Case Report: Pearls and Pitfalls
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
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
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
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
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
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.
References
1. Susan M Nimmo, Lorraine S Harrington. What is the role of epidural analgesia in abdominal surgery ? Continuing Education in Anaesthesia, Critical care and Pain 2014; Vol.14.
2. Schliech D. Schmerzlose Operationen. In Springer Verlag; 1899.p.240-58 (4th edition)
3. Thomas H Seldon. Regional anesthesia for surgery of the thorax and abdominal wall. Section on Anesthesia 1941, Mayo Clinic, Rochester, Minnesota; Vol.2.
4. Rafi AN. Abdominal field block ; a new approach via the lumbar triangle. Anaesthesia 2001; 56(10) : 1024-6.
5. Mc Donnell JG, O’Donnell BD, Farrell T et al. Transversus abdominis plane block ; a cadaver and radiological evaluation. Reg Anesth Pain med.2001; 32 ;399-404.
6. Hebbard P, Fujiwara Y, Shibata Y, Royse C. ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive care 2007 Aug; 35(4) : 616-7.
7. Ki Jinn Chin, John G McDonnell, Brendan Carvalho et al. essentials of our current understanding : abdominal wall blocks. Reg Anesth Pain Med 2017; 42 : 133-183.
8. DN Onwochei, J Borglum, A Pawa. Abdominal wall blocks for intra-abdominal surgery. BJA Education 2018; Vol.18, No.10.
9. FH Willard, A Vleeming, MD Schuenke et al. the thoracolumbar fascia : anatomy, function and clinical considerations. Journal of Anatomy 2012; 221(6) : 507-536.
10. Ferguson S, Thomas V, Lewis I. the rectus sheath block in pediatric anaesthesia : new indications for an old technique ? Pediatric Anesthesia 1996 Dec; 6(6) : 463-6.
11. Melesse DY, Chekol WB, Tawuye HY, Denu ZA et al. Assessment of the analgesic effectiveness of rectus sheath block in patients who had an emergency midline laparotomy : prospective observational cohort study. International Journal of Surgery open 2020; 24 :27-31.
12. Lee THW, Barrington MJ, Tran TNM, Wong D, Hebbard P. Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block. Anaesthesia and Intensive care 2010 May; 38(3): 452-460.
13. Yoshiyoma S, Ueshima H, Sakai R, Otake H. A posterior TAP block provides more effective analgesia than a lateral TAP block in patients undergoing laparoscopic gynaecologic surgery : a retrospective study. Anesthesiology Research and Practice 2016; 2016 :1-5.
14. Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesthesia and Analgesia 2008; 106(2).
15. Klaassen Z, Marshall E, Tubbs RS, Louis RGJ et al. Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat. 2011 May; 24(4) : 454-61.
16. Hebbard P. Transversalis fascia plane block, a novel ultrasound guided abdominal wall nerve block. Can J Anesth. 2009 Aug; 56(8) :618-20.
17. Hesham Elsharkawy, Kariem El-Boghdadly, Michael Barrington. Quadratus lumborum block : anatomical concepts, mechanisms and techniques. Anesthesiology Feb 2019; Vol.130, No.2.
18. Sauter AR, Ullensvang K, Niemi G, Lorentzen HT, Bensten TF, Borglum J. The shamrock lumbar plexus block : a dose finding study. Eur J Anaesthesiol 2015; 32 : 764-70.
19. Murouchi T. Quadratus lumborum block intramuscular approach for pediatric surgery. Acta Anesthesiologica Taiwanica 2016.
20. TVS Gopal. Ultrasound guided transmuscular quadratus lumborum plane catheters : in the plane or out of it ? Editorial- Indian J Anaesth 2019; 63 :609-10.
21. Diwan S, Kulkarni M, Kulkarni N, Nair A. A radiological inquest to determine the destiny of ultrasound guided transmuscular quadratus lumborum plane catheters. Indian J Anaesth 2019; 63 : 667-70.
22. Lancaster P, Chadwick M. Liver trauma secondary to ultrasound-guided transversus abdominis plane block. Br J Anaesth. 2010 Apr;104(4):509–10.
23. Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block. Reg Anesth Pain Med. 2008 Jun;33(3):274–5.
24. Frigon C, Mai R, Valois-Gomez T, Desparmet J. Bowel hematoma following an iliohypogastric-ilioinguinal nerve block. Paediatr Anaesth. 2006 Sep;16(9):993–6.
25. Yuen PM, Ng PS. Retroperitoneal hematoma after a rectus sheath block. J Am Assoc Gynecol Laparosc. 2004 Nov;11(4):448.
26. Griffiths JD, Barron FA, Grant S, Bjorksten AR, Hebbard P, Royse CF. Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block. Br J Anaesth. 2010 Dec;105(6):853–6.
27. Hessian EC, Evans BE, Woods JA, Taylor DJ, Kinkel E, Bjorksten AR. Plasma ropivacaine concentrations during bilateral transversus abdominis plane infusions. British Journal of Anaesthesia. 2013 Sep 1;111(3):488–95.
28. Shivashanmugam T, Kundra P, Sudhakar S. Iliac compartment block following ilioinguinal iliohypogastric nerve block. Paediatr Anaesth. 2006 Oct;16(10):1084–6.
29. Ghani KR, McMillan R, Paterson-Brown S. Transient femoral nerve palsy following ilio-inguinal nerve blockade for day case inguinal hernia repair. J R Coll Surg Edinb. 2002 Aug;47(4):626–9.
30. Manatakis DK, Stamos N, Agalianos C, Karvelis MA, Gkiaourakis M, Davides D. Transient femoral nerve palsy complicating “blind” transversus abdominis plane block. Case reports in anesthesiology. 2013;2013:874215.
31. Quek KHY, Phua DSK. Bilateral rectus sheath blocks as the single anaesthetic technique for an open infraumbilical hernia repair. Singapore Med J. 2014 Mar;55(3):e39-41.
32. Rajwani KM, Butler S, Mahomed A. In children undergoing umbilical hernia repair is rectus sheath block effective at reducing post-operative pain? Best evidence topic (bet). International Journal of Surgery. 2014;12(12):1452–5.
33. Tudor ECG, Yang W, Brown R, Mackey PM. Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery. Ann R Coll Surg Engl. 2015 Oct;97(7):530–3.
34. Godden AR, Marshall MJ, Grice AS, Daniels IR. Ultrasonography guided rectus sheath catheters versus epidural analgesia for open colorectal cancer surgery in a single centre. Ann R Coll Surg Engl. 2013 Nov;95(8):591–4.
35. Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The Analgesic Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block in Adult Patients: A Meta-Analysis. Anesthesia & Analgesia. 2015 Dec;121(6):1640–54.
36. De Oliveira GS, Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus Abdominis Plane Block to Ameliorate Postoperative Pain Outcomes After Laparoscopic Surgery: A Meta-Analysis of Randomized Controlled Trials. Anesthesia & Analgesia. 2014 Feb;118(2):454–63.
37. Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anesth/J Can Anesth. 2012 Aug;59(8):766–78.
38. Hannallah RS, Broadman LM, Belman AB, Abramowitz MD, Epstein BS. Comparison of caudal and ilioinguinal/iliohypogastric nerve blocks for control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology. 1987 Jun;66(6):832–4.
39. Markham SJ, Tomlinson J, Hain WR. Ilioinguinal nerve block in children. A comparison with caudal block for intra and postoperative analgesia. Anaesthesia. 1986 Nov;41(11):1098–103.
40. Reid MF, Harris R, Phillips PD, Barker I, Pereira NH, Bennett NR. Day-case herniotomy in children. A comparison of ilio-inguinal nerve block and wound infiltration for postoperative analgesia. Anaesthesia. 1987 Jun;42(6):658–61.
41. Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015 Nov;32(11):812–8.
42. Mieszkowski MM, Mayzner-Zawadzka E, Tuyakov B, Mieszkowska M, Żukowski M, Waśniewski T, et al. Evaluation of the effectiveness of the Quadratus Lumborum Block type I using ropivacaine in postoperative analgesia after a cesarean section – a controlled clinical study. Ginekol Pol. 2018;89(2):89–96.
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. |
