Rural to Remote to the Recent Trends in Regional Anaesthesia
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
1. Moka E. Transforming Perioperative Care: Evolving Paradigms of the Expanding Role of Regional Anesthesia and Acute Pain Management. J Clin Med. 2025 Sep 4;14(17):6257.
2. Ramachandran S, Malhotra N, Velayudhan S, Singh Bajwa SJ, Joshi M, Mehdiratta L, Hiremath VR. Regional anaesthesia practices in India: A nationwide survey. Indian J Anaesth. 2021 Dec;65(12):853-861.
3. Lee, Seung, Azuka Onye, Asad Latif. Emergency Anesthesia in Resource-Limited Areas. Advances in Anesthesia, 2020 Volume 38, 209 – 227
4. Ariyo P, Trelles M, Helmand R, Amir Y, Hassani GH, Mftavyanka J, Nzeyimana Z, Akemani C, Ntawukiruwabo IB, Charles A, Yana Y, Moussa K, Kamal M, Suma ML, Ahmed M, Abdullahi M, Wong EG, Kushner A, Latif A. Providing Anesthesia Care in Resource-limited Settings: A 6-year Analysis of Anesthesia Services Provided at Médecins Sans Frontières Facilities. Anesthesiology. 2016 Mar;124(3):561-9.
5. Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Clin Sports Med. 2022 Apr;41(2):329-343.
6. Marhofer P, Greher M, Kapralet S. Ultrasound guidance in regional anaesthesia. British Journal of Anaesthesia, Volume 94, Issue 1, 7 – 17
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).
10. Tippireddy S, Ghatol D. Anesthetic Management for Enhanced Recovery After Major Surgery (ERAS) [Updated 2023 Jan 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574567/
11. Alrasheedi, N. T., Alkhubran, A. J., Alanazi, S. D. S., Al-Sahman, S. M. A., Asiri, R. A. A., Almoushawa, A. A., Alturaif, A. S., Almosa, J. A., Aldosari, A. F. (2023). “Tele-Anesthesia and Remote Supervision: Changing Perioperative and General Medical Care”, Integrative Biomedical Research (Journal of Angiotherapy), 7(1),1-9,10317
12. Balavenkatasubramanian J, Kumar S, Sanjayan RD. Artificial intelligence in regional anaesthesia. Indian J Anaesth. 2024 Jan;68(1):100-104.
13. Biyani G, Metta R. The Illusion of Precision: Artificial Intelligence Unmasked. IJRA 2025, current issue.
14. Bhuvaneshwari B, Diwan S. Genomics and Precision Analgesia – Is This the Era? IJRA 2025, current issue
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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Alright, real talk about the Miami rental game — it’s a straight-up jungle out here. Then you show up at the lot. Plus they freeze $2500 on your card for a week. Fool me eight times? That’s just another Tuesday in the 305. luxury car rental miami fl. Miami without decent wheels is basically a hostage situation. South of Fifth brunch, Design District shopping, or a spontaneous Keys trip — AC must be arctic cold and unlimited miles non-negotiable. most are shiny turds with five-star fake reviews on Google Maps. Finally found one outfit that doesn’t play stupid games. Here’s the only honest source for premium wheels across South Florida
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Let me give it to you straight — renting a decent car in Miami is way harder than it should be. You see this amazing deal online — shiny Audi, unlimited miles, price that makes you want to book right now. Plus they put a $5000 hold on your card and say “don’t worry about it”. Fool me nineteen times? That’s just Miami being Miami. luxury car rental miami fl. anyone who’s taken the bus here knows what I mean. leather seats that won’t melt your skin in August. most are shiny garbage with fake five-star reviews. no games, no switch, no hidden fees. prices change daily so check it out:
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Let me save you some serious pain with this Miami rental nonsense. You see this gorgeous deal online — clean spec, fair price, looks like a dream. Completely different car sitting there — dents everywhere, smells like cheap air freshener covering something worse, and that “dream price”? Doesn’t include the mandatory $50 daily insurance or the $300 “administrative fee” they invent at checkout. Eleven years in South Florida and these clowns still almost get me. luxury car rental miami fl. anyone who’s tried the bus here knows exactly what I mean. leather seats that won’t fuse to your legs in August. I’ve tested maybe 60 rental companies across Dade, Broward, and Collier. no games, no switch, no hidden BS in paragraph 12 of the contract. prices change hourly so check before the weekend crowd wipes them out:
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