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

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

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

Open Access License: CC BY-NC 4.0

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

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

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

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

Address of Correspondence

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

Abstract

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

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How to Cite this Article: Grewal A, Challa RB, Sharma J. Regional Anaesthesia for Cancer Surgery and Its Impact on Recurrence and Metastasis: What Is the Evidence? International Journal of Regional Anaesthesia. January-June 2025; 6(1): 20-27. DOI: https://doi.org/10.13107/ijra.2025.v06.i01.118

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The Illusion of Precision: Artificial Intelligence Unmasked

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

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

Open Access License: CC BY-NC 4.0

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

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

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

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

Address of Correspondence

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

Abstract

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

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14. Srinivasareddy S. Artificial Intelligence in Anesthesia: What Might the Future Hold. Int J Clin Anesthesiol 2024; 12(1): 1131.
15. Karmakar A, Khan MJ, Abdul-Rahman ME, Shahid U. The Advances and Utility of Artificial Intelligence and Robotics in Regional Anesthesia: An Overview of Recent Developments. Cureus 2023; 15(8): e44306.
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How to Cite this Article: Biyani G, Metta R. The Illusion of Precision: Artificial Intelligence Unmasked. International Journal of Regional Anaesthesia. January-June 2025; 6(1): 04-07. DOI: https://doi.org/10.13107/ijra.2025.v06.i01.0112

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Rural to Remote to the Recent Trends in Regional Anaesthesia

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

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

Open Access License: CC BY-NC 4.0

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

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

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

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

Address of Correspondence

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

Editorial

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

References

1. Moka E. Transforming Perioperative Care: Evolving Paradigms of the Expanding Role of Regional Anesthesia and Acute Pain Management. J Clin Med. 2025 Sep 4;14(17):6257.
2. Ramachandran S, Malhotra N, Velayudhan S, Singh Bajwa SJ, Joshi M, Mehdiratta L, Hiremath VR. Regional anaesthesia practices in India: A nationwide survey. Indian J Anaesth. 2021 Dec;65(12):853-861.
3. Lee, Seung, Azuka Onye, Asad Latif. Emergency Anesthesia in Resource-Limited Areas. Advances in Anesthesia, 2020 Volume 38, 209 – 227
4. Ariyo P, Trelles M, Helmand R, Amir Y, Hassani GH, Mftavyanka J, Nzeyimana Z, Akemani C, Ntawukiruwabo IB, Charles A, Yana Y, Moussa K, Kamal M, Suma ML, Ahmed M, Abdullahi M, Wong EG, Kushner A, Latif A. Providing Anesthesia Care in Resource-limited Settings: A 6-year Analysis of Anesthesia Services Provided at Médecins Sans Frontières Facilities. Anesthesiology. 2016 Mar;124(3):561-9.
5. Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Clin Sports Med. 2022 Apr;41(2):329-343.
6. Marhofer P, Greher M, Kapralet S. Ultrasound guidance in regional anaesthesia. British Journal of Anaesthesia, Volume 94, Issue 1, 7 – 17
7. Muthu SC. Simplified Block Techniques for Rural and Remotely Placed Hospitals IJRA 2025; current issue.
8. Arora D. Intrafascicular injection: Can ai, ultrasound, pressure monitoring, and echogenic needles prevent it? IJRA; 2025: Current issue.
9. Dost, B. Fascial plane blocks in the era of modern regional anesthesia: shaping the future of pain management. J Anesth Analg Crit Care 5, 49 (2025).
10. Tippireddy S, Ghatol D. Anesthetic Management for Enhanced Recovery After Major Surgery (ERAS) [Updated 2023 Jan 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574567/
11. Alrasheedi, N. T., Alkhubran, A. J., Alanazi, S. D. S., Al-Sahman, S. M. A., Asiri, R. A. A., Almoushawa, A. A., Alturaif, A. S., Almosa, J. A., Aldosari, A. F. (2023). “Tele-Anesthesia and Remote Supervision: Changing Perioperative and General Medical Care”, Integrative Biomedical Research (Journal of Angiotherapy), 7(1),1-9,10317
12. Balavenkatasubramanian J, Kumar S, Sanjayan RD. Artificial intelligence in regional anaesthesia. Indian J Anaesth. 2024 Jan;68(1):100-104.
13. Biyani G, Metta R. The Illusion of Precision: Artificial Intelligence Unmasked. IJRA 2025, current issue.
14. Bhuvaneshwari B, Diwan S. Genomics and Precision Analgesia – Is This the Era? IJRA 2025, current issue
15. Grewal et al.Regional Anaesthesia for Cancer Surgery and Its Impact on Recurrence and Metastasis: What Is the Evidence? IJRA 2025; current issue. DOI: https://doi.org/10.13

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

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Redefining Limits: Shoulder Disarticulation Under Regional Anaesthesia Alone

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Vol 5 | Issue 2 | July-December 2024 | Page 16-19| Vandana Mangal, Momoson Maring Tontanga, Chitra Singh, Tuhin Mistry

DOI: https://doi.org/10.13107/ijra.2024.v05.i02.98

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2024; The Author(s).

Submitted: February 18-11-2024; Reviewed: 25-11-2024; Accepted: 02-12-2024; Published: 10-12-2024

Authors: Vandana Mangal [1], Momoson Maring Tontanga [1], Chitra Singh [1], Tuhin Mistry [2]

[1] Department of Anaesthesiology and Critical Care, SMS Medical College, Jaipur, Rajasthan, India.
[2] Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre and Hospitals Pvt Ltd, Coimbatore, India

Address of Correspondence

Dr. Tontanga Momoson Maring
Department of Anaesthesiology and Critical Care, SMS Medical College, Jaipur, Rajasthan, India.
Email id: drmomoson@gmail.com

Abstract

Shoulder disarticulation following of animal bites is not uncommon and is often performed for various indications, including vascular insufficiency. General anaesthesia is usually the preferred choice in optimized patients, with or without regional anaesthesia. Phantom limb pain is a distressing and frequently encountered condition following limb amputation. In addition to their well-established benefits, nerve blocks not only provide effective perioperative analgesia but may also reduce the incidence of phantom limb pain. In this case, we undertook shoulder disarticulation exclusively under regional anaesthesia, as the patient’s respiratory condition was not optimal for general anaesthesia.

Keywords: Shoulder disarticulation, Regional anaesthesia, Subclavian perivascular block, Superficial cervical plexus block, Pectoserratus plane block.

References

1. Mahajan, A., Luther, A., & Chhabra, A. (2015). Brachial artery injury caused by camel bite. Indian Journal of Vascular and Endovascular Surgery, 2(1), 33. https://doi.org/10.4103/0972-0820.152834
2. Abu-Zidan FM, Hefny AF, Eid HO, Bashir MO, Branicki FJ. Camel-related injuries: Prospective study of 212 patients World J Surg. 2012;36:2384–9
3. Maduri P, Akhondi H. Upper Limb Amputation. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540962/
4. Donnelly, M. R., & Hacquebord, J. H. (2023). Shoulder level amputation: Forequarter and brachial plexus-level amputation. Operative Techniques in Orthopaedics, 33(3), 101056. https://doi.org/10.1016/j.oto.2023.101056
5. Kilicaslan A, Gok F, Colak TS, Keklicek O, Kucuksen MF. Combined interscalene, superficial cervical plexus and thoracic intertransverse process blocks for surgical anaesthesia of the shoulder disarticulation. Anaesth Rep. 2024;12(1):e12306. Published 2024 May 29. doi:10.1002/anr3.12306
6. Mbabazi P, Mwaniki M, Wambua G, Kagua S, Kamau RW, Daggett J, Nthumba PM. Successful Shoulder Disarticulation under Local Anesthesia in the COVID-19 Era. Plast Reconstr Surg Glob Open. 2023 Sep 13;11(9):e5266. doi: 10.1097/GOX.0000000000005266. PMID: 37711723; PMCID: PMC10499080.
7. Duggappa DR, Rao GV, Kannan S. Anaesthesia for patient with chronic obstructive pulmonary disease. Indian J Anaesth. 2015 Sep;59(9):574-83. doi: 10.4103/0019-5049.165859. PMID: 26556916; PMCID: PMC4613404.
8. Miniato MA, Anand P, Varacallo MA. Anatomy, Shoulder and Upper Limb, Shoulder. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536933/
9. Hamadnalla, H., Elsharkawy, H., Shimada, T. et al. Cervical erector spinae plane block catheter for shoulder disarticulation surgery. Can J Anesth/J Can Anesth 66, 1129–1131 (2019). https://doi.org/10.1007/s12630-019-01421-9
10. Mbabazi P, Mwaniki M, Wambua G, Kagua S, Kamau RW, Daggett J, Nthumba PM. Successful Shoulder Disarticulation under Local Anesthesia in the COVID-19 Era. Plast Reconstr Surg Glob Open. 2023 Sep 13;11(9):e5266. doi: 10.1097/GOX.0000000000005266. PMID: 37711723; PMCID: PMC10499080.

How to Cite this Article: Mangal V, Tontanga MM, Singh C, Mistry T | Redefining Limits: Shoulder Disarticulation Under Regional Anaesthesia Alone | International Journal of Regional Anaesthesia | July-December 2024; 5(2): 16-19 | DOI: https://doi.org/10.13107/ijra.2024.v05.i02.98

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Are We Depleted of Research Questions in Regional Anaesthesia?

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Vol 5 | Issue 1 | January-June 2024 | Page 03-06| Divesh Arora

DOI: https://doi.org/10.13107/ijra.2024.v05.i01.083

Authors: Anju Grewal [1], Gegal Pruthi [1], Hemanthkumar Tamilchelva [1]

[1] Department of Anaesthesiology, AIIMS, Bathinda, Punjab, India

Address of Correspondence

Dr. Gegal Pruthi,
Department of Anaesthesiology, AIIMS, Bathinda, Punjab, India
E-mail: drpkc12@gmail.com

Abstract

Regional anaesthesia has significantly evolved, shaping pain management in surgery. This article examines whether research question in this field are becoming exhausted, or if new avenues remain unexplored. Key trends include the integration of ultrasound guidance for precision, optimizing drug combinations for enhanced safety and efficacy, and focusing on patient-concerned outcomes to improve satisfaction and recovery. Tailored approaches for special populations and long-term safety studies are also crucial. Future research may explore innovations in drug delivery, novel local anaesthetic adjuncts, neurostimulation techniques, global access, interdisciplinary collaborations, and the application of artificial intelligence. Emphasizing simplicity, innovation, and patient centric care will ensure continued progress in regional anaesthesia, fostering advancement that enhance both scientific knowledge and clinical practices.
Keywords: Pain management, Regional anaesthesia, Research trends

References

1. Han JR, Tran J, Agur AM. Overview of the Innervation of Ankle Joint. (1) Rangappa P. History of analgesia and regional anaesthesia through philately. Anaesthesia and intensive care. 2008 Jul;36(1_suppl):12-8.
(2) COVIDSurg Collaborative, GlobalSurg Collaborative, Nepogodiev D, Simoes JF, Li E, Picciochi M, Glasbey JC, Baiocchi G, Blanco‐Colino R, Chaudhry D, AlAmeer E. Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study. Anaesthesia. 2021 Jun;76(6):748-58.
(3) https://www.nmc.org.in/wp-content/uploads/2019/09/MD-Anesthesia.pdf
(4) Beverly A, Kaye AD, Ljungqvist O, Urman RD. Essential elements of multimodal analgesia in enhanced recovery after surgery (ERAS) guidelines. Anesthesiology clinics. 2017 Jun 1;35(2):e115-43.
(5) Yun JS, Chung MJ, Kim HR, So JI, Park JE, Oh HM, Lee JI. Accuracy of needle placement in cadavers: non-guided versus ultrasound-guided. Annals of rehabilitation medicine. 2015 Apr 24;39(2):163-9.
(6) Johnson AN, Peiffer JS, Halmann N, Delaney L, Owen CA, Hersh J. Ultrasound-Guided needle technique accuracy: prospective comparison of passive magnetic tracking versus unassisted echogenic needle localization. Regional Anesthesia & Pain Medicine. 2017 Mar 1;42(2):223-32.
(7) Wu CL, Fleisher LA. Outcomes research in regional anesthesia and analgesia. Anesthesia & Analgesia. 2000 Nov 1;91(5):1232-42.
(8) Turbitt LR, Mariano ER, El‐Boghdadly K. Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia. 2020 Mar;75(3):293-7.
(9) Gadsden J, Orebaugh S. Targeted intracluster supraclavicular brachial plexus block: too close for comfort. British Journal of Anaesthesia. 2019 Jun 1;122(6):713-5.
(10) Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review. Anaesthesia. 2021 Jan;76:100-9.
(11) Kurdi MS, Agrawal P, Thakkar P, Arora D, Barde SM, Eswaran K. Recent advancements in regional anaesthesia. Indian Journal of Anaesthesia. 2023 Jan;67(1):63.
(12) Bowness J, Varsou O, Turbitt L, Burkett‐St Laurent D. Identifying anatomical structures on ultrasound: assistive artificial intelligence in ultrasound‐guided regional anesthesia. Clinical Anatomy. 2021 Jul;34(5):802-9.

How to Cite this Article: Grewal A, Pruthi G, Tamilchelva H | Are We Depleted of Research Questions in Regional Anaesthesia? | International Journal of Regional Anaesthesia | January-June 2024; 5(1): 03-06 | DOI: https://doi.org/10.13107/ijra.2024.v05.i01.83

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Making Regional Anaesthesia Safe

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

DOI: https://doi.org/10.13107/ijra.2023.v04i02.079

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

Authors: Ashish A. Bartakke [1]

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

Address of Correspondence
Dr. Ashish A. Bartakke,
Senior Faculty Consultant, Department of Anaesthesiology and Perioperative Medicine, Hospital Valle de los Pedroches, Pozoblanco, Andalucia, Spain.
E-mail: ashishbartakke@gmail.com

Abstract

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

References

1. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki Declaration on Patient Safety in Anaesthesiology. Eur J Anaesthesiol. 2010;27(7):592-597. doi:10.1097/EJA.0b013e32833b1adf
2. Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome?. Br J Anaesth. 2011;107 Suppl 1:i90-i95. doi:10.1093/bja/aer340
3. Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth. 2020;125(4):492-504. doi:10.1016/j.bja.2020.06.063
4. Fanelli A, Balzani E, Memtsoudis S, Abdallah FW, Mariano ER. Regional anesthesia techniques and postoperative delirium: systematic review and meta-analysis. Minerva Anestesiol. 2022;88(6):499-507. doi:10.23736/S0375-9393.22.16076-1
5. Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’ Association, Regional Anaesthesia UK, Campbell J, Plaat F, Checketts M et al. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014; 69: 1279e86
6. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2013;(3):CD003949. Published 2013 Mar 28. doi:10.1002/14651858.CD003949.pub3
7. Bomberg H, Bayer I, Wagenpfeil S et al. Prolonged catheter use and infection in regional anesthesia: a retrospective registry analysis. Anesthesiol J Am Soc Anesthesiol 2018; 128: 764e73
8. Keys M, Sim BZ, Thom O, Tunbridge MJ, Barnett AG, Fraser JF. Efforts to Attenuate the Spread of Infection (EASI): a prospective, observational multicentre survey of ultrasound equipment in Australian emergency departments and intensive care units. Crit Care Resusc J Australas Acad Crit Care Med 2015; 17: 43e6
9. Ecoffey C, Bosenberg A, Lonnqvist PA, Suresh S, Delbos A, Ivani G. Practice advisory on the prevention and management of complications of pediatric regional anesthesia. J Clin Anesth. 2022;79:110725. doi:10.1016/j.jclinane.2022.110725
10. Neal JM. Ultrasound-guided regional anesthesia and patient: update of an evidence-based analysis. Reg Anesth Pain Med 2016; 41: 195e204
11. Topor B, Oldman M, Nicholls B. Best practices for safety and quality in peripheral regional anaesthesia. BJA Educ. 2020;20(10):341-347. doi:10.1016/j.bjae.2020.04.007
12. Dohlman LE, Kwikiriza A, Ehie O. Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings. Local Reg Anesth. 2020;13:147-158. Published 2020 Oct 22. doi:10.2147/LRA.S236550
13. Mulroy MF, Weller RS, Liguori GA. A checklist for performing regional nerve blocks [published correction appears in Reg Anesth Pain Med. 2014 Jul-Aug;39(4):357]. Reg Anesth Pain Med. 2014;39(3):195-199. doi:10.1097/AAP.0000000000000075
14. Stop before you block. Available from: https://www.ra-uk.org/index.php/stop-before-you-block. [Accessed 25 March 2020]

How to Cite this Article:   Bartakke AA | Making Regional Anaesthesia Safe | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 21-26 | DOI: https://doi.org/10.13107/ijra.2023.v04i02.079

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

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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

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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
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[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

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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

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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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