Locoregional Anesthesia Research Articles

Simulation-Based Medical Education and Training Enhance Anesthesia Residents' Proficiency in Erector Spinae Plane Block.

BackgroundAdvances in regional anesthesia and pain management led to the advent of ultrasound-guided fascial plane blocks, which represent a new and promising route for the administration of local anesthetics. Both practical and theoretical knowledge of locoregional anesthesia are therefore becoming fundamental, requiring specific training programs for residents. Simulation-based medical education and training (SBET) has been recently applied to ultrasound-guided regional anesthesia (UGRA) with remarkable results. With this in mind, the anesthesia and intensive care residency program of the University of Milano-Bicocca organized a 4-h regional anesthesia training workshop with the BlockSim® (Accurate Srl, Cesena) simulator. Our study aimed to measure the residents' improvement in terms of reduction in time required to achieve an erector spinae plane (ESP) block.MethodsFifty-two first-year anesthesia residents were exposed to a 4-h training workshop focused on peripheral blocks. The course included an introductory theoretical session held by a locoregional anesthetist expert, a practical training on human models and mannequins using Onvision® (B. Braun, Milano) technologies, and two test performances on the BlockSim simulator. Residents were asked to perform two ESP blocks on the BlockSim: the first without previous practice on the simulator, the second at the end of the course. Trainees were also also asked to complete a self-assessment questionnaire.ResultsThe time needed to achieve the block during the second attempt was significantly shorter (131 [83, 198] vs. 68 [27, 91] s, p < 0.001). We also observed a reduction in the number of needle insertions from 3 [2, 7] to 2 [1, 4] (p = 0.002), and an improvement aiming correctly at the ESP from 30 (58%) to 46 (88%) (p < 0.001). Forty-nine (94%) of the residents reported to have improved their regional anesthesia knowledge, 38 (73%) perceived an improvement in their technical skills and 46 (88%) of the trainees declared to be “satisfied/very satisfied” with the course.ConclusionsA 4-h hands-on course based on SBET may enhance first-year residents' UGRA ability, decrease the number of punctures and time needed to perform the ESP block, and improve the correct aim of the fascia.

Pathophysiological Advantages of Spontaneous Ventilation.

Surgical procedures cause stress, which can induce an inflammatory response and reduce immune function. Following video-assisted thoracoscopic surgery (VATS), non-intubated thoracic surgery (NITS) was developed to further reduce surgical stress in thoracic surgical procedures. This article reviews the pathophysiology of the NITS procedure and its potential for reducing the negative effects of mechanical one-lung ventilation (mOLV). In NITS with spontaneous ventilation, the negative side effects of mOLV are prevented or reduced, including volutrauma, biotrauma, systemic inflammatory immune responses, and compensatory anti-inflammatory immune responses. The pro-inflammatory and anti-inflammatory cytokines released from accumulated macrophages and neutrophils result in injury to the alveoli during mOLV. The inflammatory response is lower in NITS than in relaxed-surgery cases, causing a less-negative effect on immune function. The increase in leukocyte number and decrease in lymphocyte number are more moderate in NITS than in relaxed-surgery cases. The ventilation/perfusion match is better in spontaneous one-lung ventilation than in mOLV, resulting in better oxygenation and cardiac output. The direct effect of relaxant drugs on the acetylcholine receptors of macrophages can cause cytokine release, which is lower in NITS. The locoregional anesthesia in NITS is associated with a reduced cytokine release, contributing to a more physiological postoperative immune function.

The Dorsomedian Ligamentous Strand: An Evaluation In Vivo with Epiduroscopy.

Several anatomical studies have described the morphology of the spinal space; however, researchers do not all agree on the presence of the dorsomedian ligamentous strand (DLS), which divides the epidural space. The possible existence of this structure still influences some clinical practice, such as locoregional anesthesia and pain therapy. Since the number of procedures occurring inside the epidural space have increased, this study’s primary objective was to describe the composition of this space through epiduroscopy. We conducted a retrospective analysis of video recorded during epiduroscopy. Two independent doctors performed blind analyses of morphological aspects of peridural space visualized during the procedure in each patient for the maximum possible extension depending on the underlying pathology in the tract from S1 to L1. We enrolled 106 patients who underwent epiduroscopy; 100% of patients presented no medial longitudinal segmentation dividing the epidural channel at any level of the spinal tract investigated, including in the epidural space with pathological fibrotic scars and in those with no adherence. The main finding of our study was the visual absence of any anatomical structure dividing the epidural channel. We report that in vivo, in our experience, with direct epiduroscopy, the DLS is not visible.

Estimation of the carbon footprint of arthroscopic rotator cuff repair in France

Objectives:Global warming is certainly one of the greatest challenges of the century. The objective of this work is to estimate the carbon footprint of arthroscopic rotator cuff repair, and to evaluate the positive impact of the following actions: ambulatory surgery, performed under loco-regional anesthesia, and filtration of surgical fluids.Methods:The assessment protocol was compliant with the Greenhouse Gas Protocol, which has three components: 1/ use of volatile anesthetic agents; 2/ electric consumption related to the procedure (heating and air conditioning, ventilation, computer); 3/ related to patient and staff travel, implant delivery and waste management. The study covered the period from November 2020 to April 2021, and included any patient undergoing arthroscopic shoulder replacement surgery. Three actions aimed at improving the carbon footprint were taken: ambulatory surgery, performed under local anesthesia, and filtration of surgical fluids by Neptune® (Stryker). To examine the effectiveness, each patient included during the review period was matched to a patient who underwent surgery during 2018 before the implementation of this protocol.Results:Finally, 26 patients were included. The carbon footprint of arthroscopic rotator cuff repair was estimated at 260.5 +/- 35.03 kgCO2 eq. The main impacts could be attributed to single-use equipment (53.5%), restocking anchors (27.2%), contaminated waste incineration (5.9%), the sterilization process (5.4%), and traveling by the patient (4.1%). Setting up ambulatory surgery without the use of anesthetic gases and a water purifier reduced emissions by 25.9 +/- 2.5 kgCO2 eq (9.3%) per procedure.Conclusion:The carbon footprint of arthroscopic rotary cuff repair corresponds to a bit more than 60 km traveled in a car. The main factor that should be addressed is the impact related to single-use materials and inventory management.

Ultrasound-Guided Saphenous Nerve Block in Rabbits (Oryctolagus cuniculus): A Cadaveric Study Comparing Two Injectate Volumes.

Simple SummaryGeneral anesthesia in rabbits is associated with significantly higher mortality than in dogs and cats. In addition, as prey animals, rabbits tend to mask signs of pain, making early detection particularly difficult. Loco-regional anesthesia represents a fundamental component of a multimodal approach to pain management and is an effective strategy to reduce the need for systemic anesthetic and analgesic drugs, thereby limiting their associated side effects. The saphenous nerve is the largest sensory branch of the femoral nerve and provides sensory supply to areas of the hind-limb. Saphenous nerve blockade allows for analgesia of the front and inner parts of the pelvic limb without affecting femoral nerve motor function, thus allowing optimal pain relief but permitting continued mobilization, which may be of particular importance in rabbits as it allows preservation of normal physiological prey behavior (e.g., hiding, kicking). This cadaveric study describes an ultrasound-guided saphenous nerve block technique in rabbits and compares the length of the nerves stained following injection of two different dye volumes. The results show that both volumes consistently stained the saphenous but not the femoral nerve. This technique has the potential to provide hind-limb analgesia while preserving femoral motor function in rabbits.Ultrasound-guided (US-guided) loco-regional anesthesia techniques allow direct visualization and blockade of sensory nerves. The saphenous nerve (SN), a terminal branch of the femoral nerve (FN), is strictly a sensory nerve for which electrical locator devices are ineffective for localization as no effector muscle contractions can be evoked. US-guided SN block in species other than rabbits produces hind-limb analgesia without affecting FN motor function. The aims of this study were to develop a US-guided SN block technique in rabbits and to compare the spread obtained using two different dye volumes. Twelve hind-limbs from six cadavers (1.6 ± 0.1 kg) were included; after randomization, the SN block was performed on the right or left hind-limb, injecting 0.05 mL kg−1 or 0.1 mL kg−1 of tissue dye in lidocaine (1:50 v:v). Subsequent dissections allowed nerve staining measurements. All SNs were identified, and 17.8 ± 4.6% and 31.0 ± 8.9% of the SN length were stained using low-volume and high-volume of the dye, respectively. Regardless of the volume used, the SN was consistently stained while the motor branch of the FN was not. This US-guided technique may provide hind-limb analgesia without affecting FN motor function in rabbits undergoing mid-distal hind-limb surgeries.

A Study of Hand Flap Viability when Using a Wide Awake Local Anesthesia No Tourniquet (WALANT) Technique

Objectives Flap surgery using a wide awake local anesthesia no tourniquet (WALANT) technique has historically been avoided because of technical challenges and concerns regarding the vasoconstriction caused by the necessary injection of epinephrine alongside the local anesthetic. The objective of our work was to evaluate the viability of the hand flaps performed using a WALANT technique compared with those performed under regional with a tourniquet.Materials and Methods Seventy-four patients were enrolled in a prospective comparative single-center study and subsequently divided into two groups: 36 patients in the locoregional anesthesia group and 38 patients in the WALANT group. Flap viability was evaluated on day 2 and day 10 using predetermined criteria.Results We did not find any significant difference in outcomes assessed for flap viability between the two groups postoperatively.Conclusion There was no evidence to suggest that vascularization of the flaps was compromised by the injection of epinephrine. The WALANT technique may, therefore, potentially be able to be safely deployed within this population.

Combined opioid free and loco-regional anaesthesia enhances the quality of recovery in sleeve gastrectomy done under ERAS protocol: a randomized controlled trial

BackgroundIt is debatable whether opioid-free anaesthesia (OFA) is better suited than multimodal analgesia (MMA) to achieve the goals of enhanced recovery after surgery (ERAS) in patients undergoing laparoscopic sleeve gastrectomy.MethodsIn all patients, anaesthesia was conducted with an i.v. induction with propofol (2 mg. kg-1), myorelaxation with cisatracurium (0.15 mg.kg-1), in addition to an ultrasound-guided bilateral oblique subcostal transverse abdominis plane block. In addition, patients in the OFA group (n = 51) received i.v. dexmedetomidine 0.1 μg.kg-1 and ketamine (0.5 mg. kg-1) at induction, then dexmedetomidine 0.5 μg. kg-1.h-1, ketamine 0.5 mg.kg-1.h-1, and lidocaine 1 mg. kg-1.h-1 for maintenance, while patients in the MMA group (n = 52) had only i.v. fentanyl (1 μg. kg-1) at induction. The primary outcome was the quality of recovery assessed by QoR-40, at the 6th and the 24th postoperative hour. Secondary outcomes were postoperative opioid consumption, time to ambulate, time to tolerate oral fluid, and time to readiness for discharge.ResultsAt the 6th hour, the QoR-40 was higher in the OFA than in the MMA group (respective median [IQR] values: 180 [173–195] vs. 185 [173–191], p < 0.0001), but no longer difference was found at the 24th hour (median values = 191 in both groups). OFA also significantly reduced postoperative pain and morphine consumption (20 mg [1–21] vs. 10 mg [1–11], p = 0.005), as well as time to oral fluid tolerance (238 [151–346] vs. 175 min [98–275], p = 0.022), and readiness for discharge (505 [439–626] vs. 444 min [356–529], p = 0.001), but did not influence time to ambulate.ConclusionWhile regional anaesthesia achieved most of the intraoperative analgesia, avoiding intraoperative opioids with the help of this OFA protocol was able to improve several sensible parameters of postoperative functional recovery, thus improving our knowledge on the OFA effects.Clinical trial numberRegistration number NCT04285255.

Patient and Surgeon Reported Experiences of Locoregional Anesthesia in Hand Surgery

Introduction Locoregional anesthesia techniques have been increasingly adopted for use in hand surgery in recent years. However, locoregional anesthesia techniques may place patients under significant psychological stress, and there has been limited evaluation of acceptance and satisfaction rates of these techniques.Materials and Methods An observational study was conducted in a single tertiary institution. Data were collected from patients undergoing upper limb surgery procedures with locoregional anesthesia. After completion of surgery, a questionnaire adapted from Evaluation du Vecu de l’Anesthesie LocoRegionale (EVAN-LR), with scores from 1 to 5 on the Likert scale, was conducted on the same day to evaluate patient satisfaction. Responses were also obtained from the operating surgeon to assess satisfaction.Results A total of 101 patients were evaluated as part of the study. All EVAN-LR domains received a mean score >4.5. Responses from surgeons also showed good acceptance of locoregional anesthesia techniques with almost all giving scores ≥4 on the Likert scale.Conclusion The results of this study showed good satisfaction and acceptance of locoregional anesthesia among patients for upper limb procedures. This provides reassurance regarding the quality of care with locoregional anesthesia techniques. It remains important to be aware of potential sources of discomfort such as tourniquet pain to minimize discomfort and maximize patient satisfaction.

Determinants of Maternal Morbidity and Mortality Related to Anesthesia in Course of Cesarean Section in a Low-Income Country: Experience from the Centre Hospitalier M&amp;#232;re-Enfant Monkole

Objective: The role of anesthesia in maternal mortality is unknown in the Democratic Republic of Congo (DRC). This study was conducted with the objective of analyzing the determinants of morbidity and maternal mortality linked to anesthesia in course of cesarean section. Methods: This is a prospective, analytical and mono-centric study carried out on women who underwent cesarean section at the Centre Hospitalier Mère-Enfant Monkole from January 1st, 2011 to December 31st, 2018. The variables analyzed were socio-demographic, clinical, biological and anesthetic as well as the maternal issues. Data analysis was performed with SPSS 21.0 software. The determinants of mortality were sought by logistic regression with p Results: During this period, 1954 cesarean sections were performed. The mean age of the women was 31 years (range 14 to 47), 1549 women (79.3%) had completed prenatal consultation in Monkole and 405 (20.7%) elsewhere. The emergency was extreme in 192 cases (9.82%), absolute in 445 (22.77%) and relative in 1317 (67.4%). Locoregional anesthesia (LRA) was performed in 1811 cases (92.68%). The main complications were marked by arterial hypotension (22.9%) due to spinal anesthesia, and mortality was 0.56%. In multivariate analysis, only extreme emergency (aOR 7.62 95% CI: 2.80 - 71.23 p = 0.007), coma on admission (aOR 10.44 95% CI: 1.81 - 60.13 p = 0.009), general anesthesia (aOR 15.41 95% CI: 2.11 - 40.21 p = 0.007) and intraoperative transfusion due to anemia/hemorrhage (aOR 8.63 95% CI: 1.07 - 69.55 p = 0.043) persisted as determinants of maternal death. Conclusion: Maternal mortality (0.56%) in this series was relatively low for a low-income country and no death was directly related to anesthesia. General anesthesia, extreme urgency, intraoperative transfusion due to anemia/bleeding, and coma on admission were the major determinants of mortality.

General anaesthesia for nonobstetric surgery during pregnancy

Nonobstetric surgery may be required in up to 1% of pregnancies. Most common procedures are urgent abdominal surgeries requiring general anaesthesia. Maintaining normal maternal physiology during anaesthesia is vital. Left lateral tilt position prevents aortocaval compression and preserves normal venous return. Preparation for a difficult airway is required in all obstetric patients due to the known anatomical and physiological changes. Aspiration prophylaxis and a rapid sequence induction are traditionally recommended to avoid the (probably overestimated) risk of aspiration. Although the minimum alveolar concentration (MAC) of volatile anaesthetic agents is reduced by 30 to 40%, awareness occurs more frequently in the obstetric population. Maternal outcomes from surgery are comparable with those of nonpregnant women, but increased incidences of foetal loss, preterm delivery, low birth weight and caesarean section have been reported. Although animal studies have observed impaired foetal brain development after antenatal exposure to anaesthesia, the translational value of these studies remain controversial. Clinical evidence is nearly absent. Withholding urgent/essential procedures is certainly more threatening than proceeding with the surgery. To increase the safety of mother and foetus, nonurgent or nonessential procedures should be postponed until after delivery, and if procedures cannot wait, locoregional anaesthesia should be used if possible. Where general anaesthesia cannot be avoided, the duration of exposure should be kept to a minimum. This narrative review summarises the literature of the past 20 years concerning the anaesthetic management and outcomes of nonobstetric surgery under general anaesthesia during pregnancy.

Continuous Epidural Block and Balanced General Anesthesia in Abdominal Aortic Aneurysm Surgery in a General Hospital. Case Report

Introduction: Abdominal Aortic Aneurysms (AAA) are becoming more frequent in our population; the surgical management of this pathology represents a highly complex surgery which must be performed in a well-equipped medical unit, with implements and suitable personnel, since morbidity and mortality depends a lot on the preoperative evaluation of these patients with high coronary risk. Peripheral locoregional anesthesia techniques occupy an important place in anesthetic treatment and postoperative resuscitation due to the frequent possibility of cardiovascular, respiratory, renal complications or mesenteric ischemia, which justifies a treatment adapted to the high surgical risk, therefore, postoperative management should generally be in an Intensive Care Unit. Objective: Present the case of a patient with Abdominal Aortic Aneurysm (AAA) with acute abdomen urgently operated in a second-level hospital using mixed anesthesia. Case: Octogenarian patient with a diagnosis of infrarenal AAA, undergoing emergency surgery for abdominal pain, which was under balanced general anesthesia plus epidural block a bifurcated Dacron synthetic graft was interposed, with postoperative management in general surgery hospitalization area because there was no availability in the Intensive Care Unit (ICU), evolving properly. Conclusion: Evolution depends a lot on the anesthetic technique, which must be directed towards a multimodal strategy, where hemodynamic stability is a priority.

Evaluation of the Reasons for the Choice of Their Learning Course by Resident Physicians of Anesthesia and Intensive Care Medicine (ICU) in Mali

Anesthesia and intensive care is a medical specialty of the third cycle of medical studies characterized by a diversified practical training and an important theoretical training little approached during the second cycle of medical studies. In Mali, this young medical discipline is still looking for its bearings. we felt it was imperative to evaluate the motivations behind the choice of their apprenticeship program in order to understand the reasons behind the collapse of the numbers recruited and the dropouts during the program. Patients and Method: We conducted a prospective study using a self-administered questionnaire in the population of residents in Anesthesia and Intensive Care at the Faculty of Medicine of the Bamako University. Our study was conducted during the 2018-2019 academic year. An anonymous questionnaire was’ sent by email to all students of anesthesia-resuscitation of the specialized study diploma of Mali during the month of April 2019. Results: A total of 16/25 complete questionnaires were completed and returned that’s to say a response rate of 64%. Two-thirds (62%) of the residents had already attended the anesthesia-intensive care sector during the second cycle of medical studies before their admission to the specialty probationary period. Versatility, intellectual interest, emergency management, and technical aspect seemed to be the most attractive elements of the specialty. The points that might have made residents hesitate when choosing the specialist were the medico-legal risk, the important on-call activity, and the poor quality of life in the long term. Also, 12% (n = 2) were considering changing their specialized study diploma. Half of the residents were considering a professional practice in a public university hospital (50%), for 25% this choice was for the private sector and 12% in the humanitarian sector. On-call duty was perceived as formative for 75% of the anesthesia and intensive care students, while 18% of them considered it too numerous or even painful for 25%. 80% of the residents observed safety rest. During their internship in the different hospitals, the most appreciated points were, among others, their autonomy of decision, and the most negative were the fact of being too often alone. Residents in anesthesia-intensive care wished to have a depth training in locoregional anesthesia for 56% and pediatric anesthesia for 31%. Conclusion: Despite a relevant motivation for their choice, the difficult living and learning conditions were a source of demotivation for the anesthesia residents in Mali.

Perioperative cardiac risk assessment by anesthesiology residents

Major adverse cardiac events (MACE) occurring during non-cardiac surgery (NCS) are a common cause of morbidity and mortality. An individual preoperative MACE risk stratification during NCS based on the patient-specific risk factors and the surgical risk is highly recommended by learned societies. The aim of our study was to evaluate the perioperative management of cardiac risk in NCS by anesthesiology residents. We conducted a prospective, longitudinal and descriptive study. One hundred anesthesiology residents practicing their residency training in several Tunisian university hospital centers (UHC) were asked to take a survey inspired by The French RICARDO survey. A quarter of residents reported that they never conducted multidisciplinary team meetings (MDTMs) during the preoperative care and that there were no validated protocols elaborated with cardiologists of their departments. The majority (96,3%) requested an ECG according to the patient's age and 33% a resting Transthoracic Echocardiography (TTE) for coronary artery disease risk assessment. A ß-blocker was initiated by 44,4% of residents. Acetylsalicylic acid and clopidogrel were systematically stopped by respectively 7,4% and 51.9% of residents. Intraoperatively, the anesthetic technique was general anesthesia in 52% of cases versus locoregional anesthesia in 48% of cases. Postoperatively, 14,8% required troponins, ECG, continuous monitoring, and cardiologist follow-up. In the case of troponins elevation, 81,5% requested an ECG, and 59% involved cardiologists. Through our work, we found a discrepancy between the recommendations and the anesthetic practices. Better dissemination of guidelines and the development of local standardized protocols for CV risk assessment would be beneficial.

Anaesthesia for thyroidectomy at the Niamey National Hospital

Objectives: To describe anesthesiological management of thyroidectomy at Niamey National Hospital. Method: This was a prospective study conducted from, January 1st to June 30th 2018. Were been included all patients who underwent an anesthesiological procedure with a complete record for a thyroidectomy at the National Hospital of Niamey. The following variables were studied: age, sex, comorbidity, ASA class Status, Mallampati class, operative indication, anesthesia technique, anesthetic protocol, intraoperative anesthetic incidents and accidents, duration of surgery, duration of anesthesia, duration in resuscitation room, postoperative follow-up. The data were analyzed by the software Word 2013 and Epi Info 3.5.4. Results: The series included 33 patients, 28 women (84.84%) and 5 men (15.16%). The average age was 42 years ± 8.3 with extremes of 24 years to 78 years. The operative indications were dominated by multinodular goiter with 42.42%; the Mallampati 1 class was predominant with 51.51% of cases; the ASA 2 class status represent 54.54% of cases; difficult intubation involved 18.20% of patients. General anesthesia was the only technique used in all our patients. Hypotension was the major perioperative incident for 6 of 7 patients involved. Total thyroidectomy was the most performed procedure in 72.72% of patients. Postoperative analgesia was provided by paracetamol, NSAIDs, tramadol and nefopam with a predominance of paracetamol+tramadol combination in 66.60% of cases. The average duration of the surgery was 80 minutes with extremes of 36 minutes to 120 minutes. The operative follow-ups were simple in 97% of cases with a zero-mortality rate. The average hospital stay was 7 days with extremes of 3 days to 14 days. Conclusion: Thyroidectomy under general anesthesia is a well-understood procedure today in our context, but it is necessary to train teams in the practice of locoregional anesthesia adapted to our environment.

Advantages and issues of concern regarding approaches to peripheral nerve block for total hip arthroplasty.

In older patients with comorbidities, hip fractures are both an important and debilitating condition. Since multimodal and multidisciplinary perioperative strategies can hasten functional recovery after surgery improving clinical outcomes, the choice of the most effective and safest pathway represents a great challenge. A key point of concern is the anesthetic approach and above all the choice of the locoregional anesthesia combined with general or neuraxial anesthesia.

Assessment of Duplex Ultrasound Carried Out by the Vascular Surgeon After Locoregional Anesthesia for Preferred Arteriovenous Fistula Access

Preoperative vascular mapping by duplex ultrasound is required in construction of an arteriovenous fistula for hemodialysis (AVF). Due to venous vasospasm in cool temperatures and variability of the dialysis patient's blood volume, the conditions for performing this examination may be less than ideal. However, local regional anesthesia (LRA) resulting in vasodilation of the limb, can allow the use of veins considered to be of insufficient caliber during preoperative ultrasound mapping. The aim of this study was to assess the functionality of AVF when duplex ultrasound is performed by the surgeon following LRA. These results were compared with those from the preceding year, during which preoperative duplex ultrasound had been performed without LRA by vascular specialists, (Clinical Trial registration number: NCT04978155). This is a prospective study of all the patients having received AVF after systematic immediate preoperative ultrasound (US) under LRA (US-LRA group) in 2020. The initial surgical programming based on the Silva criteria was reported by a vascular medicine specialist. The change of AVF strategy following US-LRA was reported together with AVF usability and patency and compared to the results of the control group, in which AVF had been performed in 2019 without US-LRA. Ninety patients were included in the US-LRA group and 93 in the control group. Modified surgical planning was observed in 38% of cases (35/90) in the US-LRA group including more distal AVF in 28% of patients (26/90) and alternative target vein in 6.6% (6/90). AVF usability at 6 weeks was 80% (72/90) in the US-LRA group and 51.6% (48/93) in the control group (P < 0.001). Median follow-up was 12 months [IQR:9-15] in the US-LRA group and 13 months [IQR:9-18] in the control group. Primary patency at 6, 12, 18 months was significantly better in the US-LRA group (73.6% vs. 57.4%, 54.4% vs. 40.2%, 31.3% vs. 28.2%, respectively, P < 0.001). Assisted patency and secondary patency were comparable in the two groups. This study showed the benefit of having the surgeon perform US-LRA before starting the procedure, thereby allowing for more distal AVF, better usability and patency.

WALANT technique versus locoregional anesthesia in the surgical management of metacarpal and phalangeal fractures: Lessons from the Covid-19 crisis

Wide Awake Local Anesthesia No Tourniquet (WALANT) is an anesthetic method which uses a local injection of anesthetic and epinephrine, avoiding use of a tourniquet. During the COVID-19 pandemic, human and logistic resources had to be reorganized, and WALANT ensured resilience in our department to maintain access to surgical care. The objective of the present study was to compare hand function recovery 3 months after surgery for unstable metacarpal or phalangeal fracture under regional anesthesia versus WALANT. From November 2020 to May 2021, 36 patients presenting a metacarpal or phalangeal fracture requiring surgical treatment were included in a single-center study in a university hospital center. Nineteen patients underwent surgery under locoregional anesthesia with tourniquet, and 17 under WALANT. The main endpoint was functional recovery at 3 months on QuickDASH score. Need for complementary anesthesia, surgery duration, analgesic consumption, reintervention rate, and patient satisfaction were also assessed. There was no significant difference between groups in functional recovery at 3 months or on the secondary endpoints. In the COVID-19 context, WALANT proved to be a safe and effective method in hand fracture surgery, ensuring access to surgical care. It should be included in surgical training to optimize day-to-day surgical care and face future crises.

Evaluation of virtual reality combining music and a hypnosis session to reduce anxiety before hand surgery under axillary plexus block: A prospective study.

Preoperative anxiety, which can affect postoperative recovery, is often present in patients undergoing surgery under loco-regional anaesthesia (LRA). Minimising preoperative anxiety with premedication can be effective but results in drug-related side effects. Therefore, the use of non-pharmacological techniques should be encouraged. We evaluated whether a virtual reality (VR) incorporating music and a hypnosis session, provided during the performance of LRA, can reduce preoperative anxiety. Fifty patients scheduled for elective hand surgery under an axillary plexus block were enrolled (March-June 2019). The primary outcome measure was the change in the Amsterdam Anxiety and Preoperative Information Scale (APAIS) questionnaire 5min after the VR session as compared to before the VR session. The secondary outcome measures were the visual analog scale (VAS) for anxiety before and 2h after the surgery and the Evaluation du Vécu de l'ANesthésie-LocoRégionale (EVAN-LR) satisfaction score. Data from 48 patients were analysed. The APAIS score as well as VAS for anxiety were significantly reduced after a VR session (p<.001 for both scores). Patients were very satisfied (EVAN-LR: 92 (88, 94)). The use of VR incorporating music and a hypnosis session could be an effective tool in the management of a patient's preoperative anxiety during the performance of an axillary plexus block.

Outcome of major abdominal surgeries in COVID-19 positive patients with awake anaesthesia: surgeons’ perspective

In view of the COVID-19 pandemic, the use of locoregional anaesthesia has gained popularity as the greatest number of the major abdominal surgical cases which were usually done under general anaesthesia (GA) is now shifted towards awake anaesthesia due to fear of aerosol generation. In a COVID era, with evolving risk of aerosol generation in surgery under GA and the urge for reserving ICU beds for needy patients, this study was undertaken to assess the adequacy of surgery and other benefits with awake anaesthesia. A retrospective observational study for 8 COVID-19 positive patients, undergoing emergency major abdominal surgeries with locoregional anaesthesia in pre-operatively diagnosed COVID positive from May 2020 to May 2021 was conducted. Low to medium risk patients (ASA 1-2) were considered following assessment by anaesthesiologist. We retrospectively analysed data including perioperative events, post-op follow up. The mean operative time was 103 minutes (minimum 50 minutes; maximum 170 minutes). In one case, conversion to general anaesthesia was necessary. Post-operative pain was always well controlled. None of them required postoperative intensive care support. No perioperative major complications (Clavien Dindo ≥3) occurred. Early readmission after surgery never occurred. In our experience in the COVID-19 era, RA may help to limit the intubation-related risk of contagions inside theatres and could be feasible, safe, and painless alternative to GA in selected cases and this approach could become part of an ICU-preserving strategy.

Role of loco-regional anesthesia for non-intubated video-assisted thoracoscopic surgery: A tertiary care hospital in northern Thailand

Background: A few studies have focused on the role of regional anesthesia for non-intubated thoracoscopic surgery (NIVATS) in Thailand. The purpose of the present study was to review the feasibility and safety of loco-regional anesthesia for NIVATS in a tertiary care hospital. Methods: All patients undergoing scheduled NIVATS under loco-regional anesthesia including thoracic epidural analgesia (TEA), intercostal nerve block (ICNB), thoracic paravertebral block, and local wound infiltration from 2018 to 2021 were assessed by a retrospective chart review. Sedation was performed with propofol infusion and bispectral index monitoring. Primary outcomes were the feasibility of surgery and safety related to loco-regional anesthesia techniques. Results: Twenty-three patients were included. The average age was 43 (26-59) years. The two most common regional anesthesia techniques in this study were TEA and ICNB. The most common surgical procedure was wedge resection (13 patients, 56.5%) followed by pleurectomy (5 patients, 21.7%). The overall median technical feasible scores were 3 (2-3). Intraoperative hypotension (62.5% for TEA vs 20% for ICNB) and urinary retention (25% for TEA vs 0 for ICNB) were found. Among four patients with severe cough, three patients received intrathoracic vagal block and one patient required general anesthesia due to severe hypoxemia. Patients with ICNB had a higher degree of incisional pain and a higher amount of postoperative morphine consumption. Conclusion: NIVATS under loco-regional anesthesia could be a feasible and safe technique. A further study is recommended to compare the efficacy and safety of TEA and ICNB for NIVATS.