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

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

DOI: https://doi.org/10.13107/ijra.2023.v04i01.066

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: vanzundertandre@gmail.com & a.vanzundert@uq.edu.au

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.

References

[1] https://www.un.org/en/dayof8billion (accessed 02.01.2023)
[2] https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy (accessed 02.01.2023).
[3] https://ourworldindata.org/life-expectancy (accessed 02.01.2023).
[4] Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016 Aug 31;16(1):157.
[5] Cutfield G. Anaesthesia and perioperative card for elderly surgical patients. Aus Prescr 2002;25:42-44.
[6]] George EL, Hall DE, Youk A, et al. Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties. JAMA Surg. 2021;156(1):e205152.
[7] Cuvillon P, Lefrant JY, Gricourt Y. Considerations for the Use of Local Anesthesia in the Frail Elderly: Current Perspectives. Local Reg Anesth. 2022 Aug 10;15:71-75.
[8] Shbeer A. Regional Anesthesia (2012-2021): A Comprehensive Examination Based on Bibliometric Analyses of Hotpots, Knowledge Structure and Intellectual Dynamics. J Pain Res. 2022 Aug 15;15:2337-2350.
[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: https://doi.org/10.13107/ijra.2023.v04i01.066

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Time to Standardize Regional Anesthesia Blocks: An International Effort for a Good Cause

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Vol 3 | Issue 1 | January-June 2022 | Page 01-02 | Rafael Blanco

DOI: 10.13107/ijra.2022.v03i01.045

Authors: Rafael Blanco [1]

[1] Department of Anaesthesia, King’s College Hospital London, Dubai, UAE.

Address of Correspondence
Dr. Rafael Blanco,
Department of Anaesthesia, King’s College Hospital London, Dubai, UAE.
E-mail: rafablanco@mac.com

During the last 10 years, we have seen an explosion of novel nerve blocks based on different ways of describing either anatomical targets, fascial planes, or local anesthetic distributions. The introduction of ultrasound machines in regional anesthesia had a major impact factor in this. To put our readers in perspective more than 100 published blocks have been developed during this time. Very wisely, a group of sixty internationally recognized experts in the field of regional anesthesia embarked on a project to reach a consensus on this matter. These could be useful for educating or researching the new generation of interventional pain and regional anesthetists.

The project called the international Delphi consensus study on its first publication concentrated on abdominal, paraspinal and chest thoracic wall blocks. This is based on the popularity of these novel blocks when we look at publications in recent years.
The conclusion of the Delphi paper stated a strong consensus for the majority of block approaches. The following are some examples of this:
The posterior TAP and the lateral quadratus lumborum blocks were unified into the latter. For the paraspinal blocks there was a weak or no consensus so it will require more time for this.
The rhomboid intercostal plane block achieved strong consensus for the anatomical description only but this was not the case for the serratus plane block. Equally the PECS block did not achieve strong consensus into changing to inter pectoral plane block so will be discretionary for the time being. The same applies to the PECS II block into pecto-serratus block, which will be discretionary based on weak consensus.

Finally, there was a strong consensus that the superficial, deep, or muscle-related planes composed of connective tissue should be called fascial planes rather than interfascial planes applying only in reference to anatomical descriptions.

It is very important to address that this publication is the first of this kind and may be prone to bias and different answers, depending on the way the questions were formulated but it is a starting point. It aims to see the real impact over the coming years in the field. Simple, clear and descriptive approaches should be the three pillars to be used in regional anesthesia, the same as the three pillars that resume a good standard of care: education, research and clinical application. This year 2022 we will hopefully see published a second round on the matter, this time involving upper and lower limb blocks so we are optimistic in terms of a new era in regional anesthesia.

It is undeniable that we are living in a time of immense popularity of regional anesthesia specialty and we must not lose momentum to build recognition of the work well done. We have brought back the importance of basic medical subjects like anatomy, attracting interest within the anesthesiologist. We want our specialty to make sense and provide clear evidence of why we need to block and why the idea of “no patient without a block” or a “multimodal approach” is our goal. Regional anaesthesiologists are highly skilled doctors, with invaluable hands-on skills. Our colleagues know that and we should be proud of that. Other fields that are closely connected like chronic pain interventional medicine should be reviewed in the years to come and perhaps by them we could also address nomenclature and the technique effectiveness.

As part of this editorial, we would like to encourage our readers to work together in this direction, continue researching and sharing their expertise, their findings, for the benefit of our global community. Reevaluation will also be needed as some of the names in previously published article has gained popularity and most probably will be difficult to revert.

References

El-Boghdadly K, Wolmarans M, Stengel AD, et al. Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks Reg Anesth Pain Med 2021;46:571–580.

How to Cite this Article: Blanco R | Time to Standardize Regional Anesthesia Blocks: An International Effort for a Good Cause | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 01-02.

 

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Ultrasound and Modern Regional Anaesthesia

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Vol 2 | Issue 2 | July-December 2021 | Page 100-101  | T.V.S.Gopal

DOI: 10.13107/ijra.2021.v02i02.035

Authors: T.V.S. Gopal [1, 2, 3]

[1] Managing Director, Axon Anaesthesia Associates, Hyderabad, Telangana, India.
[2] Clinical Director, Anaesthesiology, General O.T.& C.O.P.Complex, Care Hospitals, Hyderabad, Telangana, India.
[3] Chairperson, Past Academic Director & President AORA India.

Address of Correspondence
Dr. T.V.S Gopal,
Managing Director, Axon Anaesthesia Associates, Hyderabad, Telangana, India.
Clinical Director, Anaesthesiology, General O.T.& C.O.P.Complex, Care Hospitals, Hyderabad, Telangana, India.
E-mail: tvsgopal@gmail.com

Editorial

Lazzaro Spallanzani, an 18th century Italian biologist, is credited with the discovery of ultrasound, which he coined ‘echolocation’. [1] Little may he have realized then that his revelation would transform into an all pervading technology in modern science. Though La Grange and colleagues, in 1978, were the first to employ ultrasonic blood flow detector to locate insertion point for the supraclavicular brachial plexus block, ultrasound guidance in real time motion was first utilized by S. Kapral et al for the same block in a series of forty patients in 1994, thus, heralding a fresh epoch in regional anaesthesia. [2, 3] As is often the case with the introduction of new technologies, ultrasound guidance was also met with cynicism and disdainful resistance. However, not much later, ultrasound guidance was being hailed as the ‘gold standard’ for regional anaesthesia, and it was proclaimed that the search for the elusive ‘holy grail’ had ended. [4]
Among the first nerve/plexus blocks to find wider acceptance with the adoption of ultrasound guidance was the supraclavicular brachial plexus block. The fear of arterial puncture and accidental pneumothorax magically seemed to vanish into thin air. Correlation between clinical and sono-anatomy led to a better understanding of interscalene, infraclavicular and axillary approaches to the brachial plexus. [5] Lower limb blocks began to witness a renaissance due to the widespread prescription of antiplatelet drugs as part of preventive cardiology. Though deeper to the skin in comparison to the upper limb, ultrasound guidance improved identification of neural structures.
It was reported in literature that ultrasound improves patient comfort, block acceptance, onset of block, quality of block, permits the injection of lower local anaesthetic volumes, and thereby, the potential for LAST, and reduces the incidence of certain complications that may be attributed to the block procedure. [6] However, given the resolution of current portable ultrasound machines, and the huge numbers required to reflect a statistical difference in favour of ultrasound, the rate of neurological complications seems to be comparable to other guidance techniques. Such are the rigours of evidence-based medicine!!
Familiarity with ultrasound offered precision with blocks of the brachial plexus, for eg., intertruncal blockade, combination of superior truncal and cervical plexus block (SCUT), costoclavicular approach to the infraclavicular plexus, and identification of inadvertent targets “in the path”, namely, the long thoracic and dorsal scapular nerves. [7, 8] Not surprisingly, ultrasound guidance was utilized for deeper blocks such as lumbar and sacral plexus, giving impetus to the term, “dual guidance” technique. A “window of opportunity” led to description of neuraxial sonoanatomy and the various benefits of ultrasound assistance for neuraxial blocks were widely appreciated. [9] Nearly seven decades after Mario Dogliotti invented the loss of resistance technique for identification of the epidural space, another guidance tool was incorporated. Newer approaches to older blocks were introduced, such as the suprainguinal fascia iliaca plane block. Differential blocks limited to sensory desensitization alone came into vogue, viz. PENG (Pericapsular Nerve Group), iliopsoas plane block & the i-PACK. [10, 11]
Perhaps, the most significant shift in regional anaesthesia was the introduction of interfascial plane blocks that abandoned the “search” for neural structures by beckoning regional anaesthesia enthusiasts to deposit large volumes of local anaesthetic solutions into fascial planes. What began with the ultrasound guided TAP block in 2007, rapidly found application in a variety of truncal fascial planes. The interfascial plane block added a new dimension to the multimodal analgesia regime. Simplicity of performance and safety was the overriding factor that appealed to anaesthesiologists. With some blocks, the drug was confined to the point of injection. With several others, the propensity of aponeurotic fascia to communicate with other fascial planes facilitated the theoretical spread of drug to sites far removed from the point of injection. Though conjecture exists with respect to the mechanism of action of blocks such as the QLB, future studies should put an end to controversies. [12]
The erector spinae block, first published by Forero et al, in 2016, set the world of regional anaesthesia literally on fire. [13] In the past five years, several publications, mostly case reports and limited case series, eulogizing the virtues of, the potential for, the clinical applications for, and the possible mechanism of action of this popular block, have emerged in scientific literature. [14] Currently, this ESP block, due to a lack of credible evidence on the mechanism of action, has the naysayers clamouring for this block to be rested in peace. [15] Given that the ESP has been in existence for less than five years, it is sincerely hoped that concrete studies may demystify this esoteric block.
In addition to regional anaesthesia, the appeal of modern, portable ultrasound places the FOCUS firmly on POCUS or Point Of Care Ultrasound. Today, regional anaesthesiologists are comfortable with fancy acronyms like FATE, FEEL, FAST etc. The integration of Artifical Intelligence to ultrasound technology imparts further precision. High resolution ultrasound as a diagnostic and therapeutic tool with multiple applications for clinicians is here to stay. The chorus for fusion of ultrasound into clinical practice is based on the edifice of evidence, ubiquity and durability, and NOT on the caprice of an elite core of die-hard proponents. The sooner anaesthesiologists jump on the bandwagon and hitch a ride, the better.
It is my sacred duty, as Chairperson of AORA INDIA, to place on record my appreciation to the editorial board of the International Journal of Regional Anaesthesia for embarking on this challenging journey of enlightening readers with advances in the exciting field of regional anaesthesia. In years to come, this online, peer reviewed journal will hopefully have made entry into the pantheon of impactful regional anaesthesia journals worldwide. Indeed, as the famous quote goes, “the purpose of education is to turn mirrors into windows”.

T.V.S.Gopal
Chairperson, Past Academic Director & President
AORA INDIA

References

1. Kaproth-Joslin KA, Nicola R, Dogra VS. The History of US: From Bats and Boats to the Bedside and Beyond: RSNA Centennial Article. Radiographics. 2015; 35:960-70.
2. la Grange P, Foster PA, Pretorius LK. Application of the Doppler ultrasound bloodflow detector in supraclavicular brachial plexus block. Br J Anaesth. 1978; 50:965-7.
3.Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg. 1994; 78:507-13.
4.Horlocker TT, Wedel DJ. Ultrasound-guided regional anesthesia: in search of the holy grail. Anesth Analg 2007; 104:1009–11.
5.Sites BD, Spence BC, Gallagher J, Beach ML, Antonakakis JG, Sites VR, Hartman GS. Regional anesthesia meets ultrasound: a specialty in transition. Acta Anaesthesiol Scand. 2008; 52:456-66.
6.Neal JM. Ultrasound-Guided Regional Anesthesia and Patient Safety: Update of an Evidence-Based Analysis. Reg Anesth Pain Med. 2016; 41:195-204.
7.Karmakar MK, Pakpirom J, Songthamwat B, Areeruk P. High definition ultrasound imaging of the individual elements of the brachial plexus above the clavicle. Reg Anesth Pain Med. 2020; 45:344-50.
8.Hanson NA, Auyong DB. Systematic ultrasound identification of the dorsal scapular and long thoracic nerves during interscalene block. Reg Anesth Pain Med. 2013; 38:54-7.
9.Kalagara, H., Nair, H., Kolli, S. et al. Ultrasound Imaging of the Spine for Central Neuraxial Blockade: a Technical Description and Evidence Update. Curr Anesthesiol Rep.2021; 11: 326–39.
10. Bugada D, Bellini V, Lorini LF, Mariano ER. Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiol Clin. 2018; 36:403-15..
11.Tran J, Giron Arango L, Peng P, Sinha SK, Agur A, Chan V. Evaluation of the iPACK block injectate spread: a cadaveric study. Reg Anesth Pain Med. 2019: rapm-2018-100355.
12. Gopal TVS, Maniar A, Chakraborty A, Kulkarni R. Abdominal Wall Blocks in Abdominal Surgery: An Update. International Journal of Regional Anaesthesia. January-June 2021; 2: 47-53.
13. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med. 2016; 41:621-7.
14. Chin KJ, Versyck B, Elsharkawy H, Rojas Gomez MF, Sala-Blanch X, Reina MA. Anatomical basis of fascial plane blocks. Reg Anesth Pain Med. 2021; 46:581-99.
15. Lonnqvist PA, Karmakar MK, Richardson J, Moriggl B. Daring discourse: should the ESP block be renamed RIP II block? Reg Anesth Pain Med. 2021; 46:57-60.

How to Cite this Article: Gopal TVS | Ultrasound and Modern Regional Anaesthesia | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 100-101.

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“Coming Together is a Beginning; Keeping Together is Progress; Working Together is Success”……Henry Ford

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Vol 2 | Issue 1 | January-June 2021 | Page 01 | Vrushali Ponde

DOI: 10.13107/ijra.2021.v02i01.015

Authors: Vrushali Ponde [1]

[1] National President and Ex founder secretary Academy of Regional Anaesthesia, India.

Address of Correspondence

Dr. Vrushali Ponde,
National President and Ex founder secretary
Academy of Regional Anaesthesia, India.
E-mail: vrushaliponde@gmail.com

“Team AORA” has come a long way in learning, teaching and researching and innovating regional anaesthesia. From hands-on workshops to full-fledge post-doctoral fellowships of a year’s duration looks like a joyous journey done together.
As I write this, the enthusiasm towards honing skills in regional anaesthesia, RA, is palpable. Even in the most trying times of the current pandemic scenario’s, RA stood to its promise of safety. Not just towards the patients, on this occasion, the safety of the personal in the operation theatres too. Such is the scope and play of this subject.
I take this opportunity to present to you the various protocols and simple practical clinical pearls charted out by the AORA committee of protocols and guidelines. These are done considering the uniqueness of Indian work culture and practices. This can be looked into as a bridge between the most ideal and yet practically implementable work patterns. (Annexure 1, 2 and 3)
I submit my heartfelt thanks to our editor in chief, Dr Sandeep Diwan, to have taken the initiative of embarking on and continuing with the International Journal of Regional Anaesthesia, the official publication of AORA, India.

How to Cite this Article: Ponde V | Coming Together is a Beginning; Keeping Together is Progress; Working Together is Success”……Henry Ford | International Journal of Regional Anaesthesia | January-April 2021; 2(1): 01.

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