AORA4U– A Regional Anaesthesia App for AORA Members

Vol 2 | Issue 1 | January-June 2021 | Page 78-79 | Murlidhar Thondebhavi S, Hetalkumar Vadera


Authors: Murlidhar Thondebhavi S [1], Hetalkumar Vadera [2]

[1] Department of Anaesthesia, Apollo Hospital, Bengaluru, Karnataka, India.
[2] Department of Anaesthesia, Sterling Hospital, Rajkot, Gujarat, India.

Address of Correspondence
Dr. Murlidhar Thondebhavi S,
Consultant, Anaesthesia and Pain Management, Apollo Hospitals, Bengaluru, Karnataka, Inda.
E-mail: murlidharts@gmail.com


The smartphone in our pocket is a tool with many roles to play in our lives. It has replaced the humble PC for many of our day-to-day needs. The regional anaesthesia (RA) expert needed an app to record the logs, follow-up patients, enhance the knowledge and aid in audit/research activities. AORA embarked on a mission to develop an app for the above purposes in 2017. The app was developed in six months and was launched officially during the annual scientific meeting of AORA in Indore in September 2017. The app is available for all AORA members to use without any added expense. It is available on both the Android and iOS platforms. We have released an updated version based on the feedback from users in the course of last three years and will be releasing another updated version in the coming month.

What can AORA4U do for you?
AORAU is primarily a resource/logbook app developed specifically for RA.
In our country significant proportion of the surgical cases are done in small nursing homes by freelance anaesthetists. They do many cases under RA. This app can help freelance anaesthetists and anaesthetists working in private institutes to maintain their log book and publish data. Ready reference videos on in the app can aid is continuous refinement of knowledge.

It has the following features:
1. Logbook: This is designed keeping in mind the various parameters needed to be captured for RA procedures. It has a user-friendly interface (Fig 1, 2, 3) to capture all details. The closure of a procedure is done after noting the occurrence of any complications or catheter related issues (Fig 4). A useful cloning function is provided to minimise data entry and hence save time for commonly performed operations/procedures (Fig 5). The data of the logbook will be stored locally on your phone and backed up on a secure server. There is no patient identifiable data that is captured in the process.


How to Cite this Article: Murlidhar TS, Vadera H | AORA4U– A Regional Anaesthesia App for AORA Members | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 78-79.


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Abstract

Vol 2 | Issue 1 | January-June 2021 | Page 80-85 | Sandeep M. Diwan


Authors: Sandeep M. Diwan [1]

[1] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Sandeep M. Diwan,
Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.
E-mail: editor.regional.anaesthesia@gmail.com


I as the academic director congratulate each one of the participants who have taken umpteen efforts to produce these highly academic oriented research materials. I hope this trend will be in each of you as you progress through these troubled times to end up with very bright future.
I must thank the abstract committee who understandably had a mammoth task to scrutinize and bring out the best of the abstracts and finally select the those who really deserved the best.
I thanks all the AORIANS who with their participation in AORA 2021 made a trend setter for virtual/physical/hybrid
conferences in future.
My sincere thanks to the Academic Research Group (ARG) chief Dr. Ashok Shaym and team ARG for their efforts in the initiation and sustaining IJRA.

Best Wishes
Sandeep M. Diwan
Academic Director AORA
Editor IJRA



How to Cite this Article: Diwan S | Abstract | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 80-85.

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USG Guided Forearm Nerve Block

Vol 2 | Issue 1 | January-June 2021 | Page 72-77 | Madhuri Dadke, Sandeep Diwan


Authors: Madhuri Dadke [1], Sandeep Diwan [1]

[1] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Sandeep Diwan,
Consultant Anaesthesiologist, Sancheti Hospital, Pune, Maharashtra, India.
E-mail: sdiwan14@gmail.com


Introduction

Forearm blocks (FAB) are implemented to provide anaesthesia for hand surgeries, as a rescue block for failed or patchy proximal brachial plexus block and to provide postoperative analgesia after a regional or a general anaesthetic [1]. The advantage of these distal blocks is preservation of proximal motor function and avoidance of central structures such as the pleura, subclavian or axillary artery and the phrenic nerve. The proximal muscle function is preserved with these blocks, requiring minimal doses of local anaesthetic. These blocks can be implemented in outpatients [2] and with patients on anticoagulants [3]. Distal nerve blocks do not prevent tourniquet pain since the lateral antebrachial cutaneous nerve of forearm (musculocutaneous nerve), the medial cutaneous nerve of the arm, the posterior cutaneous nerve of the arm, and the intercostobrachial nerve that provide cutaneous innervation of the upper arm are not blocked [4]. The above mentioned nerves are blocked in the arm. Blockade of multiple nerves are needed and so involves multiple injections that may cause more patient discomfort.


References


1) Sayeh Hazmenzedeh, David Bravos.Peripheral Nerve Blocks of the Distal Upper Extremity.ASRA 2019
2) Liebmann O, Price D, Mills C, Gardner R, Wang R, Wilson S, et al.Feasibility of forearm ultrasonography guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department.Ann Emerg Med 2006,48:558-62.
3) Jose Soberon,Neil Bhatt,Bobby Nossamon,Scott Duncan et al.Distal peripheral nerve blockade for patients undergoing hand surgery: a pilot study.Hand(New York)2015 Jun; 10(2): 197–204.
4) Herman Sehmbi,Caveh Madjdpour,Ushma Jitendra Shah,Ki Jinn Shin.Ultrasound guided distal peripheral nerve block of the upper limb: A technical review.JOACP 2015.Volume 31,issue3,296-307.
5) Jordan M.Brown, Corrie M. Yablon , Yoav Morag, Catherine J. Brandon, Jon A. Jacobson.Ultrasound of the Peripheral Nerves of the Upper Extremity: A Landmark Approach. RadioGraphics 2016; 36:452–463.
6) Chad Robertson,John Saratsiotis.A Review of Compressive Ulnar Neuropathy at the Elbow. Journal of manipulative and physiological therapeutics ,June 2005;28(5):345.
7) Henrich Kele.Ultrasonography of the peripheral nervous system. Perspectives in Medicine 2012.Volume 1, Issues 1–12, September 2012, Pages 417-421
8) Admir Hadzic.Ultrasound-Guided Forearm Blocks. Hadzic’s Nerve Blocks and Anatomy for Ultrasound Guided Regional Anesthesia, 2e.
9) Wachara Wongkerdsook,Sithiporn Agthong,Chavarin Amarase,Pattarapol Yotnuengnit,Thanasil Huanmanop,Vilai Chentanez. Anatomy of the lateral antebrachial cutaneous nerve in relation to the lateral epicondyle and cephalic vein. Clinical Anat. Jan 2011;24(1):56-61.
10) Thomas K, Sajjad H, Bordoni B. Anatomy, Shoulder and Upper Limb, Medial Brachial Cutaneous Nerve. Treasure Island : Feb 14,2021.
11) Starr,Dennis Lee,Peter Stern. Anatomy of the Posterior Antebrachial Cutaneous Nerve, Revisited.Scientific Article Volume 45,Issue4,April 2020.
12) M Lurf et al.Ultrasound guided ulnar nerve catheter placement in the forearm for postoperative pain relief and physiotherapy. Acta Anaesthesiology Scandinavia. Feb 2009;53(2):261-3
13) Sanjeev Bhoi, Amit Chandra, Sagar Galwankar. Ultrasound-guided nerve blocks in the emergency department Journal of emergencies trauma and shock.Jan-Mar 2010. 3(1): 82–88.
14) RA McCahon,NM Bedforth.Peripheral nerve blocks at the elbow and wrist.Critical Care & Pain journal,Volume 7, Issue 2, April 2007, Pages 42–44.
15) Brian M Ilfeld.Continuous .Peripheral Nerve Blocks: An Update of the Published Evidence and Comparison With Novel, Alternative Analgesic Modalities.Anesth Analg ,2017 Jan;124(1):308-335.


How to Cite this Article: Dadke M, Diwan S | USG Guided Forearm Nerve Block | International Journal of Regional Anaesthesia | January- June 2021; 2(1): 72-77.

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Adjuvants in Peripheral Nerve Blocks

Vol 2 | Issue 1 | January-June 2021 | Page 63-66 | Rudra Deshpande, Harshal Wagh, Satish Kulkarni


Authors: Rudra Deshpande [1], Harshal Wagh [2], Satish Kulkarni [1]

[1] Department of Anaesthesia, Lilavati Hospital & Research Centre, Mumbai, Maharashtra, India.
[2] Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Satish Kulkarni,
Consultant, Department of Anaesthesia, Lilavati Hospital & Research Centre, Mumbai, Maharashtra, India.
E-mail: drsatishkulkarni@yahoo.com


Introduction


An increase in the use of peripheral nerve blocks (PNBs) has been noted in recent years. Not only do these blocks provide adequate anaesthesia intraoperatively, but they are also now the cornerstone of perioperative pain management. Superior pain control, a significant decrease in opioid requirements as well as opioid-related side effects, improved patient satisfaction, earlier discharge from hospital and increasing use with the advancement of ultrasound technology have contributed to the increasing use of peripheral nerve blocks [1-4].
Regional anaesthesia techniques including PNBs have also become the need of the hour in recent times of the Covid19 pandemic. As per recent practice recommendations (American Society of Regional Anaesthesia May 2020), Regional anaesthesia is preferred to avoid aerosol-generating procedures associated with General anaesthesia [5].

For postoperative pain management, PNBs are used as a single injection or as a continuous catheter infusion. Single-injection nerve blocks are more commonly done as they are technically easier and quicker. They provide superior analgesia in the immediate postoperative period for various procedures in which the pain intensity is high initially and reduces over significantly over time. Oral analgesics may be effective by then as the effect of PNBs is wearing off gradually over 12 to 24 hours. Rebound pain can however be a significant problem [6]. Continuous catheter techniques are not only technically challenging but require greater monitoring and are prone to secondary block failures due to catheter blockage and displacement [7]. They are labour and resource intensive. Hence the need for adjuvants that will help prolong the duration of PNBs and avoid the placement of continuous catheters has been part of the quest of regional anaesthesiologists. Multiple classes of drugs have been tested as adjuvants in the past. Some have stood the test of time and helped improve the practice of regional anaesthesia while others proved more detrimental. Discussed below are some of the adjuvants that have been successfully used (Table 1).


References


1. Hughes MS, Matava MJ, Wright RW, Brophy RH, Smith MV. Interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review. J Bone Joint Surg Am. 2013;95(14):1318-24.
2. Liu Q, Chelly JE, Williams JP, Gold MS. Impact of peripheral nerve block with low dose local anesthetics on analgesia and functional outcomes following total knee arthroplasty: a retrospective study. Pain Med. 2015;16(5):998-1006.
3. Lenart MJ, Wong K, Gupta RK, Mercaldo ND, Schildcrout JS, Michaels D, et al. The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery. Pain Med. 2012;13(6):828-34.
4. Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev. 2014;2014(5):Cd009941.
5. Uppal V, Sondekoppam RV, Lobo CA, Kolli S, Kalagara HK. Practice recommendations on neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic. ASRA/ESRA COVID-19 Guidance for Regional Anesthesia March. 2020;31.
6. Nobre LV, Cunha GP, Sousa P, Takeda A, Cunha Ferraro LH. [Peripheral nerve block and rebound pain: literature review]. Rev Bras Anestesiol. 2019;69(6):587-93.
7. Ahsan ZS, Carvalho B, Yao J. Incidence of failure of continuous peripheral nerve catheters for postoperative analgesia in upper extremity surgery. J Hand Surg Am. 2014;39(2):324-9.
8. Karaman S, Kocabas S, Uyar M, Hayzaran S, Firat V. The effects of sufentanil or morphine added to hyperbaric bupivacaine in spinal anaesthesia for Caesarean section. Eur J Anaesthesiol. 2006;23(4):285-91.
9. Axelsson K, Johanzon E, Essving P, Weckström J, Ekbäck G. Postoperative extradural analgesia with morphine and ropivacaine. A double-blind comparison between placebo and ropivacaine 10 mg/h or 16 mg/h. Acta Anaesthesiologica Scandinavica. 2005;49(8):1191-9.
10. Flory N, Van-Gessel E, Donald F, Hoffmeyer P, Gamulin Z. Does the addition of morphine to brachial plexus block improve analgesia after shoulder surgery? British Journal of Anaesthesia. 1995;75(1):23-6.
11. Alemanno F, Ghisi D, Fanelli A, Faliva A, Pergolotti B, Bizzarri F, et al. Tramadol and 0.5% levobupivacaine for single-shot interscalene block: effects on postoperative analgesia in patients undergoing shoulder arthroplasty. Minerva Anestesiol. 2012;78(3):291-6.
12. Kesimci E, Izdes S, Gozdemir M, Kanbak O. Tramadol does not prolong the effect of ropivacaine 7.5 mg/ml for axillary brachial plexus block. Acta Anaesthesiologica Scandinavica. 2007;51(6):736-41.
13. Fanelli G, Casati A, Magistris L, Berti M, Albertin A, Scarioni M, et al. Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anaesthesia performed with ropivacaine. Acta Anaesthesiol Scand. 2001;45(5):590-4.
14. Jain N, Khare A, Khandelwal S, Mathur P, Singh M, Mathur V. Buprenorphine as an adjuvant to 0.5% ropivacaine for ultrasound-guided supraclavicular brachial plexus block: A randomized, double-blind, prospective study. Indian Journal of Pain. 2017;31(2):112-8.
15. Tulsyan V, Singh J, Thakur L, Verma V, Minhas A. A comparative study of buprenorphine in two different doses as an adjuvant to levobupivacaine in US-guided lumbar plexus block for postoperative analgesia. Ain-Shams Journal of Anesthesiology. 2021;13(1):7.
16. Virk MS, Arttamangkul S, Birdsong WT, Williams JT. Buprenorphine is a weak partial agonist that inhibits opioid receptor desensitization. J Neurosci. 2009;29(22):7341-8.
17. Schoenmakers KPW, Fenten MGE, Louwerens JW, Scheffer GJ, Stienstra R. The effects of adding epinephrine to ropivacaine for popliteal nerve block on the duration of postoperative analgesia: a randomized controlled trial. BMC Anesthesiology. 2015;15(1):100.
18. Dogru K, Duygulu F, Yildiz K, Kotanoglu MS, Madenoglu H, Boyaci A. Hemodynamic and blockade effects of high/low epinephrine doses during axillary brachial plexus blockade with lidocaine 1.5%: A randomized, double-blinded study. Reg Anesth Pain Med. 2003;28(5):401-5.
19. Schoenmakers KP, Vree TB, Jack NT, van den Bemt B, van Limbeek J, Stienstra R. Pharmacokinetics of 450 mg ropivacaine with and without epinephrine for combined femoral and sciatic nerve block in lower extremity surgery. A pilot study. Br J Clin Pharmacol. 2013;75(5):1321-7.
20. Weber A, Fournier R, Van Gessel E, Riand N, Gamulin Z. Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block. Anesth Analg. 2001;93(5):1327-31.
21. Tschopp C, Tramèr MR, Schneider A, Zaarour M, Elia N. Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses. Anesth Analg. 2018;127(1):228-39.
22. Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology. 2009;111(2):406-15.
23. Chakraborty S, Chakrabarti J, Mandal MC, Hazra A, Das S. Effect of clonidine as adjuvant in bupivacaine-induced supraclavicular brachial plexus block: A randomized controlled trial. Indian J Pharmacol. 2010;42(2):74-7.
24. McCartney CJL, Duggan E, Apatu E. Should We Add Clonidine to Local Anesthetic for Peripheral Nerve Blockade? A Qualitative Systematic Review of the Literature. Regional Anesthesia & Pain Medicine. 2007;32(4):330-8.
25. El-Boghdadly K, Brull R, Sehmbi H, Abdallah FW. Perineural Dexmedetomidine Is More Effective Than Clonidine When Added to Local Anesthetic for Supraclavicular Brachial Plexus Block: A Systematic Review and Meta-analysis. Anesth Analg. 2017;124(6):2008-20.
26. Sachdev S, Sharma V, Malawat A, Jethava D, Moin K. Comparison of levobupivacaine alone and levobupivacaine with dexmedetomidine in supraclavicular brachial plexus block: A prospective randomized clinical trial. Indian Journal of Clinical Anaesthesia. 2020;7(1):16-22.
27. Lundblad M, Trifa M, Kaabachi O, Ben Khalifa S, Fekih Hassen A, Engelhardt T, et al. Alpha-2 adrenoceptor agonists as adjuncts to peripheral nerve blocks in children: a meta-analysis. Pediatric Anesthesia. 2016;26(3):232-8.
28. Ray A, Kulkarni S, Kaur K, Paul D, Singh S, Khan S. Comparative study of two different doses of dexmedetomidine as an adjuvant to bupivacaine in the peripheral nerve block. Journal of Marine Medical Society. 2020;22(2):161-5.
29. Xue X, Fan J, Ma X, Liu Y, Han X, Leng Y, et al. Effects of local dexmedetomidine administration on the neurotoxicity of ropivacaine for sciatic nerve block in rats. Mol Med Rep. 2020;22(5):4360-6.
30. Sehmbi H, Brull R, Ceballos KR, Shah UJ, Martin J, Tobias A, et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus block. Anaesthesia. 2020. doi: 10.1111/anae.15288. Online ahead of print
31. Albrecht E, Vorobeichik L, Jacot-Guillarmod A, Fournier N, Abdallah FW. Dexamethasone Is Superior to Dexmedetomidine as a Perineural Adjunct for Supraclavicular Brachial Plexus Block: Systematic Review and Indirect Meta-analysis. Anesth Analg. 2019;128(3):543-54.
32. Choi S, Rodseth R, McCartney CJ. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2014;112(3):427-39.
33. Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev. 2017;11(11):Cd011770.
34. Marhofer P, Columb M, Hopkins PM, Greher M, Marhofer D, Bienzle M, et al. Dexamethasone as an adjuvant for peripheral nerve blockade: a randomised, triple-blinded crossover study in volunteers. Br J Anaesth. 2019;122(4):525-31.
35. Golwala M, Swadia V, Dhimar AA, Sridhar N. Pain relief by dexamethasone as an adjuvant to local anaesthetics in supraclavicular brachial plexus block. J Anaesth Clin Pharmacol. 2009;25(3):285-8.
36. Liu J, Richman KA, Grodofsky SR, Bhatt S, Huffman GR, Kelly IV JD, et al. Is there a dose response of dexamethasone as adjuvant for supraclavicular brachial plexus nerve block? A prospective randomized double-blinded clinical study. Journal of clinical anesthesia. 2015;27(3):237-42.
37. Williams BA, Hough KA, Tsui BY, Ibinson JW, Gold MS, Gebhart G. Neurotoxicity of adjuvants used in perineural anesthesia and analgesia in comparison with ropivacaine. Regional Anesthesia & Pain Medicine. 2011;36(3):225-30–30.
38. Attardi B, Takimoto K, Gealy R, Severns C, Levitan E. Glucocorticoid induced up-regulation of a pituitary K+ channel mRNA in vitro and in vivo. Receptors & channels. 1993;1(4):287-93.
39. Chong MA, Berbenetz NM, Lin C, Singh S. Perineural versus intravenous dexamethasone as an adjuvant for peripheral nerve blocks: a systematic review and meta-analysis. Regional Anesthesia & Pain Medicine. 2017;42(3):319-26.
40. Zhao W-L, Ou X-F, Liu J, Zhang W-S. Perineural versus intravenous dexamethasone as an adjuvant in regional anesthesia: a systematic review and meta-analysis. Journal of Pain Research. 2017;10:1529-43.
41. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, et al. IV and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. British journal of anaesthesia. 2013;111(3):445-52.
42. Zorrilla-Vaca A, Li J. Dexamethasone Injected Perineurally is More Effective than Administered Intravenously for Peripheral Nerve Blocks. The Clinical journal of pain. 2018;34(3):276-84.
43. Tien M, Gan T, Dhakal I, White W, Olufolabi A, Fink R, et al. The effect of anti‐emetic doses of dexamethasone on postoperative blood glucose levels in non‐diabetic and diabetic patients: a prospective randomised controlled study. Anaesthesia. 2016;71(9):1037-43.
44. Kassem H, Urits I, Viswanath O, Kaye AD, Eskander JP. Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair. Cureus. 2020;12(12):e11917-e.
45. Zusman RP, Urits I, Kaye AD, Viswanath O, Eskander J. Synergistic Effect of Perineural Dexamethasone and Dexmedetomidine (Dex-Dex) in Extending the Analgesic Duration of Pectoral Type I and II Blocks. Cureus. 2020;12(9):e10703-e.
46. Lee IO, Kim WK, Kong MH, Lee MK, Kim NS, Choi YS, et al. No enhancement of sensory and motor blockade by ketamine added to ropivacaine interscalene brachial plexus blockade. Acta Anaesthesiol Scand. 2002;46(7):821-6.
47. Nishiyama T, Matsukawa T, Hanaoka K. Continuous epidural administration of midazolam and bupivacaine for postoperative analgesia. Acta Anaesthesiol Scand. 1999;43(5):568-72.
48. Malinovsky JM, Cozian A, Lepage JY, Mussini JM, Pinaud M, Souron R. Ketamine and midazolam neurotoxicity in the rabbit. Anesthesiology. 1991;75(1):91-7.
49. Demirel E, Ugur HC, Dolgun H, Kahilogullari G, Sargon ME, Egemen N, et al. The neurotoxic effects of intrathecal midazolam and neostigmine in rabbits. Anaesth Intensive Care. 2006;34(2):218-23.
50. Mukherjee K, Das A, Basunia SR, Dutta S, Mandal P, Mukherjee A. Evaluation of Magnesium as an adjuvant in Ropivacaine-induced supraclavicular brachial plexus block: A prospective, double-blinded randomized controlled study. J Res Pharm Pract. 2014;3(4):123-9.
51. Jebali C, Kahloul M, Hassine NI, Jaouadi MA, Ferhi F, Naija W, et al. Magnesium Sulfate as Adjuvant in Prehospital Femoral Nerve Block for a Patient with Diaphysial Femoral Fracture: A Randomized Controlled Trial. Pain Research and Management. 2018;2018:2926404. https://doi.org/10.1155/2018/2926404
52. Hung Y-C, Chen C-Y, Lirk P, Wang C-F, Cheng J-K, Chen C-C, et al. Magnesium Sulfate Diminishes the Effects of Amide Local Anesthetics in Rat Sciatic-Nerve Block. Reg Anesth Pain Med. 2007;32(4):288-295.
53. Kerry Brandis. Alkalinisation of local anaesthetic solutions. Australian Prescriber Vol 34 / Number 6 / December 2011.


How to Cite this Article: Deshpande R, Wagh H, Kulkarni S | Adjuvants in Peripheral Nerve Blocks | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 63-66.

 


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Four Important Blocks of The Last Decade

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

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


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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

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.


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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.


(Abstract) (Text HTML)  (Download PDF)