Regional Anesthesia and Pain Medicine最新文献

Background: Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks.

Methods: We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement.

Results: A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research.

Conclusions: We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

In current clinical practice, spinal anesthesia and analgesia techniques-including epidural and subarachnoid procedures-are frequently executed without imaging like X-ray or epidurography. Unrecognized spinal pathology has resulted in serious morbidity in the context of performing neuraxial anesthesia. Typically, preoperative consultations incorporate a patient's medical history but lack a detailed spinal examination or consideration of recent MRI or CT scans. In contrast, within the domain of pain clinics, a multidisciplinary approach involving anesthesiologists and neuroradiologists is common. Such collaborative settings rely on exhaustive clinical history and scrutinization of recent imaging studies, which may influence the decision to proceed with invasive spinal interventions. There are no epidemiological data concerning rates of the different baseline pathologies that would potentially pose morbidity risks from neuraxial procedures, but the most common among these is canal stenosis, which significantly affects almost 20% of people over 60 years of age. This paper aims to elucidate these critical findings and advocate for incorporating meticulous preoperative assessments for individuals slated for spinal anesthesia or analgesia procedures, thereby attempting to mitigate potential risks.

Background: Surgery induces a temporal change in the immune system, which might be modified by regional anesthesia. Applying a bilateral preoperative anterior quadratus lumborum block has proven to be a safe and effective technique in pain management after abdominal and retroperitoneal surgery, but the effect on the immune response is not thoroughly investigated.

Methods: This study is a substudy of a randomized, controlled, double-blinded trial of patients undergoing laparoscopic hemicolectomy due to colon cancer. Twenty-two patients were randomized to undergo either a bilateral anterior quadratus lumborum nerve block with a total of 60 mL ropivacaine 0.375% or placebo with corresponding isotonic saline injections. The main objective of this exploratory substudy was to investigate the systemic immune response in the first postoperative day by examining changes in blood transcript levels (n=750) and stimulated secretion of cytokines (n=17) on ex vivo activation with microbial ligands and anti-CD3/CD28.

Results: Using unsupervised data analysis tools, we observed no effect of the bilateral anterior quadratus lumborum nerve block on gene expression in immune cells (permutational multivariate analysis of variance using distance matrices: F=0.52, p=0.96), abundances of major immune cell populations (Wilcoxon rank-sum test: p>0.05), and stimulated cytokine secretion (Wilcoxon rank-sum test: p>0.05).

Conclusions: Our study provides evidence that administration of bilateral anterior quadratus lumborum nerve block as a part of a multimodal analgesic regimen in an enhanced recovery after surgery for laparoscopic hemicolectomy in this cohort does not alter the systemic immune response. Trial registration number NCT03570541.

Introduction: Point-of-care ultrasound can assess diaphragmatic function and rule in or rule out paresis of the diaphragm. While this is a useful bedside tool, established methods have significant limitations. This study explores a new method to assess diaphragmatic motion by measuring the excursion of the uppermost point of the zone of apposition (ZOA) at the mid-axillary line using a high-frequency linear ultrasound probe and compares it with two previously established methods: the assessment of the excursion of the dome of the diaphragm (DOD) and the thickening ratio at the ZOA.

Methods: This is a single-centre, prospective comparative study on elective surgical patients with normal diaphragmatic function. Following research ethics board approval and patient written consent, 75 elective surgical patients with normal diaphragmatic function were evaluated preoperatively. Three ultrasound methods were compared: (1) assessment of the excursion of the DOD using a curvilinear probe through an abdominal window; (2) assessment of the thickening fraction of the ZOA; and (3) assessment of the excursion of the ZOA. The last two methods performed with a linear probe on the lateral aspect of the chest.

Results: Seventy-five patients were studied. We found that the evaluation of the excursion of the ZOA was more consistently successful (100% bilaterally) than the evaluation of the excursion of the DOD (98.7% and 34.7% on the right and left sides, respectively). The absolute values of the excursion of the ZOA were greater than and well correlated with the values of the DOD.

Conclusion: Our preliminary data from this exploratory study suggest that the evaluation of the excursion of the ZOA on the lateral aspect of the chest using a linear probe is consistently successful on both right and left sides. Future studies are needed to establish the distribution of normal values and suggest diagnostic criteria for diaphragmatic paresis or paralysis.

Trial registration number: NCT03225508.

Introduction: Regional anesthesia has been shown to be efficacious for analgesia in patients who underwent thoracotomies. The objective of this study was to analyze the association of epidurals and peripheral regional anesthesia with time to hospital discharge for these patients.

Methods: This was a retrospective cohort study using National Surgical Quality Improvement Program dataset from 2014 to 2020. Propensity-matched cohorts were assembled based on use of regional anesthesia, peripheral regional anesthesia, or epidural. Fine-Gray competing risk regressions were used to explore the association between regional anesthesia use and rate of discharge. The subdistribution hazard ratio (HR) represented relative discharge rates, and in-hospital death was a competing event. A sensitivity analysis was subsequently performed in which patients with American Society of Anesthesiologists score ≥4 were removed.

Results: There were 4350 patients included in this analysis, in which 472 (10.8%) received a peripheral regional anesthesia nerve block and 565 (13.0%) received thoracic epidural analgesia. The subdistribution HR for rate of discharge in the epidural versus non-epidural cohort was 1.09 (95% CI 1.01 to 1.18), thus epidurals were associated with an increased rate of discharge over time. However, this benefit was no longer apparent with the sensitivity analysis. The subdistribution HR for rate of discharge in the peripheral regional anesthesia versus no regional anesthesia cohort was 1.26 (95% CI 1.15 to 1.39), thus peripheral regional anesthesia was associated with an increased rate of discharge over time. This benefit remained even with the sensitivity analysis.

Conclusions: Thoracic epidural use when compared with no regional anesthesia was associated with decreased length of stay following thoracotomy in our primary analysis. The difference was no longer apparent with the sensitivity analysis. Peripheral regional anesthesia was associated with decreased length of stay even after sensitivity analysis.