{"title":"Propofol and the promise of unconsciousness in end-of-life care: a warning about the use of low-dose propofol infusions.","authors":"Thomas M Donaldson","doi":"10.1111/anae.70047","DOIUrl":"https://doi.org/10.1111/anae.70047","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"2 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145331756","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"ASA physical status classification: a relic of a bygone time?","authors":"Shaun Evans, David Mayhew","doi":"10.1111/anae.70046","DOIUrl":"10.1111/anae.70046","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"81 2","pages":"167-170"},"PeriodicalIF":6.9,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145331760","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Clístenes C de Carvalho,Amit Pawa,Kariem El-Boghdadly
{"title":"Motor-sparing regional anaesthesia in lower-limb arthroplasty: balancing analgesia and function.","authors":"Clístenes C de Carvalho,Amit Pawa,Kariem El-Boghdadly","doi":"10.1111/anae.70044","DOIUrl":"https://doi.org/10.1111/anae.70044","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"53 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145331927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Gillian D. Saffy, Gillian Lamacraft, Jacques Janse van Rensburg, Je'nine Horn-Lodewyk
<p>The erector spinae plane block, first described in 2016 for managing chronic neuropathic pain, is an effective ultrasound-guided technique for providing thoracic analgesia [<span>1</span>]. However, similar lumbar blocks have been less successful, likely due to anatomical differences in the fascial planes [<span>2</span>]. The lumbar paraspinal muscles are thicker, and the thoracolumbar fascia is more prominent [<span>3</span>], serving as a barrier to fluid spread [<span>4</span>]. The clinical effect of a lumbar erector spinae plane block depends on where the injectate spreads [<span>2-4</span>]. Anterior spread to the paravertebral space, epidural space or lumbar plexus is necessary for analgesia in hip [<span>5</span>] or abdominal surgeries, whereas posterior spread is useful for spinal surgery [<span>6</span>]. We aimed to characterise injectate spread after lumbar erector spinae plane block to clarify its clinical applications.</p><p>We undertook a prospective, interventional study of 12 patients with chronic hip pain who were receiving therapeutic hip blocks. We did not study patients with BMI > 30 kg.m<sup>-2</sup> or other contraindications for magnetic resonance imaging (MRI) or regional blockade. Following the hip block, a baseline lumbar spine MRI scan was performed. The patient was then positioned prone. We injected 30 ml 0.9% saline into the erector spinae plane at the L4 level on the contralateral side to the hip block. An ultrasound-guided, parasagittal, in-plane technique was used to direct the needle to the posterolateral tip of the L4 transverse process. We performed an MRI scan 30 min after the injection to investigate injectate spread, and a senior radiologist analysed each image to record the anatomical spread (Fig. 1).</p><p>We found that injectate spread was directed posteriorly in all patients into the erector spinae muscles. In four patients, injectate spread was directed anteriorly to structures where nerves would be blocked. In one patient, injectate spread was anterior but only into the quadratus lumborum muscle and not an area where nerves would be blocked. Mean (SD) craniocaudal spread of injectate was 140 (25.2) mm, covering 5.7 (1.1) vertebral levels. This yields 5.2 ml of injectate per vertebral level, consistent with previous studies (Table 1).</p><p>The consistent posterior spread indicates the lumbar erector spinae plane block may yield reliable analgesia for spinal surgery. However, the unpredictable anterior spread suggests it is less reliable for surgeries requiring anaesthesia to the ventral rami or related structures. This difference may be because injectate spread is determined by needle tip position relative to the middle layer of the thoracolumbar fascia. The thick, dense fascial layer acts as a barrier, which compartmentalises the injectate [<span>3</span>]. Some may suggest placing the needle tip anterior to the middle thoracolumbar fascia for anterior spread, but our study did not investigate
竖脊肌平面阻滞于2016年首次被描述用于治疗慢性神经性疼痛，是一种有效的超声引导胸椎镇痛技术。然而，类似的腰椎阻滞不太成功，可能是由于筋膜平面的解剖差异所致。腰椎棘旁肌肉较厚，胸腰筋膜较突出，可作为液体扩散的屏障。腰椎竖立者脊柱平面阻滞的临床效果取决于注射扩散的位置[2-4]。前扩至椎旁间隙、硬膜外间隙或腰丛对于髋部或腹部手术的镇痛是必要的，而后扩至脊柱手术的镇痛是有用的。我们的目的是描述腰竖肌脊柱平面阻滞后的注射扩散，以阐明其临床应用。我们对12名接受治疗性髋关节阻滞治疗的慢性髋关节疼痛患者进行了前瞻性、干预性研究。我们没有研究BMI为30 kg的患者。m-2或磁共振成像（MRI）或局部阻断的其他禁忌症。髋关节阻断后，进行基线腰椎MRI扫描。然后将患者置于俯卧位。我们在髋关节块对侧L4水平的竖脊平面注射30 ml 0.9%生理盐水。超声引导下，准矢状面内技术用于将针指向L4横突的后外侧尖端。我们在注射后30分钟进行了MRI扫描以调查注射扩散，一位高级放射科医生分析了每张图像以记录解剖扩散（图1）。我们发现，所有患者的注射扩散都指向后方的竖脊肌。在4例患者中，注射扩散被定向到神经被阻断的结构前方。在一名患者中，注射扩散在前路，但只进入腰方肌，而不是神经被阻断的区域。平均（SD）颅底扩散140 (25.2)mm，覆盖5.7（1.1）个椎体水平。每个椎体水平的注射量为5.2 ml，与之前的研究一致（表1）。一致的后展表明腰竖肌脊柱平面阻滞可为脊柱手术提供可靠的镇痛。然而，不可预测的前部扩散表明，对于需要麻醉腹支或相关结构的手术，它不太可靠。这种差异可能是因为注射扩散是由针尖相对于胸腰筋膜中间层的位置决定的。厚而致密的筋膜层起到屏障的作用，将注入的血筋膜分隔开。有些人可能建议将针尖放置在胸腰椎正中筋膜前部以进行前展，但我们的研究没有研究这种针尖位置。操作技术面临挑战。腰椎横突的深度使腰4横突的可视化变得困难。尽管通过感觉针在骨上的位置和观察竖脊肌的抬升来确认针的位置，但我们不能排除针尖在注射过程中进入胸腰筋膜中部的可能性，这允许在5次注射中发生前展。患者在中胸腰筋膜厚度和孔隙度上的差异也可能导致不可预测的扩散。Flaviano等人故意将针尖置于L3、L4和L5针尖前，以获得令人满意的髋关节手术阻滞[7]。当需要时，医生可以调整针尖位置在胸腰椎正中筋膜前，以获得更可预测的前展。注射量决定扩散。我们发现每个腰椎节段5.2 ml与现有文献[8]一致，但使用更高的容积，如其他研究中看到的40 ml[5,6]，可能会导致更频繁的前路扩散。我们观察到，一些患者在注射结束时由于组织膨胀而感到不适，这表明并非所有参与者都能耐受更高的剂量。研究的局限性包括样本量小和使用生理盐水。我们建议进一步研究使用更高质量的超声来更好地识别中胸腰段筋膜及其与针尖位置的关系，以获得更可预测的扩散。
{"title":"Posterior injectate spread following lumbar erector spinae plane blockade","authors":"Gillian D. Saffy, Gillian Lamacraft, Jacques Janse van Rensburg, Je'nine Horn-Lodewyk","doi":"10.1111/anae.70040","DOIUrl":"10.1111/anae.70040","url":null,"abstract":"<p>The erector spinae plane block, first described in 2016 for managing chronic neuropathic pain, is an effective ultrasound-guided technique for providing thoracic analgesia [<span>1</span>]. However, similar lumbar blocks have been less successful, likely due to anatomical differences in the fascial planes [<span>2</span>]. The lumbar paraspinal muscles are thicker, and the thoracolumbar fascia is more prominent [<span>3</span>], serving as a barrier to fluid spread [<span>4</span>]. The clinical effect of a lumbar erector spinae plane block depends on where the injectate spreads [<span>2-4</span>]. Anterior spread to the paravertebral space, epidural space or lumbar plexus is necessary for analgesia in hip [<span>5</span>] or abdominal surgeries, whereas posterior spread is useful for spinal surgery [<span>6</span>]. We aimed to characterise injectate spread after lumbar erector spinae plane block to clarify its clinical applications.</p><p>We undertook a prospective, interventional study of 12 patients with chronic hip pain who were receiving therapeutic hip blocks. We did not study patients with BMI > 30 kg.m<sup>-2</sup> or other contraindications for magnetic resonance imaging (MRI) or regional blockade. Following the hip block, a baseline lumbar spine MRI scan was performed. The patient was then positioned prone. We injected 30 ml 0.9% saline into the erector spinae plane at the L4 level on the contralateral side to the hip block. An ultrasound-guided, parasagittal, in-plane technique was used to direct the needle to the posterolateral tip of the L4 transverse process. We performed an MRI scan 30 min after the injection to investigate injectate spread, and a senior radiologist analysed each image to record the anatomical spread (Fig. 1).</p><p>We found that injectate spread was directed posteriorly in all patients into the erector spinae muscles. In four patients, injectate spread was directed anteriorly to structures where nerves would be blocked. In one patient, injectate spread was anterior but only into the quadratus lumborum muscle and not an area where nerves would be blocked. Mean (SD) craniocaudal spread of injectate was 140 (25.2) mm, covering 5.7 (1.1) vertebral levels. This yields 5.2 ml of injectate per vertebral level, consistent with previous studies (Table 1).</p><p>The consistent posterior spread indicates the lumbar erector spinae plane block may yield reliable analgesia for spinal surgery. However, the unpredictable anterior spread suggests it is less reliable for surgeries requiring anaesthesia to the ventral rami or related structures. This difference may be because injectate spread is determined by needle tip position relative to the middle layer of the thoracolumbar fascia. The thick, dense fascial layer acts as a barrier, which compartmentalises the injectate [<span>3</span>]. Some may suggest placing the needle tip anterior to the middle thoracolumbar fascia for anterior spread, but our study did not investigate","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"81 2","pages":"294-296"},"PeriodicalIF":6.9,"publicationDate":"2025-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.70040","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145311258","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Conscious sedation vs. general anaesthesia for the peri‐operative management of patients undergoing transcatheter aortic valve implantation","authors":"Shingo Kawashima, Hiroyuki Kinoshita, Atsushi Kobayashi","doi":"10.1111/anae.70050","DOIUrl":"https://doi.org/10.1111/anae.70050","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"100 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145311260","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>We thank Jin et al. [<span>1</span>] and Yang [<span>2</span>] for their interest in our study of the analgesic efficacy of continuous erector spinae plane block vs. an opioid-based regimen for postoperative pain management following video-assisted thoracoscopic lung resection [<span>3</span>]. Regarding the comments from Jin et al. [<span>1</span>], the non-inferiority margin was set at 8% of the cumulative area under the curve in the control group, corresponding to a value of 11.86. This translates to an average difference of approximately 0.25 on the numerical rating scale for each hour of the 48-h study period. Thus, any difference ≤ 0.25 points, which is less than the minimal clinically important difference, remains clinically acceptable.</p><p>To mitigate the risk of expectation bias, ward nurses not involved in peri-operative care were trained and collected all data. We used real-time data monitoring and weekly audits to ensure protocol compliance. Segmentectomies in this study were unplanned and resulted in comparable surgical trauma. While segmentectomy preserves more lung parenchyma, its impact on chest wall structures and postoperative pain is anatomically similar to that of lobectomy. We argue the inclusion of these patients did not influence the outcomes materially and that the non-inferiority conclusion remains valid.</p><p>While a marked reduction in postoperative pulmonary complications was observed in the erector spinae group, this outcome was secondary and assessed without blinding. This finding should be interpreted as hypothesis-generating rather than conclusive. Although serum ropivacaine levels were not measured, all patients were monitored for clinical signs of local anaesthetic systemic toxicity. No such events were observed throughout the study period. We therefore consider our dosing regimen (approximately 775 mg over 48 h) to be clinically safe under monitored conditions.</p><p>Regarding the comments from Yang [<span>2</span>], we acknowledge that the limited number of postoperative pulmonary complications (n = 26) falls below the recommended threshold of at least 10 events per predictor variable, which may affect the stability and generalisability of the multivariable model. To mitigate the risk of overfitting and enhance model reliability, candidate variables were restricted to those with strong clinical justification and a univariable association of p < 0.05. No exploratory model-building practices were employed. Following backward elimination, only continuous erector spinae plane blockade and previous chemotherapy were significant predictors. Our unadjusted analysis showed a significant reduction in postoperative pulmonary complications with continuous erector spinae blockade. The multivariable result showed a substantial reduction, which we argue has biological plausibility. However, these results should be interpreted cautiously and viewed as exploratory. They are intended to generate hypotheses for future v
我们感谢Jin等人[1]和Yang b[2]对我们研究连续竖脊肌平面阻滞与阿片类药物方案对视频胸腔镜肺切除术[3]术后疼痛管理的镇痛效果的兴趣。对于Jin et al.[1]的评论，非劣效裕度设为对照组曲线下累计面积的8%，对应值为11.86。这意味着在48小时的研究期间，每小时在数值评定量表上的平均差异约为0.25。因此，任何小于0.25分的差异，小于最小临床重要差异，在临床上仍然是可接受的。为了减少预期偏差的风险，对未参与围手术期护理的病房护士进行培训并收集所有数据。我们使用实时数据监控和每周审计来确保协议的遵从性。本研究中的节段切除术是计划外的，导致了类似的手术创伤。虽然节段切除术保留了更多的肺实质，但其对胸壁结构和术后疼痛的影响在解剖学上与肺叶切除术相似。我们认为纳入这些患者对结果没有实质性影响，非劣效性结论仍然有效。虽然在竖脊组中观察到术后肺部并发症的显著减少，但这一结果是次要的，并且没有进行盲法评估。这一发现应该被解释为假设产生，而不是结论。虽然没有测量血清罗哌卡因水平，但所有患者都监测了局部麻醉全身毒性的临床体征。在整个研究期间没有观察到此类事件。因此，我们认为我们的给药方案（约775毫克/ 48小时）在监测条件下是临床安全的。关于Yang[2]的评论，我们承认有限数量的术后肺部并发症（n = 26）低于每个预测变量至少10个事件的推荐阈值，这可能会影响多变量模型的稳定性和通用性。为了降低过拟合的风险并提高模型的可靠性，候选变量被限制为具有强烈临床理由且p <； 0.05的单变量相关性的变量。未采用探索性模型构建实践。在反向排除后，只有连续竖肌脊柱平面阻滞和既往化疗是显著的预测因素。我们的未经调整的分析显示，持续的竖脊肌阻断术显著减少了术后肺部并发症。多变量结果显示了大量减少，我们认为这具有生物学上的合理性。然而，这些结果应该谨慎地解释，并被视为探索性的。它们的目的是产生假设，以便将来在更大的、适当的研究中得到验证。我们同意，观察到的1-1.5小时的早期活动和到口服摄入时间的差异并没有转化为住院时间的减少，并且在增强恢复的背景下，这些差异的含义应该谨慎解释。住院时间受到多种非临床因素的影响，包括机构出院协议；床上的可用性;还有社会环境。因此，住院时间没有差异并不一定反映康复质量没有差异。然而，功能恢复结果的持续加速支持了连续竖肌脊柱平面阻滞作为多模态镇痛策略的一部分的价值，值得在现实世界中进一步研究。我们的研究没有包括正式的经济分析。然而，一旦掌握了阻滞技术，它可以应用于各种外科手术，在其他地方产生潜在的好处。此外，通过潜在地减少术后并发症，连续竖脊肌平面阻滞也可能缩短住院时间并减少并发症相关费用，因此具有相当大的长期成本效益潜力。
{"title":"Erector spinae plane block vs. opioid-based regimen: a reply","authors":"Wei Wei","doi":"10.1111/anae.70038","DOIUrl":"10.1111/anae.70038","url":null,"abstract":"<p>We thank Jin et al. [<span>1</span>] and Yang [<span>2</span>] for their interest in our study of the analgesic efficacy of continuous erector spinae plane block vs. an opioid-based regimen for postoperative pain management following video-assisted thoracoscopic lung resection [<span>3</span>]. Regarding the comments from Jin et al. [<span>1</span>], the non-inferiority margin was set at 8% of the cumulative area under the curve in the control group, corresponding to a value of 11.86. This translates to an average difference of approximately 0.25 on the numerical rating scale for each hour of the 48-h study period. Thus, any difference ≤ 0.25 points, which is less than the minimal clinically important difference, remains clinically acceptable.</p><p>To mitigate the risk of expectation bias, ward nurses not involved in peri-operative care were trained and collected all data. We used real-time data monitoring and weekly audits to ensure protocol compliance. Segmentectomies in this study were unplanned and resulted in comparable surgical trauma. While segmentectomy preserves more lung parenchyma, its impact on chest wall structures and postoperative pain is anatomically similar to that of lobectomy. We argue the inclusion of these patients did not influence the outcomes materially and that the non-inferiority conclusion remains valid.</p><p>While a marked reduction in postoperative pulmonary complications was observed in the erector spinae group, this outcome was secondary and assessed without blinding. This finding should be interpreted as hypothesis-generating rather than conclusive. Although serum ropivacaine levels were not measured, all patients were monitored for clinical signs of local anaesthetic systemic toxicity. No such events were observed throughout the study period. We therefore consider our dosing regimen (approximately 775 mg over 48 h) to be clinically safe under monitored conditions.</p><p>Regarding the comments from Yang [<span>2</span>], we acknowledge that the limited number of postoperative pulmonary complications (n = 26) falls below the recommended threshold of at least 10 events per predictor variable, which may affect the stability and generalisability of the multivariable model. To mitigate the risk of overfitting and enhance model reliability, candidate variables were restricted to those with strong clinical justification and a univariable association of p < 0.05. No exploratory model-building practices were employed. Following backward elimination, only continuous erector spinae plane blockade and previous chemotherapy were significant predictors. Our unadjusted analysis showed a significant reduction in postoperative pulmonary complications with continuous erector spinae blockade. The multivariable result showed a substantial reduction, which we argue has biological plausibility. However, these results should be interpreted cautiously and viewed as exploratory. They are intended to generate hypotheses for future v","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"81 1","pages":"144-145"},"PeriodicalIF":6.9,"publicationDate":"2025-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.70038","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145295450","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Pre‐oxygenation in patients living with obesity","authors":"Etienne Couture, Jean Bussières","doi":"10.1111/anae.70043","DOIUrl":"https://doi.org/10.1111/anae.70043","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"24 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145295449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ryan Vincent William Endersby, Joanna J. Fifen, Vivian H. Y. Ip
{"title":"Non‐operative management of hip fracture","authors":"Ryan Vincent William Endersby, Joanna J. Fifen, Vivian H. Y. Ip","doi":"10.1111/anae.70042","DOIUrl":"https://doi.org/10.1111/anae.70042","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"123 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145295448","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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