Breast Regional Anesthesia Practice in the Italian Public Health System (BRA-SURVEY): A Survey-Based National Study.

BACKGROUND: Breast cancer is the most common malignancy in women. Surgery is a mainstay therapy unfortunately burdened by complications as severe postoperative pain. Regional anesthesia may play a role in a multimodal strategy for prevention and treatment of postoperative pain. The main purpose of this survey was to investigate the rate of use of regional anesthesia techniques in patients undergoing breast surgery in the Italian public hospital system. METHODS: We designed an online survey that consisted of 22 questions investigating the anesthesia management of breast surgery, particularly focused on regional anesthesia. The survey lasted from November 18, 2019 to February 28, 2020. Directors of anesthesia departments of 168 Italian public health system hospitals were contacted and invited to forward the survey to every anesthesiologist in their unit. RESULTS: A total of 935 anesthesiologists received the survey; among them 460 entered the final analysis. Regional anesthesia was not used by 44.6% of the anesthesiologists and lack of experience/training was the main cause (75.6%). Logistic regression models revealed that anesthesiologists with more than 15 years of experience (odds ratio [OR] = 0.55; 95% confidence interval [CI], 0.33-0.93) or working most of their days in intensive care unit (ICU) compared to operating theater (OR = 0.25; 95% CI, 0.14-0.43) were less likely to perform regional anesthesia techniques. CONCLUSIONS: Low implementation of regional anesthesia techniques in breast surgery emerges from our survey and the major reason cited is a lack of proper training. An improved training program in regional anesthesia, especially in residents' curricula, could be useful to increase its rate of use and to standardize its practice.

Blunt Chest Trauma and Regional Anesthesia for Analgesia of Multitrauma Patients in French Intensive Care Units: A National Survey.

BACKGROUND: Chest injuries are associated with mortality among patients admitted to the intensive care unit (ICU) and require multimodal pain management strategies, including regional anesthesia (RA). We conducted a survey to determine the current practices of physicians working in ICUs regarding RA for the management of chest trauma in patients with multiple traumas. METHODS: An online questionnaire was sent to medical doctors (n = 1230) working in French ICUs, using the Société Française d'Anesthésie Réanimation (SFAR) mailing list of its members. The questionnaire addressed 3 categories: general characteristics, practical aspects of RA, and indications and contraindications. RESULTS: Among the 333 respondents (response rate = 27%), 78% and 40% of 156 respondents declared that they would consider using thoracic epidural analgesia (TEA) and thoracic paravertebral blockade (TPB), respectively. The main benefits declared for performing RA were the ability to have effective analgesia, a more effective cough, and early rehabilitation. For 70% of the respondents, trauma patients with a theoretical indication of RA did not receive TEA or TPB for the following reasons: the ICU had no experience of RA (62%), no anesthesiologist-intensivist working in the ICU (46%), contraindications (27%), ignorance of the SFAR guidelines (19%), and no RA protocol available (13%). In this survey, 95% of the respondents thought the prognosis of trauma patients could be influenced by the use of RA. CONCLUSIONS: While TEA and TPB are underused because of several limitations related to the patterns of injuries in multitrauma patients, lack of both experience and confidence in combination with the absence of available protocols appear to be the major restraining factors, even if physicians are aware that patients' outcomes could be improved by RA. These results suggest the need to strengthen initial training and provide continuing education about RA in the ICU.

Epidural analgesia for postoperative pain: Improving outcomes or adding risks?

Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits.

Contemporary training methods in regional anaesthesia: fundamentals and innovations.

Over the past two decades, regional anaesthesia and medical education as a whole have undergone a renaissance. Significant changes in our teaching methods and clinical practice have been influenced by improvements in our theoretical understanding as well as by technological innovations. More recently, there has been a focus on using foundational education principles to teach regional anaesthesia, and the evidence on how to best teach and assess trainees is growing. This narrative review will discuss fundamentals and innovations in regional anaesthesia training. We present the fundamentals in regional anaesthesia training, specifically the current state of simulation-based education, deliberate practice and curriculum design based on competency-based progression. Moving into the future, we present the latest innovations in web-based learning, emerging technologies for teaching and assessment and new developments in alternate reality learning systems.

Fundamentals and innovations in regional anaesthesia for infants and children.

Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.

Perioperative Opioid and Nonopioid Prescribing Patterns in AVF/AVG Creation.

BACKGROUND: To evaluate postoperative opioid prescribing patterns in patients undergoing hemodialysis access creation. METHODS: Operative logs were reviewed to identify patients undergoing creation of arteriovenous fistula (AVF) or graft (AVG) from September 2016 to January 2018. Immediate postoperative opioid prescriptions were compared for ambulatory patients versus inpatients. Opioid prescriptions at the time of discharge for inpatients were recorded. Rates of opioid prescribing were standardized by conversion to morphine milligram equivalents (MMEs). Opioid use postoperatively and at the time of discharge based on anesthetic technique, general anesthesia versus regional or local anesthesia with sedation were compared. Alternative pain medications administered and pain scores were recorded. Comparisons were made between the percentage of opioid use and doses administered between AVF and AVG patient groups, ambulatory and inpatients, and type of anesthetic technique used. Statistical analysis was performed with chi-square and t-tests. RESULTS: We identified 164 patients undergoing AV access creation but not receiving chronic opioid therapy. A significantly higher percentage of inpatients received opioids in the immediate postoperative period than ambulatory patients (AVF: 72% vs. 19%, P < 0.001; AVG: 62% vs. 25%, P = 0.001). Overall, all AVG patients were more likely to be discharged with an opioid prescription than all AVF patients (37% vs. 8%, P < 0.001). Of AVG patients managed in the ambulatory setting, 48% were discharged with an opioid prescription. The mean total opioid postoperative dose prescribed to inpatients was significantly higher than that prescribed to ambulatory patients for both fistulas (28.73 MMEs vs. 1.27 MMEs, P < 0.001) and grafts (22.11 MMEs vs. 2.16 MMEs, P = 0.005). General anesthesia patient groups were more likely to receive opioids postoperatively than local anesthesia with sedation patients for both AVF (54% vs. 24%, P = 0.027) and AVG creation (61% vs. 17% P < 0.001). Postoperative alternative medication use in the hospital was low with 18% acetaminophen and 1% nonsteroidal anti-inflammatory drug use for AVF patient groups and 24% acetaminophen and 0% nonsteroidal anti-inflammatory drug use for AVG patient groups. The percentage of patients reporting postoperative pain in the recovery room and on the inpatient units was comparable between ambulatory and inpatient settings (AVF: 21% vs. 28%, P = 0.534; AVG: 23% vs. 44%, P = 0.061). CONCLUSIONS: A higher percentage of inpatients undergoing hemodialysis access received opioids when compared with ambulatory patients in the immediate postoperative period. Inpatients were prescribed higher mean doses than ambulatory patients. AVG patient groups were prescribed more opioids than AVF patient groups. Alternative analgesic agent use was low, suggesting an opportunity for improved pain control and opioid reduction. Dialysis access creation represents an opportunity to improve on opioid prescribing patterns.

Regional Anesthesia is Underutilized for Carotid Endarterectomy Despite Improved Perioperative Outcomes Compared with General Anesthesia.

BACKGROUND: The choice of anesthetic for carotid endarterectomy (CEA) continues to be controversial. Recent literature suggests improved outcomes with the use of regional anesthesia (RA) compared with general anesthesia (GA). The objective of this study was to examine the utilization and outcomes of RA for CEA using a national database. METHODS: The targeted CEA files of the American College of Surgeons' National Surgical Quality Improvement Program (2011-2017) were reviewed. Patients were stratified based on anesthesia type into RA and GA, and patients' characteristics were compared between the 2 groups. The outcomes of CEA under GA and RA were compared after 2:1 propensity matching. RESULTS: There were 26,206 CEAs, and 14% (n = 3,664) were performed under RA, with no change in relative utilization during the study period (P = 0.557). Patients treated under RA were more likely to be older than 65 years (80.6% vs. 75.8%; P < 0.001) and White (90.8% vs. 83.5%; P < 0.001) but less likely to have diabetes (28.2% vs. 31.2%; P = 0.001), chronic obstructive pulmonary disease (10.2% vs. 10.5%; P < 0.001), and heart failure (1.0% vs. 1.5%; P = 0.02) and be symptomatic (37.4% vs. 42.7%; P < 0.001). After matching, there was no significant difference in baseline characteristics between the 2 groups. Patients undergoing RA were less likely to experience the combined end point of stroke, myocardial infarction, or mortality compared with GA. GA patients were more likely to have longer operating time and hospital length of stay. CONCLUSIONS: CEA performed under RA is associated with improved outcomes compared with GA. RA is underutilized in carotid surgery, and strategies to optimize its use are needed.

Comparison of regional and local anesthesia for arteriovenous fistula creation in end-stage renal disease: a systematic review and meta-analysis.

BACKGROUND: Arteriovenous fistulae (AVF) are the hemodialysis access modality of choice for patients with end-stage renal disease. However, they have a high early failure rate. Good vascular access is essential to manage long-term hemodialytic treatment, but some anesthesia techniques directly affect venous diameter as well as intra- and post-operative blood flow. The main purpose of this meta-analysis was to compare the results of regional and local anesthesia (RA and LA) for arteriovenous fistula creation in end-stage renal disease. METHODS: We conducted a systematic review and meta-analysis to synthesize evidence from 7 randomized controlled trials (565 patients) and 1 observational study (408 patients) with the aim of evaluating the safety and efficacy of RA versus LA in surgical construction of AVF. RESULTS: Pooled data showed that RA was associated with higher primary patency rates than LA (odds ratio [OR], 1.88; 95% confidence interval [CI]: 1.24-2.84; P = 0.003; I2 = 31%). Additionally, brachial artery diameter was significantly increased in the RA versus LA group (mean difference [MD], 0.83; 95% CI: 0.75-0.92; P < 0.001; I2 = 97%) and the need for intra- as well as post-operative pain killers was significantly less (RA, P = 0.0363; LA, P = 0.0318). Moreover, operation duration was significantly reduced using RA versus LA (MD, - 29.63; 95% CI: - 32.78 - -26.48; P < 0.001; I2 = 100%). CONCLUSIONS: This meta-analysis suggests that RA is preferable to LA in patients with end-stage renal disease in guaranteeing AVF patency and increasing brachial artery diameter.

Managing rebound pain after regional anesthesia.

Rebound pain after regional anesthesia can be defined as transient acute postoperative pain that ensues following resolution of sensory blockade, and is clinically significant, either with regard to the intensity of pain or the impact on psychological well-being, quality of recovery, and activities of daily living. Current evidence suggests that it represents an unmasking of the expected nociceptive response in the absence of adequate systemic analgesia, rather than an exaggerated hyperalgesic phenomenon induced by local anesthetic neural blockade. In the majority of patients, it does not appear to significantly impact cumulative postoperative opioid consumption, quality of recovery, or patient satisfaction, and is not associated with longer-term sequelae such as persistent post-surgical pain. Nevertheless, it must be considered whenever regional anesthesia is incorporated into perioperative management. Strategies to mitigate the impact of rebound pain include routine prescribing of a systemic multimodal analgesic regimen, as well as patient education on appropriate expectations regarding block offset and expected surgical pain, and timely initiation of analgesic medication. Prolonging the duration of action of regional anesthesia with continuous catheter techniques or local anesthetic adjuncts may also help alleviate rebound pain, although further research is required to confirm this.

The role of regional analgesia in personalized postoperative pain management.

Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.

Is there a place for regional anesthesia in nonoperating room anesthesia?

PURPOSE OF REVIEW: General anesthesia and monitored anesthesia care (MAC) are the most widely used techniques in nonoperating room anesthesia (NORA). However, regional anesthesia is slowly finding viable applications in this field. This review aims at providing an update on the current practice of regional anesthesia techniques outside of the operating theatre. RECENT FINDINGS: Some anesthetic departments have implemented the use of regional anesthesia in novel applications outside of the operating room. In most cases, it remains an adjunct to general anesthesia but is sometimes used as the sole anesthetic technique. The use of the paravertebral block during radiofrequency ablation of different tumors is a recent application in interventional radiology. In emergency medicine, regional anesthesia is gaining traction in analgesia for trauma patients. SUMMARY: Regional anesthesia is finding its way into broader applications every day, offering a range of potential benefits in anesthetic care. Its implementation in NORA is promising and may aid in decreasing patient morbidity. However, great care should be taken in applying the recommended safety precautions for regional anesthesia in any setting.

Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective.

The COVID-19 outbreak is on the world. While many countries have imposed general lockdown, emergency services are continuing. Healthcare professionals have been infected with the virulent severe acute respiratory syndrome coronavirus-2 (SARS), which spreads by close contact and aerosols. The anesthesiologist is particularly vulnerable to aerosols while performing intubation and other airway related procedures. Regional anesthesia (RA) minimizes the need for airway manipulation and the risks of cross infection to other patients, and the healthcare personnel. In this context, for prioritizing RA over general anesthesia, wherever possible, a structured algorithmic approach is outlined. The role of percentage saturation of hemoglobin with oxygen (oxygen saturation), blood pressure and early use of point-of-care ultrasound in differential diagnosis and specific management is detailed. The perioperative anesthetic implications of multisystem manifestations of COVID-19, anesthetic management options, the scope of RA and considerations for its safe conduct in operating rooms is described. An outline for safe and rapid training of healthcare personnel, with an Entrustable Professional Activity framework for ascertaining the practice readiness among trained residents for RA in COVID-19, is suggested. These are the authors' experiences gained from the current pandemic and similar SARS, Middle East Respiratory Syndrome and influenza outbreaks in recent past faced by our authors in Singapore, India, Hong Kong and Canada.

Daring discourse: are we ready to recommend neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic? A pro-con.

The recent joint statement from the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anesthesia and Pain Therapy (ESRA) recommends neuraxial and peripheral nerve blocks for patients with coronavirus disease 2019 (COVID-2019) illness. The benefits of regional anesthetic and analgesic techniques on patient outcomes and healthcare systems are evident. Regional techniques are now additionally promoted as a mechanism to reduce aerosolizing procedures. However, caring for patients with COVID-19 illness requires rapid redefinition of risks and benefits-both for patients and practitioners. These should be fully considered within the context of available evidence and expert opinion. In this Daring Discourse, we present two opposing perspectives on adopting the ASRA/ESRA recommendation. Areas of controversy in the literature and opportunities for research to address knowledge gaps are highlighted. We hope this will stimulate dialogue and research into the optimal techniques to improve patient outcomes and ensure practitioner safety during the pandemic.

Update of Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain from 2000 to 2018 in the US Fee-for-Service Medicare Population.

BACKGROUND: Interventional techniques for managing spinal pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic spinal pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009. OBJECTIVES: The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic spinal pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018. STUDY DESIGN: The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic spinal pain from 2000 to 2018 in the FFS Medicare population in the United States. METHODS: Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. RESULTS: Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018. LIMITATIONS: This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate. CONCLUSIONS: Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%. KEY WORDS: Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.