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.

General anesthesia is not associated with dementia in older adults with osteoarthritis for hip/knee replacements, a national population-based nested case-control study.

BACKGROUND: Dementia is a prevalent neurological condition, yet the relationship between dementia and general anesthesia remains uncertain. The study aimed to explore the association between general anesthesia and dementia using a nationwide population-based database. METHODS: The study extracted data from Taiwan's national health insurance, which encompassed the records of one million insured residents. A total of 59,817 patients aged 65 years and above, diagnosed with osteoarthritis between 2002 and 2010, were included. Among these patients, 3277 individuals with an initial diagnosis of dementia between 2004 and 2013 were matched with non-dementia patients based on age, gender, and the date of osteoarthritis diagnosis. Following a 1:2 random matching, the case group included 2171 patients with dementia, while the control group consisted of 4342 patients without dementia. The data was analyzed using conditional and unconditional logistic regressions. RESULTS: No significant differences in the odds of dementia were found between individuals exposed to general and regional anesthesia during hip/knee replacement surgeries (OR = 1.11; 95%CI: 0.73-1.70), after adjusting for age, sex, and co-morbidities. Similarly, there were no significant differences in the odds of dementia based on different durations of anesthesia exposure (General: <2 h: OR = 0.91, 95%CI = 0.43-1.92; 2-4 h: OR = 1.21, 95%CI = 0.82-1.79; >4 h: OR = 0.39, 95%CI = 0.15-1.01; compared to no exposure. Regional: <2 h: OR = 1.18, 95%CI = 0.85-1.62; 2-4 h: OR = 0.9, 95%CI = 0.64-1.27; >4 h: OR = 0.55, 95%CI = 0.15-1.96; compared to no exposure). Likewise, no significant differences were observed in the odds of dementia based on the number of replacement surgeries (twice: OR = 0.74, 95%CI = 0.44-1.23, compared to once). CONCLUSION: Neither general anesthesia nor regional anesthesia in hip/knee surgery was associated with dementia. Different numbers and durations of anesthesia exposure showed no significant differences in the odds for dementia.

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.

Vestibular Symptoms Following a Retrobulbar Block: A Case Report.

A 62-year-old male patient presented for cataract surgery under retrobulbar block anesthesia. After the regional block, the patient exhibited sudden onset and progressive symptoms of nausea, vomiting, central-type vertigo, and hearing loss. These symptoms subsided within 2 hours, and the patient was discharged after 2 days without any residual effects. This report demonstrates a combination of auditory and vertiginous symptoms after a retrobulbar block. It emphasizes continuous care and vigilance when using regional anesthesia due to the potential risks and varied complications.

Patient Satisfaction With, and Outcomes of, Ultrasound-Guided Regional Anesthesia at a Referral Hospital in Tanzania: A Cross-Sectional Study.

BACKGROUND: Regional anesthesia techniques are increasingly used in high-income countries (HICs) for both surgical anesthesia and postoperative analgesia. However, regional anesthesia has not been utilized to the same degree in low- to middle-income countries (LMICs) due to a lack of resources and trained personnel. This study evaluates patient satisfaction with, and outcomes of, ultrasound-guided regional anesthesia for extremity surgery at Kilimanjaro Christian Medical Center (KCMC) in the Northeastern zone of Tanzania. METHODS: Study patients were ≥18 years of age; American Society of Anesthesiologists (ASA) physical status I, II, or III; and underwent extremity surgery under peripheral nerve block with ultrasound guidance at KCMC. After placement, blocks were assessed for effectiveness intraoperatively, as demonstrated by the need for supplemental analgesic or sedative medication or conversion to a general anesthetic. Postoperatively, patients were assessed for satisfaction with their nerve block and pain at 12 and 24 hours. Adverse events related to regional anesthesia were assessed immediately, 45 minutes after block placement, and at 12 and 24 hours postoperatively. The primary outcome was patient satisfaction at 12 hours. Secondary outcomes were block success rate and analgesia at 12 and 24 hours postoperatively. RESULTS: A convenience sample of 170 patients was included in the study, of whom 156 (95% confidence interval [CI], 87-95) were either satisfied or very satisfied with their block. Block placement was highly successful with only 8 of 170 participants (95% CI, 2.4-8.3), requiring conversion to a general anesthetic. Analgesia continued in the postoperative period, with 164 of 170 (95% CI, 93-98) patients and 145 of 170 (95% CI, 80-90) patients reporting acceptable analgesia at 12 and 24 hours, respectively. No major adverse events, such as local anesthetic toxicity, infection, bleeding, nerve injury, or pneumothorax, were observed. CONCLUSIONS: Our study found that ultrasound-guided regional anesthesia in a resource-constrained setting was effective for extremity surgery and resulted in high patient satisfaction. No complications occurred. The use of ultrasound-guided regional anesthesia shows promise for the safe and effective care of patients undergoing extremity surgery in LMICs.

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

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

Peripheral Regional Anesthetic Techniques in Cardiac Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this systematic review was to investigate postoperative pain outcomes and adverse events after peripheral regional anesthesia (PRA) compared to no regional anesthesia (RA), placebo, or neuraxial anesthesia in children and adults undergoing cardiac surgery. DESIGN: A systematic review and meta-analysis with an assessment of the risk of bias (Cochrane RoB 1) and certainty of evidence (Grading of Recommendations, Assessment, Development, and Evaluation). SETTING: Randomized controlled trials (RCTs). PARTICIPANTS: Adults and children undergoing heart surgery. INTERVENTIONS: Any kind of PRA compared to no RA or placebo or neuraxial anesthesia. MEASUREMENTS AND MAIN RESULTS: In total, 33 RCTs (2,044 patients) were included-24 of these had a high risk of bias, and 28 were performed in adults. Compared to no RA, PRA may reduce pain intensity at rest 24 hours after surgery (mean difference [MD] -0.81 points, 95% CI -1.51 to -0.10; I2 = 92%; very low certainty evidence). Peripheral regional anesthesia, compared to placebo, may reduce pain intensity at rest (MD -1.36 points, 95% CI -1.59 to -1.13; I2 = 54%; very low certainty evidence) and during movement (MD -1.00 points, 95% CI -1.34 to -0.67; I² = 72%; very low certainty evidence) 24 hours after surgery. No data after pediatric cardiac surgery could be meta-analyzed due to the low number of included trials. CONCLUSIONS: Compared to no RA or placebo, PRA may reduce pain intensity at rest and during movement. However, these results should be interpreted cautiously because the certainty of evidence is only very low.

Retinal artery occlusion after ophthalmic surgery under regional anaesthesia: A narrative review.

Two recent cases of central retinal artery occlusion under otherwise uncomplicated sub-Tenon's block that resulted in significant visual loss after cataract surgery prompted us to undertake a literature review of such cases. We identified 97 cases of retinal artery occlusion after ophthalmic surgery under regional anaesthesia that had no immediate signs of block-related complications. These occurred after various intraocular (87%) and extraocular (13%) operations, across a wide range of ages (19-89 years) on patients with (59%) or without (39%) known risk factors. The anaesthetic techniques included 40 retrobulbar blocks, 36 peribulbar blocks, 19 sub-Tenon's blocks, one topical anaesthetic and one unspecified local anaesthetic. Different strengths of lidocaine, bupivacaine, mepivacaine and ropivacaine, either alone or in various combinations, were used. The details of the anaesthetic techniques were often incomplete in the reports, which made comparison and analysis difficult. Only nine cases had their cause (optic nerve sheath injury) identified, while the mechanism of injury was unclear in the remaining patients. Various mechanisms were postulated; however, the cause was likely to be multifactorial due to patient, surgical and anaesthetic risk factors, especially in those with compromised retinal circulation. As there were no definite risk factors identified, no specific recommendations could be made to avoid this devastating outcome. We have provided rationales for some general considerations, which may reduce this risk, and propose anaesthetic options for ophthalmic surgery on the fellow eye if required, based both on our literature review and our personal experience.

Regional anesthesia and sickle cell crisis in pediatric patients: An educational-focused review.

INTRODUCTION: Sickle cell disease (SCD) is the most common inherited hemoglobinopathy, affecting approximately 100 000 patients in United States and millions worldwide. Although the mainstay of pain management for VOC remains systemic opioids, given the potential for adverse effects including respiratory depression and hypoxemia, there remains interest in the use of regional anesthetic techniques (neuraxial or peripheral nerve blockade). METHODS: A systematic search of pubMed, Scopus, and Google Scholar was conducted using the terms sickle cell disease, sickle cell crisis, pain crisis, vaso-occlusive crisis, regional anesthesia, peripheral nerve blockade, and neuraxial anesthesia. RESULTS: We identified 7 publications, all of which were retrospective case series or single case reports, outlining the use of neuraxial anesthesia in a total of 26 patients with SCD. Additionally, we identified 4 publications, including one retrospective case series and 3 single case reports, entailing the use of peripheral blockade in patients with VOC and SCD. DISCUSSION: The available literature, albeit all retrospective or anecdotal, suggests the potential utility of regional anesthesia to treat pain in patients with SCD. Additional benefits have included avoidance of the potential deleterious physiologic effects of systemic opioids and in one case series, an improvement in respiratory function as judged by pulse oximetry. The anecdotal and retrospective nature of the available reports with an absence of prospective trials limits the evidence based medicine available from which to develop to guidlines for the optimal local anesthetic agent to use, its concentration, the rate of infusion, and the choice of adjunctive agents.

Regional Blocks Benefit Patients Undergoing Bilateral Mastectomy with Immediate Implant-Based Reconstruction, Even After Discharge.

BACKGROUND: There is limited evidence that regional anesthesia reduces pain in patients undergoing mastectomy with immediate implant-based reconstruction. We sought to determine whether regional blocks reduce opioid consumption and improve post-discharge patient-reported pain in this population. METHODS: We retrospectively reviewed patients who underwent bilateral mastectomy with immediate implant-based reconstruction with and without a regional block. We tested for differences in opioid consumption by block receipt using multivariable ordinal regression, and also assessed routinely collected patient-reported outcomes (PROs) for 10 days postoperatively and tested the association between block receipt and moderate or greater pain. RESULTS: Of 754 patients, 89% received a block. Non-block patients had an increase in the odds of requiring a higher quartile of postoperative opioids. Among block patients, the estimated probability of being in the lowest quartile of opioids required was 25%, compared with 15% for non-block patients. Odds of patient-reported moderate or greater pain after discharge was 0.54 times lower in block patients than non-block patients (p = 0.025). Block patients had a 49% risk of moderate or greater pain compared with 64% in non-block patients on postoperative day 5. There was no indication of any reason for these differences other than a causal effect of the block. CONCLUSION: Receipt of a regional block resulted in reduced opioid use and lower risk of self-reported moderate and higher pain after discharge in bilateral mastectomy with immediate implant-based reconstruction patients. Our use of PROs suggests that the analgesic effects of blocks persist after discharge, beyond the expected duration of a 'single shot' block.

Fascial plane blocks in children-Scientifically supported or not?

Since the introduction of Fascial Plane Blocks in 2007 there has been an enormous interest and application of Fascial Plane Blocks, evidenced by substantially more than 1000 PubMed items. Despite this gigantic number of publications, also including randomized controlled trials and meta-analyses in children, there is still no clear-cut insight into how much of the purported effect is in fact due to the blockade of nerve structures and how much is merely adding the well-known analgesic and anti-inflammatory effects of the plasma levels of local anesthetics that are achieved with these techniques. Furthermore, Fascial Plane Blocks appear useful only if compared to conventional multi-modal analgesia (no block or placebo) and Fascial Plane Blocks lack the potency to provide surgical anesthesia on their own and appear only to be of value when used for minor-moderate surgery. Despite the huge literature, there has so far not emerged any clinical situations where Fascial Plane Blocks have definitively been shown to be the block of choice, being decisively more effective than other established regional blocks. Lastly, Fascial Plane Blocks may appear as virtually free of complications, but case reports are emerging that point to a real risk for causing local anesthetic systemic toxicity when using Fascial Plane Blocks. This text aims to synthesize the current knowledge base regarding the Fascial Plane Blocks that are relevant to use in the pediatric context. In summary, there does currently not exist any convincing scientific evidence for the continued support for the use of Fascial Plane Blocks in children, except for the rectus sheath block and possibly also the transmuscular quadratus lumborum block.

Thoracic paravertebral nerve block combined laryngeal mask airway with preservation of spontaneous breathing can accelerate postoperative recovery.

OBJECTIVE: This study aimed to examine the potential benefits of Thoracic Paravertebral Nerve Block (TPVB) coupled with Laryngeal Mask Airway (LMA) and the maintenance of spontaneous breathing anesthesia, in contrast to general anesthesia utilizing double-lumen endobronchial intubation, on promoting recovery following thoracoscopic surgery. PATIENTS AND METHODS: A randomized controlled trial was carried out involving sixty patients set for Video-Assisted Thoracoscopic Surgery (VATS) at the Affiliated People's Hospital of Jiangsu University from February 2021 to January 2022. Patients were randomized to either the TPVB and LMA with spontaneous breathing anesthesia group (non-intubation group, NI group) or the general anesthesia with double-lumen endobronchial intubation group (Intubation group, I group). The primary outcome measured was the duration of hospitalization. Secondary outcomes included early postoperative rehabilitation indicators, postoperative complications, Visual Analogue Score (VAS), and inflammatory response markers. RESULTS: Patients in the NI group experienced significantly shorter hospital stays than those in the I group (p < 0.05). Early postoperative recovery, assessed by metrics including the first exhaust time, food intake time, first ambulation time, and duration of chest-tube placement, was superior in the NI group (p < 0.05). Postoperative complications such as nausea and vomiting, pulmonary infection, atelectasis, sore throat, and hoarseness, along with cortisol and C-reactive protein (CRP) levels at the end of the operation and 24 h post-operation, and VAS values within the first 12 h post-operation, were significantly lower in the NI group (p < 0.05). However, blood loss, operation time, and VAS values at 24 h and 48 h post-surgery showed no significant differences between the two groups. CONCLUSIONS: Our findings suggest that TPVB, in conjunction with LMA and spontaneous breathing anesthesia, may expedite postoperative recovery in patients undergoing VATS.

Comparison of the effects of general and regional anesthesia on mortality and hospital length of stay in geriatric hip fractures.

OBJECTIVE: In this study, we sought to compare the effects of general and regional anesthesia techniques on the length of hospital stay and morbidity-mortality in geriatric patients who have had hip fractures and underwent surgical treatment. PATIENTS AND METHODS: A total of 331 patients who were 65 or older and had had surgical treatment for elective or urgent hip fractures were classified into two groups; regional and general anesthesia. Recorded variables were: age, sex, American Society of Anesthesiologists (ASA) score, comorbid disease, length of stay at the clinic, mortality, morbidity, intraoperative loss of blood, the necessity of blood transfusion, and type of fracture. These variables were compared in the control groups and evaluated retrospectively. RESULTS: For the regional anesthesia group, length of stay in the clinic, loss of blood, and necessity of blood transfusion were significantly lower compared to the general anesthesia group (p<0.05). Additionally, we found general anesthesia mortality and morbidity rates were significantly higher than regional anesthesia (p<0.05). Finally, we determined that increased age and number of comorbid diseases increased the morbidity and mortality rates significantly (p<0.05). CONCLUSIONS: This study evaluated regional anesthesia's advantages over general anesthesia when treating geriatric hip fractures. This includes reduced morbidity-mortality rates, bleeding, and shorter length of hospital stay.

Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS.

Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.

Regional Anesthesia for Neonates.

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Neurological Complications of Regional Anesthesia: An Updated Review with Clinical Guidelines.

The main purpose of this article is to present the neurological complications of regional anesthesia. Our analysis may help clinicians determine when regional anesthesia can be administered safely and in which patients it needs additional precautions. Regional anesthesia has a major role in anesthesia practice. Here, we focus especially on the most common neurological complications: epidural hematoma, post-anesthesia headaches, and peripheral nerve function defect. We investigated risk factors of these states and propose ways of reducing the risks. This work is based on the available literature and the authors' experience. The research process involved using relevant keywords in various electronic databases, resulting in the selection of 32 articles published between 1989 and 2022. This manuscript provides an overview and analysis of the existing literature related to neurological complications of regional anesthesia. We believe that our article provides up-to-date information on the most common regional anesthesia complications, emphasizing differences concerning children and pregnant women and provides important guidance for clinicians in preparing for and performing anesthesia.