The Fate of Lumbar Epidural Catheters in the Postoperative Period- A Retrospective Single-center Audit

Vol 4 | Issue 2 | July-December 2023 | Page 14-17 | Sandeep Diwan, Himaunshu Dongre, Parag Sancheti


Submitted: 26-06-2023; Reviewed: 18-07-2023; Accepted: 23-10-2023; Published: 10-12-2023

Authors: Sandeep Diwan [1], Himaunshu Dongre [1], Parag Sancheti [2]


[1] Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India.
[2] Department of Orthopaedics, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Himaunshu Dongre,
Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra State, India.


This paper describes a retrospective audit of fate of epidural catheters in post operative period in adults and elderly patients (more than 65 years) receiving epidural infusion analgesia (EIA) in a single institute. Epidural catheters can either migrate inwards (inward migration of epidural catheter or IMEC) otherwise, outwards (outward migration of epidural catheter or OMEC). The OMEC can lead to failure of epidural analgesia and loss of infusate. The primary aim was to evaluate the incidence of OMEC. The secondary aim was, disconnections, kinking, knotting and breakage of catheter. The primary and secondary aim together were considered as fate of epidural catheter. Our study demonstrates the OMEC occurred at 1.12%, disconnection at 7.32%, kink and knot at 1.12% and 0.016% respectively A good communication at all levels (anesthesiologist-handlers at each level-nursing staff), in event of raised incidence (inform the QHC and concerned anesthesiologist) is mandatory to avoid mishandling of epidural assembly. After identifying some of the causes including the dressing material and fixation methods, changes were implemented which will be audited in the subsequent study.
Keywords: Epidural catheter migration, Audit, Observational Study


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How to Cite this Article:  Diwan S, Dongre H, Sancheti P | The Fate of Lumbar Epidural Catheters in the Postoperative Period- A Retrospective Single-center Audit | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 14-17 | DOI:

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Pendant Positioning Vs Traditional Sitting for Successful Spinal Punctures in Elderly

Vol 4 | Issue 2 | July-December 2023 | Page 9-13 | Tamasi Dawn, Yatindra Kumar Batra, Sunny Rupal, Komal Jit Kaur, Tanvir Samra


Submitted: 10-08-2023; Reviewed: 06-09-2023; Accepted: 24-10-2023; Published: 10-12-2023

Authors: Tamasi Dawn [1], Yatindra Kumar Batra [1], Sunny Rupal [1], Komal Jit Kaur [1], Tanvir Samra [2]

[1] Department of Anaethesiology Max superspeciality Hospital, Mohali, Punjab, India.
[2] Department of Anaesthesia PGIMER, Chandigarh, India.

Address of Correspondence
Dr. Tanvir Samra,
Associate Professor Department of Anaesthesia PGIMER, Chandigarh, India.


Background- The ability of the pendant position in increasing the intervertebral spaces translating in an increase in the 1st attempt spinal puncture success rate has been reported in pregnant females undergoing cesarean section. However, the same has not been done for the elderly patients in which age-related degenerative anatomical changes, decreased lordosis, disseminated sclerosis, and extensive osteophytosis is known to reduce the intervertebral space.
Materials and Methods- A prospective randomized controlled study was conducted in patients aged 60-80 years undergoing urological surgeries after approvalfrom the Institutional Ethics Committee and written informed consent from the patients. Primary aim was to compare the number of bone contacts during administration of subarachnoid block with the patient in either pendant (Group A) or traditional (Group B) position. Secondary aims were to compare the proportion of successful spinal needle placements, ease of palpation of spinous processes, patient’s comfort, number of spaces used, time to perform spinal puncture, time to reach grade III (as per modified bromage score) motor blockade, time to reach T10 sensory level and rate of complications in both the groups.
Results- Demographic data was comparable and there was no statistical difference in number of bone contacts, ease of administration, success of spinal needle placements, performance times of subarachnoid block and duration of spinal anaesthesia in both the groups. Complication rates were comparable.
Conclusion- Pendant positioning does not confer any advantage over the traditional sitting position in success rates and performance characteristics of subarachnoid block in elderly (60-80 years) patients scheduled for urological surgeries.
Keywords: Pendant position, Spinal-bone contact, Spinal Needle Puncture, Lumbar puncture, Spinal anesthesia, Aged


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16. Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for genitourinary surgery. In: Butterworth JF, Mackey DC, Wasnick JD, editors. Morgan and Mikhail’s Clinical Anesthesiology. US: McGraw-Hill Education; 2013. pp. 671–90.
17. Fisher KS, Arnholt AT, Douglas ME, Vandiver SL, Nguyen DH. A randomized trial of the traditional sitting position versus the hamstring stretch position for labor epidural needle placement. AnesthAnalg. 2009;109:532–4

How to Cite this Article:  Dawn T, Batra YK, Rupal S, Kaur KJ, Samra T | Pendant Positioning Vs Traditional Sitting for Successful Spinal Punctures in Elderly | International Journal of Regional Anaesthesia | July- December 2023; 4(2): 9-13 | DOI:

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Thoracic Wall Blocks for Thoracic Surgery

Vol 4 | Issue 2 | July-December 2023 | Page 01-08 | Neha Pangasa, Anjolie Chhabra


Submitted: 08-07-2023; Reviewed: 01-09-2023; Accepted: 09-10-2023; Published: 10-12-2023

Authors: Neha Pangasa [1], Anjolie Chhabra [1]

[1] Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Address of Correspondence
Dr. Neha Pangasa
Assistant Professor, Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.


Thoracic epidural, paravertebral block and intercostal nerve block were the conventional methods of providing analgesia for thoracic surgery, about a decade ago. In the modern era with the advent of ultrasound guided regional anesthesia, the fascial plane blocks came as a boon to anesthesiologists. These blocks are safer, as the needle tip remains distant from the pleura and they are technically easier to perform. We have described in brief the various techniques for thoracic wall analgesia with special emphasis to fascial plane blocks, along with the current evidence for each block.
Keywords: Thoracic wall blocks, Fascial plane blocks, Local anaesthetic


1. Chin KJ, Pawa A, Forero M, Adhikary S. Ultrasound-guided fascial plane blocks of the thorax: pectoral I and II, serratus anterior plane, and erector spinae plane blocks. Advances in Anesthesia 2019; 37: 187–205.
2. Nair S, Gallagher H, Conlon N. Paravertebral blocks and novel alternatives. BJA Education 2020, 20(5): 158-65.
3. Karmakar MK. Thoracic Paravertebral Block. Anesthesiology 2001; 95:771– 80.
4. Yeung JHY, Gates S, Naidu BV, Leuwer M, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database of Systematic Reviews 2011; 5. Art. No.: CD009121.
5. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade: failure rate and complications. Anaesthesia. 1995 Sep;50(9):813-5.
6. Chhabra A, Chowdhury AR, Prabhakar H, Subramaniam R, Arora MK, 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(2).
7. Chin KJ, Versyck B, Pawa A. Ultrasound-guided fascial plane blocks of the chest wall: a state of the art review. Anaesthesia 2021, 76: 110–26.
8. Elsharkawy H, Pawa A, Mariano ER. Interfascial plane blocks: back to basics. Reg Anesth Pain Med 2018; 43: 341–6.
9. Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66: 847–8.
10. Blanco R, Fajardo M, Parras MT. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Revista Espanola De Anestesiologia Y Reanimacion 2012; 59: 470–5.
11. 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.
12. Johnston DF, Black ND, O’Halloran R, Turbitt LR, Taylor SJ. Cadaveric findings of the effect of rib fractures on spread of serratus plane injections. Canadian Journal of Anesthesia 2019; 66: 738–9.
13. Chin KJ ,Kariem ,Boghdadly KE. Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anesth 2021; 68:387–408.
14. Moustafa MA, Alabd AS, Ahmed AM, Deghidy EA. Erector spinae versus paravertebral plane blocks in modified radical mastectomy: Randomised comparative study of the technique success rate among novice anaesthesiologists. Indian J Anaesth 2020;64:49-54.
15. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Regional Anesthesia & Pain Medicine. 2016 Sep 1;41(5):621-7.
16. Yang H.M ,Choi Y.J, Kwon HJ, J. O, Cho T.H, Kim S.H. Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: a cadaveric study. Anaesthesia 2018, 73, 1244–50.
17. Ivanusic J, Konishi Y, Barrington M.J. A Cadaveric Study Investigating the Mechanism of Action of Erector Spinae Blockade. Reg Anesth Pain Med 2018;43: 567–71.
18. 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.
19. Adhikary SD, Liu WM, Fuller E, Cruz-Eng H, Chin KJ. The effect of erector spinae plane block on respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia 2019; 74: 585–93.
20. Jüttner T, Werdehausen R, Hermanns H , Enrico Monaca E, Oliver D, Pannen B.H et al. The paravertebral lamina technique: a new regional anesthesia approach for breast surgery. J Clin. Anesth. 2011; 23, 443–50.
21. Murouchi T, Yamakage M. Retrolaminar block: analgesic efficacy and safety evaluation. J Anesth 2016;30(6):1003-07.
22. Wang Q, Wei S, Li S, Yu J, Zhang G, Ni C et al. Comparison of the analgesic effect of ultrasound-guided paravertebral block and ultrasound-guided retrolaminar block in Uniportal video-assisted Thoracoscopic surgery: a prospective, randomized study. BMC Cancer 2021; 21:1229.
23. Costache I, Neumann LD, Ramnanan C.J, Goodwin S.L, Pawa A, Abdallah F.W et al. The mid-point transverse process to pleura (MTP) block: a new end-point for thoracic paravertebral block. Anesthesia 2017; 72(10): 1230-36.
24. Chen XU, Yang J, Xia M, Wu H, Wang S, Zhang W. Postoperative Analgesia After Uniportal Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial. J.Cardiothorac.Vasc. Anesth.2022; 36 : 2432-38.
25. Shibata Y, Kampitak W, Tansatit T. The Novel Costotransverse Foramen Block Technique: Distribution Characteristics of Injectate Compared with Erector Spinae Plane Block. Pain Physician. 2020 Jun;23(3):E305-E314. PMID: 32517407.
26. Nanda S, Bhoi D, Pangasa N, Jain D. Multiple injection costotransverse block for chronic pain in a patient with granulomatous mastitis. Indian J Anaesth 2021;65:772-4.
27. Chin KJ. 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 .
28. Pascarella, G.; Costa, F.; Nonnis, G.; Strumia, A.; Sarubbi, D.; Schiavoni, L.; Di Pumpo, A.; Mortini, L.; Grande, S.; Attanasio, A.; et al. Ultrasound Guided Parasternal Block for Perioperative Analgesia in Cardiac Surgery: A Prospective Study. J. Clin. Med. 2023, 12, 2060.
29. Diwan S, Nair A. Ultrasound‐guided bilateral parasternal block: A boon for managing pain after sternal fracture/ dislocation. Saudi J Anaesth 2020;14:224‐7.
30. Versyck B, Geffen GJV , Chin KJ. Analgesic efficacy of the Pecs II block: a systematic review and meta-analysis. Anaesthesia 2019; 74: 663–73.
31. Hussain N, Brull R, McCartney CJL, et al. Pectoralis-II myofascial block and analgesia in breast cancer surgery: a systematic review and meta-analysis. Anesthesiology 2019; 131: 630–48.
32. Liu XC, Song TT, Xu HY, Chen XJ, Yin PF, Zhang JJ. The serratus anterior plane block for analgesia after thoracic surgery: A meta- analysis of randomized controlled trails. Medicine 2020;99:21(e20286).
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How to Cite this Article: Pangasa N, Chhabra A | Thoracic Wall Blocks for Thoracic Surgery | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 01-08 | DOI:

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Supra-inguinal Fascia Iliaca Block and the Obturator Nerve Obsession

Vol 4 | Issue 2 | July-December 2023 | Page 27-28 | Sandeep Diwan, Georg Feigl, Shivaprakash S


Authors: Sandeep Diwan [1], Georg Feigl [2], Shivaprakash S [3]

[1] Department of Anaesthesia, Sancheti Institute of Orthopaedic and Rehabilitation, Pune, Maharashtra, India.
[2] Department of Anatomy and Clinical Morphology, Witten / Herdecke University, Witten, Germany.
[3] Department of Anatomy, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka State, India..

Address of Correspondence
Dr. Sandeep Diwan,
Department of Anaesthesia, Sancheti Institute of Orthopaedic and Rehabilitation, Pune, Maharashtra, India.

To the Editor,

Anatomic block efficacy of lumbar plexus elements is based upon the involvement of the obturator nerve. However, despite the anatomic location of the obturator nerve and improbable translocation of local anesthetic beyond the confinement of the fascia iliacus plane [1], investigators struggle to study extensively, exhaustively, and try to explicitly describe the means and mechanism to block the obturator nerve [2].
Our anatomical dissections reveal three important dissimilar fascial planes (figure 1a). The quadratus lumborum, the fascia iliaca, and the circum-psoas planes are isolated from each other with tight fascial attachments [Figure 1b], impeding the dissemination of local anaesthetic agents unless inadvertently perforating the fascia. Further exploration revealed the femoral, lateral femoral cutaneous, obturator nerves and the lumbosacral trunk emerge from the lateral and medial of the psoas muscle respectively, and exits the psoas fascia (figure 1a,1b, and 1c) to take their respective course. The obturator nerve might further arise in a separate muscular fold (Figure 1c).
However, if the obturator nerve needs to be blocked, two we recommend two alternatives; We presume that with injections deep to the psoas sheath, the plausibility of involvement of all the nerves of the lumbar plexus (lateral femoral cutaneous nerve, femoral nerve, and ON) exists, as reported in a case series [3] and the obturator nerve needs to be blocked separately after a supra-inguinal fascia iliaca block.


1. Bendtsen TF, Pedersen EM, Moriggl B, et al. Anatomical considerations for obturator nerve block with fascia iliaca compartment block. Reg Anesth Pain Med. 2021; 46:806-12.
2. Swenson JD, Davis JJ, Stream JO, Crim JR, Burks RT, Greis PE. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve. J Clin Anesth. 2015; 27:652-7.
3. Diwan S, Nair A, Gawai N, Shah D, Sancheti P. Circumpsoas block – an anterior myofascial plane block for lumbar plexus elements: case report. Braz J Anesthesiol. 2021: S0104-0014(21)00180-9.

How to Cite this Article:   Diwan S, Feigl G, S Shivaprakash | Supra-inguinal Fascia Iliaca Block and the Obturator Nerve Obsession | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 27-28 | DOI:

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Making Regional Anaesthesia Safe

Vol 4 | Issue 2 | July-December 2023 | Page 21-26 | Ashish A. Bartakke


Submitted: 12-11-2023; Reviewed: 18-11-2023; Accepted: 25-11-2023; Published: 10-12-2023

Authors: Ashish A. Bartakke [1]

[1] Department of Anaesthesiology and Perioperative Medicine, Hospital Valle de los Pedroches, Pozoblanco, Andalucia, Spain.

Address of Correspondence
Dr. Ashish A. Bartakke,
Senior Faculty Consultant, Department of Anaesthesiology and Perioperative Medicine, Hospital Valle de los Pedroches, Pozoblanco, Andalucia, Spain.


The complexity of current practice in anaesthesiology and perioperative medicine has resulted in employing complex regional anaesthesia techniques to improve patient outcomes in terms of better postoperative pain control and thus facilitate early mobilization and recuperation of patients. However, ensuring patient safety while performing these complex procedures is of paramount importance and all efforts need to be undertaken to minimise the possibility of harm to the patient. Quality improvement and patient safety go hand in hand. Ensuring safe practices in regional anaesthesia is not just an individual task but a collective responsibility of the perioperative team. It thus involves both technical skills as well as non-technical skills and human factors.
This article provides a brief discussion of the various measures involving technical and non-technical factors to improve patient safety in modern day regional anaesthesia practice.
Keywords: Regional Anaesthesia, Patient safety, Non-technical skills, Human factors


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7. Bomberg H, Bayer I, Wagenpfeil S et al. Prolonged catheter use and infection in regional anesthesia: a retrospective registry analysis. Anesthesiol J Am Soc Anesthesiol 2018; 128: 764e73
8. Keys M, Sim BZ, Thom O, Tunbridge MJ, Barnett AG, Fraser JF. Efforts to Attenuate the Spread of Infection (EASI): a prospective, observational multicentre survey of ultrasound equipment in Australian emergency departments and intensive care units. Crit Care Resusc J Australas Acad Crit Care Med 2015; 17: 43e6
9. Ecoffey C, Bosenberg A, Lonnqvist PA, Suresh S, Delbos A, Ivani G. Practice advisory on the prevention and management of complications of pediatric regional anesthesia. J Clin Anesth. 2022;79:110725. doi:10.1016/j.jclinane.2022.110725
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12. Dohlman LE, Kwikiriza A, Ehie O. Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings. Local Reg Anesth. 2020;13:147-158. Published 2020 Oct 22. doi:10.2147/LRA.S236550
13. Mulroy MF, Weller RS, Liguori GA. A checklist for performing regional nerve blocks [published correction appears in Reg Anesth Pain Med. 2014 Jul-Aug;39(4):357]. Reg Anesth Pain Med. 2014;39(3):195-199. doi:10.1097/AAP.0000000000000075
14. Stop before you block. Available from: [Accessed 25 March 2020]

How to Cite this Article:   Bartakke AA | Making Regional Anaesthesia Safe | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 21-26 | DOI:

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Brachial Plexus Block in Lateral Position for Fracture Shaft Humerus in Severe Thoracic Kyphoscoliosis- A Case Report

Vol 4 | Issue 2 | July-December 2023 | Page 18-20 | Sandeep Mutha, Sushmitha K, Rajan Kothari, Deepak Phalgune


Submitted: 24-03-2023; Reviewed: 16-04-2023; Accepted: 11-10-2023; Published: 10-12-2023

Authors: Sandeep Mutha [1], Sushmitha K [1], Rajan Kothari [2], Deepak Phalgune [3]

[1] Department of Anaesthesiology, Poona Hospital and Research Centre, Pune, Maharashtra, India.
[2] Department of Orthopaedic Surgery, Poona Hospital and Research Centre, Pune, Maharashtra, India.

Address of Correspondence
Dr. Deepak Phalgune
Research Consultant, Poona Hospital & Research Centre, Pune, Maharashtra, India.


Patients with spine deformities, present unique challenges to the anaesthesiologists. These patients have abnormalities such as cardiovascular, pulmonary, musculo-skeletal, etc. Spinal deformities may cause difficulties with ventilation, tracheal intubation, regional anaesthesia and positioning. Due to problems associated with respiratory system, regional anaesthesia is widely preferred, though it is technically and logistically difficult. We present a case report of the anaesthetic management of an elderly female with severe thoracic kyphoscoliosis who could not lie supine on bed. She had a fracture of left upper 1/3rd shaft humerus. She was posted for open reduction and internal fixation of fractured shaft of left humerus under brachial plexus nerve block in right lateral position with a pillow under the head. The patient was given left interscalene and costoclavicular (infraclavicular) brachial plexus block under ultrasonography and peripheral nerve stimulator guidance. Major problems for brachial plexus block were positioning, approach, dosage of medications and respiratory compromise. Another difficulty was the position of the patient during the surgical procedure. The surgery was successful and the patient was pain free both intra and postoperatively. Intraoperatively no sedation or anxiolysis were required
Keywords: Kyphoscoliosis, Brachial plexus block, Fracture humerus, Patient position.


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How to Cite this Article:   Mutha S, Sushmitha K, Kothari R, Phalgune D | Brachial Plexus Block in Lateral Position for Fracture Shaft Humerus in Severe Thoracic Kyphoscoliosis- A Case Report | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 18-20 | DOI:

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