Regional Anesthesia In Patients Research Articles

Response to: reply to: regional anaesthesia in patients on antithrombotic drugs.

Response to: reply to: regional anaesthesia in patients on antithrombotic drugs.

Regional compared to general anesthesia for total shoulder arthroplasty

BackgroundTotal shoulder arthroplasty (TSA) is a common procedure for numerous shoulder pathologies, including glenohumeral arthritis, rotator cuff tears, and proximal humerus fractures. Prior literature has shown that patients undergoing total hip and knee arthroplasty under regional anesthesia (RA) are at significantly lower risk of postoperative complications and reoperation compared to general anesthesia (GA). The purpose of this study is to compare GA vs. RA in patients undergoing primary elective TSA. MethodsThe National Surgical Quality Improvement Program database was queried from 2010 to 2019 to identify all patients who underwent primary elective TSA with the use of GA (n = 24,563) or RA (n = 475). After matching based on age, sex, and the American Society of Anesthesiologists classification score, 475 matched pairs of patients undergoing TSA using GA or RA were compared. Relevant demographic characteristics and postoperative complication, readmission, and reoperation rates within 30 days of surgery were compared between groups. Operative time and total hospital length of stay (LOS) were also compared. Chi-squared tests were used to compare categorical variables. Continuous variables were compared using independent sample t-test and one-way ANOVA for binomial and multinomial groups, respectively. ResultsRA patients exhibited significantly higher rates of readmission (P < .001) and reoperation (P = .034) compared to GA patients. GA patients showed higher operative times than RA patients when comparing the two cohorts and stratifying patients by body mass index. GA patients also exhibited significantly increased LOS (P=<.001) compared to RA patients. Except for increased readmission and reoperation rates, there was no significant difference in the remaining medical complication rates between the groups. ConclusionRA patients were found to have higher rates of readmission and reoperation within 30 days of surgery compared to GA patients. GA was associated with longer operative times compared to RA across various body mass index groups. GA was associated with longer LOS compared to RA. However, for all perioperative and short-term postoperative medical complications, patients undergoing TSA under RA had similar rates to GA patients. These findings can be used to guide clinical decision-making when selecting the appropriate anesthetic strategy for patients requiring elective primary TSA.

Association between anesthetic type and perioperative outcomes in pediatric patients undergoing elective surgery: An observational study

Background: Pediatric surgeries require careful anesthetic choice. The impact of general anesthesia (GA) versus regional anesthesia (RA) on post-operative outcomes remains underexplored. Aims and Objectives: The aims and objectives of the study are to assess the association between anesthetic type and perioperative outcomes, including post-operative pain, nausea incidence, and recovery room stay duration in pediatric patients undergoing elective surgery. Materials and Methods: This observational study involved 100 pediatric patients undergoing elective surgery. Participants were grouped based on the anesthetic received: GA or RA. Outcomes measured included post-operative pain (0–10 scale), post-operative nausea incidence, and recovery room stay length. Results: The mean post-operative pain score for GA patients was 4.5 (standard deviation [SD]: 1.5), with most reporting scores between 3.0 and 6.0. For RA patients, the mean pain score was 3.8 (SD: 1.2), with the majority reporting scores between 2.6 and 5.0. Patients under RA had marginally reduced post-operative pain scores than those under GA. Regarding nausea, 56% of GA patients reported post-operative nausea, while only 36% of RA patients did. The mean recovery room stay for GA patients was 120 min (SD: 30 min), with most staying between 90 and 150 min. RA patients had an average stay of 100 min (SD: 25 min), with the majority staying between 75 and 125 min. Conclusion: Pediatric patients administered RA demonstrated slightly lower post-operative pain, decreased incidence of nausea, and a shorter recovery room stay compared to those given GA. These findings suggest potential benefits of RA in pediatric elective surgeries, although further research is warranted.

Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery

Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia. Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models. The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05). There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.

Building consensus on the selection criteria used when providing regional anaesthesia for rib fractures. An e-Delphi study amongst a UK-wide expert panel

BackgroundRib fractures are associated with significant morbidity and mortality, and providing adequate analgesia is paramount in preventing early complications from these injuries. Multiple regional anaesthetic techniques can be used to provide analgesia for these injuries; however, few evidence-based guidelines exist for their use. The aim of this study was to establish consensus within an expert group on the selection criteria used when choosing regional anaesthetic techniques for rib fractures. MethodsThe Delphi technique is a mixed-methods study format which uses a longitudinal survey process to develop consensus opinion amongst an expert group. A three-round modified e-Delphi study was undertaken using an online survey platform. Round one established cohort characteristics and identified key factors considered important by the group when selecting regional anaesthetic techniques for rib fractures. Subsequent rounds used Likert scales and free text comments to rate the participants’ level of agreement with various statements generated from the first-round responses. The final consensus threshold was established as at least 70% of respondents stating, ‘Strongly Disagree’ or ‘Disagree’ or alternatively ‘Agree’ or ‘Strongly Agree’. ResultsAn expert panel of UK-based consultants in anaesthesia and/or intensive care medicine was recruited. Participants worked in a variety of tertiary- and non-tertiary trauma care settings and were varied in their years of experience, approximate annual rib fracture caseload and preference for various anaesthetic techniques in rib fracture management. 54 participants took part in round one and generated 60 statements which were further analysed in an iterative process involving a total of three rounds. A total of 28 statements ultimately reached the pre-defined threshold for consensus within the expert group. ConclusionsThis e-Delphi study succeeded in building consensus across multiple statements relating to the selection criteria for regional anaesthesia in patients with rib fractures. These consensus statements can inform clinical practice, guide future research priorities and can be integrated into decision-making pathways across multiple hospital settings.

Pain Control with Regional Anesthesia in Patients at Risk of Acute Compartment Syndrome: Review of the Literature and Editorial View.

Acute compartment syndrome (ACS) is a devastating complication that can happen in almost every part of the human body, most noticeably after long bone fractures. The cardinal symptom of ACS is pain in excess of what would otherwise be expected from the underlying injury and unresponsive to routine analgesia treatment. There is paucity of literature on major analgesic management strategies including opioid analgesia, epidural anesthesia, and peripheral nerve blocks with regard to their differential efficacy and safety of pain management in patients at risk of developing ACS. The lack of quality data has led to recommendations that are perhaps more conservative than they should be, particularly when it comes to peripheral nerve blocks. In this review article, we attempt to make recommendations in favor of regional anesthesia in this vulnerable group of patients and strategies that will optimize adequate pain control and improve surgical outcome without jeopardizing patient safety.

General anesthesia versus regional anesthesia in patients undergoing obliterative vaginal procedures for pelvic organ prolapse.

The objective was to compare outcomes in patients receiving general versus regional anesthesia when undergoing obliterative vaginal surgery for pelvic organ prolapse. Obliterative vaginal procedures performed from 2010 to 2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Surgeries were categorized into general anesthesia (GA) or regional anesthesia (RA). Rates of reoperation, readmission, operative time, and length of stay were determined. A composite adverse outcome was calculated including any of the following: nonserious or serious adverse events, 30-day readmission, or reoperation. Propensity score-weighted analysis of perioperative outcomes was performed. The cohort included 6,951 patients, of whom 6,537 (94%) underwent obliterative vaginal surgery under GA and 414 (6%) received RA. When comparing outcomes under the propensity score-weighted analysis, operative times were shorter (median 96 vs 104 min, p<0.01) in the RA group versus GA. There were no significant differences between composite adverse outcomes (10% vs 12%, p=0.06), or readmission (5% vs 5%, p=0.83) and reoperation rates (1% vs 2%, p=0.12) between the RA and GA groups. Length of stay was shorter in patients receiving GA than in those receiving RA, especially when undergoing concomitant hysterectomy (67% discharged within 1 day in GA vs 45% in RA, p<0.01). Composite adverse outcomes, reoperation rates, and readmission rates were similar in patients who received RA for obliterative vaginal procedures compared with GA. Operative times were shorter in patients receiving RA than in those receiving GA, and length of stay was shorter in patients receiving GA than in those receiving RA.

Comparison of general and regional anesthesia on short-term complications in patients undergoing total knee arthroplasty: A retrospective study using national health insurance service-national sample cohort

This retrospective study compared the mortality and short-term complications according to the choice of general anesthesia or regional anesthesia in patients who underwent a total knee arthroplasty (TKA). We searched the Korean National Health Insurance Service National Sample Cohort database to analyze data from patients who received a TKA between January 2002 and December 2015. Before comparing the general and the regional anesthesia groups, the bias was reduced by propensity score matching. After matching, the mortality and complications occurring within 30 days after a TKA were compared between the 2 groups. In the database, 6491 primary TKA cases were identified. Nine hundred forty-three patients (14.5%) had a TKA performed under general anesthesia, and 5548 (85.5%) had a TKA performed under regional anesthesia. After propensity score matching, the data of 1886 patients were analyzed, with 943 patients in each group. There was no significant difference in mortality (0.32% vs 0.00%), transfusion rate (84.52% vs 84.73%, P = .8989), and length of hospital stay (50 vs 53, P = .5391) between the general and regional anesthesia groups. Most of the complications were not significantly different, but the major complications, including myocardial infarction (1.70% vs 0.64%, P = .0414) and acute renal failure (0.85% vs 0.11%, P = .0391), were higher in the general anesthesia group than in the regional anesthesia group. Also, admission to the intensive care unit (8.48% vs 2.33%, P < .0001) and total cost (₩8067, 400 vs ₩7487, 940, P = .0002) were higher in the general anesthesia group than in the regional anesthesia group. Our study found that regional anesthesia for TKA is associated with a decrease in major complications, including myocardial infarction and acute renal failure, and medical costs.

Regional anaesthesia in patients receiving antithrombotic therapy: low evidence and conservative views

From the Department of Anaesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Largo Medaglie d’Oro 9, Trento, Italy (TM) Correspondence to Tindaro Mogavero, Department of Anaesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Largo Medaglie d’Oro 9, Trento, Italy. E-mail: [email protected]

Regional anesthesia for a patient with extensive von Recklinghausen's disease

We report the case of a 60-year-old male posted for surgery on the left inner thigh mass with extensive neurofibromas covering the whole body. The patient was administered a subarachnoid block at L3-L4 level for excision of the mass on the left inner thigh. There were no postoperative anesthetic complications. This case report aims to highlight the importance of regional anesthesia in patients with neurofibromatosis and its anesthetic implications.

Regional Anesthesia In Patients With Parkinson's Disease

Parkinson's disease is a degenerative disease of the central nervous system, which occurs in 1% of the population over 60 years of age. This disease is caused by the loss of dopaminergic nerve fibers in the basal ganglia of the brain due to an immune response. Parkinsonism is the name given to a clinical syndrome consisting of disorders of voluntary movement (hypokinesia), stiffness, and tremors. The typical pathological picture is the destruction of nerve cells containing dopamine in the substantia nigra of the basal ganglia. The selection of anesthetic techniques in patients with Parkinson's disease plays an important role in minimizing complications and patient morbidity and mortality. Anesthetic concerns in patients with Parkinson's disease are the presence or absence of interactions with anti-Parkinson's drugs that the patient is taking, decreased organ function due to old age, such as decreased cardiovascular, respiratory, and autonomic nerve function. In this case, the patient with Parkinson's disease will undergo repositioning of the left femoral head due to the dislocation. We chose regional anesthesia because it has several advantages over general anesthesia. The results during and after surgery were good, there were no complications and the patient returned to the room.&#x0D;  

Efficacy of femoral periarterial block in preventing thigh tourniquet pain: a randomized controlled trial.

Tourniquet pain, described as a dull, tight, poorly localized aching sensation, is common in conscious patients. Although various pain-reduction methods have been implemented, none are completely effective. Femoral periarterial block (FAB) has been shown to attenuate tourniquet-induced hypertension in patients undergoing general anesthesia. We aimed to test the feasibility of FAB in inhibiting thigh tourniquet pain in orthopedic patients under conscious sedation. Forty-two patients (aged 18-64 years and ASA I-II) scheduled for below-knee orthopedic surgeries with an anticipated tourniquet duration of more than 40 min were recruited and received FAB (Group 1) or not (Group 2). The primary outcome was the occurrence of tourniquet pain. The onset time and severity of the tourniquet pain were recorded. Total doses of sedatives and analgesics administered intraoperatively and hemodynamic changes were documented. The occurrence of local anesthetic systemic toxicity was recorded. Kaplan-Meier time-to-event curves indicated an improved tourniquet tolerance and delayed pain onset. Tourniquet pain occurrence was lower in Group 1 than in Group 2 (30% vs. 95.5%, P=0.02). Tourniquet pain onset was delayed in Group 1 (80[67,84] min vs. 58[51.5,60] min, P<0.01). Fewer patients in Group 1 experienced severe pain (3(15%) vs. 18(81.8%), P<0.01), and less hemodynamic changes (2(10%) vs. 12(54.5%), P<0.01). Local anesthetic systemic toxicity was absent. FAB, applied with regional anesthesia in patients undergoing below-knee orthopedic surgeries, could reduce thigh tourniquet pain, stabilize blood pressure and heart rate, and prolong tourniquet duration.

Role of regional anesthesia in patients with acute sickle cell pain: A scoping review.

Sickle cell disease is the most prevalent inherited blood disorder in the world, with significant morbidity and mortality. Patients often have recurrent painful vaso-occlusive episodes, and the American Society of Hematology gives a conditional recommendation for the use of regional anesthesia for acute sickle cell pain management. This scoping review summarizes the current evidence and identifies gaps for future research. Our screening process is outlined, and articles that mentioned the use of regional anesthesia for acute sickle cell crises were included. We present and interpret our results and highlight opportunities for future investigation.

Effect of Regional Anesthesia Timing on Association with Delirium among Geriatric Trauma Patients with Multiple Rib Fractures

INTRODUCTION: Rib fractures cause significant morbidity among geriatric trauma patients, and elderly patients are at increased risk for delirium. Regional anesthesia (RA) has been shown to reduce the need for deliriogenic pain medications. We hypothesized that early use of RA may be associated with decreased delirium among this patient population. METHODS: We performed a retrospective review at our Level I trauma center to identify patients with 2 or more rib fractures from 2018 to 2019. We collected demographics, regional anesthesia type/timing, and outcomes including all Confusion Assessment Method (CAM) assessments recorded for each patient throughout their hospitalization. We calculated percentage of CAM negativity for each hospitalization (percentage of CAM negativity = negative CAM assessments/total CAM assessments × 100). RESULTS: A total of 636 patients with more than 1 rib fracture were identified. A total of 323 patients were older than 60 years. A total of 81 (25.1%) underwent RA (46 epidurals, 26 erector spinae blocks, 7 serratus anterior blocks, and 2 paravertebral blocks), and 242 (74.9%) did not receive RA. Mean percentage of CAM negativity was higher among RA patients than non-RA patients (95.1% vs 91.3%, p = 0.04); however, subgroup analysis showed patients receiving RA after 36 hours of admission had no difference in percentage of CAM negativity compared with non-RA patients (90.2% vs 91.3%, p = 0.78; Figure). Timing of RA did not affect in-hospital mortality, overall length of stay, ICU length of stay, or ventilator days.Figure.: CAM, Confusion Assessment Method.CONCLUSION: Among elderly trauma patients with multiple rib fractures, regional anesthesia use is associated with decreased rates of delirium; however, this effect is lost when RA is initiated more than 36 hours after admission.

Race, ethnicity, and the use of regional anesthesia in cancer patients undergoing open abdominal surgery: A single-center retrospective cohort study.

BackgroundWhere applicable, regional anesthesia has been shown to be superior to opioid or non-opioid analgesic modalities alone. However, some studies have shown ethnic-based disparities in the use of regional anesthesia in patients undergoing surgical procedures. In this study of patients who had undergone major oncologic surgery, our main objective was to compare the use of regional anesthesia between patients of different ethnicities.MethodsA retrospective review of adults who had undergone major open abdominal surgical procedures between 2016 and 2021 was performed. Logistic regression models were used to assess the association between baseline patient characteristics and the use of regional anesthesia.ResultsA total of 4,791 patients were included in the analysis. The median age was 60.5 years [interquartile range, 49, 69], the majority were female (65%), and of American Society of Anesthesiologists Physical Status Class (ASA) 3 (94.7%). Regional anesthesia was used in 2,652 patients (55.4%) and was not associated with race or ethnicity (p = 0.287). Compared to White patients, the odds of regional anesthesia use in other racial/ethnic groups were: Asian {odds ratio (OR) 0.851 [95% confidence interval (CI), 0.660–1.097]; p = 0.2125}, Black/African American [OR 0.807 (95% CI, 0.651–1.001); p = 0.0508], Hispanic/Latino [OR 0.957 (95% CI, 0.824–1.154); p = 0.7676], Other race [OR 0.957 (95% CI, 0.627–1.461); p = 0.8376]. In the multivariable analysis, age [OR 0.995 (95% CI, 0.991–1.000); p = 0.0309] and female gender [OR 1.231 (95% CI, 1.090–1.390); p = 0.0008] were associated with the use of regional anesthesia.ConclusionIn this single-institution retrospective study of adults who had undergone major open abdominal surgery, the use of regional anesthesia was not associated with race or ethnicity. In the multivariable analysis, age and female gender were associated with the use of regional anesthesia.

Regional anaesthesia in patients on antithrombotic drugs - a joint ESAIC/ESRA guideline: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Regional anaesthesia in patients on antithrombotic drugs – a joint ESAIC/ESRA guideline. This clinical practice guideline serves as a useful decision aid for Nordic anaesthesiologists providing regional anaesthesia to adult patients on antithrombotic drugs.

Regional anesthesia in patients with Charcot-Marie-Tooth disease: a historical cohort study of 53 patients.

Anesthetic management for patients with Charcot-Marie-Tooth disease (CMT) is controversial. Description of the use of regional anesthesia (RA) in patients with CMT is limited. Regional anesthesia has traditionally been avoided because of risk of nerve injury. We retrospectively reviewed patients with CMT who received RA at our institution. We performed a historical cohort study of all patients with CMT who received RA from 30 April 2010 to 30 April 2020 within our institution. Charts were reviewed for information on demographics, RA procedures, perioperative variables, evidence of neurologic complications, post-RA neurology consults, and perioperative electromyography (EMG) results. Electromyographs were reviewed by a neurologist who was blinded to the surgical and RA details. Fifty-three patients received a total of 132 regional anesthetics during the study period. Twenty-five patients received RA on more than one occasion. Fifty-five EMGs and 14 postoperative neurology consults were performed. Two patients had neurology consults with peripheral nerve block (PNB) distribution complaints years later. Neither attributed the complaints to the PNB. The other neurology consults were for unrelated complaints. No EMG results suggested injury related to PNB. This study found no evidence of documented neurologic complications or an increased risk of nerve injury related to RA in CMT patients.

A prospective randomized, controlled, double blinded study to compare the analgesic efficacy of lidocaine (3 mg/ kg 0.5%) with dexmedetomidine (0.5 mcg / kg) and lidocaine (3mg/ kg 0.5%) with normal saline for intravenous regional anesthesia in patients posted for upper limb surgeries

Intravenous regional anaesthesia may be defined as reversible state of anaesthesia, produced by administration of local anesthetics into the venous system of upper and lower extremities. This technique is simple, effective, cheap and quite safe for operations on limbs especially in emergency situations. The present study involves the comparison of analgesic efficacy of Lidocaine with normal saline vs lidocaine with dexmedetomidine in intravenous regional anesthesia. A total of 120 patients belonging to both sexes of ASA – I or ASA – II and between the age groups of 18 to 50 yrs, admitted for various orthopaedic surgeries on forearm were included in the study. They are prospectively randomised in to two groups: Group L-Lidocaine 3mg/kg 0.5%+1 ml normal saline diluted with normal saline made to 40 ml and Group LD –Lidocaine 3mg/kg0.5%+Dexmedetomidine 0.5μg/kg (diluted to 1ml) diluted with normal saline made to 40 ml. Results analysed and discussed. The addition of 0.5 µg/kg dexmedetomidine to lidocaine for intra venous regional anaesthesia has significant analgesic effect. It shortens the onset of sensory and motor block onset, improved tourniquet tolerance and prolonged postoperative analgesia with stable cardiorespiratory parameters.

Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines.

Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

Regional anaesthesia in patients receiving antithrombotic drugs: How to limit a rare but potentially serious risk.

Regional anaesthesia in patients receiving antithrombotic drugs: How to limit a rare but potentially serious risk.