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.

REKOVER study protocol: a pRospective patient treatment rEgistry of tramadol and dexKetoprofen trometamol oral fixed-dose combination (SKUDEXA) in mOderate to seVere acutE pain in Real-world setting in Asia.

INTRODUCTION: Satisfactory management of acute pain remains a major medical challenge despite the availability of multiple therapeutic options including the fixed-dose combination (FDC) drugs. Tramadol and dexketoprofen trometamol (TRAM/DKP) 75/25 mg FDC was launched in 2018 in Asia and is widely used in the management of moderate to severe acute pain. There are limited data on its effectiveness and safety in Asian patients, and therefore, a need to better understand its usage patterns in clinical practice. We aim to understand the usage pattern of TRAM/DKP FDC, its effectiveness and tolerability in patients with moderate to severe acute pain in Asia. METHODS AND ANALYSIS: REKOVER is a phase-IV, multicountry, multicentre, prospective, real-world observational study. A total of 750 postsurgical and non-surgical patients (male and female, aged 18-80 years) will be recruited from 13 tertiary-care hospitals (15 sites) in Singapore, Thailand, the Philippines and Malaysia. All patients prescribed with TRAM/DKP FDC and willing to participate in the study will be enrolled. The recruitment duration for each site will be 6 months. The severity of pain will be collected using Numeric Pain Rating Scale through the treatment period from day 1 to day 5, while satisfaction with the treatment will be evaluated using Patient Global Evaluation Scale at the end of treatment. Any adverse event reported during the study duration will be recorded for safety analysis (up to day 6). The study data will be entered into the ClaimIt portal and mobile application (app) (ObvioHealth, USA). All the inpatient data will be entered into the portal by the study site and for outpatient it will be done by patients through an app. ETHICS AND DISSEMINATION: The study has been approved by the local ethics committee from each study sites in Singapore, Thailand, the Philippines and Malaysia. Findings will be disseminated through local and global conference presentations, publications in peer-reviewed scientific journals and continuing medical education.

The Analgesic effect of adding ultrasound-guided pericapsular nerve group block to suprainguinal fascia iliaca compartment block for hip fracture surgery: A prospective randomized controlled trial.

BACKGROUND: Both suprainguinal ultrasound-guided fascia iliaca compartment block (FICB) and pericapsular nerve group (PENG) block have been used to treat pain after hip surgery. Motor-sparing PENG block may further expedite early postoperative rehabilitation. This study aimed to compare the analgesic efficacy and recovery outcome of suprainguinal ultrasound-guided FICB alone with FICB combined with PENG block for hip fracture surgery. METHODS: In this study, 59 elderly patients undergoing hip fracture surgery were randomized to receive either FICB alone or combined FICB + PENG block. The primary outcome was pain score at rest 12 hours after surgery as measured by the numerical rating scale (NRS, 0-10) and secondary outcomes were pain scores at rest and with movement measured at other time points within 48 hours, time to first sit up without pain, rescue morphine requirements, opioid-related side effects, incidence of delirium, in-hospital morbidities and mortality, and length of hospital stay. RESULTS: Both patient groups had similar demographic profile and postoperative pain scores at rest and with movement. Median NRS pain scores at rest between FICB alone or combined FICB + PENG block at 4, 8, 12, 24, 36 and 48 hours after surgery were 3 versus 3 (P = .31), 3 versus 3 (P = .21) and 3 versus 3 (P = .69), 2 versus 2 (P = .35), 2 versus 3 (P = .17), 3 versus 2 (P = .18) respectively and NRS during movement at 12, 24, 48 hours were 10 versus 8 (P = .30), 6 versus 5 (P = .54) and 3.5 versus 2.0 (P = .64), respectively. There was also no significant difference in the time for patients to first sit up without pain (17.50 vs 19.37 hours vs h; P = .058) or any other secondary outcome measures. The procedure time was, however, significantly longer for the FICB + PENG block (10 vs 5 minutes, P < .001). CONCLUSION: Addition of ultrasound-guided PENG block to FICB did not improve postoperative analgesic or recovery outcomes in elderly patients undergoing hip fracture surgery.

Efficacy of adding an interspace block to the posterior knee for perioperative pain in total knee arthroplasty: a randomized controlled trial.

BACKGROUND AND PURPOSE: The interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block is a novel anesthetic technique for total knee arthroplasty (TKA). Our objective was to compare the effect of IPACK and adductor canal block (ACB) and periarticular injection (PAI), relative to ACB and PAI only, from baseline to postoperative day 3, in patients undergoing unilateral primary TKA. PATIENTS AND METHODS: This was a single-center, double-blinded, randomized controlled trial. Adults over the age of 50 who were scheduled for unilateral primary TKA were enrolled. They were randomly assigned to ACB and PAI block (control group), or ACB, PAI, and IPACK block (IPACK group). The primary outcome was mean pain at rest during 24-48 hours post-operation using a numerical rating scale (0-10). We also investigated opioid use and ambulation pain. RESULTS: 89 patients were evaluated, 45 from the control group and 44 from the IPACK group. Despite slightly higher mean pain score at rest in the control group, no statistically significant difference was found during 0-24 hours (0.13; 95% CI -0.19 to 0.46), 24-48 hours (0.42; CI -0.06 to 0.89), and 48-72 hours (0.35; CI 0.00 to 0.69) postoperatively as well as in maximum pain scores at rest. Neither pain during ambulation nor the number of opioids used differed between the trial groups at any given time point. CONCLUSION: The addition of the IPACK block to ACB and PAI did not reduce postoperative pain intensity or opioid usage. Therefore, IPACK block may not offer any benefit for pain management in patients undergoing unilateral primary TKA who are already receiving ACB and PAI.

Percutaneous hamstring lengthening in cerebral palsy and the risk of neurovascular transection.

PURPOSE: Percutaneous hamstring lengthening is increasingly popular due to its simplicity, fast recovery rate, and low morbidity. Neurovascular anatomy changes due to knee flexion contracture and the precise proximity of peroneal nerve and Biceps femoris tendon are not well established. This study examined (1) the coronal distance between the peroneal nerve and lateral hamstring tendon ("PLD"), and (2) the distance between the popliteal vessels and medial hamstring tendons ("VMD") to determine the safe distance for percutaneous hamstring lengthening. METHODS: This prospective study recruited cerebral palsy patients aged under 15 who needed hamstring lengthening. Ultrasonography was performed after the patients were anesthetized. PLDs and VMDs at popliteal angles (PAs) of 40°, 60°, and 80° knee flexions were collected. RESULTS: Sixteen patients (32 knees) were enrolled. The mean minimum PLDs at PAs of 40°, 60°, and 80° were 3.5, 4.1, and 3.1 mm, respectively. The peroneal nerve physically touched the lateral hamstring tendon in 5/32 knees (15.6%). The mean minimum VMDs at PAs of 40°, 60°, and 80° were 19, 18.3, and 16.4 mm, respectively. One spastic diplegic patient had a minimum VMD < 3 mm on both sides. Changing the PAs demonstrated no statistical significance for both PLD and VMD (P value = 0.105 and 0.779, respectively). CONCLUSIONS: Percutaneous medial hamstring lengthening should be done with caution. We recommend open biceps femoris surgery, with preoperative ultrasonography (to check the PLD) or peroneal nerve palpation to reduce the risk of peroneal nerve transection.

Qualitative and quantitative gastric ultrasound assessment in highly skilled regional anesthesiologists.

BACKGROUND: Pulmonary aspiration is a major complication in anesthesia, and various studies have shown that gastric sonography can reliably provide valuable information relative to both the qualitative and quantitative aspects of gastric content. This study aimed to determine the accuracy of ultrasound assessment of gastric content compared between two novice anesthesiologist gastric sonographers. METHODS: This prospective cohort study of two anesthesiologists learning to perform qualitative and quantitative ultrasound assessment of gastric content on healthy volunteers was conducted at Siriraj Hospital (Bangkok, Thailand). This trial was registered with ClinicalTrials.gov (reg. no. NCT04760106). RESULTS: Of the 50 enrolled participants, three were excluded due to study protocol violation. Each anesthesiologist performed a qualitative assessment on 47 participants for an overall total of 94 scans. There were 15 males and 32 females (age 42 ± 11.7 years, weight 61.2 ± 13.1 kg, height 160.7 ± 7.3 cm, and BMI 23.6 ± 4.3 kg/m2). The overall success rate for all gastric content categories was approximately 96%. From antral cross-sectional area measurement, as the ingested volume increased, there was a tendency toward increased deviation from the actual ingested volume. Interrater agreement between anesthesiologists was analyzed using intraclass correlation coefficients (ICCs). A larger fluid volume was found to be associated with a lower level of agreement between the two anesthesiologists. The ICCs were 0.706 (95% CI: -0.125 to 0.931), 0.669 (95% CI: -0.254 to 0.920), 0.362 (95% CI: -0.498 to 0.807) for the 100 ml, 200 ml, and 300 ml fluid volumes, respectively. The mean duration to perform an ultrasound examination for each gastric content category and for the entire examination did not differ significantly between anesthesiologists (p > 0.05). CONCLUSION: Our results indicate that qualitative ultrasound assessment of gastric content is highly accurate and can be easily learned. In contrast, quantification of gastric volume by novice gastric sonographers is more complex and requires more training. TRIAL REGISTRATION: ClinicalTrials.gov no. NCT04760106 Date registered on Feb 11, 2021. Prospectively registered.

Does ultrasound-guided popliteal-sciatic nerve block have superior pain control in pediatric foot and ankle surgery? A randomized control trial.

BACKGROUND: Tendon surgery in the pediatric foot and ankle could cause severe postoperative pain, which may lead to psychologic distress and chronic pain. This study was aimed to compare the efficacy of a peripheral nerve block (PNB) and local surgical site infiltration (LSI) in pediatric foot and ankle tendon surgery. METHODS: Forty pediatric patients, who underwent foot and ankle tendon surgery were enrolled. Patients age 1-6 years old were allocated to group 1 and 7-15 years old were group 2. The popliteal-sciatic nerve block with 0.5% Bupivacaine (0.25 ml/kg) for group 1A and 2A. Group 1B and 2B received 0.5% Bupivacaine (0.25 ml/kg) local injection before wound closure. Pain score was recorded using CHEOPS in 1-6 years (Group1A, 1B), NRS in age 7-15 years (Group 2A, 2B). The post-operative morphine consumption and complications were recorded. RESULTS: For 7-15 years, pain score in group 2B was more than group 2A at postoperative 2 and 6 h [Mean difference (95% CI); -3.4 (-6.4 to -0.3), and -2 (-4.4 to 0.5), respectively], and reached MCID of 2. The number of morphine consumption was significantly higher in group 2 B at 0-6 and 6-12 h post-operatively [Mean difference (95% CI); -0.8 (-1.4 to -0.2), and -0.6 (-1.1 to -0.1), respectively, with p-value < 0.05]. For 1-6 years, there was no significant difference in pain score and number of postoperative morphine consumption. CONCLUSIONS: PNB and LSI provided effective pain management in patients aged 1-6 years old with no statistically significant difference. PNB showed significant superior pain control in patients aged 7-15 years old.

Adding a low-concentration sciatic nerve block to total knee arthroplasty in patients susceptible to the adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs): a randomized controlled trial.

BACKGROUND: This study compared the effects of adductor canal blocks with those of a low concentration of popliteal-sciatic nerve block (SNB) and dexamethasone as an adjunctive technique for total knee arthroplasties (TKA) in patients susceptible to the adverse effects of NSAIDs. METHODS: A prospective, double-blinded, randomized controlled trial was performed in 50 patients susceptible to the adverse effects of NSAIDs undergoing unilateral TKAs. All patients received spinal anesthesia, adductor canal blocks, and periarticular infiltration. The 25 patients in the intervention group received SNB (0.125% bupivacaine [20 ml] and dexamethasone [5 mg]). RESULTS: The SNB group significantly had lower median resting pain scores at 6, 12, and 18 h: the control group, 1 (0-4.5), 3 (0-5), and 3 (2-5); the intervention group, 0 (0-0), 0 (0-3), and 1 (0-3); p-values, 0.012, 0.021, and 0.010, respectively. Movement-evoked pain scores at 6, 12, and 18 h were also lower: control group, 3 (0-5.5), 5 (2.5-6.5), and 7 (4-9); intervention group, 0 (0-1.5), 2 (0-4), and 3 (2-5); p-values, 0.019, 0.005, and 0.001, respectively. There were no differences in motor function. Moreover, the mean morphine consumption 24 h was also reduced in the SNB group: control group, 3.80 ± 2.48 mg; intervention group, 1.96 ± 2 mg; p-value, 0.005. CONCLUSION: For patients susceptible to the adverse effects of NSAIDs, a low concentration of SNB and dexamethasone is an effective adjunctive technique for early postoperative pain control (especially on movement) following TKAs, without an increase in motor weakness. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03486548 , Registered 3 April 2018.

Non-Fellowship regional anesthesia training and assessment: an international Delphi study on a consensus curriculum.

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.

Risk Factors for Moderate to Severe Pain during the First 24 Hours after Laparoscopic Bariatric Surgery While Receiving Intravenous Patient-Controlled Analgesia.

OBJECTIVE: To investigate the incidence of and risk factors for moderate to severe pain during the first 24 hours after laparoscopic bariatric surgery. MATERIALS AND METHODS: This retrospective study included morbidly obese patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass at a single institution between June 2016 and July 2018. Demographic, clinical, operative, and postoperative pain data from the postanesthesia care unit (PACU) and ward were analyzed. Intravenous patient-controlled analgesia (IV-PCA) was commenced before PACU discharge. RESULTS: Ninety-seven patients were included. The mean age was 38.60 ± 12.27 years, and the mean BMI was 45.04 ± 8.42 kg/m2, and 69% were female. The incidence of moderate to severe pain was 75%. Moderate to severe pain during the first 24 hours was associated with young age, female sex, postoperative administration of NSAIDs, first pain score greater than 3 on arrival at the PACU, and inadequate pain control at PACU discharge. A multivariate analysis revealed that inadequate pain control at PACU discharge was the only factor independently associated with moderate to severe pain during the first 24 hours postoperatively (p=0.011). From PACU discharge to the end of postoperative day 3, moderate to severe pain at the end of each 24-hour period was a significant predictor of moderate to severe pain in the subsequent 24-hour period (p=0.011, p < 0.001, and p=0.004, respectively). CONCLUSIONS: Moderate to severe pain was experienced by 75% of patients undergoing laparoscopic bariatric surgery and receiving IV-PCA after PACU discharge. Inadequate pain control at PACU discharge was the only independent risk factor for moderate to severe pain during the first 24 hours postoperatively.

Comparing the Success Rate of Radial Artery Cannulation under Ultrasound Guidance and Palpation Technique in Adults.

BACKGROUND: Previous studies have shown ultrasound guidance (USG)for arterial cannulation being advantageous compared to palpation technique, but little is known about its performance by novices. OBJECTIVE: This study was to compare the utility of USG radial artery cannulation with palpation technique in terms of success rate, real-time to placement, number of attempts and complications. MATERIAL AND METHOD: After IRB approval, a randomized prospective study was performed November 2009-October 2010. Ten third-year residents, having performed USG vascular catheterization as yet less than 3 times, were coached on the pork-phantom during a workshop for real time ultrasound-guided vascular access. For the study patients were randomized to US-guided technique (US-group) and palpation (P-group); ten patients for each resident. RESULTS: One hundred adult patients undergoing neurosurgery were enrolled. There were no statistically significant differences between US-group vs. P-group in success rate (78% vs. 82%; p = 0.62), time to success (60 (12.8, 547.0) vs. 52 (6.9, 639.0) sec; p = 0.22), and number of attempts (1 (1, 4) vs. 1 (1, 3); p = 0.79). Most common complication was puncture hematoma (US-group 26% vs. P-group 24%; p = 0.82). Success was defined as no change in catheterization site, performer and technique. CONCLUSION: Regarding success rate, attended time, or number of attempts for radial arterial cannulation, we did not find any benefit of ultrasound guidance compared to palpation technique. Our findings were not in accordance to other trials. However, we have to consider operators in our study being in experienced in ultrasound-guided procedures but not in palpation techniques.

Femoral nerve block using 0.25% or 0.5% bupivacaine for analgesia after arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND: Femoral nerve block (FNB) with varying concentrations of bupivacaine is often used for postoperative analgesia after anterior cruciate ligament (ACL) reconstruction. OBJECTIVE: To determine whether FNB using 0.25% or 0.5% bupivacaine provided better analgesia with less effect on quadriceps strengths after ACL reconstruction. MATERIAL AND METHOD: One hundred patients were randomized to receive FNB with 20 mL of 0.25% or 0.5% bupivacaine. Data regarding demographic, effectiveness of FNB, time to first pain, time to first analgesic, pain scores, morphine use, and recovery of sensory and motor function were recorded. RESULTS: Median time to first morphine requirement was 12 hours in 0.5% bupivacaine group and 10 hours in 0.25% bupivacaine group (p = 0.048). Pain score at 18 hours was lower in 0.5% bupivacaine group compared with 0.25% bupivacaine group (p = 0.001). When specify to the patellar tendon graft subgroup, the patients requiring morphine were 70% in 0.5% bupivacaine group and 90% in 0.25% bupivacaine group (p = 0.03). No differences were found in demographic data, effectiveness of FNB, time to first pain, morphine consumption, and recovery of sensorimotor function. CONCLUSION: FNB with 0.5% bupivacaine provided longer time to first analgesic and lower narcotic requirements after patellar tendon graft ACL reconstruction when compared to 0.25% bupivacaine. Both concentrations showed similar effect on quadriceps strengths.

Intraocular pressure changes during general anesthesia in children, comparing no mask, undermask and laryngeal mask airway.

In a before and after study of 35 children's eyes, we compared the intraocular pressure (IOP) during general anesthesia consisting of 6-8 per cent sevoflurane in 100 per centoxygen at induction. IOP measurement, blood pressure, oxygen saturation, and heart rate were recorded in patients with an applied face mask while the patient became unconscious and proceeded to surgery. These measurements were compared with those using no face-mask and after insertion of a laryngeal mask airway (LMA). The IOP with an applied face-mask was significantly statistically different from that after insertion of a LMA (12.8 +/- 3.1 and 12.0 +/- 3.3, p < 0.05) but not significantly different cilnically. We concluded that clinically, the IOP does not change in children given general anesthesia with a correct size of face mask when compared with insertion of an LMA or no face mask.