Comments on- Time to Adequately Heed Acute Pain in the Emergency Department – More Regional Blocks Warranted

Vol 4 | Issue 1 | January-June 2023 | Page 33-34 | Arun Nagdev


Authors: Arun Nagdev [1]

[1] Highland Hospital/Alameda Health System.
[2] University of California, San Francisco, USA.

Address of Correspondence
Dr. Arun Nagdev,
Director, Emergency Ultrasound, Highland Hospital/Alameda Health System.
Associate Clinical Professor, University of California, San Francisco, USA.

To the Editor,

I read the recent article “Time to Adequately Heed Acute Pain in the Emergency Department – More Regional Blocks Warranted” by Dr. Zundert, et al. with much interest [1]. The central argument of offering adequate multimodal acute pain control to our most vulnerable patients has been the core tenant of my clinical practice and research for the last 15 years. I completely agree that If we (as the field of medicine) hope to succeed in equitable acute pain management, leveraging the skill of numerous clinicians (emergency physicians, surgeons, orthopedics, etc.) to perform single injection regional blocks will be needed [2]. Like other skills (endotracheal intubation, lumbar puncture, central venous cannulation, etc.) that have been adapted from innovators in one field and then taught to the various other specialties, ultrasound-guided regional anesthesia needs to be brought from the expert regional anesthesiologists and to the clinicians who are at the bedside caring for this cohort of patients.

Working at an academic trauma center in a low resource setting, we have had to build patient-centered pain pathways that both treat acute pain as well as ensure a reduction in opioid use. With the help of our anesthesia colleague at University of California, San Francisco, we have integrated ultrasound-guided regional blocks into our clinical practice for more than 10 years in the emergency department (ED). Just as Dr. Zundert has pointed out, this collaboration between our Anesthesia and Emergency Medicine colleagues has been an amazing success, leading to timely pain control in our acutely injured patients as well as improved patient care. For hip fractures specifically, we have worked with our anesthesia and orthopedic colleagues to develop a practice standard that asks our clinicians to perform a block in under 1 hour after recognition of a hip fracture [3]. This collaborative non-siloed based practice standard between all services dealing with acutely injured patients (trauma surgery, orthopedics, anesthesia and emergency medicine) has fostered interdepartmental education, multiple research publications and most importantly improved patient care [4, 5,6, 7].


Arun Nagdev, MD
Director, Emergency Ultrasound
Highland Hospital/Alameda Health System
Associate Clinical Professor
University of California, San Francisco


[1] Van Zundert TCRV, Van Zundert AAJ. Time to adequately heed Acute Pain in the Emergency Department – More Regional Blocks Warranted. Int J Reg Anaesth. 2022;3(2):37-41.
[2] Wroe P, O’Shea R, Johnson B, Hoffman R, Nagdev A. Ultrasound-guided forearm nerve blocks for hand blast injuries: case series and multidisciplinary protocol. Am J Emerg Med. 2016;34(9):1895-1897.
[3] Johnson B, Herring A, Shah S, Krosin M, Mantuani D, Nagdev A. Door-to-block time: prioritizing acute pain management for femoral fractures in the ED. Am J Emerg Med. 2014;32(7):801-803.
[4] Lin DY, Woodman R, Oberai T, et al. Association of anesthesia and analgesia with long-term mortality after hip fracture surgery: an analysis of the Australian and New Zealand hip fracture registry. Reg Anesth Pain Med. 2023;48(1):14-21.
[5] Morrison RS, Dickman E, Hwang U, et al. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc. 2016;64(12):2433-2439.
[6] Pawa A, El-Boghdadly K. Regional anesthesia by nonanesthesiologists. Curr Opin Anaesthesiol. 2018;31(5):586-592.
[7] Stone A, Goldsmith AJ, Pozner CN, Vlassakov K. Ultrasound-guided regional anesthesia in the emergency department: an argument for multidisciplinary collaboration to increase access while maintaining quality and standards. Reg Anesth Pain Med. 2021;46(9):820-821.

How to Cite this Article: Nagdev A | Comments on- Time to Adequately Heed Acute Pain in the Emergency Department – More Regional Blocks Warranted | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 33-34 | DOI:

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Foot Drop after Hip Surgery – An Anaesthetic Perspective

Vol 4 | Issue 1 | January-June 2023 | Page 31-32 | Vighnesh C S, Sheetal, Avneet Singh, Rajeev Kansay


Authors: Vighnesh C S [1], Sheetal [1], Avneet Singh [1], Rajeev Kansay [2]

[1] Department of Anaesthesia and Intensive Care, Government Medical College Hospital, Sector 32 Chandigarh, India.
[2] Department of Orthopaedics, Government Medical College Hospital, Sector 32 Chandigarh, India.

Address of Correspondence
Dr. Avneet Singh,
Assistant Professor, Department of Anaesthesia and Intensive Care, Government Medical College Hospital Sector 32, Chandigarh, India.

To the Editor,

Foot drop is characterized by reduced muscle strength in the ankle dorsiflexors and inability to lift the forefoot. Foot drop occurring after an orthopedic procedure can occur due to various causes [1-5] (Figure 1). Epidural anaesthesia may sometimes attract undue attention in such a situation and presence of an epidural air pocket does not rule it out altogether as a cause. We describe an algorithmic approach to investigate the cause of foot drop after acetabular surgery performed under combined spinal-epidural anaesthesia.
A 35-year-old male, American Society of Anesthesiologists’-physical status (ASA-PS) II patient admitted with an alleged history of road-traffic accident and left acetabulum and 3rd–5th left rib fractures and hemothorax. He was initially managed for hypovolemic shock and mechanically ventilated for three days in the intensive care unit. The acetabular fracture was stabilized with tibial skeletal traction under local anesthesia. After hemodynamic stabilization, and an ICU stay duration of five days, he was planned for an acetabular fracture repair by posterior approach under combined spinal epidural anaesthesia. The preoperative evaluation and patient preparation were done as per institutional guidelines. Under aseptic precautions, combined spinal anaesthesia was applied in sitting position and midline approach at L3–L4 interspace. Epidural anaesthesia was given using 18 G Tuohy’s needle using the loss of resistance to 3 ml air at a depth of 5 cm and catheter fixed at 11 cm. The spinal anaesthesia was given with 26 G in the same lumbar space, with a clear flow of cerebrospinal fluid and 15 mg of 0.5% bupivacaine (hyperbaric) was given. The procedures were uneventful, and the patient did not report any paresthesia. The duration of surgery was 210 minutes, and 0.5% bupivacaine 5 mL was administered after 2 hours. The intraoperative period was uneventful. The postoperative analgesia was managed with epidural 0.125% bupivacaine (isobaric) with 2 μg/ml fentanyl infusion at 0.05–0.1 ml/kg/hour. On the second postoperative day, on initiating passive limb physiotherapy, the patient complained of difficulty in upward movement of ankle joint of operated limb. The clinical examination and investigations are depicted in Figure 2. A non-contrast computed tomography of the spine showed air pockets in the lumbar epidural space without hematoma (Figure 3). Initially, the epidural air pocket was considered the cause. However, this was unlikely due to the unilateral and singular peripheral nerve involvement. The diagnosis of left deep peroneal nerve injury that could have occurred due to tibial pin was made. He was initiated on limb physiotherapy and foot drop splint was applied. He was discharged with tablet diclofenac 50 mg 8th hourly and vitamin B12. On follow-up, 7 days after discharge with good physiotherapy and regular medications the patient had regained full power of dorsi-flexion.


[1] Carolus AE, Becker M, Cuny J, et al. The Interdisciplinary Management of Foot Drop. Dtsch Ärztebl Int. 2019;116: 347.
[2] Issack PS, Helfet DL. Sciatic Nerve Injury Associated with Acetabular Fractures. HSS J. 2009;5: 12.
[3] Giannoudis PV, Da Costa AA, Raman R, et al. Double-crush syndrome after acetabular fractures. J Bone Joint Surg Br. 2005;87-B: 401–7.
[4] Liporace FA, Yoon RS, Kesani AK. Transient common peroneal nerve palsy following skeletal tibial traction in a morbidly obese patient – case report of a preventable complication. Patient Saf Surg. 2012;6:4.
[5] Ng J, Marson BA, Broodryk A. Foot drop following closed reduction of a total hip replacement. BMJ Case Rep. 2016;2016: bcr2016215010.

How to Cite this Article: Vighnesh CS, Sheetal, Singh A, Kansay R | Foot Drop after Hip Surgery – An Anaesthetic Perspective | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 31-32 | DOI:

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Efficacy of Butorphanol and Tramadol as an Adjuvant to Levobupivacaine for Postoperative Analgesia in Brachial Plexus Block – A Randomized Double-Blind Study

Vol 4 | Issue 1 | January-June 2023 | Page 07-12 | Jaya Lalwani, A. Sashank, Ravi Chaudhari


Authors: Jaya Lalwani [1], A. Sashank [1], Ravi Chaudhari [1]

[1] Department of Anaesthesia and Pain Management, Pt Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.

Address of Correspondence
Dr. Ravi Chaudhari,
Department of Anaesthesia and Pain Management, Pt Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.

Background: Supraclavicular brachial plexus block has evolved as a safe alternative to general anaesthesia with good postoperative analgesia. In an attempt to hasten the onset of block and increase the duration of postoperative analgesia, various adjuvant drugs are used along with local anesthetic agents.
Aim: The present study was undertaken to assess the analgesic efficacy of butorphanol (2mg) and tramadol (100 mg) as an adjuvant to levobupivacaine in supraclavicular brachial plexus block during perioperative period.
Study Design: This was a prospective, randomized, double blind study done on 100 adult patients of ASA I-III aged between 18-65 years and scheduled for various upper limb surgeries below the level of elbow.
Materials and Methodology: Patients were allocated by computer generated random draw into two groups of 50 each and were administered the study drugs under ultrasonographic guidance. Both groups received 22ml of the study drug (Group B 20 ml 0.5% levobupivacaine + Butorphanol 2mg and Group T 0.5% levobupivacaine + Tramadol 100 mg). Patients were assessed for duration of postoperative analgesia, onset & duration of sensory as well as motor blockade and occurrence of any side effects.
Results: Duration of postoperative analgesia was significantly elevated in group B (683±88.58 min), as compared to group T (483.2±45.24 min.) with p<0.001. Onset of sensory and motor blockade was comparable among both groups (p>0.05). Duration of sensory and motor block in group B was significantly longer compared to group T (p<0.001). Hemodynamics were stable and side effects were minimal in both the groups.
Conclusion: Butorphanol 2mg when added to 20ml 0.5% levobupivacaine in brachial plexus block, significantly prolongs the duration of postoperative analgesia, sensory and motor block as compared to addition of 100 mg tramadol, with minimal side effects and hemodynamic changes. However, these adjuvants shorten the onset times of sensory and motor block to a similar extent.
Keywords: Brachial plexus block, Levobupivacaine, Butorphanol, Tramadol, Analgesia.


[1] Glajchen M. Chronic pain: treatment barriers and strategies for clinical practice. J Am Board Fam Prac. 2001;14: 211-18.
[2] El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018; 11:35-44
[3] Swain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local anesthetics: Current understanding and future trends. World J Clin Cases. 2017;5: 307-323.
[4] Bajwa SS, Kaur J. Clinical profile of levobupivacaine in regional anesthesia: A systematic review. J Anaesthesiology Clinical Pharmacology 2013;29: 530-39.
[5] Howard BG, Huda A. Opioid Analgesics. In:Goodman GA, Hardman G, Lee EL, editors. The pharmacological basis of therapeutics, Opioid analgesics. 10th ed. NewYork: McGraw Hill 2001.
[6] Vazzana M, et al. Tramadol hydrochloride: Pharmacokinetics, pharmacodynamics, adverse side effects, co-administration of drugs and new drug delivery systems. Biomed Pharmacother. 2015; 3586:1-5.
[7] Kumari A, Chhabra H, Gupta R, Kaur H. Comparative Study of Effectiveness of Tramadol and Butorphanol as Adjuvants to Levobupivacaine for Supraclavicular Brachial Plexus Block. Anesth Essays Res. 2019;13: 446-51.
[8] Foster RH, Markham A. Levobupivacaine: A review of its pharmacology and use as a local anaesthetic Drugs. 2000; 59:551–79.
[9] Edinoff A N et al. Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs. Anesth Pain Med. 2021;11: 1-10.
[10] Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: A narrative review. Anaesthesia.2021;76: 100–09.
[11] Yilmaz E, Hough KA, Gebhart GF, Williams BA, Gold MS. Mechanisms underlying midazolam-induced peripheral nerve block and neurotoxicity. Reg Anesth Pain Med. 2014;39: 525–33.
[12] Krishna Prasad GV, Khanna S, Jaishree SV. Review of adjuvants to local anesthetics in peripheral nerve blocks: Current and future trends. Saudi J Anaesth 2020; 14:77‑84.
[13] Laudren PM. Axonal transport of opiate receptors in capsaicin-sensitive neurons. BrainResearch 1984; 68:413.
[14] Srikala V, Kumar MT. A Comparative Study of Buprenorphine Versus Butorphanol in Supraclavicular Brachial Plexus Block for Postoperative Analgesia. European Journal of Molecular & Clinical Medicine, 2022; 9: 2918-24.
[15] Bhavsar GM, Shah RB, Chavda HK, Shah VD, Bateriwala KM. Use of butorphanol as an adjuvant to local anaesthetics in brachial plexus block for upper limb surgery. PIJR. 2016;5: 169–72.
[16] Vinod CN, Talikoti DG. Comparison of Butorphanol and Buprenorphine as an Adjuvant to Local Anesthesia in Supraclavicular Brachial Plexus Block for Post-Operative Analgesia. Journal of Evolution of Medical and Dental Sciences 2014; 3: 4287-93
[17] Khosa A.H. & Asad, Naqibullah & Durrani, HAQ DAD. Does the addition of Tramadol to local anaesthetic mixture improve the quality of axillary brachial plexus block: A comparative study at the teaching hospital, Dera Ghazi Khan. Pakistan Journal of Medical and Health Sciences 2015;9: 1120-23.
[18] Bhatia U, Panjabi G, Patel A. Comparison of butorphanol and tramadol as an adjuvant to local anesthetic drug in axillary brachial plexus block. Ain-Shams J Anaesthesiology 2017;10: 242-46.
[19] Sharan R, Singh M, Attri J.P, Singh D. Additive effect of butorphanol in supraclavicular brachial plexus block. Int J Med Res Rev 2016;4: 910-17.
[20] Bharathi B, Praveena BL, Krishnaveni KN. Supraclavicular Brachial Plexus Block: Comparison of Varying Doses of Butorphanol Combined with Levobupivacaine – A Double-Blind Prospective Randomized Trial. Anesthesia Essays and Research. 2019;13: 174-78.
[21] Bommalingappa B, Channabasappa SM. Butorphanol as an adjuvant to levobupivacaine in supraclavicular brachial plexus block for upper limb orthopaedic surgeries: a randomized, double blind, placebo controlled study. J. Evolution Med. Dent. Sci. 2016;5: 4194-97.

How to Cite this Article: Lalwani J, Sashank A, Chaudhari R | Efficacy of Butorphanol and Tramadol as an Adjuvant to Levobupivacaine for Postoperative Analgesia in Brachial Plexus Block – A Randomized Double-Blind Study | International Journal of Regional Anaesthesia | July-December 2023; 4(1): 07-12 | DOI:

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To Remove or Not to Remove a Broken Perineural Catheter Fragment?

Vol 4 | Issue 1 | January-June 2023 | Page 26-28 | Trupti Pethkar, Harshal Wagh


Authors: Trupti Pethkar [1], Harshal Wagh [1]

[1] Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Trupti Pethkar,
Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

Fracture of femoral perineural catheter during insertion is the extremely rare complication of an otherwise low risk procedure. In such a scenario, whether to leave the catheter in situ or extract it by surgical exploration is the dilemma. We present two cases of broken femoral perineural catheter incurred during insertion. Since patients do not complain of any kind of immediate pain or discomfort, after shearing of the catheter, the decision making regarding the further management is difficult. But, there are incidences of long term complication like femoral neuritis leading to constant dragging pain. This makes us uncomfortable and force to think whether these broken fragments should left in situ.
Keywords: Femoral perineural catheter, Femoral nerve block, Fractured catheter fragment


[1] Joshi G, Gandhi K, Shah N, Gadsden J, Corman SL. Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities. Journal of Clinical Anesthesia 2016;35:524-9.
[2] Aveline C, Le Hetet H , Le Roux A, Vautier P, Gautier JF, Cognet F. Perineural ultrasound-guided catheter bacterial colonization: a prospective evaluation in 747 cases. Reg Anesth Pain Med 2011;36:579-84.
[3] Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011;113:904-25.
[4] Adam F, Jaziri S, Chauvin M. Psoas Abscess Complicating Femoral Nerve Block Catheter. Anesthesiology 2003;99:230–1.
[5] Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 2010;468(1):135-40.
[6] Lee BH and Goucke CR. Shearing of a Peripheral Nerve Catheter. Anesthesia & Analgesia 2002;95(3):760-1.
[7] Guerci P, Novy E, Guibert J, Vial F, Malinovsky JM, Bouaziz H. Cisaillements accidentels de cathéters périnerveux lors de poses échoguidées [Inadvertent peripheral nerve catheter shearing occurring during ultrasound guidance]. Ann Fr Anesth Reanim. 2013;32(5):364-7(in French).
[8] Khabiri B, Hamilton C, Norton J, Arbona F, Carlson L. The Difficulty to Remove Perineural Catheter: A Technique for Removing an Intact Catheter. Open Journal of Anesthesiology 2013;3(6):304-7.

How to Cite this Article: Pethkar T, Wagh H | To Remove or Not to Remove a Broken Perineural Catheter Fragment? | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 26-28 | DOI:

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The Frail Elderly Patient and the Need for a Video Store on Regional Anaesthesia Blocks

Vol 4 | Issue 1 | January-June 2023 | Page 01-03 | André van Zundert


Authors: André van Zundert [1]

[1] Australian & New Zealand College of Anaesthetists.
[2] Royal College of Anaesthetists – London UK.
[3] The University of Queensland, Australia.
[4] Department of Anaesthesia & Perioperative Medicine, Royal Brisbane & Women’s Hospital, Herston Campus-Brisbane, Queensland, Australia.

Address of Correspondence
Professor André van Zundert,
Lennard Travers Professor of Anaesthesia – Australian & New Zealand College of Anaesthetists.
Honorary Fellow Royal College of Anaesthetists – London UK.
Professor & Chairman Discipline of Anaesthesiology, The University of Queensland, Australia.
Faculty of Medicine & Biomedical Sciences, Brisbane, QLD, Australia.
Chair, University of Queensland Burns, Trauma & Critical Care Research Centre, Australia.
Chair, RBWH/University of Queensland Centre for Excellence & Innovation in Anaesthesia, Australia.
Department of Anaesthesia & Perioperative Medicine, Royal Brisbane & Women’s Hospital, Herston Campus-Brisbane, Queensland, Australia.
E-mail: &

According to The United Nations, the world’s population reached 8 billion people on 15 November 2022, a milestone in human development [1]. Life expectancy at birth has never been higher, reaching 80 years and over in several countries [2]. This is a testimony showing the triumph of humanity thanks to improvements in sanitation, the availability of clear running water and more abundant and safer foods, better housing, technology, education and better healthcare. This health transition began at different times in different world regions, but globally, life expectancy at birth doubled across all world regions and increased from an average of 29 in 1850 to 73 years in 2019 [3]. After two centuries of progress we can expect to live much more than twice as long as our ancestors. And this progress was not achieved in a few places. In every world region people today can expect to live more than twice as long. An even more important factor is the ‘estimated healthy life expectancy or HALE’, the average number of years that a person can expect to live in ‘full health’. Indeed, in modern healthcare, substantial resources are devoted to reducing the incidence, duration and severity of major diseases that cause morbidity and to reducing their impact on people’s lives.
Many elderly people enjoy a healthy lifestyle, but a significant part is frail, shows loss of physiological reserves with low functional performance, lack of physical activity, has loss of muscle mass which result in mobility issues and is affected by medical issues, e.g., multi-morbidity, multi-pharmacy use, malnutrition, loss of functional reserves, preoperative cognitive decline, depression, dementia and sensory deficits. It is known that preoperative cognitive impairment is a risk factor for the development of postoperative delirium and postoperative cognitive decline. Frailty and functional impairment are strong predictors of adverse postoperative outcomes, with more medical complications, prolonged hospitalisation, institutionalisation, readmission and short-term and long-term mortality [4]. Limited mobilisation and falls usually lead to functional decline, longer hospitalisation periods, discharge to a rehabilitation facility or residential care with loss to maintain independence and increased health costs. Understanding frailty measurement, mechanisms and management is important as the prevalence of frailty may be as high as 50% and more in patients aged 85 or over [5].
This all means that anaesthesiologists will be confronted with a much larger group of elderly patients undergoing surgery. Age alone is no longer a barrier to surgery [6]. Anaesthesiologists need to assess the patient’s body capacity to cope with stress of illness of surgery and the factors which contribute to poor outcomes. Anaesthesiologists can reduce postoperative morbidity and mortality to adequately control pain, correct inadequate nutrition and hydration, provide thromboprophylaxis and is alert for sepsis and delirium. The anaesthesiologist needs to understand the impact of changing physiology, pharmacodynamics and pharmacokinetics of the ageing process and aims to maintain homeostasis in the presence of surgical stress and actions of anaesthetic drugs. A tailored anaesthetic optimum management plan adjusted to the elderly patient’s condition focuses on taking care of pain, delirium, sepsis, deep vein thrombosis, poor nutrition and hydration and rehabilitation planning. Risk factors for the development of postoperative delirium and postoperative cognitive decline include pre-existing cognitive impairment, sleep deprivation, immobility, visual and hearing impairments, dehydration, and the use of sedative-, hypnotic, and anticholinergic medication. Optimum management includes recognition and prevention of infections, effective knowledge about antibiotic prophylaxis, thromboembolic prophylaxis, the use of compression stockings, attention to the needs of nutritional and hydration requirements, early mobilisation and rehabilitation planning well before and after surgery.
It is known that prolonged and aggressive surgery under general anaesthesia may result in postoperative delirium and cognitive decline due to neuroinflammation, but also extended length of hospital stay and increased morbidity and mortality, especially in the frail elderly group. George et al. [7] recently demonstrated in a cohort study of over 2.7 million frail elderly patients, the 180-day mortality rates for very frail patients across nine noncardiac surgical specialties were greater than 25%. Frail patients in all specialty categories had 15% to 18% mortality following higher stress procedures and 7% to 17% mortality after procedures causing less stress. These findings suggest that there is no such thing as a low-risk procedure for frail patients.
Among the anaesthetic techniques, four main classes are available: general anaesthesia, sedation, loco-regional anaesthesia (central neuraxial and peripheral nerve blocks) and local anaesthesia. The use of local anaesthesia in the frail population has increased tremendously over the last 10 years [5]. The main reasons for its popular use are that it is a simple, low cost, reproducible technique requiring no premedication, avoiding the side effects and complications of sedation and general anaesthesia. The application of regional anaesthesia leads to early recovery without perioperative hypothermia or hypotension and a reduction in airway and pulmonary complications, proinflammatory reaction and delirium. However, it is not a panacea that can be applied in every situation. Not every surgical intervention lends itself to perform under regional anaesthesia or local anaesthesia, i.e., major cardiac, neuro or intra-abdominal surgery. It requires patient cooperation, and the patient needs to know there may be periods of intraoperative discomfort, while in certain circumstances it is not even possible to do the operation under regional anaesthesia, e.g., in an anticoagulated patient or when there is (local) sepsis. Anaesthesiologists need to be aware of potential side effects and toxicity of local anaesthetics or their adjuncts (e.g., epinephrine in a cardiac compromised patient), especially in the frail population, and have all the precautions ready at hand in case of a local anaesthetic systemic toxic reaction [5].
Regional anaesthesia needs to be educated. It cannot be learnt from books alone. Workshops and education on manikins are helpful, but limitations are known. But how best to learn new techniques? Major illustrated textbooks offer a large range of regional anaesthesia techniques but lack the interaction. The best practice is obtained during teaching on patients in the presence of a qualified mentor, allowing discussion how to improve specific techniques and how to adjust these blocks to the frail surgical population. This is not only helpful for junior doctors, but also experienced anaesthesiologists can learn from each other.
The last decade saw a dramatical advance in regional anaesthesia techniques, benefitting from new blocks, medications, medical equipment and the application of ultrasonography and its decreasing impact on serious problems, while boosting efficacy and practicality of the blocks [8]. The last five years saw an increased annual research production on topics in regional anaesthesia. This is partly due to the trend toward less invasive surgical procedures, and the application of anaesthetic solutions that reduce systemic opioid doses, allowing same-day discharge to become more popular.
Specialized journals such as the International Journal of Regional Anaesthesia (IJRA) can substantially help in providing extra knowledge, updated to the latest standards, focusing on all kinds of regional block techniques. Scientific articles on these blocks are helpful, but video presentations of the blocks will be even more appreciated. A collection of video-recorded regional anaesthesia blocks in a new video store of the journal, providing a structured approach, with clear details of the anatomy, graphs and visual illustrations of each block, including guiding how to do the block (technical aspects) and what kind of local anaesthetic solution to use, should be provided. Clear instructions about dosing (dose, volume and concentration of the local anaesthetics and their additives) based on the individual (frail) patient; positioning of the patient; use of sedatives or not during a regional block; how to avoid wrong-side/site blocks; how to evaluate the resulting block and when to allow surgery to start; when and what to monitor during the block and during surgery; what and how to distract the patient during surgery (headphone with preferred music); are just a few of the numerous aspects of information these videos can provide.
This video teaching platform should rank videos from easy basic practice (*) to intermediate (**) and advanced (***) practice. The videos can be used during workshop discussions in a group as the instructor can focus on particular aspects of importance.
This video-store of IJRA should be built up in the coming years and made available free of access as this will help in distributing knowledge that all of us can use to provide better healthcare and safe and effective anaesthesia to our patients, especially to the frail elderly ones. The quality and quantity of these videos on regional anaesthesia techniques depend on the collaboration and willingness of our colleagues to produce high-quality video material. The journal could provide a format of what constitutes the basic information that needs to accompany any of these regional anaesthesia techniques. As such, IJRA could prove to become a major player in regional anaesthesia education.
Anaesthesiologists aim to care to a whole range of patients, young and old, healthy and frail, undergoing surgery by various specialists. Ageing is heterogenous, variable and malleable.9 Age as the passing of chronological time, is not synonymous with ageing, i.e., the increased risk of adverse outcomes over time. Comprehensive geriatric assessment is the fundamental diagnostic and management instrument, enabling us to understand that each individual has a unique profile of health status. Quantification of frailty is just the beginning of risk stratification. Clinicians can then guide their patients and caregivers through a shared decision-making process. Often, regional anaesthesia can provide the best choice for people at age, especially for the frail older people. We, as anaesthesiologists, need to be ready to provide high-standard regional anaesthesia blocks to all patient categories, whether they are young or old, healthy or frail.


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[9] Gordon EH, Hubbard RE. Frailty: understanding the difference between age and ageing. Age Ageing. 2022 Aug 2;51(8):afac185.

How to Cite this Article: Van Zundert A | The Frail Elderly Patient and the Need for a Video Store on Regional Anaesthesia Blocks | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 01-03 | DOI:

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Comparative Evaluation of Varying Volumes of Local Anaesthetic Solution in Pericapsular Nerve Group Block (PENG) on Dynamic Pain Relief after Hip Surgeries

Vol 4 | Issue 1 | January-June 2023 | Page 20-25 | Megha Sood, Richa Jain, Gurpreeti Kaur, Amol Rattan, Mirley Rupinder Kaur, Rajnish Garg, Anju Grewal


Authors: Megha Sood [1], Richa Jain [1], Gurpreeti Kaur [1], Amol Rattan [2], Mirley Rupinder Kaur [1], Rajnish Garg [1], Anju Grewal [1]

[1] Department of Anaesthesiology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India.
[2] Department of Orthopaedics, Dayanand Medical College & Hospital, Ludhiana, Punjab, India.

Address of Correspondence
Dr. Richa Jain,
Department of Anaesthesiology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India.

Background: The peri-capsular nerve group block (PENG) has reported the ability to decrease pain in hip fractures and minimize the use of opioids for postoperative analgesia. We conducted this trial to assess the efficacy of varying volumes of local anesthetic solution in PENG block in alleviating post-operative pain at rest and on dynamic hip movement after hip surgeries.
Material & Methods: A prospective, double-blinded interventional trial was conducted on 70 adult ASA I-III patients undergoing hip surgeries under general anesthesia. Enrolled subjects were divided into two groups A and B to receive either 10ml of 0.2% ropivacaine or 20ml of 0.2% ropivacaine respectively in an ultrasound-guided (USG) PENG block after administration of general anesthesia. The primary outcome was the duration of analgesia. VAS scores (at rest and on dynamic hip movement), the cumulative amount of rescue analgesic needed in the 24-hour post-operative period and patient satisfaction scores were secondary outcomes. Data thus collected were statistically analyzed.
Results: Mean duration of analgesia was significantly prolonged in group B (12.24±5.14 hours) as compared to group A (2.77±1.06 hours). There were statistically significant decreased VAS scores at rest and on dynamic hip movement in group B. Median total rescue analgesic consumption in 24 hours and patient satisfaction score was significantly reduced in group B than in group A (p=0.001).
Conclusion: In PENG block, 20 ml of 0.2% ropivacaine provides a significantly longer duration of analgesia, a statistically significant reduction in pain scores on rest and dynamic hip movement with substantially decreased 24-hour total rescue analgesic consumption, and improved patient satisfaction in patients undergoing hip surgeries.
Keywords: Pericapsular nerve group block (PENG), Hip surgeries, Ropivacaine, Visual analogue scale (VAS)


[1] Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med.2018;43:859-63.
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How to Cite this Article: Sood M, Jain R, Kaur G, Rattan A, Kaur MR, Garg R, Grewal A | Comparative Evaluation of Varying Volumes of Local Anaesthetic Solution in Pericapsular Nerve Group Block(PENG) on Dynamic Pain Relief after Hip Surgeries | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 20-25 | DOI:

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Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery

Vol 4 | Issue 1 | January-June 2023 | Page 29-30 | Chethana G. Mapari, Tuhin Mistry, Kartik B. Sonawane, Jagannathan Balavenkatasubramanian


Authors: Chethana G. Mapari [1], Tuhin Mistry [1], Kartik B. Sonawane [1], Jagannathan Balavenkatasubramanian [1]

[1] Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India.

Address of Correspondence
Dr. Tuhin Mistry
Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India.

Letter to Editor

To the Editor,

Perioperative pain management in spine surgeries poses a unique challenge to anesthesiologists. The severity of pain correlates with multiple factors, including the degree of trauma, level of injury, and complexity of the surgery. Various multimodal analgesia (MMA) strategies and regional analgesia options have been described to deal with such pain. However, the paucity of literature on pain management in traumatic sacral fractures and spinopelvic fixation surgeries warrants further exploration of various modalities. This report describes the application of the sacral multifidus plane block (SMPB) in spinopelvic fixation surgery as an adjunct to MMA. Consent was obtained for the publication of this correspondence.
An 18-year-old healthy male (weight 60 kg, height 160 cm) patient was brought to our hospital with an alleged history of falling from around 15 feet. Radiological investigations revealed comminuted type 1 sacrum fracture (bilateral zones 1, 2, and 3) extending to the left sacroiliac (SI) joint with kyphotic angulation at the fracture site without any anterior translation; comminution of S1, S2, and involvement of neural foramen, median sacral crest with diffuse marrow contusion (Figure 1a). His neuromuscular examination, other systemic examinations, and laboratory investigations were within normal limits. In the first stage, the patient had undergone emergency closed reduction and percutaneous SI joint screw fixation under general anesthesia (Figure 1b). After two days, the patient was scheduled for left L5-ilium spinopelvic fixation with decompression (Figure 1c). The anesthesia plan was discussed with the patient and his relatives and informed written consent was obtained.
In the operating room, standard monitors were attached, an 18G intravenous cannula was secured, and lactated ringer infusion was started. General anesthesia was administered using intravenous propofol 2 mg/kg, fentanyl 2 μg/kg, and rocuronium 0.6 mg/kg. The patient was mechanically ventilated following tracheal intubation, and anesthesia was maintained with nitrous oxide: oxygen (1:1) mixture and titrated desflurane. After turning the patient prone, an ultrasound-guided SMPB was performed as per the technical description by Mistry et al. [1] A high-frequency linear transducer was kept longitudinally next to the midline in the parasagittal plane (Figure 1d). After optimizing the image at the S2 level, a 23G Quincke’s spinal needle was advanced in an in-plane approach from the cephalad to the caudad direction. After hitting the underlying bone, 20 mL of local anesthetic (LA) solution (0.2% ropivacaine + 4 mg dexamethasone) was administered. An anechoic LA spread in the plane between the multifidus muscle (MFM) and the hyperechoic bony area (between the median and intermediate sacral crests) was confirmed. The craniocaudal spread of the LA in the same plane was also noted (Figure 1e). A similar procedure was repeated on the other side.
Intraoperatively, intravenous paracetamol 15 mg/kg, ketorolac 0.5 mg/kg, and 40 mg/kg magnesium sulfate were administered as a part of MMA. The patient remained hemodynamically stable and extubated uneventfully immediately after the surgery of two hours duration. Postoperatively, MMA was continued with intravenous paracetamol 15 mg/kg 6 hourly and oral pregabalin 75 mg once daily. The patient remained comfortable with pain scores of 0–3 on the numeric rating scale for 24 hours without requiring additional analgesics.
SMPB, a variant of the paraspinal plane block, has been used for various surgeries in the perineal and buttock region [1]. The innervation of the SI joint is complex and varies among individuals. It may arise from the ventral rami of L4 and L5, superior gluteal nerve, and dorsal rami of L5-S2 or almost exclusively from the sacral dorsal rami [2]. The dorsal rami also innervate the skin and the muscles in the adjacent region [3]. The lateral branches of the S1-S3 dorsal rami unite to form the medial cluneal nerve that innervates the skin overlying the posteromedial area of the buttock near the midline. The possible mechanism of action of SMPB includes blocking the terminal nerves directly by LA deposition in the myo-osseous plane and involving ventral rami, pudendal nerve (S2–S4), lumbosacral plexus, and sciatic nerve by anterior and craniocaudal spread through dorsal and ventral sacral foramina [4,5]. Postoperatively, we observed selective sensory loss in the L4-S3 dermatome without motor weakness. Being a fascial plane block, the analgesic coverage of SMPB is volume-dependent. However, unlike other fascial plane blocks, the LA spread in SMPB can be consistent due to the presence of the bony dorsal surface of the sacrum. Consistent drug spread across the sacral dorsal surface could include all procedure-specific innervations required to provide analgesia for sacral spine surgery. SMPB provided adequate analgesia in our patient, possibly because of this anatomical advantage. It also helped maintain intraoperative hemodynamic stability, reduce surgical blood loss, control opioid requirements, and facilitate postoperative enhanced recovery and mobilization.
We conclude that the inclusion of SMPB as a component of MMA can provide effective perioperative analgesia in spinopelvic fixation surgeries or sacral spine injuries. However, adequately powered studies with robust methodology are required in the future to establish the safety, and efficacy of this block, and also to determine the appropriate volume and concentration of local anaesthetic necessary for providing the desired effect.


[1] Mistry T, Sonawane K, Balasubramanian S, Balavenkatasubramanian J, Goel VK. Ultrasound-guided sacral multifidus plane block for sacral spine surgery: A case report. Saudi J Anaesth 2022; 16:236-9.
[2] Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroiliac joint: anatomy, physiology, and clinical significance. Pain Physician. 2006 Jan;9(1):61-7.
[3] Suganthy J, Irodi A, Prithishkumar IJ, Jacob TM. Cunningham’s Manual of Practical Anatomy. 16th ed. New York: Oxford University Press; 2017. pp. 279–92.
[4] Kukreja P, Deichmann P, Selph JP, Hebbard J, Kalagara H. Sacral erector spinae plane block for gender reassignment surgery. Cureus. 2020;12: e7665.
[5] Chakraborty A, Chakraborty S, Sen S, Bhatacharya T, Khemka R. Modification of the sacral erector spinae plane block using an ultrasound-guided sacral foramen injection: Dermatomal distribution and radiocontrast study. Anaesthesia. 2021; 76:1538–9.

How to Cite this Article: Mapari CG, Mistry T, Sonawane KB, Balavenkatasubramanian J | Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 29-30 | DOI:

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Converting Regional Anaesthesia Database into Publication: A Step-based Approach

Vol 4 | Issue 1 | January-June 2023 | Page 04-06 | Mayank Gupta, Gopal Jalwal, Anju Grewal


Authors: Mayank Gupta [1], Gopal Jalwal [1], Anju Grewal [1]

[1] Department of Anaesthesiology & Critical Care, AIIMS, Bathinda, Punjab, India.

Address of Correspondence
Dr. Gopal Jalwal,
Assistant Professor, Department of Anaesthesiology & Critical Care, AIIMS, Bathinda, Punjab, India.


The article discusses the benefits of regional anaesthesia (RA) and the role of point-of-care ultrasound (POCUS) in enhancing its safety and efficacy. Conducting randomized controlled trials (RCTs) to establish the efficacy of RA remains a challenge due to resource constraints and ethical considerations. The author suggests that focusing solely on RCTs can be counterproductive and advocates for the importance of other forms of research, such as case series, practice audits, and prospective observational cohort studies. These forms of research can provide a background and rationale for designing future RCTs and can help broaden the scope of research beyond the idealistic RCT paradigm. The passage also includes a table highlighting the pros and cons of different study designs. Overall, the article emphasizes the importance of expanding the scope of research to improve the safety and efficacy of RA.
Keywords: Regional anaesthesia, Point-of-care ultrasound, Randomized controlled trials, Case series, Practice audits, Prospective observational cohort studies, Efficacy, Safety


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[13] Butcher NJ, Monsour A, Mew EJ, Chan AW, Moher D, Mayo-Wilson E, Terwee CB, Chee-A-Tow A, Baba A, Gavin F, Grimshaw JM, Kelly LE, Saeed L, Thabane L, Askie L, Smith M, Farid-Kapadia M, Williamson PR, Szatmari P, Tugwell P, Golub RM, Monga S, Vohra S, Marlin S, Ungar WJ, Offringa M. Guidelines for Reporting Outcomes in Trial Reports: The CONSORT-Outcomes 2022 Extension. JAMA. 2022;328(22):2252-2264.
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How to Cite this Article: Gupta M, Jalwal G, Grewal A | Converting Regional Anaesthesia database into Publication: A step-based approach | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 04-06 | DOI:

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Prospective Comparative Double-Blind Study on Ultrasound-Guided Pericapsular Nerve Group Block Versus Suprainguinal Fascia Iliaca Block for Perioperative Analgesia in Traumatic Hip Surgeries

Vol 4 | Issue 1 | January-June 2023 | Page 13-19 | Chetana Bhalerao, Ujjwalraj Dudhedia


Authors: Chetana Bhalerao [1], Ujjwalraj Dudhedia [1]

[1] Department of Anaesthesia, Dr. L.H. Hiranandani Hospital Powai, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Chetana Vitthal Bhalerao,
Department of Anaesthesia, Dr. L.H. Hiranandani Hospital Powai, Mumbai, Maharashtra, India.


Background: Severe pain in hip fractures limits ideal positioning for spinal anaesthesia. We evaluated the analgesic efficacy of ultrasound-guided pericapsular nerve group block (PENG) and suprainguinal fascia iliaca block (SIFI) for positioning and postoperative pain relief in hip surgeries.
Methods: A prospective, randomized, double-blind study including 30 patients aged 30-90 years of either sex, American Society of Anesthesiologists’-physical status score I to II undergoing traumatic hip surgeries were divided into two groups. Each group was administered 20 ml bupivacaine 0.25% + 10 ml lignocaine 1%. Vitals and visual analogue scale (VAS) score pre-block, 10 mins post-block, after shifting to operation theatre and after positioning; at rest, and after straight leg raise (SLR) and quadriceps muscle strength were noted. The remaining aspects of perioperative care, including subarachnoid block and rescue analgesic techniques were standardized. Time to request first rescue analgesia, duration of block, and incidence of nausea was noted. Statistical analysis done using the Student t test, Chi-Square test.
Results: VAS scores in both groups 10 mins post block at rest, after SLR, and after positioning were comparable. The drop in VAS score although statistically insignificant was more in the PENG group. The motor blockade in SIFI was significantly higher compared to the PENG group (p-0.002). Duration of analgesia with SIFI 551.9 (±56.2) min was longer than PENG block 400.4 (±62.8) min (p=0.0005%). No significant difference between the groups to demographics, hemodynamic parameters, rescue analgesia and incidence of nausea.
Conclusion: PENG block provides superior and faster analgesia with potentially motor sparing effect compared to SIFI block whereas SIFI provides longer duration of analgesia.
Keywords: Analgesia, Pain, Regional Anaesthesia, Ultrasonography


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How to Cite this Article: Bhalerao C, Dudhedia U | Prospective Comparative Double-Blind Study on Ultrasound- Guided Pericapsular Nerve Group Block Versus Suprainguinal Fascia Iliaca Block for Perioperative Analgesia in Traumatic Hip Surgeries | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 13-19 | DOI:

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