Ultrasound-guided Regional Anesthesia Research Articles

Cardiac output and cerebral blood flow during carotid surgery in regional versus general anesthesia: A prospective randomized controlled study

ObjectiveCarotid endarterectomy (CEA) is a preventive procedure aimed at decreasing the subsequent risk of fatal or disabling stroke in patients with significant carotid stenosis. It is well-known that carotid surgery under ultrasound-guided regional anesthesia (US-RA) causes a significant increase in blood pressure, heart rate and stress hormone levels owing to increased sympathetic activity. However, little is known about the effects on cardiac output (CO), cardiac index (CI), and cerebral blood flow (CBF) under US-RA as compared with general anesthesia (GA). MethodsPatients scheduled for CEA were randomized prospectively to receive US-RA (n = 37) or GA (n = 41). The primary end point was the change in CI after induction of anesthesia and the change from baseline over time at four different times during the entire procedure in the respective randomized US-RA and GA groups. In addition to systolic blood pressure and heart rate, we also recorded peak systolic velocity, end-diastolic velocity, and minimum diastolic velocity as seen from transcranial Doppler ultrasound examination, as well as regional cerebral oxygenation (rSO2) as seen from near-infrared refracted spectroscopy to evaluate cerebral blood flow. ResultsIn the US-RA group, the CI increased after induction of anesthesia (3.7 ± 0.8 L/min/m2) and remained constant until the end of the procedure. In the GA group CI was significantly lower (2.4 ± 0.6 L/min/m2; P < .001). After induction of anesthesia, the rSO2 remained constant in the GA group on both the ipsilateral (63 ± 9 rSO2) and the contralateral (65 ± 7 rSO2) sides; in contrast, it significantly increased in the US-RA group (ipsilateral 72 ± 8 rSO2; P < .001; contralateral 72 ± 6 rSO2; P < .001). The transcranial Doppler ultrasound parameters (peak systolic velocity, end-diastolic velocity, and minimum diastolic velocity) did not differ between the US-RA and the GA group. The clinical outcome was similarly favorable for both groups. ConclusionsCI was maintained near baseline values throughout the procedure during US-RA, whereas a significant decrease in CI values was observed during CEA under GA. Near-infrared refracted spectroscopy values, reflecting blood flow in small vessels, were higher in US-RA patients than in those with GA. These differences did not influence clinical outcome.

Ultrasound-Guided Regional Anesthesia-Current Strategies for Enhanced Recovery after Cardiac Surgery.

With the advent of fast-track pathways after cardiac surgery, there has been a renewed interest in regional anesthesia due to its opioid-sparing effect. This paradigm shift, looking to improve resource allocation efficiency and hasten postoperative extubation and mobilization, has been pursued by nearly every specialty area in surgery. Safety concerns regarding the use of classical neuraxial techniques in anticoagulated patients have tempered the application of regional anesthesia in cardiac surgery. Recently described ultrasound-guided thoracic wall blocks have emerged as valuable alternatives to epidurals and landmark-driven paravertebral and intercostal blocks. These novel procedures enable safe, effective, opioid-free pain control. Although experience within this field is still at an early stage, available evidence indicates that their use is poised to grow and may become integral to enhanced recovery pathways for cardiac surgery patients.

Safety and effectiveness of ultrasound guided peripheral nerve blocks: Audit at tertiary care hospital.

To assess the safety and effectiveness of peripheral nerve blocks using ultrasound. The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of all patients who received peripheral nerve blocks as part of anaesthesia care between January 2015 and January 2017. The data included outcomes of peripheral nerve block effectiveness, complications and limb conditions after the block. Peripheral nerve block effectiveness was assessed by monitoring pain scores at rest and on movement, and the requirement of co-analgesia. Complications, like numbness, motor block, metallic taste, hypotension and respiratory depression, were also assessed. Data was analysed using SPSS 19. There were 299 patients who received ultrasound-guided peripheral nerve blocks. The overall mean age was 44.57±16.64 years. Of the total, 140 (47%) received transversus abdominis plane block, followed by supraclavicular block 49(16.7%). The most common complication in the recovery room was numbness 19 (6.2%). Overall, 70% patients remained pain-free, while 16% had moderate pain on movement 12 hours postoperatively. Ultrasound-guided regional anaesthesia was found to provide effective analgesia during and after surgery. Nerve blocks proved to be safe when used with ultrasound.

Laryngofissure in comorbid patient under ultrasound-guided regional anesthesia of the neck

BackgroundMajor neck surgery is done typically under general anesthesia (GA). The neural blocks of the neck include blocking of the cervical plexus, superior laryngeal nerve, trans-laryngeal, block of the glossopharyngeal nerve, and local anesthetic infiltration. In patients with a high risk of GA, including those with pulmonary dysfunction, and prior myocardial ischemia or infarction, regional anesthesia is mainly indicated.Case presentationWe record a case of a comorbid geriatric patient with dysphonia and left glottic mass that was diagnosed as squamous cell papilloma by transoral biopsy using curved biopsy forceps under local spray anesthesia, and after 6 months, this patient developed stridor for which tracheostomy, laryngofissure, and left cordectomy were then performed solely under neck blocks. Surgery was performed while the patient remained pain-free and stable without any morbidity throughout the operation.ConclusionsIn high-risk patients and low-resource health systems, regional anesthesia in neck surgery can be a reasonable and cheap alternate to general anesthetics.

An Ultrasound-Guided Regional Anesthesia Elective for Emergency Medicine Residents.

This ultrasound-guided regional anesthesia elective is designed for emergency medicine residents. The proposed length of this curriculum is over one week. Ultrasound-guided regional anesthesia (UGRA) is a useful tool in the emergency department (ED) for managing painful conditions, and many programs have identified that these are useful skills for emergency providers; however, only about 53% of programs report teaching UGRA as part of their core curriculum, and there currently are no widely available or peer reviewed nerve block curricula designed for emergency medicine residents. To deliver an immersive 1-week elective to provide residents a strong foundation in principles of UGRA and an introduction to 14 nerve block procedures applicable to care provided in the ED. The educational strategies used in this curriculum include: instructional videos, written and online independent learning materials, one-on-one teaching at the bedside with an emergency ultrasound fellow, simulation of nerve block techniques using a femoral nerve block task trainer, and performance of supervised nerve block procedures on patients in the ED. All residents provided feedback through an online survey after completing the elective. Eight residents completed the elective in the first year of implementation. Following completion of the UGRA curriculum, 8/8 (100%) of residents reported increased level of confidence in performing UGRA. In addition, 8/8 (100%) of residents reported they were "likely" or "very likely" to incorporate UGRA into their future EM practice. All 8 (100%) residents responded they were "very likely" to recommend the elective to other trainees. The elective received high ratings for overall quality with an average rating of 9.4 out of 10 (±0.7). An elective in ultrasound-guided regional anesthesia can be successfully incorporated into an emergency medicine training program. The curriculum was successful in providing focused training in UGRA and resulted in increased resident confidence in performing nerve block procedures. Ultrasound-guided regional anesthesia, nerve block, resident, elective, pain.

Artificial Intelligence and Robotics in Regional Anaesthesia: Do they have a role?

Artificial Intelligence and Robotics in Regional Anaesthesia: Do they have a role?

The role of peripheral nerve stimulation in the era of ultrasound-guided regional anaesthesia.

With the widespread use of ultrasound for localising nerves during peripheral nerve blockade, the value of electrical nerve stimulation of evoked motor responses has been questioned. Studies continue to show that, compared with nerve stimulation, ultrasound guidance alone leads to: significantly improved block success; decreased need for rescue analgesia; decreased procedural pain; and lower rates of vascular puncture. Nerve stimulation combined with ultrasound does also not appear to improve block success rates, apart from those blocks where the nerves are challenging to view, such as the obturator nerve. The role of nerve stimulation has changed in the last 15years from a technique to locate nerves to that of an adjunct to ultrasound. Nerve stimulation can serve as a monitor against needle-nerve contact and may be useful in avoiding nerves that are in the needle trajectory during specific ultrasound guided techniques. Nerve stimulation is also a useful adjunct in teaching novices ultrasound-guided regional anaesthesia, especially when the position and or appearance of nerves may be variable. In this review, the changing role of nerve stimulation in contemporary regional anaesthetic practice is presented and discussed.

Ultrasound-guided regional anesthesia in cosmetic plastic surgeries of the breasts

Ultrasound-guided regional anesthesia in cosmetic plastic surgeries of the breasts

An Ultrasound-Guided Regional Anesthesia Elective for Emergency Medicine Residents

Author(s): Tucker, Ryan; Huang, Robert; Peterson, William; Munzer, Brendan; Thiessen, Molly

Ultrasound-Guided Regional Anesthesia Using a Head-Mounted Video Display: A Randomized Clinical Study

BACKGROUND: Ultrasonography is increasingly being used in every field of medicine, especially regional anesthesia. To successfully perform the procedure, a knowledge of anatomy and ultrasonoanatomy as well as technical 3D hand-eye coordination skills are required. Medical practitioners who use ultrasound devices to perform regional blocks have to correlate the position of the ultrasound probe on the patient, needle position, and ultrasound picture. To achieve that, the practitioner has to intermittently look between the patient and the ultrasonography screen. This requires extra head rotations, increasing the time and complexity of the procedure. Newer technologies are available that can alleviate the need for these extra head movements, such as head-mounted displays (HMDs), which are connected to the ultrasonography machine and project the ultrasonography picture onto the HMD goggles so that the provider can see the monitor without unnecessary head rotations. OBJECTIVE: Our theory was that the use of the HMD goggles would decrease the overall procedure duration as well as provider head rotations. STUDY DESIGN: This was a randomized clinical study. SETTING: The research was conducted at an academic medical center at the University of Texas Medical Branch, Galveston, TX. METHODS: We secured Institutional Review Board (IRB) approval to perform the study. We chose an HMD, which can be mounted on the head like regular goggles. By connecting the HMD with the ultrasonography machine, the ultrasound picture can be projected directly in front of the physician’s eyes. Twenty-four patients were randomized to receive a regional anesthetic performed by anesthesiology residents using a conventional ultrasound-guided approach or using the HMD in addition. We measured the number of attempts, head rotations, and time needed to obtain a satisfactory nerve stimulation in addition to outcomes and adverse effects. Our data were interpreted by our statistician with P &lt; .05 indicating statistical significance. RESULTS: Regional anesthetics performed with the HMD were significantly faster (59.08 vs 175.08 seconds) with significantly fewer head movements (0.83 vs 4.75) and attempts (1 vs 1.42). There were no significant differences in patient demographics, type of regional anesthetic, level of resident training, or outcomes. No complications were noted. LIMITATIONS: A limitation of our research is that neither observers nor providers were blinded to the way blocks were performed. This would have been practically impossible because participants had to wear an HMD. CONCLUSIONS: The HMD could provide advantages in regional anesthesia by decreasing the time and attempts and improving ergonomics. These findings can be easily translated into other ultrasound- or optic/camera-guided procedures outside of regional anesthesia, such as vascular access or laparoscopic surgery. IRB: UTMB IRB #12-143 KEY WORDS: Head-mounted video display, nerve blocks, randomized clinical study, regional anesthesia, regional blocks, ultrasound, vascular access

Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine.

Ultrasound-guided regional anesthesia (UGRA) can be a powerful tool in the treatment of painful conditions commonly encountered in emergency medicine (EM) practice. UGRA can benefit patients while avoiding the risks of procedural sedation and opioid-based systemic analgesia. Despite these advantages, many EM trainees do not receive focused education in UGRA and there is no published curriculum specifically for EM physicians. The objective of this study was to identify the components of a UGRA curriculum for EM physicians. A list of potential curriculum elements was developed through an extensive literature review. An expert panel was convened that included 13 ultrasound faculty members from 12 institutions and from a variety of practice environments and diverse geographical regions. The panel voted on curriculum elements through two rounds of a modified Delphi process. The panelists voted on 178 total elements, 110 background knowledge elements, and 68 individual UGRA techniques. A high level of agreement was achieved for 65 background knowledge elements from the categories: benefits to providers and patients, indications, contraindications, risks, ultrasound skills, procedural skills, sterile technique, local anesthetics, and educational resources. Ten UGRA techniques achieved consensus: interscalene brachial plexus, supraclavicular brachial plexus, radial nerve, median nerve, ulnar nerve, serratus anterior plane, fascia iliaca, femoral nerve, popliteal sciatic nerve, and posterior tibial nerve blocks. The defined curriculum represents ultrasound expert opinion on a curriculum for training practicing EM physicians. This curriculum can be used to guide the development and implementation of more robust UGRA education for both residents and independent providers.

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, 16 tables, and 72 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

Along or across the visual axis: a comparison of two ultrasound screen, needle and transducer orientation techniques

ObjectiveTo evaluate two transducer and needle handling methods, along the visual axis (AL) and across the visual axis (AC), in non-skilled and skilled clinicians. Study designProspective randomized crossover study. MethodA total of 26 students with no ultrasound locoregional anaesthesia experience (non-skilled group) and six clinicians experienced and familiar with ultrasound locoregional anaesthesia (skilled group) were enrolled. The non-skilled group was asked to perform two tasks: the first on a phantom and the second on canine cadavers, whilst the skilled group performed only the second task. The tasks consisted of guiding the tip of the needle to a target point (simulated nerve on the jelly phantom and sciatic nerve on the cadavers) using two different methods of needle handling—AL or AC. All operators performed each task three times for each method. The time to drive the needle to the target for the two methods was analysed with a paired Student t test, and the number of times the needle was not visualized on the screen between the groups was compared using an unpaired Student t test. Data are presented as mean ± standard deviation. Value of p < 0.05 was considered significant. ResultsThe AL method, compared with the AC method, resulted in shorter performance time in both skilled (9 ± 5 versus 20 ± 8 seconds for the second task) and non-skilled groups (9 ± 8 versus 17 ± 15 seconds for the first task and 18 ± 11 versus 32 ± 26 seconds for the second task). Conclusion and clinical relevanceIn both groups, the AL method significantly reduced the time to complete the task. Results from this study indicate that the AL method should be the preferred method for learning/teaching ultrasound-guided regional anaesthesia.

A single-operator technique in ultrasound-guided regional anesthesia.

A single-operator technique in ultrasound-guided regional anesthesia.

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 &gt;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&rsquo;s age was negatively associated with surgery (p &lt;0.001). The association between surgery and study group was significant in patients &ge;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.