Four Important Blocks of The Last Decade

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Vol 2 | Issue 1 | January-June 2021 | Page 54-62 | J Balavenkatasubramanian, Gurumoorthi Palanichamy, Senthil Kumar Balasubramanian, Madhanmohan Chandramohan, Vinoth Kumar Subramanian, Satish Raja Selvam Parameswaran

Authors: J Balavenkatasubramanian [1], Gurumoorthi Palanichamy [1], Senthil Kumar Balasubramanian [1], Madhanmohan Chandramohan [1], Vinoth Kumar Subramanian [1], Satish Raja Selvam Parameswaran [3]

[1] Department of Anaesthesia, Ganga Hospital, Coimbatore, Tamil Nadu, India.

Address of Correspondence
Dr. Gurumoorthi Palanichamy, Ganga Hospital, Coimbatore, Tamil Nadu, India.
E-mail: drpgurumoorthi@gmail.com

Introduction

Ultrasonography (USG) guided regional anaesthesia has become the standard practice due to its improved success rate and decreased complications. With the advent of USG regional anaesthesia has flourished in a way that every surgery can be supplemented with a regional block as a part of multimodal analgesia. USG guided regional anaesthesia became rampant in the last decade with many newer inter-fascial plane blocks involving the paraspinal, chest wall and abdominal wall being introduced. Also new approaches for the plexus blocks are being established with improved safety and success. Here in this educational article, we are discussing the intricacies of the USG guided Costoclavicular approach of brachial plexus block, PEricapsular Nerve Group (PENG) block, Serratus Plane block (SPB) and Supra inguinal Fascia Iliaca Block (SIFICB). The costoclavicular approach for brachial plexus block is phrenic nerve sparing and still consistently block all the nerves arising from the cords, making it a safer option in certain population of patient with respiratory compromise. PENG block was introduced in the last decade for providing analgesia for the hip orthopedic procedures and advantage of this block is that there is no motor involvement without any major complications. The SPB is a one of chest wall block used for providing analgesia to the anterolateral chest especially for breast surgery and pain management in rib fractures. Being superficial and technically easier using USG, SPB has been included in the standard pain management for chest trauma. USG guided SIFICB introduced was introduced in 2011 as a novel approach to block the major nerves of lumbar plexus anteriorly but it gained popularity in the recent past for its ability to block femoral nerve, lateral femoral cutanoues nerve and possibly obturator nerve. With this block the above mentioned nerves can be blocked easily without any complications of classical approach for lumbar plexus block.

1- Costoclavicular Brachial Plexus Block– A Phrenic Nerve Sparing Novel Block

2- Serratus Plane Block

3-  PENG [PEricapsular Nerve Group] Block

4- Suprainguinal Fascia Iliaca Block– Is It The True 3 In 1 Block?

References

Costoclavicular Brachial Plexus Block– A Phrenic Nerve Sparing Novel Block
1. Silva MD. The costoclavicular syndrome: a ‘new cause’. Ann Rheum Dis. 1986; 45: 916-20
2. Li JW, Songthamwat B, Samy W, Sala-Blanch X, Karmakar MK. Ultrasound-Guided Costoclavicular Brachial Plexus Block: Sonoanatomy, Technique, and Block Dynamics. Reg Anesth Pain Med. 2017 Mar/Apr;42(2):233-240.
3. Wong MH, Karmakar MK, Mok LYH, Songthamwat B, Samy W. Minimum effective volume of 0.5% ropivacaine for ultrasound-guided costoclavicular brachial plexus block: A dose finding study. Eur J Anaesthesiol. 2020 Sep;37(9):780-786. doi: 10.1097/EJA.0000000000001287. PMID: 32740321.
4. Koyyalamudi V, Langley NR, Harbell MW, Kraus MB, Craner RC, Seamans DP. Evaluating the spread of costoclavicular brachial plexus block: an anatomical study. Reg Anesth Pain Med. 2021 Jan;46(1):31-34. doi: 10.1136/rapm-2020-101585. Epub 2020 Oct 6. PMID: 33024005.
5. Oh C, Noh C, Eom H, Lee S, Park S, Lee S, Shin YS, Ko Y, Chung W, Hong B. Costoclavicular brachial plexus block reduces hemidiaphragmatic paralysis more than supraclavicular brachial plexus block: retrospective, propensity score matched cohort study. Korean J Pain. 2020 Apr 1;33(2):144-152.

Serratus Plane Block
1. Blanco R, Parras T, McDonnell JG, et al. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68:1107-1113
2. Piracha MM, Thorp SL, Puttanniah V, et al. ‘‘A tale of two planes’’: deep versus superficial serratus plane block for postmatectomy pain syndrome. Reg Anesth Pain Med. 2017;42:259-262
3. Jadon A, Jain P. Serratus Anterior Plane Block-An Analgesic Technique for Multiple Rib Fractures: A Case Series. American J Anesth Clin Res. 2017;3(1): 001-004
4. Mayes J, Davison E, Panahi P, et al. An anatomical evaluation of the serratus anterior plane block. Anaesthesia. 2016;71:1064-1069
5. ChinKJ.Thoracic wall blocks: from paravertebral to retrolaminar to serratus to erector spinae and back again—a review of evidence. Best Pract Res Clin Anaesthesiol. 2019;33:67-77
6. Sayan Nath, Devesh Bhoj, Virender Kumar mohan et al. USG-guided continuous erector spinae block as a primary mode of perioperative analgesia in open posterolateral thoracotomy: A report of two cases. Saudi J Anaesthesia,2018 July-Sep;12(3):471-474
7. Chong M, et al. The serratus plane block for postoperative analgesia in breast and thoracic surgery: a systematic review and meta- analysis Reg Anesth Pain Med 2019;44:1066–1074. doi:10.1136/rapm-2019-100982

PENG [PEricapsular Nerve Group] Block
1. Bugada D, Bellini V, Lorini LF, Mariano ER. Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiol Clin. 2018;36(3):403-415. doi:10.1016/j.anclin.2018.04.001
2. Short AJ, Barnett JJG, Gofeld M, et al. Anatomic Study of Innervation of the Anterior Hip Capsule: Implication for Image-Guided Intervention. Reg Anesth Pain Med. 2018;43(2):186-192. doi:10.1097/AAP.0000000000000701
3. Nielsen TD, Moriggl B, Søballe K, Kolsen-Petersen JA, Børglum J, Bendtsen TF. A cadaveric study of ultrasound-guided subpectineal injectate spread around the obturator nerve and its hip articular branches. Reg Anesth Pain Med. 2017;42(3):357-361. doi:10.1097/AAP.0000000000000587
4. Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med. 2018;43(8):859-863. doi:10.1097/AAP.0000000000000847
5. Bilal B, Öksüz G, Boran ÖF, Topak D, Doğar F. High volume pericapsular nerve group (PENG) block for acetabular fracture surgery: A new horizon for novel block. J Clin Anesth. 2020;62. doi:10.1016/j.jclinane.2020.109702
6. Kukreja P, Avila A, Northern T, Dangle J, Kolli S, Kalagara H. A Retrospective Case Series of Pericapsular Nerve Group (PENG) Block for Primary Versus Revision Total Hip Arthroplasty Analgesia. Cureus. 2020;12(5). doi:10.7759/cureus.8200
7. Acharya U, Lamsal R. Pericapsular Nerve Group Block: An Excellent Option for Analgesia for Positional Pain in Hip Fractures. Case Rep Anesthesiol. 2020;2020:1-3. doi:10.1155/2020/1830136
8. Mistry T, Sonawane KB, Kuppusamy E. PENG block: Points to ponder. Reg Anesth Pain Med. 2019;44(3):423-424. doi:10.1136/rapm-2018-100327
9. Enes Aydin M, Borulu F, Ates I, Kara S, Ahiskalioglu A. Letters to the Editor A Novel Indication of Pericapsular Nerve Group (PENG) Block: Surgical Anesthesia for Vein Ligation and Stripping. J Cardiothorac Vasc Anesth. 2020;34:843-845. doi:10.1053/j.jvca.2019.08.006
10. Yu HC, Moser JJ, Chu AY, Montgomery SH, Brown N, Endersby RVW. Inadvertent quadriceps weakness following the pericapsular nerve group (PENG) block. Reg Anesth Pain Med. 2019;44(5):611-613. doi:10.1136/rapm-2018-100354
11. Morrison C, Brown B, Lin DY, Jaarsma R, Kroon H. Analgesia and anesthesia using the pericapsular nerve group block in hip surgery and hip fracture: A scoping review. Reg Anesth Pain Med. 2021;46(2):169-175. doi:10.1136/rapm-2020-101826

Suprainguinal Fascia Iliaca Block– Is It The True 3 In 1 Block?
1. Hebbard P, Ivanusic J, Sha S. Ultrasound-guided suprainguinal fascia iliaca block: a cadaveric evaluation of a novel approach. Anaesthesia 2011; 66: 300e5.
2. Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 1989; 69: 705e13.
3. Stevens M, Harrison G, McGrail M. A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty. Anesth Intensive Care 2007; 35: 949e52
4. Vermeylen K, Soetens F, Leunen I, Hadzic A, Van Boxtael S, Pomés J, Prats-Galino A, Van de Velde M, Neyrinck A, Sala-Blanch X. The effect of the volume of supra-inguinal injected solution on the spread of the injectate under the fascia iliaca: a preliminary study. J Anesth. 2018 Dec;32(6):908-913. doi: 10.1007/s00540-018-2558-9. Epub 2018 Sep 24. PMID: 30250982.
5. Singh, Harsimran, Jones, David. Hourglass-Pattern Recognition Simplifies Fascia Iliaca Compartment Block. Reg Anesth Pain Med. 2013;38(5):467-8. doi:10.1097/AAP.0b013e3182a1f772.

How to Cite this Article: Balavenkatasubramanian J, Palanichamy G, Balasubramanian S, Chandramohan M, Subramanian VK, Parameswaran SRS | Four Important Blocks of The Last Decade | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 54-62.

 

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Regional Anaesthesia for Breast Surgery

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Vol 2 | Issue 1 | January-June 2021 | Page 40-46 | Anjolie Chhabra, Divya Sethi, Abhijit Nair

Authors: Anjolie Chhabra [1], Divya Sethi [2], Abhijit Nair [3]

[1] Department of Anaesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.
[2] Department of Anaesthesia, Employees’ State Insurance Cooperation Postgraduate Institute of Medical Sciences and Research, New Delhi, India.
[3] Department of Anaesthesia, Ibra Hospital, North Sharqiya Governorate, Ibra-414, Sultanate of Oman.

Address of Correspondence
Dr. Anjolie Chhabra,
Professor, Department of Anaesthesiology, AIIMS, New Delhi, India.
E-mail: anjolie5@hotmail.com

Introduction

Innervation of the breast:
The breast receives innervation mainly from the 2 to 6 thoracic (T2-6) spinal nerves. The thoracic spinal nerves after emerging from the intervertebral foramina divide into dorsal and ventral ramii [1]. The dorsal ramii provide innervation to the skin and the muscles of the medial back. Each ventral ramus continues anteriorly as an intercostal nerve, accompanied by an intercostal artery and vein lying between the innermost and the internal intercostal muscle along the inferior borders of the respective ribs. Near the midpoint of the hemithorax corresponding to the midaxillary line, each intercostal nerve gives a lateral cutaneous branch that further divides into an anterior and posterior branch. Sensory supply of lateral aspect of breast is provided by the anterior divisions of the lateral cutaneous branches of T2–T6 intercostal nerves with contributions from T1 and T7 nerves. The intercostal nerves interconnect providing overlapping nerve supply to the breast. The main intercostalnerve continues anteriorly and terminates as an anterior cutaneous branch that further divides into a medial and lateral divisions which provide cutaneous innervation over the sternum and medial part of the breast respectively [2-4] (Figure 1) [5].
The intercostobrachial nerve (T2) mainly provides cutaneous innervation to the axillary tail of the breast, the axilla, and the medial upper arm. The medial cutaneous nerve of the arm (branch of the brachial plexus) may also supply the roof of the axilla and may receive contributions from T1 and T3 nerves. The supraclavicular nerves of the cervical plexus provide sensory supply to the infraclavicular or supramammary area [6, 7], (Figure 1).
The muscles of chest wall underlying the breast, the pectoralis major (PMM) and pectoralis minor (PmM) are innervated by mixed motor and sensory nerves, the lateral pectoral nerves (LPN) (C5-7, lateral cord) and the medial pectoral nerves (MPN) (C7-T1, medial cord), branches of the brachial plexus. These nerves also possess proprioceptive and nociceptive fibres and thus traction, stretching or muscle spasm of these muscles can lead to dull, aching perioperative pain. In addition, the long thoracic nerve (LTN) (C5-7) and the thoracodorsal nerve (TDN) (C6-8, posterior cord) branches of the brachial plexus innervate the serratus anterior (SAM) and the latissimus dorsi (LD) muscles, that form part of the axilla [8].
Therefore, the breast, axilla and the surrounding tissues are supplied by interconnected network of T2-T6 intercostal nerves, branches of the brachial plexus and the lower branches of the cervical plexus (Figure 1) [5].

References

1. Wijayasinghe N, Andersen KG, Kehlet H. Neural blockade for persistent pain after breast cancer surgery. Reg Anesth Pain Med. 2014;39:272-8.
2. Woodworth GE, Ivie RMJ, Nelson SM, Walker CM, Maniker RB. Perioperative Breast Analgesia: A Qualitative Review of Anatomy and Regional Techniques. Reg Anesth Pain Med. 2017; 42:609-31.
3. Cheng GS, Ilfeld BM. An Evidence-Based Review of the Efficacy of Perioperative Analgesic Techniques for Breast Cancer-Related Surgery. Pain Med. 2017 Jul 1; 18:1344-65.
4. Cheng GS, Ilfeld BM. A review of postoperative analgesia for breast cancer surgery. Pain Manag. 2016; 6:603-18.
5. Kim DH, Kim S, Kim CS, Lee S, Lee IG, Kim HJ, Lee JH, Jeong SM, Choi KT. Efficacy of Pectoral Nerve Block Type II for Breast-Conserving Surgery and Sentinel Lymph Node Biopsy: A Prospective Randomized Controlled Study. Pain Res Manag. 2018 May 15;2018:4315931.
6. Wisotzky EM, Saini V, Kao C. Ultrasound-Guided Intercostobrachial Nerve Block for Intercostobrachial Neuralgia in Breast Cancer Patients: A Case Series. PM R. 2016; 8:273-7.
7. Sarhadi NS, Shaw-Dunn J, Soutar DS. Nerve supply of the breast with special reference to the nipple and areola: Sir Astley Cooper revisited. Clin Anat. 1997; 10:283-7. Nair AS. Cutaneous innervations encountered during mastectomy: A perplexing circuitry. Indian J Anaesth. 2017; 61:1026-27.
8. Nair AS. Cutaneous innervations encountered during mastectomy: A perplexing circuitry. Indian J Anaesth. 2017; 61:1026-27.
9. Ravi PR, Jaiswal P. Thoracic epidural analgesia for breast oncological procedures: A better alternative to general anesthesia. J Mar Med Soc 2017;19: 91-5.
10. Chan KK, Welch KJ. Cardiac arrest during segmental thoracic epidural anesthesia. Anesthesiology. 1997;86: 503-5.
11. Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001;95:771–780.
12. Kairaluoma PM, Bachmann MS, Rosenberg PH, Pere PJ. Single injection paravertebral block before general anaesthesia enhances analgesia after breast cancer surgery with and without associated lymph node biopsy. Anesthesia and Analgesia 2004;99(6):1837-43.
13. Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. Single-injection paravertebral block compared to general anaesthesia in breast surgery. Acta Anaesthesiologica Scandinavica 1999;43(7):770-4.
14. Terheggen MA, Wille F, Borel Rinkes IH, Ionescu TI, Knape JT. Paravertebral blockade for minor breast surgery. Anesthesia & Analgesia 2002;94(2):355-9.
15. Greengrass R, O’Brien F, Lyerly K, Hardman D, Gleason D, D’Ercole F, et al. Paravertebral block for breast cancer surgery. Canadian Journal of Anaesthesia 1996;43(8):858-61.
16. Abdallah FW, Morgan PJ, Cil T, McNaught A, Escallon JM, Semple JL, et al. Ultrasound-guided multilevel paravertebral blocks and total intravenous anesthesia improve the quality of recovery after ambulatory breast tumor resection. Anesthesiology 2014;120(3):703-13.
17. Eason MJ, Wyatt R. Paravertebral thoracic block-a reappraisal. Anaesthesia 1979;34: 638-42.
18. Naja MZ, Ziade MF, Lonnqvist PA. Nerve stimulator guided paravertebral blockade versus general anaesthesia for breast surgery: a prospective randomized trial. Eur J Anaesthesiology 2003;20: 897-903.
19. Krediet AC, Moayeri N, van Geffen GJ, Bruhn J, Renes S, Bigeleisen PE, et al. Different Approaches to Ultrasound-guided Thoracic Paravertebral Block: An Illustrated Review. Anesthesiology. 2015;123:459-74.
20. Chhabra A, Roy Chowdhury A, Prabhakar H, Subramaniam R, Arora M Kumar, Srivastava A, Kalaivani M. Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery. Cochrane Database of Systematic Reviews 2021, Issue 2. Art. No.: CD012968
21. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia 1995;50: 813-5.
22. Patnaik R, Chhabra A, Subramaniam R, Arora MK, Goswami D, Srivastava A, et al. A Randomized Controlled Trial. Comparison of Paravertebral Block by Anatomic Landmark Technique to Ultrasound-Guided Paravertebral Block for Breast Surgery Anesthesia. Reg Anesth Pain Med 2018;43: 385-90.
23. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anaesth Pain Med 2016;41:621-7.
24. Huang W, Wang W, Xie W, Chen Z, Liu Y. Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis. J Clin Anesth. 2020;66:109900.
25. Altıparmak B, Korkmaz Toker M, Uysal Aİ, Turan M, Gümüş Demirbilek S. Comparison of the effects of modified pectoral nerve block and erector spinae plane block on postoperative opioid consumption and pain scores of patients after radical mastectomy surgery: A prospective, randomized, controlled trial. J Clin Anesth. 2019;54: 61-5.
26. Gürkan Y, Aksu C, Kuş A, Yörükoğlu UH. Erector spinae plane block and thoracic paravertebral block for breast surgery compared to IV-morphine: a randomized controlled trial. J Clin Anesth. 2020; 59: 84-8.
27. Zhang J, He Y, Wang S, Chen Z, Zhang Y, Gao Y, Wang Q, Xia Y, Papadimos TJ, Zhou R. The erector spinae plane block causes only cutaneous sensory loss on ipsilateral posterior thorax: a prospective observational volunteer study. BMC anesthesiology. 2020 Dec;20:1-8.
28. Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66:847-8.
29. Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012;59:470-5.
30. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68:1107-13.
31. Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial. Br J Anaesth. 2016;117:382-86.
32. Franco CD, Inozemtsev K. Reg Anesth Pain Med. 2020;45:151–154.

33. George R, Dahl K, Blair DHJ. How I Do It: Transversus Thoracic Plane and Pecto-Intercostal Fascial Block. ASRA NEWS. Available at https://www.asra.com/asra-news/article/250/how-i-do-it-transversus-thoracic-plane-a and Pecto-Intercostal Fascial Block. Last accessed on December 15, 2020.
34. Murata H, Hida K, Hara T. Transverse thoracic muscle plane block. Reg Anesth Pain Med. 2016;41:411–12.
35. Ueshima H, Otake H. Addition of transversus thoracic muscle plane block to pectoral nerves block provides more effective perioperative pain relief than pectoral nerves block alone for breast cancer surgery. Br J Anaesth. 2017;118:439–43

How to Cite this Article: Chhabra A, Sethi D, Nair A | Regional Anaesthesia for Breast surgery | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 40-46.

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Case Report: Pearls and Pitfalls

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Vol 2 | Issue 1 | January-June 2021 | Page 19-21 | Anju Grewal

Authors: Anju Grewal [1]

[1] Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Address of Correspondence
Dr. Anju Grewal,
Professor, Department of Anaesthesiology, Dayanand Medical College and Hospital,
Ludhiana-141001, Punjab, India.
Email: dranjugrewal@gmail.com

Introduction

  • What are case reports:
    A case report is a focussed narrative of a medical problem or an unexpected presentation/outcome faced by the physician in one or several patients.[1] A case report may describe an unusual clinical disease, a challenging differential diagnosis or management, an unusual, or unique setting /technical approach for care, an information that cannot be reproduced due to ethical reasons, or adverse interactions.[2,3]
  • Need and importance of reporting
  • Can we improve the reporting of case reports to make them useful to evidence based scientific literature?
  • Pearls & Pitfalls Common pitfalls inviting rejection are
  • It is desirable to incorporate a range of unique characteristics, such as
  • Conclusion
    Novel, accurate and transparent case reports are challenging to write and publish. High-quality case reports are more likely when authors follow the CARE guidelines and the specific journal instructions to authors.

References

1. Joel J. Gagnier, Gunver Kienlec, Douglas G. Altman, David Moher, Harold Sox, David Riley, and the CARE Group. The CARE guidelines: consensus-based clinical case report guideline Development. Journal of Clinical Epidemiology 2014; 67:46e51
2. Rakesh Garg, Shaheen E. Lakhan and Ananda K. Dhanasekaran. How to review a case report. Journal of Medical Case Reports.2016; 10:88 DOI 10.1186/s13256-016-0853-3
3. Cohen H. How to write a patient case report. Am J Health-Syst Pharm. 2006;63:1888–92.
4. David S. Riley, Melissa S. Barber, Gunver S. Kienle, Jeffrey K. Aronson,
Tido von Schoen-Angerer, Peter Tugwell et al. CARE guidelines for case reports: explanation and elaboration document. Journal of Clinical Epidemiology 2017; 89: 218e235
5. Alberto J Cabán-Martinez1, and Wilfredo F García Beltrán. Advancing medicine one research note at a time: the educational value in clinical case reports. BMC Research Notes 2012; 5:293
6. Hauben M, Aronson JK. Gold standards in pharmaco-vigilance: the use of definitive anecdotal reports of adverse drug reactions as pure gold and high-grade ore. Drug Saf 2007;30(8):645e55.
7. Aleksandra G. Florek, Robert P. Dellavalle. Case reports in medical education: a platform for training medical students, residents, and fellows in scientific writing and critical thinking.J Med Case Rep. 2016; 10: 86. doi: 10.1186/s13256-016-0851-5
8. Sandeep B Bavdekar1, Sushma Save2. Writing Case Reports: Contributing to Practice
and Research. Journal of The Association of Physicians of India 2015; 63.
9. Kaszkin-Bettag M, Hildebrandt W. Case report on cancer therapies: the urgent need to improve the reporting quality. Glob Adv Health Med 2012;1(2):8e10. http://dx.doi.org:10.7453/gahmj.2012.1.2.002.
10. Moher D, Schulz KF, Simera I, Altman DG. Guidance for developers of health research reporting guidelines. Plos Med 2010;7(2): e1000217.
11. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley DS. The CARE Group. The CARE guidelines: consensus-based clinical case report guideline development. Glob Adv Health Med 2013;2(5):38e43
12. Trygve Nissen and Rolf Wynn.The clinical case report: a review of its merits and Limitations. BMC Research Notes 2014, 7:264
13. J P Vandenbroucke. In Défense of case reports and case series. Ann Intern Med 2001 Feb 20;134(4):330-4.
14. Maja Ivančević Otanjac, Irina Milojević. Writing a Case Report in English. Srp Arh Celok Lek. 2015 Jan-Feb;143(1-2):116-118
15. Yuliia Lysanets, Halyna Morokhovets and Olena Bieliaieva. Stylistic features of case reports as a genre of medical discourse. Journal of Medical Case Reports (2017) 11:83

How to Cite this Article: Grewal A | Case Report: Pearls and Pitfalls | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 19-21.

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Future Directions of Regional Anaesthesia

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Vol 2 | Issue 1 | January-June 2021 | Page 17-18 | André van Zundert, Sandeep Diwan

Authors: André van Zundert [1], Sandeep Diwan [2]

[1] Department of Anaesthesiology, The University of Queensland, Brisbane, Australia.
[2] Department of Anaesthesiology, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Prof. André van Zundert,
Professor & Chairman Discipline of Anaesthesiology, The University of Queensland, Brisbane, Australia.
E-mail: vanzundertandre@gmail.com

Since the 19th century, we have seen general and regional anaesthesia develop as complementary fields rather than opponents to provide high-quality anaesthesia and analgesia for patients. Combination of the two techniques often results in better outcomes with decreased incidence of adverse effects. General and regional anaesthesia, or loco-regional anaesthesia alone provide patient benefits including a pain free recovery.

Anaesthesiologists would want to be acquainted with regional techniques that would benefit the patient and cause the least harm. In fact, the key question is what the best solution is for a particular patient considering current problems, the type of surgical intervention, the available skills and support from the surgeon and anaesthetist. Many surgeons are unaware of the possibility of combining regional and general anaesthesia. Also, local practice differs in different parts in the world. In some countries, patients are well-informed and know what to expect during regional anaesthesia blocks and stay awake during the whole procedure (regional block and surgical intervention), or appreciate some distraction using a headphone with their favourite music. In other countries, patients want to receive sedation or even general anaesthesia during the regional anaesthesia procedure and/or during the surgical intervention as they prefer to be unaware of the whole procedure.

Nevertheless, patients expect to get superb service from a skilled and experienced anaesthetist in a wide range of regional anaesthesia techniques demonstrating extensive knowledge in applied anatomy, pharmacology, toxicology, monitoring, and expect no less than a perfect pain-free technique without complications and a quick recovery. However, regional anaesthesia is not always perfect. In general anaesthesia, any deviation from the normal can easily be managed in the unconscious patient. In awake patients undergoing regional anaesthesia, complications of regional blockade may be recognized by the patient, which could be stressful for the patient.

In learning regional anaesthesia techniques, there is no substitute for personal tuition while performing numerous interventions from experienced practitioners. However, trainees need to study textbooks and attend workshops and conferences on regional anaesthesia to perfect techniques, as well as accessing online courses, seminars, video clips, apps, guidelines from professional societies (e.g. AORA) and journal articles.

Ultrasound-guided techniques are preferredare preferred and superior to blind techniques, allowing more precise localisation of nerves (peripheral nerve blocks) or location of the subarachnoid and epidural space (central neuraxial anaesthesia). The International Journal of Regional Anaesthesia (IJRA), an official publication of AORA is such a specialised journal offering peer-reviewed articles on a variety of topics focused on local-regional anaesthesia and pain with an emphasis on visualisation of the technique using colourful imaging to illustrate anatomical and other practical aspects. As the scope of the IJRA expands, the Editorial Board aims to bring up-to date reliable and practical information for the practitioner with clinical articles, review articles, Letters-to-the Editor, but also on updates of books, e-books, atlases, apps, videos, infograms and provide website links to guidelines, useful for the practicing on regional anaesthesia.

Newer block techniques have evolved over time including use of ultrasound techniques. Anaesthetists need to master a variety of regional blocks including central neuraxial and peripheral nerve blocks to be qualified in regional anaesthesia.

Regional anaesthesia plays an essential role in our practice. Some golden rules apply to maximise safety and efficacy: a) Discuss the regional blockade with the patient, explaining benefits and risks and obtain informed written consent; b) Discuss with the surgeon what procedure you intend to perform and the site of incision; c) Discuss with the patient any potential complication/side effect and document these in your anaesthesia chart; d) Perform the regional block with the best intention for the patient, not for the best interest of the anaesthetist; e) Perform regional anaesthesia blocks in an appropriate setting (well-equipped, adequately-staffed, safe environment) capable of handling complications (ventilator at hand; resuscitation drugs/equipment/Intralipid at hand) with intravenous access in situ, applying adequately-monitored according standards; f) Always fractionate any doses, check their impact on the patient, and respect dose limits; g) Document the surgical intervention, positioning of the patient on the operating table and record any problem/complication (e.g., haemorrhage, pneumothorax and paraesthesia); h) In case of a neurological complication check the patient yourself and refer to a neurologist at an early stage; and i) Always have a plan B, in case of an unsuccessful block. Infrastructure and ergonomics play an important part in success of the block. SimilarlySimilarly, important is to avoid wrong-route, wrong-dose, wrong-side, wrong-site injections and to carefully label all connections and tubing. Management of paediatric patients requires even greater efforts as children cannot be relied upon to ask for analgesia during a procedure. Regional anaesthesia techniques are excellent tools also in children, but these procedures themselves can be painful. In obstetric anaesthesia, pain relief during childbirth may be stressful with the woman in full labour requiring an immediate epidural.

The growing popularity of ultrasonography is a very welcome addition to regional anaesthesia and allows more precision application in regional anaesthesia, in particular peripheral nerve blocks. It provides bedside imaging and dynamic assessment for nerve localisation and target-specific injections, visualising needle advancement in real time and observation of local anaesthetic spread around nerve structures. Use of ultrasound is an evolving aspect of our specialty, offering major advantages and superiority over blind techniques, such as real-time visualisation of soft tissues, muscles, nerves, veins and arteries, improving safe practice. Shortcomings with ultrasound include limited resolution at deep levels especially in the obese, and artefacts created by bone structures. Anaesthetists practising regional anaesthesia with ultrasound need to know the basic principles of ultrasound imaging and knobology, regional anatomy specifically related to interventional procedures, ultrasound scanning and image interpretation and the technical considerations for needle insertion and injection (step-by-step, easy-to-follow, how-to-do-it instructions). Whether ultrasonography can be further improved in obtaining the best possible resolution of the area, ruling out the need for extra monitoring devices (e.g., nerve stimulator) and landmark techniques is still under debate. It is wise however, to limit the injection pressure to 15 psi using an injection pressure monitor device.

NYSORA (New York Society of Regional Anaesthesia) recently introduced the Next Level CMETM programme (https://nextlevelcme.com) under the inspirational leadership of Professor Admir Hadzic. This educational and technology entity provides a personalised and boutique learning experience for medical practitioners utilising a custom-built eLearning platform and a range of propriety cognitive aids, illustrations and animations. The aim is to have all your study materials organised in one place, accessible anytime anywhere. NexLevel CMETM allows the practitioner to create their own customised and condensed study scripts (personal, departmental, region, country) in minutes to make learning faster and more engaging. The focus is on an in-depth, customised complete training portfolio in anaesthesia, for point of care ultrasound and pain and perioperative medicine, which allows control of learning processes.

IJRA is a distinguished journal, carefully prepared by the Editorial team of dedicated anaesthetists interested in regional anaesthesia, for those medical practitioners who want to learn extra steps in regional anaesthesia practice for them and patients’ benefit.

We hope you’ll find in this issue of IJRA comprehensive, inspiring and practical information about regional anaesthesia and nerve block techniques with clinical applicability that will influence the professional lives of many colleagues. It is important to remember that injection of the local anaesthetic drugs is just the beginning and not the end of the anaesthetic. When this approach is followed considerable benefits can accrue to the patient.

A special thanks goes to…..

AORA
Chairman: Dr. TVS Gopal, Dr. J Balvenkatasubramanian,
President: Dr. Vrushali Ponde,
Vice President: Dr Sudhakar Koppad,
AORA Core Committee: Dr. Satish Kulkarni, Dr. Ashit Mehta, Dr Javed Khan.
AORA Executive committee.
IJRA
Editorial Team, Editorial Committee Members, International Executive Committee Members,
Author & Contributor to the Articles.
Dr. Ashok Shyam,
Journal Coordinator & Academic Research Group (Journal Publisher).

 

How to Cite this Article: Zundert AV, Diwan S | Future Directions of Regional Anaesthesia | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 17-18.

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Implications of Regional Anaesthesia for Favourable Postoperative Outcomes

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Vol 2 | Issue 1 | January-June 2021 | Page 13-16 | Abhijit Nair, Sandeep Diwan

Authors: Abhijit Nair [1, 2], Sandeep Diwan [3]

[1] Department of Anaesthesia, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, Telangana State, India.
[2] Department of Anaesthesiology, Ibra Hospital, North Sharqiya Governorate, Ibra-414, Sultanate of Oman.
[3] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Abhijit Nair,
Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, Telangana State, India.
Ibra Hospital, North Sharqiya Governorate, Ibra-414, Sultanate of Oman.
E-mail: abhijitnair95@gmail.com

Introduction

Patient centered outcomes after surgery are described in terms of improving quality of life and functional status, prevent cognitive impairment, delirium, anxiety and depression and preserve organ function [1]. Regional anaesthesia (RA) when used solely or for postoperative analgesia with general anaesthesia (GA) indeed provides better quality of analgesia, lesser opioid consumption and lesser adverse events like postoperative nausea/vomiting (PONV) due to opioids, bleeding or renal toxicity (due to non-steroidal anti-inflammatory drugs). However, the benefits of RA are not just confined to providing opioid-sparing analgesia but many other important early and late postoperative outcomes which has established RA as an integral part of perioperative analgesia [2]. In this editorial, the term RA is used for central neuraxial blocks (spinal and epidural anaesthesia), the peripheral nerve blocks and the fascial plane blocks depending on the type of surgery and the purpose of RA i.e., surgical anaesthesia or postoperative pain relief.

References

1. Bowyer AJ, Royse CF. Postoperative recovery and outcomes–what are we measuring and for whom? Anaesthesia. 2016;71 Suppl 1:72-7.
2. Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome? Br J Anaesth. 2011;107 Suppl 1: i90-5.
3. Small C, Laycock H. Acute postoperative pain management. Br J Surg. 2020 ;107: e70-e80.
4. Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017; 10:2287-98.
5. Kessler J, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth. 2015; 114:728-45.
6. Milosavljevic SB, Pavlovic AP, Trpkovic SV, Ilić AN, Sekulic AD. Influence of spinal and general anesthesia on the metabolic, hormonal, and hemodynamic response in elective surgical patients. Med Sci Monit. 2014; 20:1833-40.
7. Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016; 33:160-71.
8. Moon YE. Postoperative nausea and vomiting. Korean J Anesthesiol. 2014; 67:164-170.
9. Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020; 131:411-48.
10. Li J, Zhu Y, Chen W, Zhao K, Zhang J, Meng H et al. Incidence and locations of deep venous thrombosis of the lower extremity following surgeries of tibial plateau fractures: a prospective cohort study. J Orthop Surg Res. 2020; 15:605.
11. Wang H, Kandemir U, Liu P, Zhang H, Wang PF, Zhang BF, Shang K, Fu YH, Ke C, Zhuang Y, Wei X, Li Z, Zhang K. Perioperative incidence and locations of deep vein thrombosis following specific isolated lower extremity fractures. Injury. 2018; 49:1353-7.
12. Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and Combined Neuraxial/General Anesthesia Compared to General Anesthesia for Major Truncal and Lower Limb Surgery: A Systematic Review and Meta-analysis. Anesth Analg. 2017; 125:1931-45.
13. Johnson RL, Kopp SL, Burkle CM, Duncan CM, Jacob AK, Erwin PJ, Murad MH, Mantilla CB. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth. 2016; 116:163-76.
14. Pozek JP, Beausang D, Baratta JL, Viscusi ER. The Acute to Chronic Pain Transition: Can Chronic Pain Be Prevented? Med Clin North Am. 2016; 100:17-30.
15. Ahuja V, Thapa D, Ghai B. Strategies for prevention of lower limb post-amputation pain: A clinical narrative review. J Anaesthesiol Clin Pharmacol. 2018; 34:439-49.
16. Wang W, Wang Y, Wu H, et al. Postoperative cognitive dysfunction: current developments in mechanism and prevention. Med Sci Monit. 2014; 20:1908-12.
17. Kotekar N, Kuruvilla CS, Murthy V. Post-operative cognitive dysfunction in the elderly: A prospective clinical study. Indian J Anaesth. 2014; 58:263-8.
18. Mason SE, Noel-Storr A, Ritchie CW. The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium: a systematic review with meta-analysis. J Alzheimers Dis. 2010;22 Suppl 3:67-79.
19. Davis N, Lee M, Lin AY, et al. Postoperative cognitive function following general versus regional anesthesia: a systematic review. J Neurosurg Anesthesiol. 2014; 26:369-76.
20. Zywiel MG, Prabhu A, Perruccio AV, Gandhi R. The influence of anesthesia and pain management on cognitive dysfunction after joint arthroplasty: a systematic review. Clin Orthop Relat Res. 2014; 472:1453-66.
21. Nair AS, Naik V, Saifuddin MS, Narayanan H, Rayani BK. Regional anesthesia prevents cancer recurrence after oncosurgery! What is wrong with the hypothesis? Indian J Cancer 2020; XX: XX-XX. 10.4103/ijc.IJC_331_20 (Accepted manuscript)
22. Divatia JV, Ambulkar R. Anesthesia and cancer recurrence: What is the evidence? J Anaesthesiol Clin Pharmacol 2014; 30:147–50.
23. Yap A, Lopez‑Olivo MA, Dubowitz J, Hiller J, Riedel B. Global Onco‑Anesthesia Research Collaboration Group. Anesthetic technique and cancer outcomes: A meta‑analysis of total intravenous versus volatile anesthesia. Can J Anaesth 2019; 66:546‑61.
24. Sessler DI, Pei L, Huang Y, Fleischmann E, Marhofer P, Kurz A et al; Breast Cancer Recurrence Collaboration. Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial. Lancet. 2019;394(10211):1807-15.
25. Neal JM. Ultrasound-Guided Regional Anesthesia and Patient Safety: Update of an Evidence-Based Analysis. Reg Anesth Pain Med. 2016; 41:195-204.
26. Topor B, Oldman M, Nicholls B. Best practices for safety and quality in peripheral regional anaesthesia. BJA Educ. 2020; 20:341-7.
27. Shivaprakash S, Diwan SM | Anatomy of Brachial Plexus Above The Clavicle |International Journal of Regional Anaesthesia | January-June 2021; 2(1): 29-34.
28. Sivashanmugam | Volume of Local Anaesthetic Agents and Block Efficacy in Blocks Above the Clavicle |International Journal of Regional Anaesthesia | January-June 2021; 2(1): 35-38.
29. Mirle R, Mukundan S | Cadaveric Workshop and Implications in Regional Anaesthesia | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 22-28.
30. Gopal TVS, Amjad Maniar A, Chakraborty A, Kulkarni R | Abdominal WallBlocks in Abdominal Surgery: An Update | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 47-53.
31. Sethi D, Nair A, Chhabra A | Regional Anaesthesia for Breast surgery |International Journal of Regional Anaesthesia | January-June 2021; (1): 40-46.
32. Giri S | Landmark and PNS Guided Forearm Blocks | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 67-71.
33. Murlitondebhavi | IAORA4U– A Regional Anaesthesia App for AORA Members | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 72-73.
34. Ponde V | Sterility Protocols During Regional Anaesthesia |International Journal of Regional Anaesthesia | January-June 2021; 2(1): 05-12.
35. Grewal A | Case Report: Pearls and Pitfalls | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 09-21.

How to Cite this Article: Nair A, Diwan S | Implications of Regional Anaesthesia for Favourable Postoperative Outcomes | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 13-16.

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AORA Checklist: First Confirm Then Perform

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Vol 2 | Issue 1 | January-June 2021 | Page 04 | Archana Areti, Ritesh Roy, Kapil Gupta, Vrushali Ponde, Mohammad Azam Danish, Neha Singh, Amjad Maniar, Rammurthy Kulkarni

Authors: Archana Areti [1], Ritesh Roy [2], Kapil Gupta [3], Vrushali Ponde [4], Mohammad Azam Danish [5], Neha Singh [6], Amjad Maniar [7], Rammurthy Kulkarni [7]

[1] Department of Anaesthesia, Mahatma Gandhi Medical College Research Institute Puducherry, India.
[2] Associate Clinical Director and HOD, Care Hospitals, Bhubaneshwar, Odisha, India.
[3] Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India.
[4] Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
[5] Department of Anaesthesia, B. M. Jain Hospital, Bengaluru, Karnataka, India.
[6] Department of Anaesthesia, AIIMS, Bhubhaneshwar, Odisha, India.
[7] Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, Karnataka, India.

Address of Correspondence
Dr. Vrushali Ponde,
Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
E-mail: vrushaliponde@gmail.com

How to Cite this Article: Areti A, Roy R, Gupta K, Ponde V, Danish MA, Singh N, Maniar A, Kulkarni R| AORA Checklist: First Confirm Then Perform | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 04.

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A Quick Guide: Ultrasound Guided Nerve Blocks

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Vol 2 | Issue 1 | January-June 2021 | Page 02-03 | Vrushali Ponde, Kapil Gupta, Neha Singh

DOI: 10.13107/ijra.2021.v02i01.016

Authors: Vrushali Ponde [1], Kapil Gupta [2], Neha Singh [3]

[1] National President and Ex founder secretary, Academy of Regional Anaesthesia, India.
[2] Department of Anaesthesia, V.M.M.C & Safdarjung Hospital, New Delhi, India.
[3] Department of Anaesthesia, AIIMS, Bhubaneshwar, Odisha, India.

Address of Correspondence
Dr. Vrushali Ponde,
National President and Ex founder secretary, Academy of Regional Anaesthesia, India.
E-mail: vrushaliponde@gmail.com

Ultrasound Machine and Image Acquisition Scanning Preparation
1. Obtain written informed consent for the block- AORA Written Consent Form
2. Re-examine the patient before administering the block
3. Checklist ticked before the block –(anaesthesiologist and nurse to be present)

AORA Checklist
– Ensure we have correct patient/block and marked site/side of block
– Check Documents and Equipment before initiating the procedure
– I.V cannula secured before performing the block
-Minimum ASA standard monitoring (pulse oxymeter, NIBP, ECG) started

4. Ergonomics- Ultrasound machine should be in direct line of sight of the anaesthesiologist performing the block
5. Selection of Pre-Set in certain machines to better visualize that structure (eg: Nerves/ Musculoskeletal/Vascular)
6. Probe selection – High frequency probe (13-6 MHz) for superficial nerves/structures and Low frequency probe (5-2 MHz) for deeper nerves/structures and neuraxial blocks
7. Tegaderm, Cling Wrap or Camera Cover wrapped around the probe for sterility
8. Oxygen administration via ventimask /nasal prongs
9. I.V. sedation like Midazolam /Fentanyl I.V. before initiating the block, but after finishing timeout/checklist
10. Maintenance of strict asepsis during the block procedure- AORA Sterility Precautions
11. Skin infiltration with 1% Lignocaine 1 min before inserting the needle; at the site of needle entry
12. Probe holding: Pen holding method is preferable for most blocks
13. At end of procedure- probe should be cleaned with Soap and water

Image Optimisation
The following movements of the probe can be utilized for optimization of image:
Transducer Movements:
1. Sliding
2. Tilting
3. Rocking
4. Rotation
5. Compression

Needle Approaches
In Plane- Whole length of the needle is visualized
Out of Plane- Only needle tip is visualized

Clinical Pearls
1. Optimize the image by setting the appropriate focus, depth and gain
2. Focus the target in centre of the screen
3. Ensure that the skin sterilizing solution has dried, before inserting the needle for block, as contact of sterilizing solution with the nerve can lead to nerve injury (neuropraxia /neurotemesis /axonotemesis)
4. Incremental injection of Local Anaesthetic in 2-3 ml aliquots after repeated aspiration
5. Stop administration of perineural drug, if the patient complains of pain during injection; as it can be a feature of intraneural injection of drug and lead to nerve injury
6. When using peripheral nerve stimulator, never inject the drug, if muscle contraction occurs at current less than 0.3 MA; as it can be a feature of intraneural (intrafascicular) administration of drug and cause nerve injury
7. Scan with the Colour Doppler while doing Brachial Plexus Block (especially Interscalene and Infraclavicular blocks); to avoid inadvertent intravascular injection
These practical tips decrease the potential complications, making ultrasound guided regional anaesthesia a safer technique. Acquisition of a better image improves the success rate of the block.

From the protocols and guidelines committee of AORA

Dr. Kapil Gupta
Professor, Anesthesiology,
V.M.M.C & Safdarjung Hospital, New Delhi, India.

Dr. Neha Singh
Additional Professor, Anesthesiology,
AIIMS, Bhubaneshwar, Odisha, India.

How to Cite this Article: Ponde V, Gupta K, Singh N | A Quick Guide: Ultrasound-Guided Nerve Blocks | International Journal of Regional Anaesthesia | January-April 2021; 2(1): 02-03.

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Abdominal Wall Blocks in Abdominal Surgery: An Update

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Vol 2 | Issue 1 | January-June 2021 | Page 47-53 | TVS Gopal, Amjad Maniar, Arunangshu Chakraborty,
Rammurthy Kulkarni

Authors:  TVS Gopal [1], Amjad Maniar [2], Arunangshu Chakraborty [3], Rammurthy Kulkarni [2]

[1] Department of Anaesthesia, Care Hospitals, Banjara Hills, Hyderabad, Andhra Pradesh, India.
[2] Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, India.
[3] Department of Anaesthesia, Tata Medical Center, Kolkata, India.

Address of Correspondence
Dr. TVS Gopal,
Clinical Director, Care Hospitals, Banjara Hills, Hyderabad, Andhra Pradesh, India.
E-mail: tvsgopal@gmail.com

Abstract

Abdominal wall blocks provide an alternative to the gold standard, epidural analgesia, as a part of a multimodal analgesic regime for pain relief following a variety of abdominal surgeries. The ubiquitous availability of ultrasound and the paradigm shift to deposition of local anaesthetic into interfascial planes popularized abdominal wall blocks. Over the years, a better understanding of cadaveric, clinical sonoanatomy, and techniques have emerged. However, with certain abdominal wall blocks, the spread of local anaesthetic is neither consistent nor predictable. This concise update presents details pertaining to ultrasound-guided abdominal wall blocks.

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43. Ishio J, Komasawa N, Kido H, Minami T. Evaluation of ultrasound-guided posterior quadratus lumborum block for postoperative analgesia after laparoscopic gynecologic surgery. J Clin Anesth. 2017 Sep;41:1–4.
44. Öksüz G, Bilal B, Gürkan Y, Urfalioğlu A, Arslan M, Gişi G, et al. Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Children Undergoing Low Abdominal Surgery: <em>A Randomized Controlled Trial</em>. Reg Anesth Pain Med. 2017 Sep 1;42(5):674..
45. Aditianingsih D, Pryambodho, Anasy N, Tantri AR, Mochtar CA. A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy. BMC Anesthesiology. 2019 Dec 5;19(1):221.

How to Cite this Article: Gopal TVS, Maniar A, Chakraborty A, Kulkarni R | Abdominal Wall
Blocks in Abdominal Surgery: An Update | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 47-53.

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“Coming Together is a Beginning; Keeping Together is Progress; Working Together is Success”……Henry Ford

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Vol 2 | Issue 1 | January-June 2021 | Page 01 | Vrushali Ponde

DOI: 10.13107/ijra.2021.v02i01.015

Authors: Vrushali Ponde [1]

[1] National President and Ex founder secretary Academy of Regional Anaesthesia, India.

Address of Correspondence

Dr. Vrushali Ponde,
National President and Ex founder secretary
Academy of Regional Anaesthesia, India.
E-mail: vrushaliponde@gmail.com

“Team AORA” has come a long way in learning, teaching and researching and innovating regional anaesthesia. From hands-on workshops to full-fledge post-doctoral fellowships of a year’s duration looks like a joyous journey done together.
As I write this, the enthusiasm towards honing skills in regional anaesthesia, RA, is palpable. Even in the most trying times of the current pandemic scenario’s, RA stood to its promise of safety. Not just towards the patients, on this occasion, the safety of the personal in the operation theatres too. Such is the scope and play of this subject.
I take this opportunity to present to you the various protocols and simple practical clinical pearls charted out by the AORA committee of protocols and guidelines. These are done considering the uniqueness of Indian work culture and practices. This can be looked into as a bridge between the most ideal and yet practically implementable work patterns. (Annexure 1, 2 and 3)
I submit my heartfelt thanks to our editor in chief, Dr Sandeep Diwan, to have taken the initiative of embarking on and continuing with the International Journal of Regional Anaesthesia, the official publication of AORA, India.

How to Cite this Article: Ponde V | Coming Together is a Beginning; Keeping Together is Progress; Working Together is Success”……Henry Ford | International Journal of Regional Anaesthesia | January-April 2021; 2(1): 01.

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Sterility Protocols During Regional Anaesthesia: An AORA Initiative

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Vol 2 | Issue 1 | January-June 2021 | Page 05-12 | Rammurthy Kulkarni, Amjad Maniar, Neha Singh, Vrushali Ponde, Kapil Gupta, Mohammad Azam Danish, Ritesh Roy, Archana Areti

Authors: Rammurthy Kulkarni [1], Amjad Maniar [1], Neha Singh [6], Vrushali Ponde [4], Kapil Gupta [3], Mohammad Azam Danish [5], Ritesh Roy [2], Archana Areti [7]

[1] Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, Karnataka, India.
[2] Department of Anaesthesia, AIIMS, Bhubhaneshwar, Odisha, India.
[3] Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
[4] Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India.
[5] Department of Anaesthesia, B. M. Jain Hospital, Bengaluru, Karnataka, India.
[6] Associate Clinical Director and HOD, Care Hospitals, Bhubaneshwar, Odisha, India.
[7] Department of Anaesthesia, Mahatma Gandhi Medical College Research Institute Puducherry, India.

Address of Correspondence
Dr. Vrushali Ponde, Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
E-mail: vrushaliponde@gmail.com

Introduction

The frequency of infection following peripheral nerve block (PNB) is not very clear. The major reason for the paucity of literature is under-reporting of infectious complications. Though rare, the infectious complications associated with peripheral nerve blocks can be devastating and occasionally fatal.1 One case of necrotising fasciitis following an axillary approach to brachial plexus blockade for carpal tunnel release has been reported where the PNB was directly attributed to the infection. With the increase in the number of peripheral nerve block procedures being performed (both single injection and continuous techniques), it is expected that the infectious complication rate may also increase.
There is no uniform consensus amongst anaesthesiologists across the globe regarding the appropriate sterile technique that should be practised during the administration of regional anaesthesia. In a UK and Ireland based survey of obstetric anaesthesiologists, only half of the responders wore a face mask for both neuraxial (spinal and epidural) techniques. One-third of those who did not wear a mask believed that the mask actually increased the risk of infection.2 It can be easily assumed that a similar attitude is present while performing PNBs.
The aseptic chain starts right from hand washing and ends after the block needle has been taken out from the patient’s body (in a single injection technique) or till the perineural catheter is completely removed (in a continuous technique). Any breach in this chain may increase the chances of introducing infection.

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How to Cite this Article: Kulkarni R, Maniar A, Singh N, Ponde V, Gupta K, Danish MA, Roy R, Areti A | Sterility Protocols During Regional Anaesthesia: An AORA Initiative | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 05-12.

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