Latest Advances in Regional Anaesthesia

Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.

Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective

The COVID-19 outbreak is on the world. While many countries have imposed general lockdown, emergency services are continuing. Healthcare professionals have been infected with the virulent severe acute respiratory syndrome coronavirus-2 (SARS), which spreads by close contact and aerosols. The anesthesiologist is particularly vulnerable to aerosols while performing intubation and other airway related procedures. Regional anesthesia (RA) minimizes the need for airway manipulation and the risks of cross infection to other patients, and the healthcare personnel. In this context, for prioritizing RA over general anesthesia, wherever possible, a structured algorithmic approach is outlined. The role of percentage saturation of hemoglobin with oxygen (oxygen saturation), blood pressure and early use of point-of-care ultrasound in differential diagnosis and specific management is detailed. The perioperative anesthetic implications of multisystem manifestations of COVID-19, anesthetic management options, the scope of RA and considerations for its safe conduct in operating rooms is described. An outline for safe and rapid training of healthcare personnel, with an Entrustable Professional Activity framework for ascertaining the practice readiness among trained residents for RA in COVID-19, is suggested. These are the authors' experiences gained from the current pandemic and similar SARS, Middle East Respiratory Syndrome and influenza outbreaks in recent past faced by our authors in Singapore, India, Hong Kong and Canada.

Update of Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain from 2000 to 2018 in the US Fee-for-Service Medicare Population

BACKGROUND

Interventional techniques for managing spinal pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic spinal pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009.

OBJECTIVES

The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic spinal pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018.

STUDY DESIGN

The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic spinal pain from 2000 to 2018 in the FFS Medicare population in the United States.

METHODS

Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018.

RESULTS

Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018.

LIMITATIONS

This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate.

CONCLUSIONS

Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%.

KEY WORDS

Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.

[Peripheric blockades in plastic and reconstructive surgery: up-to-date trends and prospects (a 30-year experience)]

The article presents the own 30-year experience in the use of more than 1000 prolonged peripheral nerves and plexus block anaesthesia in reconstructive surgery, based on experimental and clinical studies. The evolution peripheric blockades technique is given:from a separate anaesthesia method to balanced anesthesia based on peripheric blockades. The current state of the problem was analyzed according to the literature.

[Practical problems of contemporary neuroanesthesiology]

The paper written in the format of lecture, focuses on practical problems of neuroanesthesiology, current tendencies in technologies and medicaments, prevention and management of complications.

Trends in regional anaesthesia for caesarean section in a Nigerian tertiary health centre

BACKGROUND

Most caesarean sections were previously performed under general anaesthesia but there has been an increasing trend worldwide in the use of regional anaesthesia as the preferred method of anaesthesia for caesarean delivery.

OBJECTIVE

To evaluate the trend of practice of regional anaesthesia for caesarean section in a tertiary hospital in South-western part of Nigeria.

METHODS

The obstetric operating room records at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria were reviewed for a twenty-year period: January 1986 to December 2005. The anaesthetic techniques for caesarean section and the level of training of the attending anaesthetist were noted.

RESULTS

A total of 1,785 patients were delivered by caesarean section during the twenty-year period . Most patients [1578(88.4%)] had caesarean section under general anaesthesia while 207(11.6%) had regional anaesthesia. Subarachnoid block accounted for 89(5%) of the patients and 118(6.6%) had the caesarean section under epidural block. One hundred and ten (21.5%) of the regional techniques were in the first quarter of the 20-year period. This figure fell to eight (2%) in the second quarter; zero in the third quarter and rose to 82(13.7%) in the last quarter demonstrating an increasing trend of regional technique for caesarean section. Majority of the epidural blocks were conducted by nurse-anaesthetists while the subarachnoid blocks were administered by anaesthetists.

CONCLUSION

There is an overall low practice or usage of regional anaesthetic for caesarean section. A trend towards increasing administration of regional technique for caesarean section is demonstrated. A dedicated period for hand on the job workshop in regional blocks may enhance early and prompt acquisition of relevant skills in regional anaesthesia for caesarean delivery.

Ultrasound-Guided Regional Anesthesia: Current Concepts and Future Trends

The scope of ultrasound imaging guidance for regional anesthesia is growing rapidly. Preliminary data, although limited, suggest that ultrasound can improve block success rate and decrease complications. In this review, we describe the basic principles of ultrasound scanning and needling techniques for nerve blocks, highlight some of the data on clinical outcome, discuss specific limitations of ultrasound for regional anesthesia, and speculate on the future direction for physician training and competency assessment with this technology.

Complications of regional anesthesia

PURPOSE OF REVIEW

The use of regional anesthesia, either alone or as an adjunct to general anesthesia, is at an all-time high. Demonstrated benefits include reduced side effects, more efficient use of facilities and enhanced patient satisfaction with the improved postoperative pain relief. New advances in equipment, techniques and medications have been incorporated over the past 10 years, and especially over the last 2 years. As the number of practitioners and procedures increase, the number of complications may rise as well.

RECENT FINDINGS

The specific issues of nerve damage, treatment of local anesthetic toxicity with lipid solutions and prevention of wrong-sided procedures are examined with special reference to recent publications.

SUMMARY

Specific needle shapes, appropriate pharmacologic resuscitation from intravascular injection of local anesthetics and institutional procedures to positively identify patients and the correct block location are all part of a strategy to minimize the occurrence of adverse outcomes and to mitigate the consequences of those adverse events when they do occur. More importantly, these are changes that can be instituted immediately with minimal expense to the institution and great benefit to the patient.

Future of regional anaesthesia

The development and refinement of regional anaesthetic techniques for various types of surgery, mainly obstetric, ophthalmic and orthopaedic surgery, and of continuous regional analgesia continues. Suitable analgesic drug mixtures, and concentrations, will be further tested in order to find the ideal analgesic regimen for each type of surgery and for the individual patient. No new local anaesthetics or equipment for clinical use are expected in the near future. Improvement therefore depends much on how the anaesthesiologists use the present drugs, needles, nerve detection devices, catheters and pumps. During training in regional anaesthesia for the speciality of anaesthesiology and intensive care medicine, it may suffice to concentrate only on certain common techniques such as epidural block, spinal block, axillary brachial plexus block, intravenous regional anaesthesia and femoral nerve block. Rare regional anaesthetic blocks and invasive techniques should be mastered and taught by specially trained regional anaesthesiology experts. In chronic pain, regional anaesthetic blocks with local anesthetics are not expected to play any major therapeutic role. However, nerve blocks can be useful for diagnostic purposes and in order to facilitate rehabilitation in chronic pain syndromes.

[What's new in ophthalmic anaesthesia?]

In the past few years, there have been many changes in ophthalmic anaesthesia. Application of drugs in general anaesthesia with excellent controllability enhances patient safety and allows a more efficient OR-management. Regional anaesthesia is gaining widespread use for ophthalmic surgery, especially topical anaesthesia for cataract surgery. Patients for ophthalmic surgery concomitantly often display high age and a high level of co-morbidity and, therefore, belong to the anaesthesiological risk groups ASA III-IV. Life-threatening adverse events including cardiovascular depression are associated with general and regional anaesthesia. Intervention by anaesthesiologists is frequently required for treatment of hypertension or dysrhythmias, and sedation. Thus, monitored anaesthesia care ("standby") is justified. Drugs applied for regional and general anaesthesia may change intraocular pressure. There are a lot of publications about the impact of anaesthesia on intraocular pressure (IOD), however, few on the effects of anaesthesia on pulsatile ocular blood flow. it has to be kept in mind that the effects of anaesthesia on intra-ocular pressure and pulsatile ocular blood flow may diverge. To avoid an increase of the IOD, especially during anaesthesia induction, drugs, such as succinylcholin, rocuronium and opiates, in particular remifentanil, can be applied. In addition, the use of the laryngeal mask may be advantageous compared to general anaesthesia associated with laryngoscopic tracheal intubation. The management of patients treated with anticoagulants and antiplatelet agents, has to be taken on the balance of risks. There are risks not only in continuing therapy, but also in discontinuing it perioperatively. Postoperative nausea and vomiting (PONV) remains a distressing and common problem after strabismus repair in particular in children. The incidence of PONV depends on the type of ophthalmic surgery and drugs applied. To reduce PONV in ophthalmic surgery, application of long-lasting opiates should be avoided, and non-opiate analgesics and, depending on the kind of operation, antiemetic prophylactics are recommended.

An update on Intravenous Regional Anaesthesia of the arm

Intravenous Regional Anaesthesia (IVRA) has been first described in 1908 by the german surgeon August KG Bier. Although the technique was easy to perform and effective in giving surgical anaesthesia, the newer plexus block techniques largely replaced in a short time the "Bier block", because of time limitations of IVRA and safety considerations. Throughout the years modifications in procedure and new pharmacologic adjuvants have been shown to prevent toxic reactions to anaesthetics and mitigate limitations of IVRA. This paper rewiews the technique itself, its historical background, procedural modifications to improve its safety and efficiency, pharmacologic adjuvants acting on onset time of anaesthesia and on tourniquet pain, and drugs improving postoperative analgesia and muscle relaxation. The economic side of IVRA is also discussed.

[Ultrasound in local anaesthesia. Part I: technical developments and background]

The localisation of the nerve to be blocked is one of the special challenges in local anaesthesia. Since the first time local anaesthesia procedures were carried out approximately 100 years ago, the basic limitations of this method have always been the unsatisfactory success rate and the specific risks involved. Even by variation of the access route to the various nerves and use of different identification methods, no ideal blockade technique has been found which allows a 100% success rate and at the same time reduces the risks to a minimum. The clinical introduction of various aids, such as nerve stimulation or Doppler sonography, have brought no statistically significant advantages despite showing clear improvements. In recent years there has been a trend towards local anaesthesia in perioperative care due to the proven advantages and range of possibilities. Several working groups have developed methods for the sonographic identification of nerves or the epidural space and to an exact placing of needles or catheters from the information obtained. In this way the application of catheters and the injection of local anaesthetic agents can be carried out in an accurate and controlled manner. Although sonography is a procedure which has been used in local anaesthesia for over 10 years, there are at present only few practising local anaesthetists who can use this method. However, interest in this method is growing especially due to the aspect of quality assurance. Organising committees have established that this method will be the future direction. Perhaps even the prediction of Alon P. Winnie for ultrasound-guided local anaesthesia will become true: "Sooner or later someone will make a sufficiently close examination of the anatomy involved, so that exact techniques will be developed."

Preemptive analgesia II: recent advances and current trends

PURPOSE

This two-part review summarizes the current knowledge of physiological mechanisms, pharmacological modalities and controversial issues surrounding preemptive analgesia.

SOURCE

Articles from 1966 to present were obtained from the MEDLINE databases. Search terms included analgesia, preemptive; neurotransmitters; pain, postoperative; hyperalgesia; sensitization, central nervous system; pathways, nociception; anesthetic techniques; analgesics, agents.

PRINCIPAL FINDINGS

In Part I of this review article, techniques and agents that attenuate or prevent central and peripheral sensitization were reviewed. In Part II, the conditions required for effective preemptive techniques are evaluated. Specifically, preemptive analgesia may be defined as an antinociceptive treatment that prevents establishment of altered central processing of afferent input from sites of injury. The most important conditions for establishment of effective preemptive analgesia are the establishment of an effective level of antinociception before injury, and the continuation of this effective analgesic level well into the post-injury period to prevent central sensitization during the inflammatory phase. Although single-agent therapy may attenuate the central nociceptive processing, multi-modal therapy is more effective, and may be associated with fewer side effects compared with the high-dose, single-agent therapy.

CONCLUSION

The variable patient characteristics and timing of preemptive analgesia in relation to surgical noxious input require individualization of the technique(s) chosen. Multi-modal analgesic techniques appear more effective.

Lacrimal fossa block: an audit of a minimally invasive regional anaesthetic technique for endoscopic dacryocystorhinostomy (DCR)

The lacrimal fossa block (LFB), a new development to provide regional anaesthesia for endoscopic dacryocystorhinostomy, is reported. Cadaveric study showed that the block needle, inserted as described, made direct contact with the periosteum of the frontal process of the maxilla within the lacrimal fossa. This technique enables both relevant divisions of the trigeminal nerve to be anaesthetized through a single entry site and, as this injection is confined to the anterior part of the orbit, ocular complications are minimized. An audit of 66 patients has shown that this technique, combined with standard intranasal local anaesthesia, provides good intraoperative analgesia, causes minimal diplopia and has a high level of patient acceptability.

New trends in regional anaesthesia

In this review, some of the newer developments in regional anaesthesia (RA) are discussed. The relationship between paraesthesiae and nerve stimulator responses has been shown to be unclear, and sometimes at a needle tip location where a paraesthesia is found, there is no response to the nerve stimulator. It is recommended to use whichever end point is found first. The debate as to the safety of RA in anaesthetised patients remains unresolved and strong opinions are often based on individual case reports. The training and skill of the anaesthetist still appears to be a more important factor. The problems of RA and impaired coagulation are well understood and guidelines are in place in many countries. The value of neuraxial blocks for postoperative pain management is well established and the increasing use of peripheral nerve blocks often using continuous methods is to be encouraged. The use of PCA for blocks as well as intravenously and the extension of the use of RA into the home are important developments. The beneficial effects of RA on postoperative morbidity and mortality are becoming clearer, and the introduction of the two new local anaesthetic agents, ropivacaine and levobupivacaine have improved safety. There has, however, been very slow progress in the development of long awaited ultralong acting local anaesthetics or in the introduction of slow release formulations.

An introduction to the World Wide Web

BACKGROUND AND OBJECTIVES

Anesthesiologists are increasingly utilizing the Internet for personal and professional purposes. Without guidance, the task of searching the Internet for information may be time-consuming and frustrating. This article includes a basic introduction to the Internet with suggestions and guidelines for accessing information resources. Future articles will address locating articles about human anatomy, regional anesthesia and pain medicine.

EDITORS NOTE

This is the first in an informal series of articles demonstrating and describing information technology. The articles will include nontechnical information and will detail the experiences and wisdom obtained from experienced anesthesiologists. The series is geared toward the computer novice with interest in regional anesthesia and pain medicine. These articles are also available in full text on the American Society of Regional Anesthesia website (www.asra.com) with links to the websites in the article.

Clinical aspects of CRNA practice. Regional anesthesia

Regional techniques have become increasingly popular for anesthesia and analgesia for surgical patients. It is also frequently used for the patient with nonsurgical pain such as cancer. New discoveries in physiology, pharmacology, pain modulation and transmission as well as pain management therapies are a dynamic field of study in regional anesthesia and analgesia. Nurse-anesthetists provide regional techniques as part of their armamentarium of clinical skills.

Future of regional anaesthesia and pain management

Consideration of the future practice of regional anaesthesia and pain management must include more than scientific advances. With advances in technology, the practice of medicine will increasingly become international in scope. Socio-economic issues will also have increasing impact on the practice of regional anaesthesia and pain management. More attention will be given to improved outcome and reduced morbidity as addressed by the "closed claims study" of the American Society of Anesthesiologists. Advances in the practice of spinal and epidural anaesthesia will come through improved understanding of nociceptive conduction and receptor physiology. New drugs will focus on specific neural function so that motor, sensory and autonomic blockade may be invoked and antagonized as clinical circumstances require. Advances in peripheral neural blockade will focus on drugs that can provide markedly prolonged effects in the range of days to weeks. Alternate approaches will be the development of neural specific lytic agents that will not spread to or damage surrounding tissues.

Regional anesthesia and analgesia in obstetrics

Regional analgesia and anesthesia for obstetrical patients are undergoing revolutionary changes which will, ultimately, benefit parturients and neonates. These changes have taken place in the arena of techniques, equipment, as well as in medications. This review will cover the management techniques both for vaginal delivery and cesarean section.