Genomics and Precision Analgesia: Is this the era?

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Vol 6 | Issue 1 | January-June 2025 | Page 15-19 | Bhuvaneswari Balasubramanian, Sandeep Diwan

DOI: https://doi.org/10.13107/ijra.2025.v06.i01.116

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted: 24-02-2025; Reviewed: 19-03-2025; Accepted: 19-05-2025; Published: 10-06-2025

Authors: Bhuvaneswari Balasubramanian [1]

 Sandeep Diwan [2]

[1] Department of Anaesthesiology & Critical Care, AIIMS, Nagpur, Maharashtra, India.
[2] Department of Anaesthesiology, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence

Dr. Bhuvaneswari Balasubramanian
Department of Anaesthesiology & Critical Care, AIIMS, Nagpur, Maharashtra, India.
Email: docbhuvaneswari@gmail.com

Abstract

Interindividual variability in analgesic response reflects heritable differences in drug metabolism, receptor expression, neurotransmitter turnover, and central nervous system drug transport. Pharmacogenomic advances have clarified functional consequences of polymorphisms in CYP2D6, CYP3A4, UGT2B7, OPRM1, COMT, and ABCB1, each of which influences opioid and non-opioid pharmacokinetics and pharmacodynamics. CYP2D6 metabolizer status determines conversion of prodrugs such as codeine and tramadol to active metabolites, while CYP3A4 variation modulates systemic opioid clearance. OPRM1 A118G alters μ-opioid receptor binding affinity and signaling, COMT Val158Met influences catecholamine-mediated pain sensitivity, and ABCB1 variants affect opioid penetration across the blood–brain barrier. Clinical studies demonstrate genotype-associated differences in analgesic efficacy and toxicity, though effect sizes vary across populations and analgesic classes. Implementation remains constrained by limited genotype-stratified randomized trials, testing turnaround time, unclear cost-effectiveness, and underrepresentation of Asian and Southeast Asian ancestry groups in genomic datasets. This mini-review synthesizes mechanistic foundations, clinical evidence, population variation, and practical considerations for integrating pharmacogenomics into perioperative and chronic pain management.
Keywords: Genomics, Pharmacogenetics, Precision medicine, Analgesia, CYP2D6, Postoperative pain, Opioids

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How to Cite this Article: Balasubramanian B, Diwan S. Genomics and Precision Analgesia – Is This the Era? International Journal of Regional Anaesthesia. January-June 2025; 6(1): 15-19. DOI: https://doi.org/10.13107/ijra.2025.v06.i01.116

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Intrafascicular Injection: Can AI, Ultrasound, Pressure Monitoring, and Echogenic Needles Prevent It?

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Vol 6 | Issue 1 | January-June 2025 | Page 08-14 | Divesh Arora

DOI: https://doi.org/10.13107/ijra.2025.v06.i01.114

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted: 28-02-2025; Reviewed: 22-03-2025; Accepted: 25-05-2025; Published: 10-06-2025

Authors: Divesh Arora [1]

[1] Department of Anaesthesia & OT Services, Asian Hospital, Faridabad, Haryana, India.

Address of Correspondence

Dr. Divesh Arora,
Director & HOD, Department of Anaesthesia & OT Services, Asian Hospital, Faridabad, Haryana, India.
Email ID: drdivesh@gmail.com

Abstract

Intrafascicular injection represents one of the most serious complications in regional anaesthesia, potentially resulting in irreversible neurological injury. Despite the advances in ultrasound-guided techniques, inadvertent intraneural and intrafascicular injections still occur. This review synthesizes the current understanding of nerve microanatomy, mechanisms of nerve injury, and the diagnostic and preventive strategies aimed at avoiding this catastrophic event. It highlights the role of ultrasound technology, echogenic needle innovations, injection pressure monitoring, neurostimulation, and emerging applications of artificial intelligence in enhancing procedural safety. The integration of these multimodal safety tools can significantly reduce operator dependency and improve real-time feedback during nerve block procedures. With continued technological refinement, structured training, and incorporation of AI-assisted imaging and robotics, the risk of intrafascicular injection can be minimized, thereby improving patient safety and outcomes in regional anaesthesia.
Keywords: Intrafascicular injection, Regional anaesthesia safety, Ultrasound guidance, Echogenic needles, Pressure monitoring, Artificial intelligence.

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How to Cite this Article: Arora D. Intrafascicular Injection: Can AI, Ultrasound, Pressure Monitoring, and Echogenic Needles Prevent It? International Journal of Regional Anaesthesia. January-June 2025; 6(1): 08-14. DOI: https://doi.org/10.13107/ijra.2025.v06.i01.114

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Regional Anaesthesia for Cancer Surgery and Its Impact on Recurrence and Metastasis: What Is the Evidence?

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Vol 6 | Issue 1 | January-June 2025 | Page 20-27 | Anju Grewal, Revanth Babu Challa, Jyoti Sharma

DOI: https://doi.org/10.13107/ijra.2025.v06.i01.118

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted: 15-01-2025; Reviewed: 08-02-2025; Accepted: 22-04-2025; Published: 10-06-2025

Authors: Anju Grewal [1], Revanth Babu Challa [2], Jyoti Sharma [1]

[1] Department of Anaesthesiology, All India Institute of Medical Sciences, Bathinda, Punjab, India.
[2] Department of Anaesthesiology, All India Institute of Medical Sciences, Nagpur, Maharashtra, India.

Address of Correspondence

Dr. Jyoti Sharma
Associate Professor, Department of Anaesthesiology, All India Institute of Medical Sciences, Bathinda, Punjab, India.
Email- drjyotisharma1014@gmail.com

Abstract

Regional anaesthesia (RA) is thought to potentially affect cancer recurrence and metastasis by reducing the perioperative stress response, supporting immune function, and decreasing the use of opioids and volatile agents. This review examines the mechanistic evidence and clinical results across eight major cancer types. Although RA reliably enhances pain management and perioperative recovery, its impact on cancer outcomes remains uncertain. The most notable reductions in recurrence are observed in bladder and oesophageal cancers, while the effects on breast, colorectal, gastric, and gynaecological cancers are limited. Variability in study methods, confounding variables, and a scarcity of high-quality randomised controlled trials hinder definitive conclusions. Until more solid evidence is available, personalised anaesthetic strategies are essential.
Keywords: Regional Anaesthesia, Cancer Recurrence, Metastasis

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47. Kochhar A, Banday J, Ahmad Z, Panjiar P, Vajifdar H. Cervical epidural analgesia combined with general anesthesia for head and neck cancer surgery: A randomized study. J Anaesthesiol Clin Pharmacol. 2020 Apr 1;36(2):182–6.
48. Cata JP, Zafereo M, Villarreal J, Unruh BD, Truong A, Truong DT, et al. Intraoperative opioids use for laryngeal squamous cell carcinoma surgery and recurrence: A retrospective study. J Clin Anesth. 2015 Dec 1;27(8):672–9.
49. Merquiol F, Montelimard AS, Nourissat A, Molliex S, Zufferey PJ. Cervical epidural anesthesia is associated with increased cancer-free survival in laryngeal and hypopharyngeal cancer surgery: A retrospective propensity-matched analysis. Reg Anesth Pain Med. 2013;38(5):398–402.
50. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can Anesthetic Technique for Primary Breast Cancer Surgery Affect Recurrence or Metastasis? Anesthesiology. 2006 Oct 1;105(4):660–4.
51. Li M, Zhang Y, Pei L, Zhang Z, Tan G, Huang Y. Potential Influence of Anesthetic Interventions on Breast Cancer Early Recurrence According to Estrogen Receptor Expression: A Sub-Study of a Randomized Trial. Front Oncol. 2022 Feb 10;12.
52. Zhang J, Chang CL, Lu CY, Chen HM, Wu SY. Paravertebral block in regional anesthesia with propofol sedation reduces locoregional recurrence in patients with breast cancer receiving breast conservative surgery compared with volatile inhalational without propofol in general anesthesia. Biomedicine and Pharmacotherapy. 2021 Oct 1;142.
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63. Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ. Anesthetic Technique for Radical Prostatectomy Surgery Affects Cancer Recurrence A Retrospective Analysis [Internet]. Vol. 109, Anesthesiology. 2008. Available from: www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf.
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66. Wuethrich PY, Schmitz SFH, Kessler TM, Thalmann GN, Studer UE, Burkhard FC. PERIOPERATIVE MEDICINE Potential Influence of the Anesthetic Technique Used during Open Radical Prostatectomy on Prostate Cancer-related Outcome A Retrospective Study [Internet]. Vol. 113, Anesthesiology. 2010. Available from: www.anesthesiology.org
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How to Cite this Article: Grewal A, Challa RB, Sharma J. Regional Anaesthesia for Cancer Surgery and Its Impact on Recurrence and Metastasis: What Is the Evidence? International Journal of Regional Anaesthesia. January-June 2025; 6(1): 20-27. DOI: https://doi.org/10.13107/ijra.2025.v06.i01.118

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The Illusion of Precision: Artificial Intelligence Unmasked

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Vol 6 | Issue 1 | January-June 2025 | Page 04-07 | Ghansham Biyani, Rajasekhar Metta

DOI: https://doi.org/10.13107/ijra.2025.v06.i01.112

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted: 16-01-2025; Reviewed: 08-02-2025; Accepted: 22-04-2025; Published: 10-06-2025

Authors: Ghansham Biyani [1], Rajasekhar Metta [1]

[1] Department of Anaesthesiology, AIIMS Mangalagiri, Guntur, Andhra Pradesh, India.

Address of Correspondence

Dr. Rajasekhar Metta,
Assistant Professor, Department of Anaesthesiology, AIIMS Mangalagiri, Guntur, Andhra Pradesh, India.
Email ID: rajamc6@gmail.com

Abstract

Artificial intelligence (AI), defined by John McCarthy as the science and engineering of making intelligent machines, has evolved to encompass systems capable of performing complex cognitive tasks. In regional anaesthesia (RA), AI has shown promise in enhancing ultrasound (US) image interpretation, improving accuracy through convolutional neural networks (CNNs) and computer vision. Current evidence suggests that AI-assisted systems can increase first-attempt success rates, reduce procedural duration, and improve postoperative outcomes by accurately identifying sonoanatomical structures. Moreover, AI-based educational tools offer standardized, scalable training models for novice medical learners. However, current limitations include difficulty in object tracking due to low tissue contrast, variable accuracy across anatomical regions, and inadequate validation of patient-centred outcomes. Ethical, legal, and data privacy concerns further hinder widespread clinical adoption. While AI holds potential to augment, but not replace, clinical expertise in US-guided RA, further large-scale studies and regulatory frameworks are essential before it can be reliably integrated into routine anaesthetic practice.
Keywords: Artificial intelligence, Regional anaesthesia, Predictive analytics, Machine learning, Color overlay, Peripheral nerve blocks

References

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2. McKendrick M, Yang S, McLeod GA. The use of artificial intelligence and robotics in regional anaesthesia. Anaesthesia 2021; 76: 171-81.
3. Balavenkatasubramanian J, Kumar S, Sanjayan RD. Artificial intelligence in regional anaesthesia. Indian J Anaesth 2024; 68(1): 100-4.
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6. Bowness JS, Macfarlane AJR, Burckett-St Laurent D, Harris C, Margetts S, Morecroft M, et al. Evaluation of the impact of assistive artificial intelligence on ultrasound scanning for regional anaesthesia. Br J Anaesth 2023; 130(2): 226-33.
7. Oh TT, Ikhsan M, Tan KK, Rehena S, Han NR, Sia ATH, et al. A novel approach to neuraxial anesthesia: Application of an automated ultrasound spinal landmark identification. BMC Anesthesiol 2019; 19(1): 57.
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10. Viderman D, Dossov M, Seitenov S, Lee MH. Artificial intelligence in ultrasound-guided regional anesthesia: A scoping review. Front Med (Lausanne) 2022; 9: 994805.
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How to Cite this Article: Biyani G, Metta R. The Illusion of Precision: Artificial Intelligence Unmasked. International Journal of Regional Anaesthesia. January-June 2025; 6(1): 04-07. DOI: https://doi.org/10.13107/ijra.2025.v06.i01.0112

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Rural to Remote to the Recent Trends in Regional Anaesthesia

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Vol 6 | Issue 1 | January-June 2025 | Page 01-03 | Anju Gupta, Sandeep Diwan

DOI: https://doi.org/10.13107/ijra.2025.v06.i01.110

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted: 14-03-2025; Reviewed: 26-03-2025; Accepted: 18-05-2025; Published: 10-06-2025

Authors: Anju Gupta [1], Sandeep Diwan [2]

[1] Department of Anaesthesiology & Critical Care, AIIMS, Delhi, India.
[2] Department of Anaesthesiology, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence

Dr. Anju Gupta,
Department of Anaesthesiology & Critical Care, AIIMS Delhi, India.
Email ID: dranjugupta09@gmail.com

Editorial

Regional anaesthesia (RA) has undergone significant transformation over the last few decades from being a dispensable part of anaesthesia to presently being the core skill and foundational pillar of anaesthesia in contemporary anaesthesia practice. RA has always been a flexible field—focused on pragmatism, using minimal resources efficiently, tailoring anaesthesia to individual perioperative needs, and prioritising patient-centred outcomes [1]. This practical based approach of maximizing resource utilisation has been most evident in rural and remote areas, where clinicians have since long turned limited resources into innovative solutions. Today, the same values that helped RA thrive in such settings are fueling its newest exciting developments: portable technology, built-in safety, interdisciplinary collaboration, scientific breakthroughs, and advent of artificial intelligence, all contributing to reconfiguration of RA to be a more refined, evidence–based, and widely adopted approach in contemporary medical practice [1, 2]. From its roots in resource limited rural practice to its cutting-edge modern advances, RA continues to make progress in tandem with our dynamic speciality.
RA has been a key skill in the armamentarium of anaesthesiologists working in rural and remote areas since ages to solve the limited infrastructures and to navigate the complex clinical scenarios that were far fetched with general anaesthesia (GA). It has been more of a necessity than a luxury in these set ups which have furthered innovations in this field. Conditions in many of these set ups is far from the recommended guidelines for basic minimum standards to provide anaesthesia with an overall limited access to clean and well equipped operation rooms with central pipelines, anaesthesia workstations, advanced monitoring techniques, ventilators with advance modes, anaesthesia and emergency drugs, fluid and blood products, and post-operative high-dependency or intensive care unit [3, 4]. The only monitor might be the vigilant eye of an experienced anaesthesiologist. The emphasis has always been on minimally resource intensive opioid sparing anaesthesia techniques requiring lesser consumables and drugs, preserving spontaneous ventilation, allowing faster recovery and hospital discharge, and minimising opioid related adverse events [4]. These objectives can readily be met by incorporating RA into anaesthesia Use of RA to provide procedural anaesthesia avoids the need to handle the airway in these resource limited facilities while ensuring patient safety as the complications have remained astonishingly low [5]. Similarly, RA has revolutionised trauma care in remote areas—be it on-arrival blocks, facilitating closed reductions, physiotherapy; providing rib fracture analgesia with safer fascial plane blocks.
While resource constraint and economical use of resources has been the main driving factor in RA adoption in these rural and remote set-ups, safety remains the topmost priority. The widespread use of nerve stimulators and now even ultrasound is a testament to that. Anaesthesiologists working in these areas have realised the importance of safety and precision especially since rescue options are limited. Ultrasound has enhanced the safety of RA multi-folds by visualising needle trajectory and avoiding critical structures, reducing the dose of local anaesthetist and improving the block success [6]. Innovations like portable and pocket-sized ultrasound compatible with smartphones have made the integration of ultrasound even more feasible for freelancers who carry their own equipment. However, cost concerns and stringent laws by the government have made procurement and use of ultrasound difficult for free lancers in India and they may still have to rely on landmark or neurostimulation guided blocks. In the present issue, Muthu SC identify simplified landmark or neurostimulation guided block techniques for rural and remotely placed hospitals which can be utilised with reasonable success rates when visualised needle placement is not an option [7].
Furthermore, even with the use of ultrasound intraneural injection cannot be ruled out. Hence, use of multimodal techniques comprising ultrasound, injection pressure monitoring, echogenic needles, use of AI and neurostimulation has been advocated as identified by Arora D in a review article on intrafasicular injection in this issue [8]. However, these would not be available in majority remote and rural areas. A breakthrough in the RA practice is the introduction and widespread popularity of fascial plane blocks such as transversus abdominis plane (TAP) block, erector spinae plane block (ESPB), serratus anterior plane block (SAPB) etc., permitting excellent analgesia with remarkable safety profile, preserving hemodynamic stability and avoiding damage to critical structures facilitating easy recovery and discharge [9]. Hence, these techniques have further expanded our armamentarium and provided us with enumerable options to choose from to suit individual patient profiles.
Enhanced recovery after surgery (ERAS) pathways utilise the multimodal analgesia with RA as a central component [10]. The concept of multimodal analgesia was rooted in the rural and remote anaesthesia practice as a means to reduce risk due to opioid analgesics by incorporating various non-opioid analgesics and RA. Recent trends favour ambulatory-friendly modalities: single-shot blocks with long-acting local anaesthetics; low-volume techniques that spare motor function; and even portable disposable infusion pumps which allow continuous peripheral nerve block on ambulatory basis. Though considered contemporary developments, these practices providing safe analgesic management are a boon to anaesthesiologists working in rural and remote settings furthering the safety and efficacy.
Another major advancement which has changed the landscape of RA in rural and remote areas is easy access to training and mentorship. Tele-mentoring has bridged the gap in guidance and supervision available in remote areas [11]. Various educational forums on social media enable discussion and almost instant problem-solving. Furthermore, the expanding research base has provided newer insights on the nitty-gritty of RA.
Artificial intelligence (AI) is entering RA, but the most promising applications are humble: real-time probe orientation hints, automatic structure labelling, and needle-tip detection—tools that teach as they guide [12]. Augmented reality overlays may soon help a novice reproduce an expert’s probe and needle alignment. Importantly, these tools should augment—not replace—anatomical understanding and clinical judgement. Rural contexts will keep us honest: technology that fails offline, drains batteries by noon, or confuses the user will be abandoned. The winners will be simple, robust, and clinically meaningful.
In this issue of International Journal of Regional Anaesthesia, Biyani and Metta discuss the promising role of AI in addressing the challenges in image interpretation during ultrasound guided RA especially in the subset of patients with difficult sonoanatomy or deep/difficut blocks like neuraxial blocks [13]. They have comprehensively discussed various applications of AI in RA and the various pros and cons of use of AI for RA. They have aptly pointed out that the quality of AI generated data relies heavily on inputs provided by the operator. Notably, authors mention that AI tools are expensive and often impractical to use in resource-limited settings.
Contemporary medical practice aims towards precision based medicine and RA is not behind. Recent advances in pharmacogenetics and genomics hold promise to revolutionise RA and pain management through precision analgesia. A review article by Bhuvaneshwari and Diwan explores the current landscape, challenges, and potential of genomics-driven precision analgesia in perioperative and critical care settings [14].
Among the reasons for a growing interest in RA for oncoanaesthesia is its promising role of RA in preventing cancer recurrence by reducing the perioperative stress response, supporting immune function, and decreasing the use of opioid and volatile anaesthetics. Grewal et al. [15] appropriately notice that although RA reliably enhances pain management and perioperative recovery, its impact on cancer outcomes remains uncertain. The main reason cited in their article is the variability in study methods, confounding variables, and a scarcity of high-quality randomised controlled trials to draw definitive conclusions. Authors caution that until more solid evidence is available, personalised anaesthetic strategies are essential.
To conclude, the path of RA is not fixed linear progress forward but more of a pragmatic and dynamic one where individualised patient management is the goal with a focus on safety. Rural and remote RA practice has always centered on the principles of sound knowledge of anatomy and physiology, portable equipment, creative thinking and deep concern for patient safety. Modern RA practice has only amplified those values and techniques to further the cause of patient safety and best outcomes. Incorporating novel tools like ultrasound and artificial intelligence into the ethos of rural RA techniques has taken RA to new heights where it is now considered the foundational pillars of anaesthesia. Whether in a small remote clinic or an urban hi-tech facility, whether done on a high-end ultrasound machine or with a handheld ultrasound, the essence of RA stays the same: precise, thoughtful care that supports natural physiology and helps patients recover well. The move from rural beginnings to cutting-edge technology driven practice is not a breaking free from the past but moving forward in the best possible way—a targeted, profound care while respecting patient physiology and empowering early recovery. To sum it up, the journey of RA from rural and remote roots to the current leading edge era is not a departure; it is a reunification.

References

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7. Muthu SC. Simplified Block Techniques for Rural and Remotely Placed Hospitals IJRA 2025; current issue.
8. Arora D. Intrafascicular injection: Can ai, ultrasound, pressure monitoring, and echogenic needles prevent it? IJRA; 2025: Current issue.
9. Dost, B. Fascial plane blocks in the era of modern regional anesthesia: shaping the future of pain management. J Anesth Analg Crit Care 5, 49 (2025).
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13. Biyani G, Metta R. The Illusion of Precision: Artificial Intelligence Unmasked. IJRA 2025, current issue.
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15. Grewal et al.Regional Anaesthesia for Cancer Surgery and Its Impact on Recurrence and Metastasis: What Is the Evidence? IJRA 2025; current issue. DOI: https://doi.org/10.13

How to Cite this Article: Gupta A, Diwan S. Genomics and Precision Analgesia – Is This the Era? International Journal of Regional Anaesthesia. January-June 2025; 6(1): 01-03.DOI: https://doi.org/10.13107/ijra.2025.v06.i01.110

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