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2.
Anaesthesia ; 76 Suppl 1: 53-64, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33426656

RESUMO

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.


Assuntos
Anestesia por Condução/métodos , Anestesia por Condução/tendências , Anestesiologia/educação , Educação de Pós-Graduação em Medicina/métodos , Educação de Pós-Graduação em Medicina/tendências , Anestesiologia/tendências , Competência Clínica , Educação Baseada em Competências , Currículo , Humanos , Treinamento por Simulação
3.
Anaesthesia ; 76 Suppl 1: 74-88, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33426659

RESUMO

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.


Assuntos
Anestesia por Condução/métodos , Pediatria/métodos , Adolescente , Anestesia por Condução/tendências , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Pediatria/tendências
4.
Curr Opin Anaesthesiol ; 33(4): 561-565, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32628403

RESUMO

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.


Assuntos
Anestesia por Condução/tendências , Anestesiologia/tendências , Medicina de Emergência , Humanos , Salas Cirúrgicas , Segurança do Paciente , Radiologia Intervencionista
6.
Reg Anesth Pain Med ; 45(7): 536-543, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32471930

RESUMO

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.


Assuntos
Anestesia por Condução/tendências , Betacoronavirus , Tomada de Decisão Clínica/métodos , Infecções por Coronavirus/cirurgia , Infecção Hospitalar/prevenção & controle , Pandemias , Pneumonia Viral/cirurgia , Anestesia por Condução/normas , Anestesiologistas/normas , Anestesiologistas/tendências , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Infecção Hospitalar/epidemiologia , Humanos , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão
7.
Reg Anesth Pain Med ; 45(10): 831-834, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32447292

RESUMO

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.


Assuntos
Anestesia por Condução/métodos , Bloqueio Nervoso Autônomo/métodos , Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Anestesia por Condução/efeitos adversos , Anestesia por Condução/tendências , Anestésicos Locais/administração & dosagem , Bloqueio Nervoso Autônomo/efeitos adversos , Bloqueio Nervoso Autônomo/tendências , Infecções por Coronavirus/epidemiologia , Humanos , Pneumonia Viral/epidemiologia
8.
Pain Physician ; 23(2): E133-E149, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32214289

RESUMO

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.


Assuntos
Denervação/tendências , Medicare/tendências , Bloqueio Nervoso/tendências , Manejo da Dor/tendências , Doenças da Coluna Vertebral/terapia , Articulação Zigapofisária , Idoso , Idoso de 80 Anos ou mais , Anestesia por Condução/métodos , Anestesia por Condução/tendências , Raquianestesia/métodos , Raquianestesia/tendências , Dor Crônica/epidemiologia , Estudos de Coortes , Denervação/métodos , Feminino , Humanos , Injeções Intra-Articulares , Masculino , Bloqueio Nervoso/métodos , Procedimentos Neurocirúrgicos/tendências , Dor/epidemiologia , Manejo da Dor/métodos , Estudos Retrospectivos , Doenças da Coluna Vertebral/epidemiologia , Estados Unidos/epidemiologia , Articulação Zigapofisária/cirurgia
11.
Best Pract Res Clin Anaesthesiol ; 33(4): 499-505, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31791566

RESUMO

Just two decades ago, regional anesthesia was performed blindly with dubious outcomes and little support from surgeons and patients. Technological advances in regional anesthesia have revolutionized techniques and largely improved outcomes. Ultrasound (US) technology continues to advance and has become more affordable. Improvements have come in the form of picture quality, resolution, portability, and smaller equipment. The US technology can identify otherwise unrecognized pathology and can help to optimize patient flow by allowing for more accurate triage and effective treatments and providing timelier interventions. In recent years, several different strategies to help improve and ease US-guided needle identification and placement have been developed, including magnetically guided needle US technology. Three-dimensional (3D) and four-dimensional (4D) US use is another potential way to help improve first-pass success and limit patient harm for regional anesthetics. The advent of echogenic needles and the resulting improvement in needle visualization under US has had a positive impact on physician comfort in performing regional anesthesia and on visualization time of the needle during US-guided procedures. To reduce variability and to reduce the anesthesiologist's workload, the use of robots in regional anesthesia has been assessed in recent years. Peripheral nerve stimulation (PNS) has also demonstrated efficacy in acute and chronic pain settings. Additional research and randomized controlled trials are necessary to evaluate novel technologies.


Assuntos
Anestesia por Condução/tendências , Desenvolvimento Industrial/tendências , Bloqueio Nervoso/tendências , Ultrassonografia de Intervenção/tendências , Anestesia por Condução/métodos , Anestésicos Locais/administração & dosagem , Humanos , Bloqueio Nervoso/métodos , Ultrassonografia de Intervenção/métodos
12.
Best Pract Res Clin Anaesthesiol ; 33(4): 507-522, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31791567

RESUMO

New cancer incidences worldwide will eclipse 18 million in 2019, with nearly 10 million cancer-related deaths. It is estimated that in the United States, almost 40% of individuals will be diagnosed with cancer in their lifetime. Surgical resection of primary tumors remains a cornerstone of cancer treatment; however, the surgical process can trigger an immune-suppressing sympathetic response, which promotes tumor growth of any residual cancerous cells post surgery. Regional and local anesthesia have become staples of anesthesia and analgesia during and after surgery. Recently, much evidence in the form of retrospective and prospective studies has come to light regarding the protective, antitumor properties of anesthetic and analgesic agents across a wide variety of cancers and patient demographics. It is believed that by blocking afferent pain signals, the body does not mount the sympathetic response that contributes to the perpetuation of disease after surgical treatment. This review, therefore, investigates these studies as they pertain to the treatment and outcomes of cancers treated surgically to elucidate the role of regional anesthesia in the propagation of cancer.


Assuntos
Anestesia por Condução/efeitos adversos , Recidiva Local de Neoplasia/etiologia , Recidiva Local de Neoplasia/imunologia , Neoplasias/imunologia , Neoplasias/cirurgia , Anestesia por Condução/tendências , Humanos , Recidiva Local de Neoplasia/diagnóstico , Neoplasias/diagnóstico , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/tendências , Estudos Prospectivos , Estudos Retrospectivos
15.
Best Pract Res Clin Anaesthesiol ; 33(1): 111-123, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31272649

RESUMO

The subspecialty of regional anesthesiology and acute pain medicine (RAAPM) is in a position to lead changes that may impact the current opioid crisis. At the hospital level, RAAPM experts can implement evidence-based multimodal analgesic clinical pathways featuring regional anesthesia. Multimodal analgesia consists of using two or more analgesic modalities targeting pain pathways at various levels to improve pain control, while also aiming to reduce opioid utilization and related adverse effects. These types of pathways or protocols have been widely applied in the joint replacement population. This review focuses on the current state of the evidence regarding individual elements of a multimodal analgesic pathway for patients with total knee arthroplasty including new regional anesthesia techniques like the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block and suggests future research directions to improve the clinical care of this surgical population in the future.


Assuntos
Analgésicos Opioides/administração & dosagem , Anestesia por Condução/métodos , Artroplastia do Joelho/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Analgesia/métodos , Analgesia/tendências , Anestesia por Condução/tendências , Artroplastia do Joelho/efeitos adversos , Humanos , Bloqueio Nervoso/tendências , Dor Pós-Operatória/diagnóstico por imagem
16.
Best Pract Res Clin Anaesthesiol ; 33(1): 23-35, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31272650

RESUMO

Ultrasound technology has transformed the practice of regional anaesthesia. Anaesthesiologists routinely use real-time images to guide needle and local anaesthetic placement adjacent to nerves. It is widely accepted that the era of ultrasonography has improved peripheral nerve block success rates and lessened the dose of local anaesthetic required to achieve success. Contemporary reports of harm in relation to nerve injury or local anaesthetic systemic toxicity are reassuring. The safety and efficacy of regional anaesthesia have thus been enhanced. Ultrasound guidance is, however, not a panacea. Ultrasound guidance requires the development of complex psychomotor skills. Harm may still occur where the needle or local anaesthetic is misplaced, resulting in nerve injury, vascular injury or local anaesthetic systemic toxicity. Advances in both imaging and needle technology may further enhance the safety and efficacy of ultrasound-guided regional anaesthesia. This review will focus on peer review literature to characterise the clinical challenges and explore the potential solutions.


Assuntos
Anestesia por Condução/métodos , Impedância Elétrica/uso terapêutico , Nervos Periféricos/diagnóstico por imagem , Ultrassonografia de Intervenção/métodos , Anestesia por Condução/tendências , Previsões , Humanos , Bloqueio Nervoso/métodos , Bloqueio Nervoso/tendências , Ultrassonografia de Intervenção/tendências
18.
Best Pract Res Clin Anaesthesiol ; 32(2): 83-99, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30322466

RESUMO

Regional and neuraxial anesthesia can provide a safer perioperative experience, greater satisfaction, reduced opioid consumption, and reduction of pain, while minimizing side effects. Ultrasound technology has aided clinicians in depositing local anesthetic medication in precise proximity to targeted peripheral nerves. There are a plethora of adjuvants that have been utilized to prolong local anesthetic actions and enhance effects in peripheral nerve blocks. This manuscript describes the current state of the use of adjuncts, e.g., dexmedetomidine, dexamethasone, clonidine, epinephrine, etc., in regional anesthesia. Additionally, evidence behind dosing and block prolongation is summarized along with patient outcomes, adverse effects, and future directions.


Assuntos
Anestesia por Condução/métodos , Anestésicos Locais/administração & dosagem , Bloqueio Nervoso Autônomo/métodos , Dor Pós-Operatória/prevenção & controle , Assistência Perioperatória/métodos , Analgésicos Opioides/administração & dosagem , Anestesia por Condução/tendências , Bloqueio Nervoso Autônomo/tendências , Quimioterapia Combinada , Humanos , Assistência Perioperatória/tendências
19.
Reg Anesth Pain Med ; 43(7): 689-698, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30052550

RESUMO

This article in our series on point-of-care ultrasound (US) for the regional anesthesiologist and pain management specialist describes the emerging role of gastric ultrasonography. Although gastric US is a relatively new point-of-care US application in the perioperative setting, its relevance for the regional anesthesiologist and pain specialist is significant as our clinical practice often involves providing deep sedation without a secured airway. Given that pulmonary aspiration is a well-known cause of perioperative morbidity and mortality, the ability to evaluate for NPO (nil per os) status and risk stratify patients scheduled for anesthesia is a powerful skill set. Gastric US can provide valuable insight into the nature and volume of gastric content before performing a block with sedation or inducing anesthesia for an urgent or emergent procedure where NPO status is unknown. Patients with comorbidities that delay gastric emptying, such as diabetic gastroparesis, neuromuscular disorders, morbid obesity, and advanced hepatic or renal disease, may potentially benefit from additional assessment via gastric US before an elective procedure. Although gastric US should not replace strict adherence to current fasting guidelines or be used routinely in situations when clinical risk is clearly high or low, it can be a useful tool to guide clinical decision making when there is uncertainty about gastric contents.In this review, we will cover the relevant scanning technique and the desired views for gastric US. We provide a methodology for interpretation of findings and for guiding medical management for adult patients. We also summarize the current literature on specific patient populations including obstetrics, pediatrics, and severely obese subjects.


Assuntos
Anestesia por Condução/métodos , Anestesiologistas , Conteúdo Gastrointestinal/diagnóstico por imagem , Manejo da Dor/métodos , Especialização , Estômago/diagnóstico por imagem , Anestesia por Condução/tendências , Anestesiologistas/tendências , Humanos , Manejo da Dor/tendências , Sistemas Automatizados de Assistência Junto ao Leito/tendências , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/tendências , Especialização/tendências , Ultrassonografia/métodos , Ultrassonografia/tendências
20.
Anesthesiology ; 129(3): 448-458, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29939847

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Neuraxial labor analgesia may benefit obese women by optimizing cardiorespiratory function and mitigating complications related to emergency general anesthesia. We hypothesized that obese women have a higher rate of neuraxial analgesia compared with nonobese parturients. METHODS: Using U.S. natality data, our cohort comprised 17,220,680 deliveries, which accounts for 61.5% of 28 million births in the United States between 2009 and 2015. We examined the relationships between body mass index class and neuraxial labor analgesia, adjusting for sociodemographic, antenatal, pregnancy, and peripartum factors. RESULTS: The study cohort comprised 17,220,680 women; 0.1% were underweight, 12.7% were normal body mass index, 37% were overweight, and 28.3%, 13.5%, and 8.4% were obesity class I, II, and III, respectively. Rates of neuraxial analgesia by body mass index class were as follows: underweight, 59.7% (9,030/15,128); normal body mass index, 68.1% (1,487,117/2,182,797); overweight, 70.3% (4,476,685/6,368,656); obesity class I, 71.8% (3,503,321/4,881,938); obesity class II, 73.4% (1,710,099/2,330,028); and obesity class III, 75.6% (1,089,668/1,442,133). Compared to women with normal body mass index, the likelihood of receiving neuraxial analgesia was slightly increased for overweight women (adjusted relative risk, 1.02; 95% CI, 1.02 to 1.02), obese class I (adjusted relative risk, 1.04; 95% CI, 1.04 to 1.04), obese class II (adjusted relative risk, 1.05; 95% CI, 1.05 to 1.05), and obese class III (adjusted relative risk, 1.06; 95% CI, 1.06 to 1.06). CONCLUSIONS: Our findings suggest that the likelihood of receiving neuraxial analgesia is only marginally increased for morbidly obese women compared to women with normal body mass index.


Assuntos
Analgesia Obstétrica/tendências , Índice de Massa Corporal , Parto Obstétrico/tendências , Saúde Materna/tendências , Obesidade/epidemiologia , Vigilância da População , Adolescente , Adulto , Analgesia Obstétrica/métodos , Anestesia por Condução/métodos , Anestesia por Condução/tendências , Estudos de Coortes , Parto Obstétrico/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Obesidade/diagnóstico , Vigilância da População/métodos , Gravidez , Estudos Retrospectivos , Adulto Jovem
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