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

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

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

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

DOI: https://doi.org/10.13107/ijra.2023.v04i01.067


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

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

Address of Correspondence
Dr. Gopal Jalwal,
Assistant Professor, Department of Anaesthesiology & Critical Care, AIIMS, Bathinda, Punjab, India.
E-mail: gopaljalwal@gmail.com


Abstract


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


References


[1] Hutton M, Brull R, Macfarlane AJR. Regional anaesthesia and outcomes. BJA Educ. 2018 Feb;18(2):52-56. doi: 10.1016/j.bjae.2017.10.002. Epub 2017 Nov 27.
[2] Chin KJ, Mariano E, El-Boghdadly KE. Advancing towards the next frontier in regional anaesthesia. Anaesthesia 2021; 76(S1): 3–7.
[3] Shelley BG, Anderson KJ, Macfarlane AJR. Regional anaesthesia for thoracic surgery: what is the PROSPECT that fascial plane blocks are the answer? Anaesthesia 2022; 77(3): 252–256.
[4] Kearns RJ, Womack J, Macfarlane AJ. Regional anaesthesia research – where to now? Br J Pain. 2022 Apr;16(2):132-135. doi: 10.1177/20494637221091139.
[5] Dohlman LE, Kwikiriza A, Ehie O. Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings. Local Reg Anesth. 2020 Oct 22;13:147-158. doi: 10.2147/LRA.S236550.
[6] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008 Apr;61(4):344-9. doi: 10.1016/j.jclinepi.2007.11.008.
[7] Carey TS, Boden SD. A critical guide to case series reports. Spine (Phila Pa 1976). 2003 Aug 1;28(15):1631-4. doi: 10.1097/01.BRS.0000083174.84050.E5.
[8] Kayir S, Kisa A. The evolution of the regional anesthesia: a holistic investigation of global outputs with bibliometric analysis between 1980-2019. Korean J Pain. 2021 Jan 1;34(1):82-93. doi: 10.3344/kjp.2021.34.1.82.
[9] New journals for publishing medical case reports. Akers KG. J Med Libr Assoc. 2016;104:146–149.
[10] Sayre JW, Toklu HZ, Ye F, Mazza J, Yale S. Case Reports, Case Series – From Clinical Practice to Evidence-Based Medicine in Graduate Medical Education. Cureus. 2017 Aug 7;9(8):e1546. doi: 10.7759/cureus.1546.
[11] Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D; CARE Group*. The CARE Guidelines: Consensus-based Clinical Case Reporting Guideline Development. Glob Adv Health Med. 2013 Sep;2(5):38-43. doi: 10.7453/gahmj.2013.008.
[12] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008 Apr;61(4):344-9. doi: 10.1016/j.jclinepi.2007.11.008.
[13] Butcher NJ, Monsour A, Mew EJ, Chan AW, Moher D, Mayo-Wilson E, Terwee CB, Chee-A-Tow A, Baba A, Gavin F, Grimshaw JM, Kelly LE, Saeed L, Thabane L, Askie L, Smith M, Farid-Kapadia M, Williamson PR, Szatmari P, Tugwell P, Golub RM, Monga S, Vohra S, Marlin S, Ungar WJ, Offringa M. Guidelines for Reporting Outcomes in Trial Reports: The CONSORT-Outcomes 2022 Extension. JAMA. 2022;328(22):2252-2264.
[14] Sayre JW, Toklu HZ, Ye F, Mazza J, Yale S. Case Reports, Case Series – From Clinical Practice to Evidence-Based Medicine in Graduate Medical Education. Cureus. 2017 Aug 7;9(8):e1546. doi: 10.7759/cureus.1546.


How to Cite this Article: Gupta M, Jalwal G, Grewal A | Converting Regional Anaesthesia database into Publication: A step-based approach | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 04-06 | DOI:https://doi.org/10.13107/ijra.2023.v04i01.067


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

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

DOI: https://doi.org/10.13107/ijra.2023.v04i01.069


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

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

Address of Correspondence
Dr. Chetana Vitthal Bhalerao,
Department of Anaesthesia, Dr. L.H. Hiranandani Hospital Powai, Mumbai, Maharashtra, India.
E-mail: chetana.bhalerao999@gmail.com


Abstract


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


References


[1] Shteynberg A, Riina LH, Glickman LT, Meringolo JN, Simpson RL. Ultrasound guided lateral femoral cutaneous nerve (LFCN) block: safe and simple anesthesia for harvesting skin grafts. Burns. 2013;39: 146-9.
[2] Martins RS, M G Siqueira, Silva FC Jr, Heise CO, Teixeira MJ. A practical approach to the lateral cutaneous nerve of the thigh: an anatomical study. Clin Neurol Neurosurg. 2011; 113:868-71.
[3] Aszmann OC, Dellon ES, Dellon AL. Anatomical course of the lateral femoral cutaneous nerve and its susceptibility to compression and injury. Plast Reconstr Surg. 1997;100: 600-4.
[4] Benezis I, Boutaud B, Leclerc J, Fabre T, Durandeau A. Lateral femoral cutaneous neuropathy and its surgical treatment: a report of 167 cases. Muscle Nerve. 2007;36: 659-63.
[5] Marhofer P, Nasel C, Sitzwohl C, Kapral S. Magnetic resonance imaging of the distribution of local anesthetic during the three-in-one block. Anesth Analg. 2000;90: 119-24.
[6] 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.
[7] Steenberg J, Møller AM. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation. Br J Anaesth. 2018;120: 1368-1380.
[8] Ueshima H, Otake H. Supra-inguinal fascia iliaca block under ultrasound guidance for perioperative analgesia during bipolar hip arthroplasty in a patient with severe
cardiovascular compromise: A case report. Medicine. 2018; 97(40).
[9] Short AJ, Barnett JJG, Gofeld M, Baig E, Lam K, Agur AMR, Peng PWH. Anatomic Study of Innervation of the Anterior Hip Capsule: Implication for Image-Guided Intervention. Reg Anesth Pain Med. 2018;43: 186-192.
[10] Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med. 2018;43: 859-63.
[11] White S, Stott P. Fascia iliaca block for primary hip arthroplasty. Anaesthesia. 2017;72 :409.
[12] K Shankar, Srinivasan Rangalakshmi, AB Ashwin, et al. Comparative Study of Ultrasound Guided PENG [Pericapsular Nerve Group] Block and FIB [Fascia Iliaca Block] for Positioning and Postoperative Analgesia Prior to Spinal Anaesthesia for Hip Surgeries: Prospective Randomized Comparative Clinical Study. Indian J Anesth Analg.2020;7: 798-803.
[13] Jadon A, Mohsin K, Sahoo RK, Chakraborty S, Sinha N, Bakshi A. Comparison of supra-inguinal fascia iliaca versus pericapsular nerve block for ease of positioning during spinal anaesthesia: A randomised double-blinded trial. Indian J Anaesth. 2021;65: 572-578.
[14]Bhattacharya A, Bhatti T, Haldar M. ESRA19-0539 Pericapsular nerve group block–is it better than the rest for pain relief in fracture neck of femur? Regional Anesthesia and Pain Medicine. 2019; 44(Suppl 1): A116.
[15] Vermeylen K, Desmet M, Leunen I, Soetens F, Neyrinck A, Carens Det al. Supra-inguinal injection for fascia iliaca compartment block results in more consistent spread towards the lumbar plexus than an infra-inguinal injection: a volunteer study. Regional Anesthesia & Pain Medicine. 2019;44: 483-91.
[16] Gasanova I, Alexander JC, Estrera K, Wells J, Sunna M, Minhajuddin A, Joshi GP. Ultrasound-guided suprainguinal fascia iliaca compartment block versus periarticular infiltration for pain management after total hip arthroplasty: a randomized controlled trial. Reg Anesth Pain Med. 2019;44: 206-211.
[17] Ridderikhof ML, De Kruif E, Stevens MF, Baumann HM, Lirk PB, Goslings JC, Hollmann MW. Ultrasound guided supra-inguinal Fascia Iliaca Compartment Blocks in hip fracture patients: An alternative technique. Am J Emerg Med. 2020;38: 231-236.
[18] Bali C, Ozmete O. Supra-inguinal fascia iliaca block in older-old patients for hip fractures: a retrospective study. Braz J Anesthesiol. 2021: S0104-0014(21)00336-5.
[19] Yamada K, Inomata S, Saito S. Minimum effective volume of ropivacaine for ultrasound-guided supra-inguinal fascia iliaca compartment block. Sci Rep. 2020;10: 21859.
[20] Aydin ME, Borulu F, Ates I, Kara S, Ahiskalioglu A. A Novel Indication of Pericapsular Nerve Group (PENG) Block: Surgical Anesthesia for Vein Ligation and Stripping. J Cardiothorac Vasc Anesth. 2020;34: 843-845.


How to Cite this Article: Bhalerao C, Dudhedia U | Prospective Comparative Double-Blind Study on Ultrasound- Guided Pericapsular Nerve Group Block Versus Suprainguinal Fascia Iliaca Block for Perioperative Analgesia in Traumatic Hip Surgeries | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 13-19 | DOI:https://doi.org/10.13107/ijra.2023.v04i01.069


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Current Concepts in Regional Analgesia Techniques for Postoperative Pain Management after Total Shoulder Arthroplasty: A Narrative Review

Vol 3 | Issue 2 | July-December 2022 | Page 42-48 | Prasanna Khare, Rijuta Kashyapi, Manjiri Ranade

DOI: 10.13107/ijra.2022.v03i02.055


Authors: Prasanna Khare [1], Rijuta Kashyapi [1], Manjiri Ranade [1]

[1] Department of Anaesthesiology, Deenanath Mangeshkar Hospital & Research Centre, Pune, Maharashtra, India.

Address of Correspondence
Dr. Manjiri Ranade
Department of Anaesthesiology, Deenanath Mangeshkar Hospital & Research Centre, Pune, Maharashtra, India.
E-mail: manjirir47@gmail.com


Abstract

Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Interscalene brachial plexus block, which is administered either as since injection (ssISB) or with continuous catheter (ccISB) technique, is the gold standard. Ultrasonography (USG) guidance facilitates a faster, more accurate block with a lower local anaesthetic volume in ssISB. USG also helps for accurate catheter placement in ccISB. Hemi-diaphragmatic palsy is a common complication of ISB. This can be a major concern for patients with a respiratory compromise so it necessitates the administration of diaphragm-sparing nerve blocks. Phrenic nerve sparing block like suprascapular nerve block (SSNB) singly or along with axillary nerve block, subomohyoid anterior suprascapular block, superior trunk block, erector spinae plane block, individually, provide perioperative analgesia non-inferior to ISB. Subacromial or intraarticular infiltration of local anaesthesia (SAIA) is not recommended due to its limited clinical efficacy. Extended analgesic effects have been observed with liposomal bupivacaine when used as a field block. This article provides an overview of regional anaesthesia techniques for postoperative analgesia following Total shoulder arthroplasty (TSA)
Keywords: Shoulder arthroplasty, Pain management, Regional anaesthesia, Interscalene brachial plexus block


References


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17. Fredrickson MJ, Leightley P, Wong A, Chaddock M, Abeysekera A, Frampton C. An analysis of 1505 consecutive patients receiving continuous interscalene analgesia at home: a multicentre prospective safety study. Anaesthesia. 2016 Apr;71(4):373-9.
18. Hewson DW, Oldman M, Bedforth NM. Regional anaesthesia for shoulder surgery. BJA Educ. 2019 Apr;19(4):98-104.
19. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001 Oct;95(4):875-80.
20. Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth. 2008 Oct;101(4):549-56.
21. Hasan SS, Rolf RH, Sympson AN, Eten K, Elsass TR. Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial. J Am Acad Orthop Surg Glob Res Rev. 2019 Jun 11;3(6):e014.
22. Vorster W, Lange CP, Briët RJ, Labuschagne BC, du Toit DF, Muller CJ, de Beer JF. The sensory branch distribution of the suprascapular nerve: an anatomic study. J Shoulder Elbow Surg. 2008 May-Jun;17(3):500-2.
23. Tran J, Peng PWH, Agur AMR. Anatomical study of the innervation of glenohumeral and acromioclavicular joint capsules: implications for image-guided intervention. Reg Anesth Pain Med. 2019 Jan 11:rapm-2018-100152.
24. Jezierski H, Podgórski M, Stefańczyk L, Kachlik D, Polguj M. The Influence of Suprascapular Notch Shape on the Visualization of Structures in the Suprascapular Notch Region: Studies Based on a New Four-Stage Ultrasonographic Protocol. Biomed Res Int. 2017;2017:5323628.
25. Price DJ. The shoulder block: a new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain. Anaesth Intensive Care. 2007 Aug;35(4):575-81.
26. Hussain N, Goldar G, Ragina N, Banfield L, Laffey JG, Abdallah FW. Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology. 2017 Dec;127(6):998-1013.
27. Siegenthaler A, Moriggl B, Mlekusch S, Schliessbach J, Haug M, Curatolo M, Eichenberger U. Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach. Reg Anesth Pain Med. 2012 May-Jun;37(3):325-8.
28. Abdallah FW, Wijeysundera DN, Laupacis A, Brull R, Mocon A, Hussain N, Thorpe KE, Chan VWS. Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery: A Multicenter Randomized Trial. Anesthesiology. 2020 Apr;132(4):839-853.
29. Tran DQ, Elgueta MF, Aliste J, Finlayson RJ. Diaphragm-Sparing Nerve Blocks for Shoulder Surgery. Reg Anesth Pain Med. 2017 Jan/Feb;42(1):32-38.
30. El-Boghdadly K, Chin KJ, Chan VWS. Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical Considerations. Anesthesiology. 2017 Jul;127(1):173-191.
31. Kim DH, Lin Y, Beathe JC, Liu J, Oxendine JA, Haskins SC, Ho MC, Wetmore DS, Allen AA, Wilson L, Garnett C, Memtsoudis SG. Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial. Anesthesiology. 2019 Sep;131(3):521-533.
32. Kang R, Jeong JS, Chin KJ, Yoo JC, Lee JH, Choi SJ, Gwak MS, Hahm TS, Ko JS. Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery. Anesthesiology. 2019 Dec;131(6):1316-1326.
33. Forero M, Rajarathinam M, Adhikary SD, Chin KJ. Erector spinae plane block for the management of chronic shoulder pain: a case report. Can J Anaesth. 2018 Mar;65(3):288-293. English.
34. Diwan S, Nair A. Erector Spinae Plane Block for Proximal Shoulder Surgery: A Phrenic Nerve Sparing Block! Turk J Anaesthesiol Reanim. 2020 Aug;48(4):331-333.
35. Ciftci B, Ekinci M, Gölboyu BE, Kapukaya F, Atalay YO, Kuyucu E, Demiraran Y. High Thoracic Erector Spinae Plane Block for Arthroscopic Shoulder Surgery: A Randomized Prospective Double-Blind Study. Pain Med. 2021 Apr 20;22(4):776-783.
36. Sandeep Diwan; Xavier Sala Blanch; Abhijit Nair; Dipal Shah. Anatomic and radiological correlation of injectate spread from first thoracic costotransverse junction in cervical erector spinae plane. Autopsy and Case Reports, vol 11, e2021275, 2021. Hospital Universitario da Universidade de Sao Paulo.
37. Bjørnholdt KT, Jensen JM, Bendtsen TF, Søballe K, Nikolajsen L. Local infiltration analgesia versus continuous interscalene brachial plexus block for shoulder replacement pain: a randomized clinical trial. Eur J Orthop Surg Traumatol. 2015 Dec;25(8):1245-52.
38. Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia. 2010 Jun;65(6):608-624.
39. Bailie DS, Ellenbecker TS. Severe chondrolysis after shoulder arthroscopy: a case series. J Shoulder Elbow Surg. 2009 Sep-Oct;18(5):742-7.
40. Kolade O, Patel K, Ihejirika R, Press D, Friedlander S, Roberts T, Rokito AS, Virk MS. Efficacy of liposomal bupivacaine in shoulder surgery: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2019 Sep;28(9):1824-1834.
41. Dinges HC, Wiesmann T, Otremba B, Wulf H, Eberhart LH, Schubert AK. The analgesic efficacy of liposomal bupivacaine compared with bupivacaine hydrochloride for the prevention of postoperative pain: a systematic review and meta-analysis with trial sequential analysis. Reg Anesth Pain Med. 2021 Jun;46(6):490-498.
42. Vandepitte C, Kuroda M, Witvrouw R, Anne L, Bellemans J, Corten K, Vanelderen P, Mesotten D, Leunen I, Heylen M, Van Boxstael S, Golebiewski M, Van de Velde M, Knezevic NN, Hadzic A. Addition of Liposome Bupivacaine to Bupivacaine HCl Versus Bupivacaine HCl Alone for Interscalene Brachial Plexus Block in Patients Having Major Shoulder Surgery. Reg Anesth Pain Med. 2017 May/Jun;42(3):334-341.
43. Panchamia JK, Amundson AW, Jacob AK, Sviggum HP, Nguyen NTV, Sanchez-Sotelo J, Sperling JW, Schroeder DR, Kopp SL, Johnson RL. A 3-arm randomized clinical trial comparing interscalene blockade techniques with local infiltration analgesia for total shoulder arthroplasty. J Shoulder Elbow Surg. 2019 Oct;28(10):e325-e338.
44. Auyong DB, Hanson NA, Joseph RS, Schmidt BE, Slee AE, Yuan SC. Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology. 2018 Jul;129(1):47-57.
45. Auyong DB, Yuan SC, Choi DS, Pahang JA, Slee AE, Hanson NA. A Double-Blind Randomized Comparison of Continuous Interscalene, Supraclavicular, and Suprascapular Blocks for Total Shoulder Arthroplasty. Reg Anesth Pain Med. 2017 May/Jun;42(3):302-309.


How to Cite this Article: Khare P, Kashyapi R, Ranade M | Current Concepts in Regional Analgesia Techniques for Postoperative Pain Management after Total Shoulder Arthroplasty: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 42-48.


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Time to adequately heed Acute Pain in the Emergency Department – More Regional Blocks Warranted

Vol 3 | Issue 2 | July-December 2022 | Page 37-41 | Tom C. R. V. Van Zundert, André A. J. Van Zundert

DOI: 10.13107/ijra.2022.v03i02.054


Authors: Tom C. R. V. Van Zundert [1, 2], André A. J. Van Zundert [2, 3]

[1] Department of Emergency Medicine, Holy Heart Hospital, Mol, Belgium.
[2] Udayana University, Bali, Indonesia.
[3] Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital and The University of Queensland, Brisbane, QLD, Australia.

Address of Correspondence
Professor André A.J. Van Zundert,
Professor and Chair of Anaesthesiology, Royal Brisbane and Women’s Hospital & The University of Queensland, Brisbane, QLD, Australia.
E-mail: vanzundertandre@gmail.com


Introduction

All healthcare stressors converge in the emergency department (ED), which sees an annual increase of 6-7% with more than 25 million patient visits in the UK. This translates to 44,435 attendances per 100,000 population in the period 2019-2020 [1]. Acute pain is the primary reason patients seek emergency medical care. Consequently, substandard acute pain treatment is one of the most frequently heard complaints and has been labelled as a public health problem [2]. Pain remains under-acknowledged, -assessed and -treated, mainly in case of overcrowding in the ED and especially in the more vulnerable groups, including the elderly and children. Many patients express an initial pain score of 10 out of 10 on the visual analogue scale (VAS) in the ED. Generally, initial pain treatment combines oral acetaminophen, NSAID and/or (IV) opioids. Nevertheless, despite these pain killers, most patients continue to suffer and score their pain at 8/10 or higher. Untreated pain can have both short- and long-term effects, including sensitisation to pain episodes in later life [3].

Most visits to the emergency department involve patients with conditions that include: a) injuries and trauma from (motor vehicle) accidents, physical assaults or falls, with or without circulatory shock; b) cardiovascular and cerebral attacks or loss of consciousness; c) severe pain of diverse causes, both acute and chronic origin; d) acute worsening of a serious illness or disease, including problems with breathing and bleeding; e) mental illness; f) burns; g) anaphylactic and allergic reactions; g) drug overdoses and poisoning; and h) pregnancy-related complications. In most of these cases, patients present with pain as a substantial factor.

Keywords: Emergency department, Hip fracture, Pain, Regional anaesthesia, Nerve blocks, Ultrasonography


References


1. NHS Report. Hospital Accident & Emergency Activity 2020-21. 30.09.2021. https://digital.nhs.uk/data-and-information/publications/statistical/hospital-accident–emergency-activity/2020-21# (accessed 20.05.2022).
2. Keating L, Smith S. Acute Pain in the Emergency Department: The Challenges. Rev Pain. 2011;5(3):13-17.
3. Duggan NM, Nagdev A, Hayes BD, Shokoohi H, Selame LA, Liteplo AS, Goldsmith AJ. Perineural Dexamethasone as a Peripheral Nerve Block Adjuvant in the Emergency Department: A Case Series. J Emerg Med. 2021 Nov;61(5):574-580.
4. Verbeek T, Adhikary S, Urman R, Liu H. The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery. Curr Pain Headache Rep. 2021 Mar 11;25(4):22.
5. Veronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury 2018;49:1458-1460.
6. Amin NH, West JA, Farmer T, Basmajian HG. Nerve Blocks in the Geriatric Patient With Hip Fracture: A Review of the Current Literature and Relevant Neuroanatomy. Geriatr Orthop Surg Rehabil. 2017 Dec;8(4):268-275.
7. Salottolo K, Meinig R, Fine L, Kelly M, Madayag R, Ekengren F, Tanner A, Roman P, Bar-Or D. A multi-institutional prospective observational study to evaluate fascia iliaca compartment block (FICB) for preventing delirium in adults with hip fracture. Trauma Surgery & Acute Care Open 2022;7:e000904.
8. Hao J, Dong B, Zhang J, Luo Z. Pre-emptive analgesia with continuous fascia iliaca compartment block reduces postoperative delirium in elderly patients with hip fracture. A randomized controlled trial. Saudi Med J. 2019 Sep;40(9):901-906.
9. Lee HK, Kang BS, Kim CS, Choi HJ. Ultrasound-guided regional anaesthesia for the pain management of elderly patients with hip fractures in the emergency department. Clin Exp Emerg Med. 2014 Sep 30;1(1):49-55.
10. Hards M, Brewer A, Bessant G, Lahiri S. Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review. Prehosp Disaster Med. 2018 Jun;33(3):299-307.
11. Okereke IC, Abdelmonem M. Fascia Iliaca Compartment Block for Hip Fractures: Improving Clinical Practice by Audit. Cureus. 2021;13:e17836. doi: 10.7759/cureus.17836
12. Nice Guidelines. The management of hip fracture in adults. Updated 2019. https://www.nice.org.uk/guidance/cg124/evidence/full-guideline-pdf-183081997 (accessed 24.05.2022).
13. Butler MM, Ancona RM, Beauchamp GA, Yamin CK, Winstanley EL, Hart KW, Ruffner AH, Ryan SW, Ryan RJ, Lindsell CJ, Lyons MS. Emergency Department Prescription Opioids as an Initial Exposure Preceding Addiction. Ann Emerg Med. 2016 Aug;68(2):202-8.
14. Ketelaars R, Stollman JT, van Eeten E, Eikendal T, Bruhn J, van Geffen G-J. Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in The Netherlands. Int J Emerg Med 2018;11:12.
15. Reavley P, Montgomery AA, Smith JE, Binks S, Edwards J, Elder G, Benger J. Randomised trial of the fascia iliaca block versus the ‘3-in-1’ block for femoral neck fractures in the emergency department. Emerg Med J. 2015;32:685-689.
16. Nagel EM, Gantioque R, Taira T. Utilizing Ultrasound-Guided Femoral Nerve Blocks and Fascia Iliaca Compartment Blocks for Proximal Femur Fractures in the Emergency Department. Adv Emerg Nurs J. 2019 Apr/Jun;41(2):135-144.
17. Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med. 2018 Aug;36(8):1391-1396.
18. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM. 2016 Jan;18(1):37-47.
19. Jaffe TA, Shokoohi H, Liteplo A, Goldsmith A. A Novel Application of Ultrasound-Guided Interscalene Anaesthesia for Proximal Humeral Fractures. The Journal of Emergency Medicine. 2020;59:265-269.
20. De Buck F, Devroe S, Missant C, Van de Velde M. Regional anaesthesia outside the operating room: indications and techniques. Curr Opin Anaesthesiol. 2012 Aug;25(4):501-7.
21. Steenberg J, Møller AM. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation. Br J Anaesth. 2018 Jun;120(6):1368-1380.
22. Scarpa J, Wu CL. The role for regional anaesthesia in medical emergencies during deep space flight. Reg Anesth Pain Med. 2021 Oct;46(10):919-922.
23. Cappelleri G, Fanelli A, Ghisi D, Russo G, Giorgi A, Torrano V, Lo Bianco G, Salomone S, Fumagalli R. The Role of Regional Anaesthesia During the SARS-CoV2 Pandemic: Appraisal of Clinical, Pharmacological and Organizational Aspects. Front Pharmacol. 2021 Jun 4;12:574091.
24. Wiercigroch D, Ben-Yakov M, Porplycia D, Friedman SM. Regional anaesthesia in Canadian emergency departments: Emergency physician practices, perspectives, and barriers to use. CJEM. 2020 Jul;22(4):499-503.
25. Herring AA. Bringing Ultrasound-guided Regional Anaesthesia to Emergency Medicine. AEM Educ Train. 2017 Mar 29;1(2):165-168.


How to Cite this Article: Van Zundert TCRV, Van Zundert AAJ | Time to Adequately Heed Acute Pain in the Emergency Department- More Regional Blocks Warranted | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 37-41.


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Technological and Pharmacological Advancements in Regional Anaesthesia and Acute Postoperative Pain

Vol 3 | Issue 1 | January-June 2022 | Page 03-07 | Abhijit S. Nair, Sandeep Diwan

DOI: 10.13107/ijra.2022.v03i01.046


Authors: Abhijit S. Nair [1], Sandeep Diwan [2]

[1] Department of Anaesthesia, Ibra Hospital, Ministry of Health-Oman, Ibra, Sultanate of Oman.
[2] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Abhijit S. Nair,
Department of Anaesthesia, Ibra Hospital, Ministry of Health-Oman, Ibra, Sultanate of Oman.
E-mail: abhijitnair95@gmail.com


The last two decades have seen immense popularity and interest for using ultrasound (US) in the practice of regional anaesthesia (RA) for performing regional nerve blocks, fascial plane blocks, and even for central neuraxial blocks. [1-3] Use of US in RA not only increase the success rate; it also reduced the complications and also facilitated several new blocks especially the fascial plane blocks in recent years. Probably this was just a beginning because, in recent years, many technological advances have been made to popularize RA, to make it safe, and to provide long-lasting analgesia to the patient. [4,5] This editorial describes the technological and pharmacological advances made in the last decade related to RA and acute pain medicine.

Advanced Gadgets and Technology for RA:
Conventionally, the US machine used in routine RA practice is 2D or 2-dimensional, and the same is used in teaching institutes and workshops. The present US machines are light-weight, portable, have advanced features like touch-screen, high-resolution images, better needle visibility, taking snapshots or recording videos, and many more. Few papers have described the use of 3D US in RA. However, the issues with 3D-US in RA are a slow refresh rate than 2D and difficulty in real-time needle visualization and tracking. [6,7] Few RA enthusiasts have demonstrated successful use of 4D-US in RA. By using the 4D US, the performer can simultaneously visualize multiple planes like longitudinal, cross-sectional, and coronal adjusting the probe. 4D also provided a spatial relationship between anatomical structures of interest compared to standard imaging, which could prevent undesirable complications. With 4D US accurate volume measurements of LA can be made with visualization of the spread of LA at the site of interest. However, the issues are 4D US needs a different machine and probe which might not be feasible for someone who already has the 2D US. [8]
Portability has reached the next level with the introduction of the Lumify probe by Philips, USA. This probe can be connected to a smartphone or a tablet. [9] A Philips Lumify Ultrasound App is available for download on both Android and Apple phones for free. However, in India, the RA enthusiast needs to comply with the Pre-Conception and Pre-Natal Diagnostic Techniques (PC-PNDT) act before planning to buy and use it. [10]

Robotics in US-guided RA:
In the medical field, the principles of robotics have been applied successfully in robotic-assisted surgeries, rehabilitation, medical transportation, sanitation of hospitals, and drug dispensing. In 2002, Cleary et al used a robotic system developed by URobotics (Urology Robotics) Laboratory to perform nerve and facet blocks at the lumbar region of embalmed cadavers successfully thus opening a new avenue for performing RA techniques using advanced technology. [11] Later Tighe et al performed US-guided nerve blocks in phantom using the da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, CA). [12] This system is also used for robotic-assisted surgeries. The authors demonstrated successful single injections and perineural catheters using the robotic system. This led to the development of a task-specific robotic device for RA. Magellan system is a robotic system exclusively developed for US-guided regional anaesthesia. [13] The Magellan system comprises a joystick, a robotic arm, and a software control system.
Hemmerling et al described the first robotic US-guided nerve blocks in humans using the Magellan system which is a robotic system for US-guided RA. [14] The authors employed the sciatic nerve block in 13 patients all of which were successful and required 3-4 minutes to perform. Morse et al conducted a study in which they compared success rates, learning curves, and inter-subject performance variability of robot-assisted and manual US-guided nerve block needle guidance in simulation. [15] A Magellan robotic nerve block system was used for this study. The authors concluded that robot-assisted nerve blocks lead to faster learning of needle guidance over manual positioning and reduce inter-subject performance variability. Currently, the Magellan system is not FDA-approved, is costly, has not been validated by comparative, randomized studies.

Injection Pressure Monitoring:
In the current practice of RA, monitoring injecting pressure while injecting LA for a peripheral nerve block or a fascial plane block is considered the gold standard. A high injection pressure i.e., more than 20 pounds per square inch (PSI) has been associated with intraneural or intrafascicular injection leading to unwanted neurological consequences postoperatively. [16,17] At present there are three monitors available in the market with different pros and cons.
B-SmartTM (B. Braun Medical, Bethlehem, Pennsylvania, USA) was the first disposable, injection pressure monitor released in the market. It uses membrane sensing technology to monitor real-time injection pressure while injecting LA. [18] When the injection pressure crosses 15 psi, the piston-color changes from white to yellow, and after reaching a pressure of more than 20 psi, there is a change in piston color from yellow to orange. [19] NerveGuard® (Pajunk Medical Systems, Geisingen, Germany) is another gadget available for a similar purpose but with different technology. It detects high pressure while injecting (more than 20 psi) and automatically stops the injection of LA while performing a block. This is due to the presence of a Luer lock mechanism between the syringe and the extension tubing of the nerve block needle. [20,21] Recently, Medovate, a company in the United Kingdom introduced the SAFIRA (SAFer Injection in Regional Anaesthesia) pump which gives a combined benefit of injection pressure monitoring and controlled injection of LA. [22] The SAFIRA system consists of three components; a sterile single-use syringe, a driver, and a foot pedal. The foot pedal has two parts, a green and a yellow. On pressing the green part of the foot pedal, the syringe loaded with LA will infuse the LA at the site of interest. On pressing the yellow part of the foot pedal, the loaded LA is aspirated before injection. There are three driver indicator lights. When the green is on, it means LA is infusing. A yellow light indicated aspiration, and red light is suggestive of either a low battery or an empty syringe. The company mentions that the driver and foot pedal can be used for up to 200 peripheral nerve blocks comfortably. [23] The pump is currently available in the UK, USA, Australia, Israel, and a few European countries.

Needle Visualization on the US:
The SonixGPS® system (Ultrasonix Medical Corp, Richmond, BC, Canada) is an electromagnetic needle tracking system developed for US-guided needle interventions. This needs specially designated needles for planned interventions. Niazi et al used this system in 20 patients for performing spinal anaesthesia and concluded that with its use, the procedure is simplified especially with an out-of-plane approach. [24] The experience of Brinkmann et al with 20 patients in whom they performed spinal anaesthesia was similar. They concluded that US-guided subarachnoid block was easy to perform, with a low rate of failure and complications. [25]

Long-Acting, Sustained-Release Local Anaesthetics:
Liposomal bupivacaine, marketed as Exparel (Pacira Pharmaceuticals, Inc., Parsippany, NJ, USA) is an extended-release formulation of bupivacaine which was approved by US-FDA for a single-shot infiltration of the surgical site in 2011. [26] In a review article published by Hamilton et al in Cochrane Database Systematic Review, it was concluded that the use of Exparel did appear to reduce postoperative pain when compared to a placebo. [27]
Exparel consists of encapsulated multivesicular liposomes (DepoFoam formulation Multivesicular spherical lipid particles in a honeycomb formation). This unique liposomal-based structure confers stability and extended-release properties to the formulation. The median diameter of the liposome particles ranges from 24 to 31 μm. [28] Although Exparel was approved for use only for infiltration at the surgical site, researchers published their experiences of off-label use of Exparel in various peripheral nerve blocks of upper and lower extremities. To date, papers have been published with the use of Exparel in popliteal, ankle, femoral, intercostal, penile, pectoral nerve block, and transversus abdominis plane block with variable results. [29-32] With the introduction of liposome-based LA and analgesics and after the success depicted in case series and certain comparative studies, in the last few years there were several pharmacological agents which were launched in the market.

SABER Bupivacaine:
Durect Pharmaceuticals, California, USA developed an experimental drug with a working name: SABER bupivacaine (POSIMIR®). It is available as a thick, translucent solution and consists of bupivacaine, biodegradable depot composition (sucrose acetate isobutyrate), and benzyl alcohol thereby causing extended-release of bupivacaine after infiltration at the surgical site. In a 5 ml solution, there is 132 mg per ml of bupivacaine base which is equivalent to 743 mg of bupivacaine hydrochloride in the 5 ml solution. Studies have shown that the analgesic efficacy after infiltration peaks at 13-17 hours and fades by 72 hrs.
Hadj et al randomized patients undergoing open hernia repair to receive 2.5 ml (330 mg), 5 ml (660 mg) of SABER-bupivacaine with placebo. In both the groups which received the experimental drug, the analgesic efficacy was better than the placebo with no interference in wound healing and devoid of any adverse events. [33] BESST (Bupivacaine Effectiveness and Safety in SABER Trial) is registered with clinicaltrials.gov and has 3 cohorts: 1-laparotomy, 2- laparoscopic cholecystectomy, 3- laparoscopic-assisted colectomy. The results of this trial have not been published yet. [34] As of now, SABER-bupivacaine still awaits US-FDA approval.

HTX-011:
HTX-011, now marketed as ZYNRELEF™ by Heron Therapeutics, Inc. is a novel formulation comprising extended-release, fixed-ratio of bupivacaine as the main drug with low-dose meloxicam to enhance the effectiveness of infiltrated bupivacaine. [35] This combination is integrated into a bioerodible polymer (Biochronomer®). On injection at the surgical site, there is controlled hydrolysis of the polymer which leads to sustained release of both bupivacaine and meloxicam for 3 days.
In the EPOCH-2 study, which is a phase 3, randomized, double-blind, active-controlled multicenter study; Viscusi et al enrolled 18 patients into 3 groups. In one group the patients received HTX-011, in second bupivacaine infiltration, and the third group received placebo. On analysis, the authors concluded that there was a significant improvement in postoperative pain control and a significant reduction in opioid consumption when compared to bupivacaine. [36] In another phase 2b, double-blind, placebo-controlled, and active-controlled trial by Lachiewicz et al, authors enrolled 232 patients undergoing unilateral total knee arthroplasty into 4 groups. [37] The first group received HTX-011 400 mg bupivacaine/12 mg meloxicam, applied without a needle into the surgical site. In the second group, patients received the same dose of HTX-011 with an additional 50 mg ropivacaine injection into the posterior capsule. The patients in the third and fourth group received bupivacaine 125 mg injection, and saline placebo injection respectively. On analysis, the authors concluded patients in the first two groups which received HTX-011 had better pain scores when compared to bupivacaine alone and placebo. ZYNRELEFTM is now US-FDA approved for treating acute postoperative pain by infiltration at the surgical site. [38]

Neosaxitoxin:
Neosaxitoxin is a phycotoxin derived from the shellfish and has demonstrated a reversible block of voltage-gated sodium channels at the neuronal level. Neosaxitoxin shows more affinity to sodium channels in peripheral nerves when compared to that in the myocardium. This favorable property paved way for research in using it for prolonging the analgesic effect of LA.
Rodriguez-Navarro et al conducted a randomized, double-blind, placebo-controlled trial by recruiting 10 healthy volunteers who received subcutaneous injections in the middle posterior skin of the calf. One leg received 50 μg neosaxitoxin, and the contra-lateral leg received a placebo. The authors concluded that neosaxitoxin is an effective LA when injected into a subcutaneous plane. [39] In 2011, Rodriguez-Navarro et al conducted a randomized, double-blind trial comparing neosaxitoxin with bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy. [40] On analysis, the authors concluded that neosaxitoxin is safe, prolonged postoperative analgesia when compared to the control group. Later, Lobo et al investigated the safety and efficacy of neosaxitoxin alone and in combination with 0.2% bupivacaine with and without epinephrine in a double-blind, randomized, controlled trial involving 84 healthy male volunteers aged 18 to 35 years. [41] The authors concluded that neosaxitoxin combination did prolong LA and had a tolerable side effect profile. As of now, neosaxitoxin continues to be an experimental medication with no formal US-FDA approval and also lacks studies involving off-label use in clinical situations.

Percutaneous Peripheral Nerve Stimulation:
Percutaneous nerve stimulation (PNS) is a neuromodulation technique that has been used successfully in managing acute postoperative pain and chronic pain of varying causes.[42] The stimulating electrode of PNS is placed under US guidance in or around the muscle/nerve, usually 1–3 cm from the target. Initially, the electrodes are tested by placing them at the desired site using a Tuohy needle. Once convinced, the electrodes are connected to an external battery source (implanted) to generate current for stimulation. This modality is not only opioid-free but does not even need LA. It can be kept in situ for up to 60 days. [43] The product is US-FDA approved for chronic pain, post-traumatic, and postoperative pain. The stimulator is marketed by SPRINT® PNS System. [44]
In summary, the popularity of RA amongst all anaesthesiologists resulted in extensive research in developing newer and safer technologies that can be applied in RA. The newer pharmacological agents which are either approved or under investigation can be useful in providing cost-effective and opioid-sparing analgesia in the postoperative period. In other words, the future of RA and acute pain medicine looks bright.


References


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How to Cite this Article: Nair AS, Diwan S | Technological and Pharmacological Advancements in Regional Anaesthesia and Acute Postoperative Pain | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 03-07.

 


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Regional Anaesthesia to the Rescue: A Post-Covid Patient with Lumbar Spine Injury Undergoing Lower Limb Orthopedic Surgery

Vol 2 | Issue 2 | July-December 2021 | Page 141-142 | Vandana Mangal, Hardika Mangal, Aashna Pareek, Tuhin Mistry

DOI: 10.13107/ijra.2021.v02i02.043


Authors: Vandana Mangal [1], Hardika Mangal [1], Aashna Pareek [1], Tuhin Mistry [2]

[1] Department of Anaesthesiology, Trauma Centre, S. M. S. Medical College, Jaipur, India.
[2] Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.

Address of Correspondence
Dr Tuhin Mistry,
Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.
E-mail: tm.tuhin87@gmail.com


Letter to Editor


Sir,
Coronavirus disease of 2019 (COVID-19) has revamped the management of trauma patients worldwide like many other specialties. Regional anaesthesia (RA) techniques such as central neuraxial block (CNB) and/or peripheral nerve block (PNB) have been advocated strongly over general anesthesia (GA) whenever feasible by various societies [1]. RA not only avoids aerosol generation in COVID-19 patients, but it may also reduce postoperative pulmonary complications, especially in covid recovered patients with compromised lung function. We wish to share our experience using peripheral nerve blocks as an alternative to central neuraxial blocks for managing lower limb fracture in a post-covid patient with lumbar spine injury.
A 33-years-old lady was brought to the emergency room with an alleged history of severe back pain and bilateral leg injury following a fall from height. On examination, her heart rate, blood pressure, and room air saturation were 118 beats/min, 90/70 mm Hg, and 56%, respectively. Following primary resuscitation, she was put on a non-rebreather mask with 15 L of oxygen. Radiological investigations revealed fractures of bilateral leg bones (both the tibia and fibula) and L1vertebral body (AO type A2) (Figure 1a). High-resolution computed tomography of the chest showed bilateral ground-glass opacities and a severity score of 18/25 (Figure 1b). Her Reverse Transcription Polymerase Chain Reaction test for COVID-19 was negative, but serum inflammatory markers were increased. Her injuries were managed conservatively, and the surgery was deferred. She was shifted to the intensive care unit and managed with antibiotics, steroids, anticoagulants, and noninvasive ventilation. She was gradually weaned off from oxygen support after 25 days. She was scheduled for intramedullary nailing of the left tibia and closed reduction and plaster cast application of the right leg. Her neurological assessment revealed normal sensory and medical research council grade 3 muscle powers. The anesthesia plan was discussed with the patient and her relatives and informed written consent was obtained.
In the operating room, standard monitors were attached, and one 18 G intravenous (IV) cannula was secured. The patient was placed in the supine position. Under all aseptic precautions, ultrasound-guided left-sided femoral nerve block (FNB) and popliteal sciatic nerve block (PSNB) were performed (Figure 1c,d,e,f) using a 23G 3.5 inch Quincke spinal needle and high-frequency linear transducer (L38e, 10-5 MHz, MicroMaxx, Fujifilm SonoSite Inc., Bothell, WA, USA). 10 ml of 0.5 % bupivacaine and 20 ml of 0.5% bupivacaine were administered for FNB and PSNB, respectively, after negative aspiration for blood. Intraoperatively, IV paracetamol 1 gm, ketorolac 30 mg, and 8 mg dexamethasone were given. Closed reduction and intramedullary nailing of the left tibia was completed in one hour. Then, IV fentanyl 25 µg was given, and closed reduction and cast application of the right leg was done. The patient was comfortable throughout the surgery without any significant change in hemodynamics and did not require oxygen or any additional anesthetic medication. She was under observation in the post-anesthesia care unit for the next 24 hours. She recovered well and was discharged after five days.
The CNB or PNB is the preferred RA technique as the respiratory functions are preserved. The subarachnoid block or combined spinal-epidural anesthesia is usually practiced for manipulations and fixation of lower limb fractures as it provides a dense sensory and motor blockade. We avoided CNB as our patient had a fracture of the lumbar spine. We preferred PNB over CNB or GA because of the second wave of COVID-19, superadded oxygen scarcity, and the compromised lung function following covid pneumonia. Ultrasound-guided combined PSNB and adductor canal block has been used for below-knee surgeries in high-risk patients to maintain hemodynamic stability and postoperative pain management [2]. We used a combination of FNB and PSNB for intramedullary tibial nailing in our patient. This combination is a simple and straightforward technique to avoid CNB or GA in below-knee surgeries where use of tourniquet is not necessary. However, this appears to be an underutilized RA technique as there is a paucity in the current literature. Selvi et al. used a combination of FNB and PSNB in a patient with severe emphysematous lung disease for femoral-popliteal arterial bypass surgery [3]. Imbelloni et al. used a lateral, continuous, combined FNB and high sciatic nerve block via a single skin puncture for postoperative analgesia in a supine adult patient undergoing tibial intramedullary nailing [4]. The detection of compartment syndrome may get delayed because of the insensibility of the nerves following the block. So, we objectively assess the patient every three hours for signs of compartment syndrome that did not develop.
We faced a challenge in performing PSNB as the patient was supine and could not be turned lateral or prone position due to the presence of multiple. The anterior approach to high sciatic nerve block would have been more appropriate, but the curvilinear probe was unavailable. Hence, we performed the PSNB via lateral approach in the supine position (Figure 1e,f) as described by Gray and colleagues [5]. This technique was convenient for the patient and offered optimal needle visibility.
The combination of FNB and PSNB suited our patient. More extensive studies need to be done on a combination of blocks for outpatients coming with closed fractures of leg bones in addition to high-risk patients where CNB has to be avoided.


References


1. Macfarlane AJR, Harrop-Griffiths W, Pawa A. Regional anaesthesia and COVID-19: first choice at last? Br J Anaesth. 2020;125:243-7.
2. Arjun B K, Prijith R S, Sreeraghu G M, Narendrababu M C. Ultrasound-guided popliteal sciatic and adductor canal block for below-knee surgeries in high-risk patients. Indian J Anaesth 2019; 63:635-9.
3. Selvi O, Bayserke O, Tulgar S. Use of Femoral and Sciatic Nerve Block Combination in Severe Emphysematous Lung Disease for Femoral Popliteal Arterial Bypass Surgery. Cureus. 2018;10:e2140.
4. Imbelloni L. E., Rava C., Gouveia M. A. A new, lateral, continuous, combined, femoral-sciatic nerve approach via a single skin puncture for postoperative analgesia in intramedullary tibial nail insertion. Local and Regional Anesthesia. 2013; 6:9–12.
5. Gray AT, Huczko EL, Schafhalter-Zoppoth I. Lateral popliteal nerve block with ultrasound guidance. Reg Anesth Pain Med. 2004;29:507-9.


How to Cite this Article: Mangal V, Mangal H, Pareek A, Mistry T | Regional Anaesthesia to the Rescue: A Post- Covid Patient with Lumbar Spine Injury Undergoing Lower Limb Orthopedic Surgery | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 141-142.

 


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Randomized Controlled Trials

Vol 2 | Issue 2 | July-December 2021 | Page 107-110 | Nidhi Bhatia, Anju Grewal
DOI: 10.13107/ijra.2021.v02i02.037


Authors: Nidhi Bhatia [1], Anju Grewal [2]

[1]  Department of Anaesthesiology & Intensive Care, PGIMER, Chandigarh, India.
[2]  Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Address of Correspondence
Dr. Anju Grewal, Professor & Head,
Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
E-mail: dranjugrewal@gmail.com


Abstract


A randomized controlled trial (RCT) is a prospective, comparative, quantitative experiment/study that is performed under controlled conditions with random allocation of interventions to comparison groups. Among all the clinical study designs, evidence generated from RCTs is considered to be at top of the evidence pyramid. There are many different RCT designs and they can be classified on the basis of interventions evaluated, participants’ exposure and level of blinding. All RCTs should be planned prospectively, a research question should be formulated, sample population approached and informed consent obtained from participants of the trial. These consented subjects are randomly assigned to any of the study arms and the changes are then measured over time. The basic principles to designing an RCT include formulating a research question, developing a protocol, randomization, allocation concealment, blinding, sample size calculation and registering of RCTs. Appropriate guidelines for reporting RCTs should be followed and RCTs should only be conducted if they are ethically viable, economical and clinically worthwhile.
Keywords: Randomised Control Trial (RCT)


References


1. Zabor EC, Kaizer AM, Hobbs BP. Randomized Controlled Trials. Chest 2020; 158: S79-S87.
2. Bhide A, Shah PS, Acharya G. A simplified guide to randomized controlled trials. Acta Obstet Gynecol Scand 2018;97:380-387.
3. White H, Sabarwal S, De Hoop T. Randomized Controlled Trials (RCTs): Methodological Briefs 2014 ; Impact Evaluation No. 7, Methodological Briefs no. 7.
4. Stolberg HO, Norman G, Trop I. Randomized controlled trials. AJR Am J Roentgenol 2004;183:1539-44.
5. Thiruvenkatachari B. Randomized controlled trials: The technique and challenges. J Indian Orthod Soc 2015;49:42-7.
6. World Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. JAMA. 2013;310(20):2191–2194. doi:10.1001/jama.2013.281053.
7. Elliott TR. Registering randomized clinical trials and the case for CONSORT. Exp Clin Psychopharmacol. 2007 Dec;15(6):511-8. doi: 10.1037/1064-1297.15.6.511. PMID: 18179303; PMCID: PMC2518067.
8. Akobeng AK. Understanding randomised controlled trials. Arch Dis Child 2005 ;90:840-4.


How to Cite this Article: Bhatia N, Grewal A | Randomized Controlled Trials | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 107-110.



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Anatomy of Lumbar Plexus and Implications to Regional Anaesthesiologist

Vol 2 | Issue 2 | July-December 2021 | Page 102-106 | G. Amudha, Sandeep Diwan

DOI: 10.13107/ijra.2021.v02i02.036


Authors: G. Amudha [1], Sandeep Diwan [2]

[1] Department of Anatomy, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India.
[2] Department of Anaesthesia, Sancheti Hospital Pune, Maharashtra, India.

Address of Correspondence
Dr. G.Amudha,
Department of Anatomy, PSG Institute of Medical Sciences and Research, Coimbatore, India
E-mail: ammuramesh@gmail.com


Abstract


Lumbar plexus is one of the two nerve plexuses which supply the lower limb. It is formed in the posterior abdominal wall within the psoas major muscle. The branches of the plexus exit via the medial and lateral borders as well as its ventral surface. It is a complex plexus which gives a branch to complete the formation of lumbo sacral plexus. The branches mainly supply the groin, anterior and medial compartments of thigh. They also supply the hip and knee joints. The cutaneous innervation by the branches of lumbar plexus is limited to the anterior, lateral and medial parts of the thigh, medial side of the leg and foot and also the lower part of anterior abdominal wall and perineum. Regional anaesthesia is a highly skilled and precise technique used widely in the patients to reduce the drug usage and decrease the intra and post operative complications. Lumbar plexus block can be used in surgeries related to hip joint and anterior part of thigh and groin. To execute the procedure successfully, sound knowledge in anatomy of lumbar plexus is required.
Keywords: Lumbar plexus, Branches, Regional anaesthesia.


References


1. Standring S. Gray’s Anatomy: The anatomical Basis of Clinical Practice. In pelvic girdle, gluteal region and thigh:41st edition: London. Elsevier; 2015; 1371-73.
2. Mahakkanukrauh P et al. A cadaveric study of the anatomical variations of the lumbar plexus with clinical implications. J.Anat. Soc. India, 2016;65:24-8.
3. Javier J. Polania Gutierrez; Bruce Ben-David .2020. Lumbar plexus block. https://www.ncbi.nlm.nih.gov/books/NBK556116.
4. Philip A Anloague, Peter Hujibregts. Anatomical variations of the lumbar plexus: A descriptive anatomy study with proposed clinical implications. The J. Man. Manip.Ther. 2009;17(4): e107-e114.
5. Deepti Arora, Subhash Kaushal, Gurbachan Singh. Variations of lumbar plexus in 30 adult human cadavers – A unilateral prefixed plexus. Int. J. Plant, Animal and Environmental sciences. 2014; 4: 225 – 28.
6. Prof.Gamal S Desouki et al. Study of anatomical pattern of lumbar plexus in human (cadaveric study). Az.J.Pharm Sci. 2016; 54:54-69.
7. Dr.Fasila P. Asis, Dr.Priya Ranganath. A Human cadaveric study on variations in formation and branching pattern of lumbar plexus with its clinical implications.Sch.J of App. Med. Sci.2017;58-63.
8. Ahiskalioglu A, Tulgar S, Celik M, Ozer Z, Alici HA, Aydin ME. Lumbar Erector Spinae Plane Block as a Main Anesthetic Method for Hip Surgery in High Risk Elderly Patients: Initial Experience with a Magnetic Resonance Imaging. Eur. J Med 2020; 52(1): 16-20.
9. Chayen D, Nathan H, Chayen M. The psoas compartment block. Anesthesiology. 1976 Jul; 45(1):95-9.


How to Cite this Article: Amudha G, Diwan S | Anatomy of Lumbar Plexus and Implications to Regional Anaesthesiologist | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 102-106.


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