT
BACKGROUND AND OBJECTIVES: While there are several published recommendations and guidelines for trainees undertaking subspecialty Fellowships in regional anesthesia, a similar document describing a core regional anesthesia curriculum for non-fellowship trainees is less well defined. We aimed to produce an international consensus for the training and teaching of regional anesthesia that is applicable for the majority of worldwide anesthesiologists. METHODS: This anonymous, electronic Delphi study was conducted over two rounds and distributed to current and immediate past (within 5 years) directors of regional anesthesia training worldwide. The steering committee formulated an initial list of items covering nerve block techniques, learning objectives and skills assessment and volume of practice, relevant to a non-fellowship regional anesthesia curriculum. Participants scored these items in order of importance using a 10-point Likert scale, with free-text feedback. Strong consensus items were defined as highest importance (score ≥8) by ≥70% of all participants. RESULTS: 469 participants/586 invitations (80.0% response) scored in round 1, and 402/469 participants (85.7% response) scored in round 2. Participants represented 66 countries. Strong consensus was reached for 8 core peripheral and neuraxial blocks and 17 items describing learning objectives and skills assessment. Volume of practice for peripheral blocks was uniformly 16-20 blocks per anatomical region, while ≥50 neuraxial blocks were considered minimum. CONCLUSIONS: This international consensus study provides specific information for designing a non-fellowship regional anesthesia curriculum. Implementation of a standardized curriculum has benefits for patient care through improving quality of training and quality of nerve blocks.
Subject(s)
Anesthesia, Conduction , Fellowships and Scholarships , Clinical Competence , Consensus , Curriculum , Delphi Technique , HumansABSTRACT
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.