Pediatric Regional Anesthesia Research Articles

Ultrasound-Guided Pediatric Regional Anesthesia for Orthopedic Surgery

Ultrasound-Guided Pediatric Regional Anesthesia for Orthopedic Surgery

Enhancing Pediatric Regional Anesthesia: A Narrative Review of Adjuvants used with Local Anesthetics

Abstract Pediatric regional anesthesia has become an integral part of perioperative pain management strategies in children. Adjuvants play a pivotal role in augmenting the efficacy and prolonging the duration of regional anesthesia techniques, thereby improving postoperative pain control, and reducing opioid consumption. This review provides a comprehensive overview of the various adjuvants utilized in pediatric regional anesthesia, highlighting their mechanisms of action, clinical applications, efficacy, and safety profiles.

Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS.

Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.

Regional anaesthesia for ambulatory surgery.

Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19.

Nalbuphin as an Adjuvant to Levobupivacaine in Caudal Analgesia in Children

Abstract Background Caudal anethesia is the single most important pediatric regional anethetic technique and is increasingly performed in pediatric regional anesthesia practices. It is preferred in order to relieve intraoperative and postoperative pain in children of all age groups undergoing pelvi-abdominal or lower limbs surgeries using levobupivacaine 0.25%.Various adjuvant have been added to levobupivacaine to prolong postoperative caudal analgesia. Nalbuphine as many opioids can be added in caudal analgesia. This prospective randomised double blind study was done to compare the effects of plain levobupivacaine 0.25% versus Levobupivacaine 0.25% plus nalbuphine 0.1 mg/kg single-shot for postoperative pain relief in children undergoing hypospadius repair surgery. Materis and Methods At total of 64 pediatric patient 1 to 3 years old with American society of Anethesiologist (ASA) status | to |‖, undergoing hypospadius repair surgery were prospectively randomized into two groups, Group 1 received levobupivacaine 0.25% only 1 ml/kg plus 1 ml normal saline and group 2 received levobupivacaine 0.25% 1 ml/kg plus 0.1 mg/kg in 1 ml normal saline. The primary outcome of the study were time to first analgesia request, total consumption of rescue analgesia and the FLACC scale (face, legs, activity, cry and consonlability). The secondary outcome were heart rate (HR), mean arterial blood pressure (MAP), Oxygen saturation, occurrence of complications (respiratory depression, pruritis, xerostomia and postoperative nausea and vomiting). Results During surgery adequate intraoperative analgesia was defined by hemodynamic stability. An increase in the HR or MAP within 15 minutes greater than 15% compared to the baseline values obtained before skin incision recieved a rescue opioid in the form of fentanyl 5 mcg /kg and was excluded from the study. The difference between the two groups regarding time to first analgesia request was highly significant, group 1 (7.28±1.07), group 2 (11.59±2.54) (p < 0.01).The comparison between the two groups regarding the total consumption of rescue analgesia was also significant, group 1 (23.47±8.17), group 2 (19.23±7.31) (p < 0.05). There was statistically significant increase in FLACC in group 1 than group 2 at 30 min and up to 8 hours. There was no significant decrease in HR or MAP in group 2 more than group 1 except between 20 min and 8 hours. There was no statistically significant difference found between two studied groups regarding oxygen saturation regarding intraoperative and postoperative follow up. No patients in both groups had respiratory depression, xerostomia or pruritis.Few patients (3 _4) had postoperative nausea and vomiting with no statistically significant difference between the two groups. Conclusion The combination between nalbuphine and Levobupivacaine was valuable as regarding efficacy and safety profiles in pediatric analgesia. The intensity and duration of analgesia were remarkable compared to levobupivacaine alone. Fortunately, there were no side effects of systemic hazards recorded from systemic absorption of nalbuphine. To recommend considering nalbuphine as one of the valuable adjuvants to levobupivacaine in epidural analgesia according to its efficacy and safety profile.

The history of pediatric anesthesia

The beginnings of pediatric anesthesiology go back to the middle of the 19th century and it is associated with a rural physician Crawford W. Long, MD, who in the 1842 recorded the first case of giving diethyl ether anesthesia to an eight-year-old boy. The start of development of contemporary pediatric anesthesia is considered to be in 1930, which marked two periods of progress. In the first period, anesthesia techniques and accessories adjusted to different children?s ages were developed. In the second period, modern anesthetic medications and supervision were introduced into everyday clinical practice in order to better protect vital organs and their functions in the child?s body. The first multidisciplinary pediatric intensive care unit at the Children?s Hospital of Gothenburg in Sweden was established in 1955. Dr. Branka Mitrovic is considered to be the founder of pediatric anesthesiology in Serbia, as she founded the Department of Anesthesiology and Reanimation at the University Children?s hospital in 1955. The history of pediatric regional anesthesia began after its introduction in adults, which occurred after the invention of cocaine in 1884. The Ministry of Health of the Republic of Serbia approved a specialization in pediatric anesthesiology in 2018. The development of pediatric anesthesia is fascinating because it completely followed the development of pediatric surgery. Modern pediatric anesthesiology is entirely prepared to meet the needs of the most complex surgical interventions, as well as the treatment of critically ill children, and significantly contributes to better treatment outcomes of pediatric surgical patients.

Current Status of Pediatric Regional Anesthesia：Results of a Questionnaire Survey of Members of the Japanese Association of Children's Hospitals and Related Institutions

日本における小児の区域麻酔の現状を明らかにすることを目的として，日本小児総合医療施設協議会加入施設を対象としてアンケート調査を行った．代表的な小児手術に対する区域麻酔の選択，局所麻酔薬の選択，硬膜外麻酔の詳細の傾向や，重篤な合併症の発生状況が，一定の範囲内ではあるが明らかになった．

Unique Issues Related to Regional Anesthesia in Pediatric Orthopedics

This article will narrow its focus largely to notable issues related to regional anesthesia in pediatrics. First, the controversy surrounding awake versus anesthetized block placement will be addressed. There will also be a discussion on the use of regional anesthetics in orthopedics cases and the risk of compartment syndrome. Subsequently, the concern for regional anesthetics in the setting of an instrumented spine (eg, following spine fusion, baclofen pump placement) will be reviewed as such can have significant ramifications for patients. Finally, this article will consider ambulatory regional catheters and their increasing use in pediatric orthopedic anesthesia. Their utilization during the COVD epidemic played a key role in facilitating procedures that would have been canceled due to the protracted hospital bed shortage.

Regional Anesthesia (2012–2021): A Comprehensive Examination Based on Bibliometric Analyses of Hotpots, Knowledge Structure and Intellectual Dynamics

In the last decade, there has been a significant advancement in the area of regional anesthesia (RA). Continuous evaluation of research in any developing field using modern technologies and available software is critical to identify future trends, hot spots, and intellectual dynamics. The current study was designed to bibliometrically evaluate the global research in RA using VOSviewer, MS Excel, and CVS-Scopus bibliographic data (2012–2021). Knowledge structure and intellectual dynamics were analyzed using clustering of keyword co-occurrence. Literature screening in the last decade found 6092 original articles (96.1%) and conference papers (3.9%). The top four countries producing articles were the United States (n = 30.57%), India (7.51), the United Kingdom (7.22%), and Canada (6.06%). A significant positive correlation was found in global publication productivity (R2 = 0.9161). The most productive organizations were Harvard University, the University of Toronto, and the Hospital for Special Surgery – New York. A tremendous collaboration was spotted nationally and internationally, especially in pediatric RA. This comprehensive study, which summarizes and evaluates 6902 original research materials on regional anesthesia, may serve as a resource for anesthesiologists, physicians, researchers, and students.

Efficacy of a Novel Face-to-Face Lateral Position (Partha’s Technique) in Children to Aid Identification of Caudal Space during Single Dose Caudal Epidural Anaesthesia for Elective Infraumblical Surgeries- A Feasibility Study

Introduction: A single-dose of caudal epidural block accounts for 30-40% of paediatric regional anaesthesia. For infraumblical procedures, it is administered with or without general anaesthesia. The traditional patient position for assisting caudal blocks in children is lateral, with the child's back facing the anaesthesiologist. For caudal epidural block, a novel face-toface orientation of the anaesthesiologist with respect to the child in lateral position was used. Aim: To determine whether a novel face-to-face position of the anesthesiologist and the child is feasible in identification of the caudal epidural space during administration of caudal epidural anaesthesia following general anaesthesia in paediatric patients undergoing elective infraumblical surgery. Materials and Methods: This prospective feasibility study was conducted from November 2020 to November 2021 on 15 children belonging to American Society of Anaesthesiologists (ASA) 1, who were scheduled for elective infraumblical procedures under general anaesthesia, with single dose caudal epidural anaesthesia. While performing caudal block, a novel face-toface orientation of the anaesthesiologist and patient was used. The following variables were recorded: first pass success rate, number of attempts, block performance time, block failure rate, performer satisfaction score, duration of postoperative analgesia, and complications. Results: There were eight males and seven females. The mean age of the population was 6.6±2 years and the mean weight was 20.6±3.4 kilograms. The first pass success rate was 86.6% (13/15) with overall success rate of 100%. Number of attempts for successful block were 1.2±0.5. Block performance time and duration of postoperative analgesia were 31.8±12.1 seconds and 176±31.8 minutes respectively. Performer’s satisfaction score was excellent in 86.6% (13/15) and good in 13.4% (2/15). No incidence of block failure and complications were noted. Conclusion: The novel face-to-face position in child ergonomics with respect to anaesthesiologist during caudal epidural block performance is a feasible and effective method in children undergoing elective infraumblical procedures.

Piloting a New Curriculum: Guided At-Home Pediatric Regional Anesthesia Education Using a Portable Ultrasound.

Ultrasound-guided regional anesthesia is the standard of care for most regional blocks in pediatric anesthesiology.Training programs must educate physicians to perform regional blocks safely and efficiently. Hands-on learning with simulation and live models is the gold standard. The coronavirus disease 2019 (COVID-19) pandemic has greatly hampered our ability to safely hold in-person workshops. We describe an at-home, guided virtual workshop using portable ultrasound to safely continue experiential trainee education.The primary objective of this pilot virtual workshop was to develop an effective experiential learning program without the need for live child models. The main goal was to give trainees hands-on experience obtaining anatomical ultrasound images necessary for regional anesthesia blocks in a guided-virtual setting and to evaluate the effectiveness of skills acquisition. This workshop included two pediatric anesthesiology fellows and a pediatric anesthesiologist.Trainees were instructed on ultrasound-guided regional block acquisition. For two weeks, trainees acquired images/movies of regional block anatomy at home using their own children. Virtual video assistance was available. Trainees then used acquired images/movies to discuss needle and local anesthetic placement with a pediatric regional anesthesiologist. Trainees completed pre- and post-workshop surveys assessing attitudes, perceived educational efficacy, and procedural skill acquisition. The faculty member also assessed trainees’ skills.The virtual workshop was successful. Trainees expressed successful active learning and increased comfort in performing regional blocks on live patients. They correctly identified relevant anatomy of acquired images/movies, as well as needle and local anesthetic placement at the time of debriefing. Faculty were pleased with trainees’ initial performance of regional blocks.Adapting an in-person workshop to an at-home guided experience is a safe, feasible, and well-received method for anesthesiology trainees to obtain experiential learning of ultrasound-guided regional anesthesia. This facilitated at-home learning experience allows for hands-on skill practice while preventing exposure of child models to the hospital setting during a pandemic.

Error traps in pediatric regional anesthesia.

Ultrasound-guided nerve blocks have revolutionized the way we provide regional anesthesia. By providing effective perioperative pain control, regional anesthesia reduces opioid consumption, decreases length of stay, and increases patient/parental satisfaction. However, error traps (circumstances that lead to erroneous actions) can defeat its inherent benefits and may result in adverse outcomes. This article focuses on promoting a culture of safety by highlighting five common avoidable error traps encountered while providing regional anesthesia for pediatric patients. They include failure to confirm intended block site, failure to optimize ultrasound images and identify artifacts, failure to recognize when regional anesthesia is an acceptable option, failure to implement alternative imaging techniques when anatomy is challenging, and failure to recognize disease states with abnormal anatomy that may require alternative blocks. These issues are easily addressed if the pediatric regionalist is cognizant of the appropriate ways to mitigate them, and, as such, we review strategies to avoid them.

Pediatric Regional Anesthesia: New Techniques, Better Outcomes?

Pediatric Regional Anesthesia: New Techniques, Better Outcomes?

Fundamentals and innovations in regional anaesthesia for infants and children.

Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.

The promising novelty nerve blocks in the paediatric population

The number of nerve blocks performed in the pediatric population is constantly increasing nowadays, contributing to better post-op analgesia and outcomes. Multiple studies by the Pediatric Regional Anesthesia Network (PRAN) and the French-Language Society of Pediatric Anesthesiologists (ADARPEF), the use of ultrasound, the push for multimodal analgesia on the one hand, and the evolution of various innovative interfascial nerve blocks performed on the thoracic and the abdominal wall (i.e., Pecs blocks, Posterior TAP, Serratus Anterior Plane block, Rectus Sheath Block, Quadratus Laborum blocks, Erector Spinae block, super-inguinal fascia illiaca) on the other hand, have led to this trend. The ease of their performance, the steeper learning curve and the safer adverse effect profile compared to other “traditional” central regional techniques, still providing comparable analgesic results, accounts for this trend towards interfascial plane blocks performed for pediatric surgeries lately. This presentation focuses on the techniques of administration (using ultrasound), the anatomic considerations, the indications and limitations of these innovative interfascial nerve blocks performed on children. We are also going to talk about the appropriate for age doses and concentrations of local anesthetics and the adjuvant drugs used for blocks in the pediatric population, the more often and the most serious complications we can come across when performing these “high volume” blocks, what should alert us in the sleeping child and what is the best way to cope with an inadvertent complication, should this happen. After all is it really worth the trouble and why. Finally, we will talk about the reinvasion of subarachnoid anesthesia in the pediatric anesthesia practice and some issues of current debate in the pediatric regional anesthesia literature.

The Role of Interfascial Plane Blocks in Paediatric Regional Anaesthesia: A Narrative Review of Current Perspectives and Updates.

Regional anaesthesia has been increasingly used for analgesia in the perioperative period in paediatric anaesthesia for better pain control and improved patient outcomes. Interfascial plane blocks are considered as a subgroup of peripheral nerve blocks. The advent of ultrasound in modern regional anaesthesia practice has led to the evolution of various interfascial plane blocks. The ease of their performance and the low complication rates, compared with neuraxial anaesthesia, have led to their increased use in the perioperative period. Interfascial plane blocks are often incorporated in the multimodal analgesia regimen in the early recovery and ambulation after surgery protocols for various chest wall and abdominal surgeries. This achieves better pain control and decreases the requirements of opioids in the perioperative period, thereby facilitating early mobilization and discharge. This narrative review focuses on the relevant anatomic considerations, technique for the performance of each block along with its current applications and limitations, and includes a review of the current literature on various interfascial plane blocks in paediatric regional anaesthesia.

Complications in paediatric regional anaesthesia: a narrative review

Paediatric anaesthesia and paediatric regional anaesthesia are intertwined. Currently, almost all paediatric patients posted for surgery could and should be given a regional block unless and until contraindicated. This is because the scope, techniques, and their benefits have a wide range and complications are rare. The first report that used regional anaesthesia in children was in 1898, and over the last 120 years it has been developed with many scholars’ wisdom, ideas and publications. Paediatric regional anaesthesia (PRA) has many advantages but requires experience and expertise. For a long-time, exclusively landmark-guided techniques were used and gradually the development of new techniques such as the use of neuro-stimulator and ultrasound-guided (USG) blocks developed into PRA. Especially, the application of ultrasonography (US) has revolutionised the practice of PRA. Few limitations of regional anaesthesia can be tackled by the use of US, leading to shorter time to perform the block, reduced time for block onset and use of a smaller volume of local anaesthetic. Life threatening complications of regional anaesthesia are rare and the riskbenefit ratio is favourable. However, a thorough insight into RA complications, no matter how rare they are, is essential for safe practice. This is because they can be life-threatening, and no matter how small the percentage is, when complications occur, for that individual patient statistics is irrelevant.

Variation in pediatric local anesthetic dosing for peripheral nerve blocks: an analysis from the Pediatric Regional Anesthesia Network (PRAN).

Variation of local anesthetic dosing has been reported for adult peripheral nerve blocks (PNBs) and infant caudal blocks. As higher doses of local anesthetics (LA) are potentially associated with increased risk of complications (eg, local anesthetic systemic toxicity), it is important to understand the source of LA dose variation. Using the Pediatric Regional Anesthesia Network (PRAN) database, we aimed to determine if variation in dosing exists in pediatric single-injection PNBs, and what factors influence that variation.The primary aim of this study was to determine the factors associated with dosing for the 10 most commonly performed PNBs, with the secondary aim of exploring possible factors for variation such as number of blocks performed versus geographic location. The PRAN database was used to determine the 10 most common pediatric PNBs, excluding neuraxial regional anesthetics. The 10 most common pediatric PNBs in the PRAN database were analyzed for variation of LA dose and causes for variation. In a cohort of 34 514 children receiving PNBs, the mean age was 10.38 (+/-5.23) years, average weight was 44.88 (+/-26.66) kg and 61.8% were men. The mean bupivacaine equivalent (BE) dose was 0.86 (+/-0.5) mg kg-1 and ropivacaine was used in 65.4% of blocks. Dose decreases with age (estimate -0.016 (-0.017, -0.015; p<0.001)). In all blocks for all age groups, the range of doses that make up the central 80% of all doses exceeds the mean BE dose for the block. Variation is not related to the number blocks performed at an institution (p=0.33 (CI -0.42 to 0.15)). The dose administered for a PNB is driven in order of impact by the institution where the block was performed (Cohen's ƒ=0.45), then by weight (0.31), type of block (0.27), LA used (0.15) and age (0.03). Considerable variation in dosing exists in all age groups and in all block types. The most impactful driver of local anesthetic dose is the institution where the block was performed, indicating the dosing of a potentially lethal drug is more based on local culture than on evidence.

Updates on neurologic complications in pediatric regional anesthesia.

Regional anesthesia has grown in popularity as a multimodal approach to analgesia. However, some anesthesiologists are fearful of regional blocks in pediatric patients as most require general anesthesia. One of the most alarming complications is neurologic injury. While there are limited case reports regarding the devastating neurologic injuries in pediatric patients, review of large databases has shown a level of safety in pediatric regional anesthesia that is comparable to that in adult patients. This review aimed to provide an update on the relevant literature regarding neurologic complications and the safety of regional blocks in pediatric patients. These large data sets have confirmed that regional anesthesia is a useful and safe modality in pediatric patients.

Acute Pain Medicine

Acute Pain Medicine is a book with an innovative goal to apply case-based learning to acute pain medicine. This is a very readable book, in which leading physicians in pain medicine communicate their lifetime professional experience and knowledge, to give the reader the impression of having learned a valid clinical approach by being with them for years. The book is organized into 3 sections with chapters that treat several topics related to perioperative and nonperioperative pain conditions. Section I (The Practice of Acute Pain Medicine, Chapters 1–2) details the economic problem of implementing acute pain medicine services. This section underlines the value of pain management as a service and the centrality of acute pain services in the integration between multimodal analgesia, regional analgesia, protocols of enhanced recovery after surgery (ERAS), and the use of procedure-specific postoperative pain management (PROSPECT) protocols. Section II (Case-Based Acute Pain Medicine, Chapters 3–25) constitutes the most interesting part of the book. It offers a variety of scenarios in acute pain medicine that can be encountered in practice. The range of topics is wide and includes orthopedic, thoracic, abdominal, and pediatric surgery, as well as some nonperioperative pain conditions and polytrauma. The structure of the case-based chapters is exceptional and represents an excellent method of clinical thinking. The authors start with questions that arise daily in clinical practice. At the beginning of each chapter, the authors put forward a case-based pain problem (in Greek πρό [pró, “before”] + βάλλω [bállō, “throw, cast”] mean, “to put forward”). The authors advance their reasoning through the problem’s fundamental expression, “the question,” spanning clinical, diagnostic, and therapeutic considerations. All chapters contain a special focus on pharmacology. Up-to-date references and guidelines support each section. This is a book made of many good questions with corresponding concise but sufficiently detailed answers. Readers will find an immediate response to all aspects of the proposed pain problem. They will also appreciate the fact that questions and answers cover all aspects of each single case in a truly holistic fashion. For future editions, we expect that clinical cases will be organized into a more defined etiological classification and also include obstetrical pain syndromes and more nonorthopedic pain conditions. The third section of the book (Advanced Regional Anesthesia and Analgesia, Chapters 26–60) is an updated version of the Military Advanced Regional Anesthesia and Analgesia Handbook (MARAA II) where almost every type of regional block can be found. Image quality of regional procedures for specific areas of the body is good; the text is simple but complete and includes basic pediatric regional anesthesia, acupuncture treatments on the battlefield, acute pain nursing, acute pain treatment in the battlefield, and air transport of the critically injured patient. With this text, the authors underline the problem of experience and its transmission into medical education in the 21st century. Dealing with pain clinics requires a skilled use of intelligence. In its Latin origin (intus/inter + legere) the word “intelligence” means literally “to read through, read inside.” However, who can help us to read reality and increase our clinical experience? In this unique era of the history of medicine, we have plenty of readily available information supported by improved scientific methodology, but we again need to “read through” and to pick what is more adapted to the individual clinical situation, because every patient is unique. “Experience, as development of the person, connotes the fact of becoming aware of one’s growth in the understanding of reality.”1 As opposed to what happens in the scientific field, where we can add today’s advances to those of the past, experience in its basic form is not simply an additional process.2 Experience needs to be transmitted by someone who has gained it through intelligence and needs to be renewed during a lifetime’s work for knowledge. The clinical eye of a good mentor on the treatment of a patient can be learned only from the mentor himself (Figure 1).3 That is why mentorship and case-based learning are the original and fundamental methods of learning in medicine. The Acute Pain Medicine book is unique, and it attempts to bridge the gap by transmitting the experience of great mentors. For these reasons, fellows and residents should have this book, and the book is also recommended to those physicians who know that the long journey to knowledge never ends.Figure.: André Brouillet. Un Leçon Clinique à la Salpêtrière (Jean-Martin Charcot demonstrating in a clinical lecture to his colleagues). 1887. Université Paris Descartes, Paris. From Wikipedia; available at: https://www.google.com/search?q=andre+brouillet+salpetriere&client=ms-android-huawei&prmd=nimv&sxsrf=ALeKk02q9w_Ks2S-6pf45k2zrdUDNk86Ug:1591737381299&source=lnms&tbm=isch&sa=X&ved=2ahUKEwjt_L_p0_XpAhW1WxUIHfM1DK0Q_AUoAnoECBUQAg&biw=480&bih=656#imgrc=wEDppSZRfwtxvM.Zhirajr Mokini, MDDhurata Vrenozi, MDDepartment of AnesthesiologyClinique Saint FrançoisChâteauroux, France[email protected]