Ultrasound-guided Regional Anesthesia Research Articles

A retrospective comparison of percutaneous radiofrequency ablation of osteoid osteoma using three anesthesia modalities

Objectives: The objectives of the study were to compare the safety and effectiveness of ultrasound-guided regional anesthesia (USGRA) with monitored anesthesia care (MAC) plus light sedation (MAC + LS) versus MAC with deep sedation (MAC + DS) versus general anesthesia (GA) for percutaneous radiofrequency ablation (PRFA) of lower extremity osteoid osteoma (OO). Material and Methods: Patients who underwent PRFA of lower extremity OO from May 2016 to February 2020 were retrospectively reviewed. Three groups were constructed based on the primary anesthetic utilized: (i) USGRA with MAC + LS, (ii) MAC + DS, and (iii) GA. USGRA patients were administered sciatic or tibial nerve blocks using local anesthetic (LA) mixtures consisting of 1.5% mepivacaine ± 2% lidocaine or 2% chloroprocaine. Data were collected on the frequency of conversion to GA, post-procedure ambulatory falls, prolonged neurosensory blockade, technical success of the block, post-procedure visual analog pain scale (VAS), milligram morphine equivalent (MME) administered, procedure and recovery times, and time to resolution of the block. Data were also collected on patient age, sex, and the tumor size and location. Kruskal–Wallis and Pearson’s Chi-squared tests were performed to compare outcomes in the three study groups. Results: Nineteen patients (12 men; mean age 20.9 ± 5.9 years) with a median tumor volume of 66 mm3 [IQR 36, 150] were included. Lesion locations included the tibia (10 cases), femur (4 cases), fibula (3 cases), and calcaneus (2 cases). Four patients were provided USGRA and MAC + LS, eight patients underwent MAC + DS, and seven patients received GA. There were no significant differences in patient demographic characteristics between the three study groups. Technical success was achieved in all four patients receiving USGRA. None required conversion to GA, had post-procedure ambulation difficulty, or prolonged neurosensory deficits. Post-procedure VAS score was 0 at all measured time intervals, and no USGRA patients required opioids. Conversely, patients receiving MAC + DS or GA had varying mean VAS scores (GA: 1.8 ± 0.9; MAC + DS: 1.7 ± 1.7) and opioid requirements (median [IQR]) (GA: 0 [0, 0] MME; MAC + DS: 0 [0, 3.75] MME). Tumor volumes >100 mm3 frequently required opioid analgesia. VAS scores were significantly lower in USGRA patients at 30 min post-recovery area arrival (P = 0.027) and on average over 0–120 min post-recovery area arrival (P = 0.016). Procedure duration was similar between the three anesthesia groups (P = 0.939). There was no significant difference in mean recovery times in the USGRA group (230 ± 111 min) compared to the MAC + DS (136 ± 71 min) or GA (113 ± 34 min) groups (P = 0.305). Of note, both time to USGRA resolution (254 min) and recovery time (70 min) were quickest in the patient who received a mixture of 1.5% mepivacaine and 2% chloroprocaine. Conclusion: USGRA can be implemented safely and effectively for PRFA of OO as an alternative primary anesthetic technique. It decreases post-procedural discomfort without ambulation difficulty, prolonged neurosensory deficit, or recovery time. The potential for prolonged block duration may be addressed using a mepivacaine/chloroprocaine LA mixture for periprocedural analgesia with quick resolution.

Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings.

Safe and accessible surgical and anesthetic care is critically limited for over half of the world’s population, particularly in Sub-Saharan African and Southeast Asian countries. Increasing the use of regional anesthesia in these areas has potential benefits regarding access, safety, and cost-effectiveness. Perioperative anesthesia-related mortality is significantly higher in resource-limited countries and every effort should be made to encourage the use of anesthetic techniques in these countries that are safest under the present conditions. Studies from Sub-Saharan Africa, although limited in number, have shown a lower risk of death with regional compared to general anesthesia. Regional anesthesia has the further benefit of decreasing the risk of COVID-19 spread to healthcare providers by avoiding the aerosol-generating procedures that occur during general anesthesia. Neuraxial regional anesthesia is relatively easy to teach and perform and is considered the anesthetic of choice for surgeries below the umbilicus in resource-limited settings due to its safety, efficacy, and low cost. Although regional anesthesia has multiple potential advantages, education and training of anesthetic providers in low-and-middle-income countries (LMIC) are a significant barrier to growth. Anesthesia professionals, especially in Sub-Saharan Africa, are often poorly supported and undervalued, and recruitment and retention of adequate numbers of trained practitioners are a continuing problem. Greater use of regional anesthesia could be one way to safely increase anesthesia access and simultaneously create value and enthusiasm for the field. Deficits in anesthesia infrastructure, equipment, and drugs also limit anesthesia capacity in low-and middle-income countries. Ultrasound-guided regional anesthesia may be helpful in improving access to safe and reliable anesthesia in low-resource countries as it continues to become more user-friendly, durable, and affordable.

Ultrasound-guided regional anaesthesia and reduction of distal radius fractures in an emergency department.

Distal radius fractures are among the most common fractures. Ultrasound is gaining importance in the treatment of and as a tool to diagnose distal radius fractures, guide regional anaesthesia and support reductions. Our aim was to demonstrate safety, feasibility and outcome in patients with a distal radius fractures undergoing ultrasound-guided regional anaesthesia (UGRA) with ultrasound-guided reduction (UGR), as compared with procedural sedation for the reduction. This retrospective cohort study was carried out in the emergency department of the University Hospital Basel (Switzerland) between February 2014 and October 2017. Adults with an isolated forearm fracture were eligible. The intervention group was treated with UGRA of the brachial plexus and subsequent ultrasound-assisted fracture reduction. Patients in the control group received usual care, which is blind fracture reduction with extension and immobilisation under procedural sedation. 71 patients were enrolled in the intervention group and 142 were to the control group. There was one (1.4%) complication (pneumothorax) in the UGR group. Twenty-five patients (35%) in the intervention group and 67 patients (47%) in the control group underwent surgery. The association between surgery and study group was not significant (p = 0.08). The patient’s age was negatively associated with surgery (p <0.001). The association between surgery and study group was significant in patients ≥60 years (p = 0.035). The combination of ultrasound-guided regional anaesthesia and ultrasound-guided reduction of distal radius fractures is feasible. Safety was shown by 70 out of 71 cases of UGRA being without complication. Effectiveness regarding the necessity of subsequent operation was comparable to usual care; in patients over 60 it may be lower with UGR.

Impact of video games on ultrasound-guided regional anesthesia skills

BackgroundThere is an association between video game practice and laparoscopic expertize in trainee surgeons. Ultrasound-guided regional anesthesia has many parallels with laparoscopic surgery. The aim of this study was to...

Education and training in ultrasound-guided regional anaesthesia and pain medicine.

Effective and safe regional anaesthesia and pain medicine procedures require clinicians to learn and master complex theoretical knowledge and motor skills. This review aims to summarize articles relevant to education and training in these skill sets in the previous 2 years. Twenty-two articles were identified, investigating nine out of the 13 top-ranked research topics in education and training in regional anaesthesia. Research topics addressed by these articles included prerotation simulation, deliberate practice combined with formative assessment tools, validation of assessment tools, three-dimensional-printed models, and knowledge translation from simulation to clinical practice. Emerging concepts investigated for their applications in regional anaesthesia included eye-tracking as a surrogate metric when evaluating proficiency, and elastography aiding visual salience to distinguish appropriate perineural and inappropriate intraneural injections. Research into education and training in regional anaesthesia covered multiple and diverse topics. Methodological limitations were noted in several articles, reflecting the difficulties in designing and conducting medical education studies. Nonetheless, the evidence-base continues to mature and innovations provide exciting future possibilities.

Diaphragm-sparing brachial plexus blocks: a focused review of current evidence and their role during the COVID-19 pandemic.

Given that COVID-19 can severely impair lung function, regional anesthesia techniques avoiding phrenic nerve paralysis are relevant in the anesthetic management of suspected/confirmed COVID-19 patients requiring shoulder and clavicle surgical procedures. The objective of this review is to provide an overview of recently published studies examining ultrasound-guided diaphragm-sparing regional anesthesia techniques for the brachial plexus (BP) to favor their preferent use in patients at risk of respiratory function compromise. In the last 18 months, study findings on various diaphragm-sparing regional anesthesia techniques have demonstrated comparable block analgesic effectivity with a variable extent of phrenic nerve paralysis. The impact of hemi-diaphragmatic function impairment on clinical outcomes is yet to be established. Existing diaphragm-sparing brachial plexus regional anesthesia techniques used for shoulder and clavicle surgery may help minimize pulmonary complications by preserving lung function, especially in patients prone to respiratory compromise. Used as an anesthetic technique, they can reduce the risk of exposure of healthcare teams to aerosol-generating medical procedures (AGMPs), albeit posing an increased risk for hemi-diaphragmatic paralysis. Reducing the incidence of phrenic nerve involvement and obtaining opioid-sparing analgesia without jeopardizing efficacy should be prioritized goals of regional anesthesia practice during the COVID-19 pandemic.

Sedoanalgesia Versus Infraclavicular Block for Closed Reduction of Pediatric Forearm Fracture in Emergency Department: Prospective Randomized Study.

Procedural sedoanalgesia is commonly used in pediatric patients in the emergency department (ED) for interventional procedures, diagnosis, and treatment. However, this method causes serious systemic complications, such as respiratory and cardiac depression. To minimize these complications, ultrasound-guided regional anesthesia methods have been used in recent years. We aimed to compare the use of procedural sedoanalgesia (PSA) and infraclavicular block (ICB) in the pain management of pediatric patients who underwent closed reductions of forearm fractures. This prospective, randomized, clinical study included patients aged 3 to 15 years who presented to the ED with forearm fractures. The patients were divided into 2 groups: the procedural sedoanalgesia group (group PSA, n = 30) and ultrasound-guided ICB group (group ICB, n = 30). Pain scores of the patients were evaluated using the Wong-Baker FACES Scale before and during the procedure. Pain scores and parental and operator satisfaction were compared between the groups. There was no statistical significance in terms of demographic data. The pain scores observed during the procedures were significantly higher in the group PSA than in the group ICB (3.07 ± 1.55 vs 0.47 ± 0.86, respectively; P < 0.001). The parental and operator satisfaction of the ICB group was significantly higher than that of the PSA group (P < 0.001). Ultrasound-guided ICB is a safe and effective method in the management of pain during closed reduction of forearm fracture in pediatric patients in EDs. It can be used safely in emergency rooms and has a high level of both parental and operator satisfaction.

A new score for characterizing the visibility of anatomical structures during ultrasound guided regional anesthesia: a retrospective cohort study.

To identify anatomical structures using sonography can be challenging, yet it is a basic requirement for effective and safe ultrasound guided nerve blocks. In clinical routine, we find a wide variety in the visibility of anatomical structures. Aim of this study was to evaluate the feasibility of a newly developed visibility score for anatomical structures in ultrasound guided regional anesthesia. We retrospectively evaluated the blockades from the routine documentation of ultrasound-guided regional anesthesia over an arbitrary period of 15 months at a university hospital with a Visibility Score (VIS) of one (best) to five (worst visibility). The study analyzed 983 blockades (femoral, saphenous, infragluteal and popliteal sciatic, transversus abdominis plane, interscalene, supraclavicular, axillary and suprascapular blockades). The following VIS were found: 1: 80.6%; 2: 14.0%; 3: 4.0%; 4: 1.2%; 5: 0.2%. The mean Body Mass Index (BMI) was 27.9 kg/m2. The best cut-off for poor VIS was a BMI of 28.9 kg/m2<inf>.</inf> For infragluteal sciatic nerve block VIS was significantly higher (mean VIS 1.71±1.0) compared to all the other recorded blockades except the supraclavicular block. VIS was feasible in clinical routine. Compared to the other evaluated blocks, the VIS for the infragluteal access to the sciatic nerve was rated worst. VIS is found to be worse in obese patients. Further research is needed to evaluate VIS and its suitability for specific questions as for instance anesthetists' learning curves, comparison of different patient populations, ultrasound devices or different nerve blocks.

Effect of mental rotation skills training on ultrasound-guided regional anaesthesia task performance by novice operators: a rater-blinded, randomised, controlled study

BackgroundThe effect of mental rotation training on ultrasound-guided regional anaesthesia (UGRA) skill acquisition is currently unknown. In this study we aimed to examine whether mental rotation skill training can improve UGRA task performance by novice operators. MethodsWe enrolled 94 volunteers with no prior experience of UGRA in this randomised controlled study. After a baseline mental rotation test, their performance in a standardised UGRA needling task was independently assessed by two raters using the composite error score (CES) and global rating scale (GRS). Volunteers with low baseline mental rotation ability were randomised to a mental rotation training group or a no training group, and the UGRA needling task was repeated to determine the impact of the training intervention on task performance. The study primary outcome measure was UGRA needling task CES measured before and after the training intervention. ResultsMultivariate analyses controlling for age, gender, and previous performance showed that participants exposed to the training intervention made significantly fewer errors (CES B=-0.66 [standard error, se=0.17]; P<0.001; 95% confidence interval [CI], -0.92 to -0.26) and displayed improved overall performance (GRS B=6.15 [se=2.99], P=0.048, 95% CI=0.06 to 12.13) when undertaking the UGRA needling task. ConclusionsA simple training intervention, based on the manipulation and rotation of three-dimensional models, results in improved technical performance of a UGRA needling task in operators with low baseline mental rotation skills.

Ultrasonographic needle tip tracking for in-plane infraclavicular brachialis plexus blocks: a randomized controlled volunteer study

BackgroundOnvision is a new technology for needle tip detection and tracking in ultrasound-guided regional anesthesia. The system consists of a piezoelectric sensor close to the needle tip and an electronic...

Chinese Association of Anesthesiologists Expert Consensus on the Use of Perioperative Ultrasound in Coronavirus Disease 2019 Patients

The COVID-19 pandemic is spreading globally. COVID-19 has an effect on the systemic state, cardiopulmonary function and primary disease of patients undergoing surgery. COVID-19's high contagiousness makes anesthesia and intraoperative management more difficult. This expert consensus aims to comprehensively introduce the application of perioperative ultrasound in COVID-19 patients, including pulmonary ultrasound and anesthesia management, ultrasound and airway management, ultrasound-guided regional anesthesia and echocardiography for COVID-19 patients.

Teaching ultrasound guided femoral nerve block in the emergency department.

Patients with hip fracture are often not given adequate analgesia in the Emergency Department. Ultrasound guidedfemoral nerve block is an effective option but it is not commonly used due to limited experience, inadequate training andinfrequent clinical exposure. We aimed to develop a workshop to bridge the current gap in the training of ultrasound guidedfemoral nerve block. A 3-hour workshop was developed in accordance to guidelines for education andtraining in ultrasound-guided regional anesthesia. The components included an online learning module for pre-reading, as wellas team-based learning and simulation practice during the session. Evaluation of the participants was performed and feedbackof the course was collected. The workshop was conducted successfully for a total of 30 participants. All participantsachieved the minimum standard required. Across all domains, the mean scores for the workshop were more than 4.7 out of 5on the Likert scale. Participants were satisfied with the workshop and would recommend it to a colleague. Thisworkshop met its educational objectives and various principles of medical education were used effectively in the delivery ofthe content. Further research is necessary to demonstrate the impact of this educational effort on clinical practice and patientoutcomes.

Does Early Administration of Ultrasound Guided Regional Anesthesia for Long Bone Fractures Effect Long Term Patient Opioid Usage

Does Early Administration of Ultrasound Guided Regional Anesthesia for Long Bone Fractures Effect Long Term Patient Opioid Usage

Acute Care: Pain Management

Pain is a chief complaint in more than 50% of emergency department (ED) visits. Injury accounts for approximately one-third of presentations associated with pain; other common diagnoses include neck and back pain, minor infections, abdominal pain, and headache. In the ED, pain is underdiagnosed and undertreated, and existing pain management practices in the ED are inconsistent. Inadequate pain management is common, and pain remains unchanged or worsens during the ED visit for more than 40% of patients. Patient satisfaction improves when expectations for pain control are met. This review covers the pathophysiology of pain and the practice of pain management. Figures show the approach to pain management in the ED, an example of a numerical and visual analog scale pain rating scale, field block of the pinna, ultrasound probe and hand position for ultrasound-guided regional anesthesia, regional anesthesia of the face, innervation of the hand and fingers, regional anesthesia of the median, radial and ulnar nerves, innervation of the foot, ultrasound-guided regional anesthesia of the posterior tibialis nerve, regional anesthesia of the sural nerve, and method of regional anesthesia of the dorsal foot. This review contains 13 figures, 15 tables, and 71 references. Key words: Acute pain, Pain management, Oligoanalgesia, Pain assessment, Inadequate pain management, Acute pain management, Pain management in the emergency department, Pain in the ED, Pain presentation

Retroclavicular vs Infraclavicular block for brachial plexus anesthesia: a multi-centric randomized trial

BackgroundThe coracoid approach is a simple method to perform ultrasound-guided brachial plexus regional anesthesia (RA) but its simplicity is counterbalanced by a difficult needle visualization. We hypothesized that the retroclavicular (RCB) approach is not longer to perform when compared to the coracoid (ICB) approach, and improves needle visualization.MethodsThis randomized, controlled, non-inferiority trial conducted in two hospitals, included patients undergoing distal upper limb surgery. Patients were randomly assigned to a brachial plexus block (ICB or RCB). The primary outcome was performance time (sum of visualization and needling time), and was analyzed with a non-inferiority test of averages. Depth of sensory and motor blockade, surgical success, total anesthesia time, needle visualization, number of needle passes and complications were also evaluated. Subgroup analysis restricted to patients with higher body mass index was completed.ResultsWe included 109 patients between September 2016 and May 2017. Mean RCB performance time was 4.8 ± 2.0 min while ICB was 5.2 ± 2.3 min (p = 0.06) with a 95% CI reaching up to 5.8% longer. RCB conferred an ultrasound-needle angle closer to 0° and significantly improved needle visibility after the clavicle was cleared and before local anesthetic administration. No differences were found in the secondary outcomes. Similar results were found in the subgroup analysis.ConclusionRCB approach for brachial plexus anesthesia was similar to ICB approach in terms of time performance. Needle visibility, which represent an important clinical variable, was superior and angle between needle and ultrasound probe was close to 0° in the RCB group.Clinical trial registrationClinicalTrials.gov (NCT02913625), registered 26 September 2016.

The Effect of Transversus Abdominis Plane Block for Analgesia in Patients Undergoing Liver Transplantation: A Systematic Review and Meta-Analysis.

Ultrasound-guided regional anaesthesia using transversus abdominis plane (TAP) block is a newer and safer method that can be used in patients undergoing liver transplant surgeries. This systematic review and meta-analysis was done to quantify the analgesic potential and opioid-sparing capability of TAP block in these patients. The studies comparing TAP-block to conventional analgesic regimens for liver transplant were searched. The studies evaluating the comparative 24-h morphine consumption during postoperative period in patients undergoing liver transplant surgeries were searched and included as the primary outcome in the analysis. We found two randomised controlled trials and two retrospective studies that on meta-analysis showed that TAP block group had significantly lower requirement of morphine (WMD=27.59 mg; 95% CI: 33.47-21.70) at 24 h for pain mitigation. Also, postoperative nausea and vomiting was lower (RR=0.76; 95% CI: 0.47-1.22) but not statistically significant. Ultrasound-guided TAP block provides postoperative analgesic efficacy in patients undergoing liver transplant surgeries. This study was registered in International prospective register of systematic reviews [PROSPERO: CRD42018094595].

Let Go’ technique in ultrasound guided Regional Anaesthesia

Background: The local anaesthetic(LA) injection technique during ultrasound guided nerve blocks varies worldwide. This online poll was conceived to explore the current practice among the anaesthesiologists. Methodology: Two separate polls were created and posted at the same time with appropriate multiple choices in a closed Facebook group ‘The Anaesthetist’. Participants were allowed to take part in these online-based polls over a period of seven days. The responses were collected and put down in the Excel sheet to calculate absolute numbers and percentages. Results: Among the respondents, 63.45% of the ultrasound users keep hold on to the needle and let a trained assistant inject the LA while 14.61 % of the responders use ‘Let Go’ of the needle technique and inject the LA themselves. Amongst 248 ultrasound users, only one anaesthesiologist use Jedi grip but no one is currently using other grips described in the literature. Conclusion: LA injection technique varies among the anaesthesiologists throughout the globe. Majority of the anaesthesiologists let a trained assistant inject the LA and some inject the LA themselves. Keywords: Ultrasound, Regional Anaesthesia, Jedi grip, Bedforth grip, On-lock grip, ‘let-go’ of the needle, Single-handed injection technique, Online poll

Deep visual nerve tracking in ultrasound images

Ultrasound-guided regional anesthesia (UGRA) becomes a standard procedure in surgical operations and pain management, offers the advantages of nerve localization, and provides region of interest anatomical structure visualization. Nerve tracking presents a crucial step for practicing UGRA and it is useful and important to develop a tool to facilitate this step. However, nerve tracking is a very challenging task that anesthetists can encounter due to the noise, artifacts, and nerve structure variability. Deep-learning has shown outstanding performances in computer vision task including tracking. Many deep-learning trackers have been proposed, where their performance depends on the application. While no deep-learning study exists for tracking the nerves in ultrasound images, this paper explores thirteen most recent deep-learning trackers for nerve tracking and presents a comparative study for the best deep-learning trackers on different types of nerves in ultrasound images. We evaluate the performance of the trackers in terms of accuracy, consistency, time complexity, and handling different nerve situations, such as disappearance and losing shape information. Through the experimentation, certain conclusions were noted on deep learning trackers performance. Overall, deep-learning trackers provide good performance and show a comparative performance for tracking different kinds of nerves in ultrasound images.

Ultrasound-guided regional anesthesia simulation: use of meat glue in inexpensive and realistic nerve block models

BackgroundUltrasound-guided regional anesthesia (UGRA) is increasingly used by emergency physicians to provide safe and effective pain relief for patients. However, one of the factors limiting its widespread use is the lack of realistic models available for learners to train on. There are currently no inexpensive nerve block models available that are injectable and that closely mimic nerves, fascial planes, muscles, and other landmarks. Our aim is to create inexpensive, injectable nerve block models that can be used as effective medical training tools for UGRA.MethodsBy using a lean cut of pork such as pork loin, yarn soaked in ultrasound gel to simulate peripheral nerves, and drinking straws filled with gel to represent vascular structures, we created various nerve block models. Meat glue applied between sections of meat appears hyperechoic under ultrasound, thereby mimicking fascial planes and has the added benefit of helping to secure the components of the model together. Using these elements, we were able to create realistic peripheral nerve, fascia iliaca compartment, serratus anterior plane, and interscalene brachial plexus models.ResultsOne of the necessary skills in performing UGRA involves placing the needle tip along a fascial plane and visualizing hydrodissection of this plane with the local anesthetic. When meat glue (transglutaminase) is applied between layers of meat such as pork loin, the meat binds together and creates a hyperechoic line that mimics a fascial plane. When meat glue is applied to two apposing fascial layers naturally occurring on the meat, the fascial plane can be injected, and fluid can be seen hydrodissecting in this space. We created several nerve block models using meat glue and other components to mimic normal landmarks.ConclusionsWe have developed inexpensive and easily reproducible models that create the realistic appearance of tissues, nerves, and fascial planes under ultrasound. They can also accurately simulate hydrodissection of fluid in fascial planes. We hope these nerve block models will allow for the education in UGRA to be more widespread and accessible to learners from all specialties.

Erector Spinae Plane (ESP) Block: a New Paradigm in Regional Anesthesia and Analgesia

The erector spinae plane (ESP) block is an ultrasound-guided regional anesthesia technique that has enjoyed unprecedented popularity since its description in 2016. This review summarizes the applied anatomy, technical performance, and clinical application of the ESP block. Dissection and imaging studies indicate that paravertebral local anesthetic spread is a primary mechanism of action of the ESP block. A large volume of case report literature supports its efficacy in myriad clinical settings, including thoracic surgery, thoracic trauma, cardiac surgery, abdominal surgery, spine surgery, and painful conditions of the upper and lower limbs. Several randomized controlled trials have also been published that report significant analgesic benefit compared with systemic analgesia alone. The ESP block is a highly effective and versatile technique for the management of acute and chronic pain. Further studies are needed to definitively determine its efficacy compared with more established techniques.