Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of upper and lower limb nerve blocks

BACKGROUND

Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks.

METHODS

We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement.

RESULTS

A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research.

CONCLUSIONS

We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Serum concentrations of local anesthetics after unilateral interpectoral-pectoserratus plane block in breast cancer surgery: a pharmacokinetic study

INTRODUCTION

The ultrasound-guided interpectoral-pectoserratus plane block is a fascial plane block for superficial surgery of the anterolateral chest wall. This technique involves injecting a relatively large volume of local anesthetics (typically 30 mL of 0.25%-0.50%, ie, 75-150 mg ropivacaine) underneath the major and minor pectoral muscles of the anterior thoracic wall. There is a potential risk of toxic serum concentrations of local anesthetics due to systemic absorption.

METHODS

22 patients scheduled for elective unilateral breast cancer surgery were included in this study. All surgery was performed with general anesthesia and an ultrasound-guided interpectoral-pectoserratus plane block with 2.5 mg/kg ropivacaine. Ten venous blood samples were collected at 0 (two samples) 10, 20, 30, 45, 60, 90 and 120 min and at 4 hours after performing the block. Free and total ropivacaine levels were measured at each time point. Albumin and alpha-1-acid-glycoprotein were measured to monitor shifts between the free and bound fraction of ropivacaine.

RESULTS

Samples of 20 patients were analyzed. The mean dose of ropivacaine was 172.8 (22.5) mg. In 50% of the patients, the potentially toxic threshold of 0.15 µg/mL free ropivacaine concentration was exceeded. Mean peak serum concentration occurred at 20 min postinjection.

CONCLUSIONS

This pharmacokinetic study demonstrated that a 2.5 mg/kg ropivacaine interpectoral-pectoserratus plane block may result in exceeding the threshold for local anesthetic systemic toxicity.

Deep posterior gluteal compartment block for regional anaesthesia of the posterior hip: a proof-of-concept pilot study

Background

Various regional anaesthesia approaches to branches of the anterior lumbar plexus have been proved effective in providing analgesia in hip surgery. However, some patients still experience significant residual posterior hip pain attributed to the posterior nerve supply of the hip. This not only suggests that anterior approaches may not always provide sufficient pain relief, but also that the blocking of major nerves supplying the posterior pericapsular region is needed.

Methods

We present an ultrasound-guided technique to block all major nerves supplying the posterior capsule of the hip joint. The optimal target area was determined by ultrasound imaging, cross-sectional digitised anatomy, and cadaver research, and was found in the deep gluteal compartment. Furthermore, this posterior pericapsular deep-gluteal block was evaluated in two patients.

Results

The spread of dye in the cadaver was observed deep to the gluteus maximus and in between the quadratus femoris and piriformis muscles, and conformed to the presumed location during the ultrasound procedure. It included all major supplying nerves to the posterior hip capsule, that is the superior gluteal nerve, nerve to quadratus femoris and sciatic nerve. In both patients where this posterior pericapsular deep-gluteal block was applied the pain was substantially reduced (numeric rating scale: 4 to 1 and 7 to 1).

Conclusion

We present a successful ultrasound-guided technique targeting the deep gluteal compartment to block all major nerves supplying the hip joint's posterior capsule. This posterior pericapsular deep-gluteal block can be applied as an additional block in hip surgery, with also a possible role in chronic hip pathology.

Anaesthesia for elite athletes

BACKGROUND

Sports participation has been growing rapidly since the 1960s. Anaesthesiologists are increasingly confronted with athletes in a peri-operative setting. The right choice of type of anaesthesia technique, pain management of injuries, specific physiologic adaptations of the athlete and knowledge of prohibited substances are eminent for a correct approach of this subpopulation.

PURPOSE

This review aims to give an overview of athletes' specific anaesthetic management in peri-operative and postoperative settings and to guide the nonspecialised anaesthetist.

METHODS

We comprehensively reviewed the literature, gathered all the information available on, and synthesised it in a narrative way, regarding preoperative evaluation, intraoperative implications and postoperative pain management of the elite athlete undergoing a surgical procedure.

RESULTS

An anaesthesiologist should recognise the most common benign ECG findings in athletes like bradycardia, isolated left ventricle hypertrophy on voltage criteria and early repolarisation as normal features in the athlete's heart. Isotonic physiology typically produces four-chamber dilation. In contrast, isometric stress creates high intravascular pressure leading to left ventricular hypertrophy. Pre-operative evaluation should also identify possible consumers of performance-enhancing drugs. Intraoperative points of interest for the anaesthesiologist is mainly avoiding drugs on the prohibited list of the World Anti-Doping Agency (WADA). Postoperative and chronic pain management are still developing fields in this population. The International Olympic Committee (IOC) proposed treating acute pain with a combination of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, injectable NSAIDs and local anaesthetics. It may be suggested that chronic pain management in elite athletes could benefit from treatment in specialised multidisciplinary pain clinics.

CONCLUSION

This literature review aims to serve as a guide for the anaesthesiologist taking care of the elite athlete.

Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient

The Peripheral Nerve Block working group of the Belgian Association for Regional Anesthesia has revised and updated the “Clinical guidelines for the practice of peripheral nerve block in the adult” which were published in 2013.

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

BACKGROUND AND OBJECTIVES

Lumbar plexus block has been used to provide postoperative analgesia after lower limb surgery. The fascia iliaca compartment block (FICB) has been proposed as an anterior approach of the lumbar plexus targeting the femoral, obturator and lateral femoral cutaneous nerve. However, both radiological and clinical evidence demonstrated that an infra-inguinal approach to the fascia iliaca compartment does not reliably block the three target nerves.We hypothesized that a supra-inguinal approach of the fascia iliaca compartment results in a more consistent block of the three target nerves than an infra-inguinal approach.

METHODS

We performed a randomized controlled, double-blind trial in 10 healthy volunteers. Both an infra-inguinal FICB (I-FICB) and a supra-inguinal FICB (S-FICB) were performed on the left or the right side in each volunteer. Forty milliliters of lidocaine 0.5% was injected with each approach. Sensory and motor block and spread of local anesthetics (LA) on MRI were assessed.

RESULTS

After an S-FICB, 80% of the volunteers had a complete sensory block of the medial, anterior and lateral region of the thigh, compared with 30% after an I-FICB (p=0.035). There was an insignificant effect on motor function with both approaches. After an S-FICB, in 8 out of 10 volunteers there was spread of LA in the expected anatomic location of the obturator nerve on MRI compared with 1 out of 10 volunteers after an I-FICB (p=0.0017). The cranial spread of LA after an S-FICB on MRI was higher than after an I-FICB (p=0.007), whereas there was a more caudal spread of LA on MRI after an I-FICB than after an S-FICB (p=0.005).

CONCLUSIONS

An S-FICB produces a more complete sensory block of the medial, anterior and lateral region of the thigh, compared with an I-FICB. Our study demonstrates that an S-FICB with 40 mL of LA more reliably spreads LA to the anatomical location of the three target nerves of the lumbar plexus on MRI than an I-FICB. An S-FICB also leads to a more consistent spread in a cranial direction under the fascia iliaca and around the psoas muscle.

CLINICAL TRIAL REGISTRATION

This work was registered with the European clinical trial registry: Identifier Eudra CT 2015-004607-24.

A double-blind randomized controlled trial comparing dexamethasone and clonidine as adjuvants to a ropivacaine sciatic popliteal block for foot surgery

Background and aims

A popliteal block is effective in managing postoperative pain for foot surgery, but since the duration of analgesia is limited following a single-shot popliteal fossa block technique, methods to prolong effective postoperative analgesia are mandatory. The aim of this study was to assess the effect of adjuvants to ropivacaine on the duration of sensory and motor block.

Methods

In this double-blind randomized placebo-controlled study, we evaluated the analgesic effect of clonidine or dexamethasone (DXM) when added to ropivacaine for hallux valgus surgery. After obtaining institutional ethics research board approval and written informed consent, a total of 72 patients were randomly allocated. Fifty-seven of these patients were statistically analyzed. All patients received an ultrasound-guided single-shot popliteal fossa block with 30 mL of ropivacaine 0.75%, supplemented with saline, clonidine 100 µg, or DXM 5 mg. The primary end point was time to first pain sensation. Secondary end points were time to complete sensory and motor block regression.

Results

Compared to saline, duration to first pain sensation was prolonged by 9 hours (mean ± standard deviation: 31±9 hours) (42%) in the DXM group (P=0.024) and by 6 hours (28±10 hours) (27%) in the clonidine group (P=0.024). Compared to saline, DXM prolonged both complete sensory and motor blockade by 12 hours (25±7 hours) (46%) and 13 hours (36±6 hours) (55%), respectively, while clonidine prolonged complete sensory and motor blockade by 7 hours (30±7 hours) (27%) and 2 hours (22±5 hours) (10%), respectively. DXM prolonged sensory block regression time by 6 hours (21±7 hours) (41%) and clonidine by 2 hours (17±6 hours) (13%) compared to the control group (P=0.006). Similarly, DXM prolonged motor block regression by 7 hours (25±7 hours) (46%) and clonidine by 4 hours (21±4 hours) (19%) (P<0.0001).

Conclusion

Addition of DXM and clonidine to ropivacaine significantly prolonged the duration of postoperative sensory and motor block.

Approach to one lung ventilation during the surgical resection of an intrathoracic ganglioneuroblastoma in a three-year-old child: a case report and review of the literature

One lung ventilation (OLV) in children is a challenge and requires creative solutions. A case of OLV with bronchial placement of a fiberscope inspection-guided vascular embolectomy catheter in a three-year-old girl, scheduled for the resection of an intrathoracic tumor through thoracotomy is described. The availability of a broad range of vascular catheters as well as of fiberscope inspection material was decisive in managing the airway intra-operatively. Over the last 20 years, the need for OLV in children has increased, and various methods for performing it have been reported. Knowing all existing strategies in that domain is important to provide optimal perioperative care. In this paper, several methods of OLV in children will be discussed, such as selective endobronchial intubation, types of bronchial blockers, Univent tube, pediatric double lumen tubes, as well as the Marraro double lumen tube.

Clinical guidelines for the practice of peripheral nerve blocks in the adult

These guidelines, made by BARA, are, like the "Safety First Guidelines" of the SARB, clinical recomendations for a good and safe practice when performing peripheral nerve blocks (PNB). These recommendations were made according to the most recent literature and experts opinion and are therefore prone to changes due to evolution of literature. The guidelines deal with "Informed Consent", preoperative visit, monitoring, equipment and the PNB procedure itself regardless of using ultrasound or neurostimultion or both. Advise is given when combining a PNB with general anesthesia and when a catheter technique is used.

Supraclavicular brachial plexus blocks: review and current practice

This article reviews the possible revival of the supraclavicular brachial plexus blockade due to the use of ultrasound guidance. The brachial plexus is a complex network of nerves, extending from the neck to the axilla, which supplies motor and sensory fibers to the upper extremity. Understanding the complexities of the formation and structure of the brachial plexus remains a cornerstone for effective regional anaesthesia. On the level of the supraclavicular fossa, the plexus is most compactly arranged. The supraclavicular approach of the brachial plexus has a high success rate including blockade of the ulnar and musculocutaneous nerve, which can be missed respectively with the interscalene and axillary approach. However, because of the proximity of the pleura, most anaesthesiologists have been reluctant to perform this supraclavicular approach. The introduction of ultrasound guidance techniques not only reduces the possible risk of pneumothorax but also allows a faster onset time of the block with a reduction of the local anaesthetic dose. This makes the supraclavicular approach a valuable alternative to the axillary, interscalene and infraclavicular approach for upper limb surgery.

Belgian recommendations on perioperative maintenance fluid management of surgical pediatric population

The European recommendations on perioperative maintenance fluids in children have recently been adapted from hypotonic to isotonic electrolyte solutions with lower glucose concentrations. In Belgium, however, the commercially approved solutions do not match with these recommendations and there is neither consensus nor mandate about the composition and volume of perioperative maintenance fluids in children undergoing surgery despite the continuing controversy in literature. This paper highlights the significant challenges and shortcomings while prescribing fluid therapy for pediatric surgical patients in Belgium. It is sensible to the authors to address these issues with national guidance through an organization such as The Belgian Association for Paediatric Anaesthesiology, and to propose Belgian recommendations on perioperative fluid management in surgical children, with the intention of improving the quality of care in this population.

Ultrasound as guidance for a combined bilateral supraclavicular and caudal block, in order to reduce the total anaesthetic dose in a two year old child after a pneumococcal sepsis

We present a case of the combination of a bilateral supraclavicular block and a caudal block in a two year old boy who needed amputations of four extremities after a pneumococcal sepsis. With the use of ultrasound guidance, reduction of local anaesthetic dose could be obtained in order not to reach the toxic dose of the local anaesthetic. Amputations of four extremities is not common practice. A good postoperative pain management is more than a challenge.

Tumour marker concentration at the start of chemotherapy is a stronger predictor of treatment failure than marker half-life: a study in patients with disseminated non-seminomatous testicular cancer

We investigated the prognostic value of the serum half-life of human chorionic gonadotrophin (HCG) and alpha-fetoprotein (AFP) during induction chemotherapy and the relative prognostic importance of initial marker concentrations and marker half-life. Marker half-lives were calculated using two abnormal values observed between day 8 and day 22 of the first chemotherapy cycle. Moreover, analyses were carried out using day 43 as the second measurement point. Treatment failure at any time was chosen as the end point. The relative prognostic influence of marker half-lives and initial marker concentrations was tested in univariate and multivariate analyses. Half-lives were considered to be prolonged if > 3 days for HCG and > 6 days for AFP. In addition, we separated patients into those with half-lives > 6 days for HCG and those with half-lives > 10 days for AFP to examine whether these long half-lives were associated with a poor prognosis. A group of 669 patients treated with cisplatin combination chemotherapy was studied. Forty-two per cent of the patients had normal HCG and 37% had normal AFP at the start of chemotherapy. At day 22, HCG was still elevated in 138 patients and AFP in 211. At day 43, the numbers of these patients were 35 and 80 respectively. Based on the measurements obtained on day 8 and day 22, a half-life of HCG > 3 days or > 6 days and/or a half-life AFP > 6 days or > 10 days did not accurately predict treatment failure (P=0.413 and P=0.851, respectively; values obtained using tests for trend). However, initial marker concentrations of HCG and/or AFP > 1000 IU l(-1) were highly significant prognosticators for treatment failure (P=0.001 and P < 0.001 respectively), independent of half-life values. Half-lives calculated with the values obtained on day 43 did not contribute to the accuracy of the prediction of treatment failure. We conclude that half-lives of HCG and AFP during induction chemotherapy are inaccurate parameters for the prediction of treatment failure. In contrast, initial serum concentrations of HCG and AFP are highly significant in the prediction of unfavourable treatment outcome.

Cisplatin, vincristine and ifosphamide combination chemotherapy of metastatic seminoma: results of EORTC trial 30874. EORTC GU Group

The aims of the trial were to establish the response rate and determine the toxicity of combination chemotherapy with ifosphamide, vincristine and cisplatin (HOP regimen) in advanced metastatic seminoma and to study the role of post-chemotherapy consolidation treatment. Patients with bulky metastatic non-alpha-fetoprotein-producing seminomas were eligible for this phase II study [serum human chorionic gonadotropin < 200 U l-1 (< 40 ng l-1)] if they presented with abdominal masses > or = 10 cm or had extra-gonadal seminoma or had relapsed after previous radiotherapy. The HOP regimen consisted of four 3-weekly cycles of the following drug combination: ifosphamide (days 1-5, 1.2 mg m-2 day-1), vincristine (day 1, 2 mg) and cisplatin (days 1-5, 20 mg m-2 day-1). Residual masses persisting 6 months after chemotherapy could be considered for consolidation surgery or radiotherapy. Maximal response to the HOP chemotherapy (evaluated at any time) was based on the WHO criteria. The median observation time was 2.5 years (range 1.8-5.5 years). Thirteen institutions treated 42 eligible patients within the study (testicular cancer stage > or = IID, 25; extragonadal, 5; relapse after previous radiotherapy, 12). Two patients were not evaluable for response owing to premature treatment discontinuation. Maximal response was as follows: complete remission (CR), 26 (65%); partial remission (PR) 11 (28%); no change (NC), 2 (5%); progressive disease (PD), 1 (3%). Four patients have died, three from their malignancy (two without previous irradiation and one with prior radiotherapy). The fourth patient died of treatment-related toxicity. The 3 year survival for all 42 eligible patients was 90%. Dose reduction and treatment postponement were necessary in 25 and 14 patients respectively. Ten patients experienced granulocytic fever. Previously irradiated patients tolerated chemotherapy as well as non-irradiated patients. Immediately after HOP chemotherapy a mass persisted in 16 of 17 patients with retroperitoneal masses of > or = 100 mm at presentation. Three of these residual lesions were resected within the following 6 months showing complete necrosis. Four lesions dissolved spontaneously during the first year of follow-up. Nine lesions persisted for > or = 1 year (one after consolidation radiotherapy) without leading to relapse. Four of seven patients with mediastinal lesions achieved CR and three a PR after HOP chemotherapy. The HOP chemotherapy regimen is highly effective in patients with advanced metastatic seminoma or those relapsing after previous radiotherapy, but is associated with a high risk of toxicity, in particular myelotoxicity.

EORTC (30885) randomised phase III study with recombinant interferon alpha and recombinant interferon alpha and gamma in patients with advanced renal cell carcinoma. The EORTC Genitourinary Group

In the treatment of renal cell carcinoma both complete (CRs) and partial remissions (PRs) have been obtained using recombinant (r) interferon alpha (IFN-alpha), with response rates ranging from 0 to 31% (mean 16%). rIFN-gamma is a potent immunostimulating agent, but the clinical experience of its use is limited and results are conflicting. In a phase II study with the combination of rIFN-alpha 2c (Boehringer Ingelheim) and rIFN-gamma (Genentech, supplied by Boehringer Ingelheim) in 31 eligible patients, a response rate of 25% was recorded. Based on this observation a randomised phase III study was initiated to investigate the possible advantage of the addition rIFN-gamma to rIFN-alpha 2c treatment. Treatment consisted of rIFN-alpha 2c 30 micrograms m-2 = 10 x 10(6) IU m-2 s.c. twice weekly in arm A and the same dose of rIFN-alpha combined with rIFN-gamma 100 micrograms m-2 = 2 x 10(6) IU m-2 in arm B. Eligibility criteria included documented progression of disease; patients with bone lesions only and overt central nervous system metastases were excluded. Between November 1988 and September 1990, 102 patients were entered into the study. An interim analysis showed a response in 7/53 (13%) patients (two CRs and five PRs) in the rIFN-alpha 2c monotherapy arm and in 2/45 (4%) (one CR and one PR) patients in the combination arm. This difference was not statistically significant (P = 0.17). The probability of missing an eventual 10% advantage for the combination is 0.001. The numbers are insufficient to rule out a negative effect of the addition of rIFN-gamma. The dose intensity of IFN-alpha 2c for the two treatment arms was the same. The addition of rIFN-gamma does not improve the response rate of rIFN-alpha 2c monotherapy. A possible detrimental effect cannot be excluded.

Orchiectomy versus goserelin and flutamide in the treatment of newly diagnosed metastatic prostate cancer. Analysis of the criteria of evaluation used in the European Organization for Research and Treatment of Cancer--Genitourinary Group Study 30853

This European Organization for Research and Treatment of Cancer (EORTC) trial 30853 is the fifth EORTC--Genitourinary Group randomized phase III trial of endocrine treatment for patients with newly diagnosed metastatic prostate cancer. Special attention was given to the assessment of response and/or progression. Each of the following factors was assessed separately as nonspecific and subjective criteria of response or progression: performance status, pain, alkaline and acid phosphatase, hemoglobin, urinary symptoms, and prostate-specific antigen (PSA). Objective progression was based on measurable disease. The observed sequence of progression was: (1) protein-specific antigen; (2) bone; (3) pain; and (4) performance status. Protein-specific antigen, an optional parameter, was the first sign of progression in more than 50% of patients whose disease had progressed.

Vinblastine in metastatic renal cell carcinoma: EORTC phase II trial 30882. The EORTC Genitourinary Group

32 patients with metastatic renal cell carcinoma (MRCC) who had had no prior chemotherapy received vinblastine 0.15 mg/kg intravenously once weekly for 6 weeks, thereafter every second week, provided no major toxicity. Dose modifications were based on haematological and neurological side-effects. Only one complete response was observed among 26 evaluable patients (response rate: 4%; 95% confidence interval: 0-20%). 4 out of 29 patients developed grade 3 leukopenia. Grade 3 peripheral neurotoxicity was recorded in 2 patients. 2 patients had grade 3 alopecia. Vinblastine has no major significance on the clinical management of MRCC.

Zoladex and flutamide versus bilateral orchiectomy. A randomized phase III EORTC 30853 study. The EORTC GU Group

A total of 327 patients with metastatic prostatic cancer were randomized to either bilateral orchiectomy or treatment with zoladex depot supplemented by flutamide 250 mg 3 qid. Statistically significant increases in time to subjective and objective progression were recorded in favor of the combination treatment. No differences in time to death by cancer or overall death were recorded. The clinical significance of these differences will be reassessed once additional follow-up is available and further analysis of the overall clinical material has been carried out.

Vitamin E and selenium concentrations in milk and milkfractions

Cow's milk of different lactation stages and of different seasons was analysed for its vitamin E and selenium contents. The concentrations of these nutrients vary with the lactation stage as well as with the sampling period. The results are compared with corresponding values for human milk. Cow's milk has appreciatly lower concentrations of vitamin E; the selenium content of cow's and human milk are the same. The lack of vitamin E when cow's milk is used for infant formulae is compensated for the addition of alpha-tocopheryl acetate. The selenium concentration of different protein fractions of cow's milk was determined. It was found that the whey proteins contain more selenium than the caseins.