Review

Authors: C C Nestor, C Ng, P Sepulveda...

Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long- and short-acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non-steroidal anti-inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non-steroidal anti-inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose-dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required.

Topics: Analgesics, Opioid; Anesthesia, Conduction; Anesthesia, Local; Anesthetics, Local; Anti-Inflammatory Agents, Non-Steroidal; Drug Therapy, Combination; Humans; Magnesium; Nerve Block

PubMed: 34904711
DOI: 10.1111/anae.15641

Review

Authors: Frances Fallon, Aneurin Moorthy, Conor Skerritt...

Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.

Topics: Humans; Anesthesia, Conduction; Anesthetics, Local; Nerve Block; Bupivacaine

PubMed: 38792918
DOI: 10.3390/medicina60050735

Authors: G Heydinger, J Tobias, G Veneziano...

Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.

Topics: Adolescent; Anesthesia, Conduction; Child; Child, Preschool; Humans; Infant; Infant, Newborn; Pediatrics

PubMed: 33426659
DOI: 10.1111/anae.15283

Review

Authors: Hadi Ufuk Yörükoğlu, Sevim Cesur, Can Aksu...

With the increase in ultrasound use, regional anesthesia practices have gained popularity and many novel techniques are being described. However, the rapidly increasing number of new block techniques also led to confusion. Therefore, seven basic regional anesthesia techniques that are effective in most of the surgeries have been listed as 'Plan A Blocks.' The purpose of this review is to introduce the basic sono-anatomy and indications of Plan A blocks.

Topics: Humans; Nerve Block; Anesthesia, Conduction; Ultrasonography; Anesthesia, Local

PubMed: 37886870
DOI: 10.14744/agri.2022.02256

Authors: R Blanco, T Parras

Topics: Anesthesia, Conduction; Anesthetics, Local; Bupivacaine; Female; Humans; Nerve Block; Thoracic Wall; Ultrasonography, Interventional

PubMed: 24443871
DOI: 10.1111/anae.12584

Review

Authors: Mark Verlinde, Markus W Hollmann, Markus F Stevens...

This review summarizes current knowledge concerning incidence, risk factors, and mechanisms of perioperative nerve injury, with focus on local anesthetic-induced neurotoxicity. Perioperative nerve injury is a complex phenomenon and can be caused by a number of clinical factors. Anesthetic risk factors for perioperative nerve injury include regional block technique, patient risk factors, and local anesthetic-induced neurotoxicity. Surgery can lead to nerve damage by use of tourniquets or by direct mechanical stress on nerves, such as traction, transection, compression, contusion, ischemia, and stretching. Current literature suggests that the majority of perioperative nerve injuries are unrelated to regional anesthesia. Besides the blockade of sodium channels which is responsible for the anesthetic effect, systemic local anesthetics can have a positive influence on the inflammatory response and the hemostatic system in the perioperative period. However, next to these beneficial effects, local anesthetics exhibit time and dose-dependent toxicity to a variety of tissues, including nerves. There is equivocal experimental evidence that the toxicity varies among local anesthetics. Even though the precise order of events during local anesthetic-induced neurotoxicity is not clear, possible cellular mechanisms have been identified. These include the intrinsic caspase-pathway, PI3K-pathway, and MAPK-pathways. Further research will need to determine whether these pathways are non-specifically activated by local anesthetics, or whether there is a single common precipitating factor.

Topics: Anesthesia, Conduction; Anesthetics, Local; Caspases; Dose-Response Relationship, Drug; Neurotoxicity Syndromes; Perioperative Period; Signal Transduction; Time Factors

PubMed: 26959012
DOI: 10.3390/ijms17030339

Review

Authors: G A McLeod, D Burke

Regional anaesthesia has seen the development of a new local anaesthetic: levobupivacaine. This review aims to outline the rationale underlying the development of levobupivacaine and to consider its place in modern regional anaesthesia.

Topics: Anesthesia, Conduction; Anesthetics, Local; Animals; Bupivacaine; Humans; Stereoisomerism

PubMed: 11284819
DOI: 10.1046/j.1365-2044.2001.01964.x

Review

Authors: Hiroaki Murata, Cristina Vanegas, Keiko Ogami-Takamura...

PURPOSE OF REVIEW

Infection control is inherent in ultrasound-guided regional anesthesia practice, because ultrasound transducer and coupling gel can be vectors for pathogen transmission. We reviewed the current standards and recommendations of ultrasound transducer cleaning, disinfection, and safe handling of ultrasound equipment. Based on the available data, we propose a set of practical recommendations applicable to coronavirus disease 2019 (COVID-19) pandemic and future epidemics.

RECENT FINDINGS

Regional anesthesia is often preferred over general anesthesia for COVID-19 patients. Avoidance of general anesthesia reduces the need for aerosol generating procedures. Administration of ultrasound-guided regional anesthesia and surgery under regional anesthesia in COVID-19 patients requires careful infectious precautions to prevent the viral spread through the use equipment.

SUMMARY

Ultrasound machine, transducer and coupling gel can serve as a vector for transmission of pathogens. In the era of COVID-19 pandemic, standardized strategies are recommended to minimize the risk of spread of COVID-19 to both patients and the healthcare providers.

Topics: Anesthesia, Conduction; COVID-19; Humans; Infection Control; Pandemics; SARS-CoV-2; Ultrasonography, Interventional

PubMed: 34231548
DOI: 10.1097/ACO.0000000000001034

Review

Authors: P Lirk, M W Hollmann

Regional anesthesia has become a widely used method to provide intraoperative anesthesia, and postoperative analgesia. This review seeks to address the question whether patient outcomes are improved to an extent that justifies using regional anesthesia as a routine method. During the past decade, a very critical appraisal of risks and benefits of regional anesthetic procedures has taken place. In general, the indications for epidural blockade have decreased, and are limited to individual high-risk patients, major upper abdominal and major vascular surgery, and thoracotomy. We review the changing role of central and peripheral regional anesthesia in the perioperative management of total knee arthroplasty. Immediate perioperative outcome after knee arthroplasty concerning function and pain is improved, and rehabilitation facilitated, by peripheral nerve blockade, but this does not translate into superior functional outcome one year later. A substantial share of the beneficial effects of regional anesthesia on the immune system, hemostasis, pain, and the duration of ileus can be duplicated using intravenous administration of local anesthetics. In general, the use of regional anesthesia should always be preceded by a weighing of potential risks and proven benefits. Regional anesthesia continues to play a major role in perioperative medicine, but its role keeps getting more defined and less non-committal.

Topics: Anesthesia, Conduction; Humans; Risk; Risk Assessment; Treatment Outcome

PubMed: 24193234
DOI: No ID Found

Authors: K J Chin, E R Mariano, K El-Boghdadly...

Topics: Anesthesia, Conduction; History, 19th Century; History, 20th Century; History, 21st Century; Humans; Nerve Block

PubMed: 33426654
DOI: 10.1111/anae.15321