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.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations.

PURPOSE: Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways. SOURCE: We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature. PRINCIPAL FINDINGS: Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen. CONCLUSION: Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

RéSUMé: OBJECTIF: L'arthroplastie par prothèse totale (APT), en particulier de la hanche et du genou, constitue l'une des interventions chirurgicales les plus couramment pratiquées. L'avancement et l'évolution des techniques chirurgicales et d'anesthésie ont permis de réaliser une APT en ambulatoire/sur la base d'un congé le jour même. Dans ce module de développement professionnel continu, nous proposons une synthèse des données probantes périopératoires qui pourraient contribuer à l'élaboration de trajectoires réussies pour l'APT en ambulatoire. SOURCES: Nous avons réalisé des recherches dans MEDLINE, Embase, CENTRAL et dans la base de données Cochrane des revues systématiques à la recherche d'articles sur les APT ambulatoires ou accélérées. En l'absence de données probantes directes dans un contexte ambulatoire, nous avons extrapolé les données probantes à partir de la littérature sur les APT en milieu hospitalier. CONSTATATIONS PRINCIPALES: La sélection des patient·es englobant les facteurs patient·es, médicaux et sociaux est fondamentale pour un congé réussi le jour même après une APT. Les données probantes portant sur le type d'anesthésie peropératoire privilégient la technique neuraxiale pour respecter les critères de congé le jour même et réduire les complications périopératoires. La disponibilité d'un anesthésique local à courte durée d'action pour l'anesthésie neuraxiale affecterait le choix de l'anesthésique. Néanmoins, dans une population bien sélectionnée, l'anesthésie générale moderne avec analgésie multimodale et antithrombotiques peut être envisagée. L'analgésie régionale fait partie intégrante d'un régime d'analgésie multimodale visant à réduire la consommation d'opioïdes et à faciliter le congé de l'hôpital le jour même, ce qui réduit le nombre de réadmissions. En ce qui concerne l'arthroplastie totale du genou en ambulatoire, la combinaison d'un bloc du canal des adducteurs et d'une infiltration périarticulaire d'anesthésique local constitue un régime approprié d'analgésie régionale. CONCLUSION: L'anesthésie pour les APT a évolué de telle sorte que le congé le jour même deviendra la norme pour certain·es patient·es. Il est essentiel d'établir des trajectoires de congé précoce afin de prévenir les effets indésirables et la réadmission dans cette population. Au fur et à mesure que davantage de données seront générées à partir d'un volume accru d'APT en ambulatoire, des données probantes plus solides émergeront pour appuyer les composantes idéales de l'anesthésie pour optimiser les devenirs.

Neuromodulation using a hybrid technique of combined perineural local anesthetic and nerve stimulation in six challenging clinical scenarios.

PURPOSE: Postamputation pain is challenging because of complex mechanisms involving a multitude of pain pathways and psychological factors. This patient population also tends to have extensive comorbidities with or without a background of chronic pain. Electrical neuromodulation such as peripheral nerve stimulation has gained traction in the realm of chronic pain. Recently, the off-label use of hybrid perineural nerve stimulation in combination with locoregional block via the stimulating nerve block catheter has been described in single-center case reports. CLINICAL FEATURES: Herein, we present a case series of six patients from two different Canadian hospitals using such a hybrid technique in three different clinical scenarios. These scenarios were (1) local anesthetic dose minimization in the presence of multiple nerve block catheters, (2) analgesia augmentation when local anesthetic alone is insufficient, and (3) provision of an analgesic adjunct as part of a multimodal regimen. A stimulating sciatic nerve block catheter was inserted under ultrasound and nerve stimulation guidance for these cases. Patients tended to experience pain on the subsequent postoperative days whereby the off-label use of nerve stimulation successfully reduced their pain score and stabilized or decreased their opioid consumption or minimized the need to increase the local anesthetic dose when doing so could have precipitated local anesthetic toxicity. CONCLUSION: Our case series supports the feasibility of using a combination of low-frequency perineural stimulation and local anesthetic infusion via a single perineural nerve block catheter to manage challenging postamputation pain.

RéSUMé: OBJECTIF: La douleur post-amputation est difficile à soulager en raison de mécanismes complexes impliquant une multitude de voies de la douleur et de facteurs psychologiques. Cette population de patients a également tendance à présenter de nombreuses comorbidités, avec ou sans antécédents de douleur chronique. Les techniques de neuromodulation électrique, telle que la stimulation nerveuse périphérique, sont de plus en plus populaires dans le domaine de la douleur chronique. Récemment, des présentations de cas monocentriques ont décrit l'utilisation hors indication d'une modalité hybride de stimulation nerveuse périneurale en combinaison avec un bloc locorégional via un cathéter de bloc nerveux stimulant. CARACTéRISTIQUES CLINIQUES: Nous présentons ici une série de cas de six patients de deux hôpitaux canadiens différents utilisant une telle technique hybride dans trois cas cliniques différents. Ces cas étaient (1) la minimisation de la dose d'anesthésique local en présence de plusieurs cathéters de blocs nerveux, (2) l'augmentation de l'analgésie lorsque l'anesthésique local seul était insuffisant, et (3) la fourniture d'un adjuvant analgésique dans le cadre d'un régime multimodal. Un cathéter stimulant pour l'administration d'un bloc du nerf sciatique a été inséré sous échoguidage et guide de stimulation nerveuse pour ces cas. Les patients ont eu tendance à ressentir de la douleur les jours postopératoires suivants, et l'utilisation hors indication de la stimulation nerveuse a alors réussi à réduire leur score de douleur, à stabiliser ou diminuer leur consommation d'opioïdes, ou à réduire la nécessité d'augmenter la dose d'anesthésique local alors que cela aurait pu précipiter une toxicité anesthésique locale. CONCLUSION: Notre série de cas soutient la faisabilité de l'utilisation d'une technique combinée de stimulation périnerveuse à basse fréquence et de perfusion d'anesthésique local via un seul cathéter de bloc nerveux périneural pour prendre en charge la douleur post-amputation.

How I Do It: Technical report on surgically-initiated rectus sheath catheter using catheter-over-needle assembly.

Development of chronic postsurgical pain following major abdominal or pelvic surgeries is increasingly recognized. Multimodal analgesia including regional anesthesia such as rectus sheath block is growing in popularity. While the literature mainly describes ultrasound-guided rectus sheath blocks, there are many advantages to surgically-initiated rectus sheath catheter performed at the end of surgery. In this technical description, we describe the rationale and technique of surgical insertion of rectus sheath catheters following major urologic surgery with midline incision which is routinely performed by urologists at our institution. Furthermore, we would like to highlight the type of catheter used during rectus sheath catheter insertion, namely the catheter-over-needle assembly. It is simple to insert while minimizes complications such as local anesthetic leakage at the insertion site causing dressing disruption and premature catheter dislodgement, as the catheter-over-needle assembly fits snugly with the skin after insertion.

Regional Anesthesia for Athletes Undergoing Upper Extremity Procedures: Techniques and Considerations.

Upper extremity injuries are frequent in athletes which may require surgeries. Regional anesthesia for postoperative analgesia is important to aid recovery, and peripheral nerve blocks for surgical anesthesia enable surgeries to be performed without general anesthetics and their associated adverse effects. The relevant nerve block approaches to anesthetize the brachial plexus for elbow, wrist and hand surgeries are discussed in this article. There is very limited margin for error when performing nerve blocks and multimodal monitoring approach to reduce harm are outlined. Lastly, the importance of obtaining informed consent prior to nerve block procedures should not be overlooked.

The catheter-over-needle assembly facilitates delivery of a second local anesthetic bolus to prolong supraclavicular brachial plexus block without time-consuming catheterization steps: a randomized controlled study.

BACKGROUND: Single-shot delivery of a supraclavicular brachial plexus block is effective for providing outpatient surgical anesthesia; however, patients generally must use oral analgesics to control pain shortly after discharge from the hospital. Catheterized delivery of supraclavicular blocks can be challenging to perform. We aimed to show that administering a second postoperative bolus of local anesthetic through a catheter placed by a catheter-over-needle assembly not only avoids time-consuming steps but also provides an extended analgesic effect compared with the traditional single-shot approach. METHODS: Patients were randomized into two groups: one group received a single-shot supraclavicular block with 25-30 mL of local anesthetic (1.5% lidocaine and 0.125% bupivacaine mixture), while the other group received a supraclavicular block via a catheter-over-needle assembly with the same volume and concentration of local anesthetic as for the single-shot block, which was followed by a second bolus of analgesic solution (0.2 % ropivacaine 20 mL) administered postoperatively through the catheter before its removal. The duration between the initial bolus and onset of pain was measured as well as the duration of pain relief from the last bolus. RESULTS: Thirty patients were enrolled and randomized into the single-shot supraclavicular block group (n = 15) and the catheter-over-needle group (n = 15). One patient withdrew from the study, and five patients were lost to follow-up. We observed no significant difference between the two groups in time to perform the blocks. The mean (standard deviation [SD]) times were 3.1 (1.9) min and 4.4 (2.7) min for the top-up group and single-shot group, respectively (single-shot took 1.3 min longer than the catheter-over-needle group; 95% confidence interval [CI]: -0.65 to 3.25; P = 0.17). The mean (SD) duration of analgesia, measured from the beginning of the local anesthetic bolus to the onset of pain requiring rescue analgesia was 617.5 (288) min in the catheter-over-needle group and 377.2 (161.3) min in the single-shot control group (difference = 240.3 min; 95% CI: 46.8 to 433.8; P = 0.03). CONCLUSIONS: Using the catheter-over-needle assembly for supraclavicular brachial plexus block facilitated effective delivery of a supplementary bolus of local anesthetic without extending the time to perform the block or increasing the number of steps. It also prolonged analgesia significantly compared with the single-shot approach. This trial was registered at: ClinicalTrials.gov, ID: NCT01522066.