7 Regional Anesthesia Questions

We invited a member of our editorial advisory board, Admir Hadzic, MD, PhD, to select a group of international experts and ask them seven questions of his own choosing. (Note that not everyone answered all of the questions.)

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1.Should regional anesthesia and nerve blocks be standardized, considering the current lack of standards compared with the well-defined guidelines for general anesthesia administration, which encompass dosing, patient monitoring and indications?

Chiao: I strongly believe as any body of knowledge advances and grows, there comes a time when standardization is both a natural and necessary evolution. The mere fact that something is standardized does not mean that innovation and flexibility are lost. I like to use sports analogies, as I am a very involved fan of tennis. When the game of tennis started, there were not really standards, but everyone was playing within some framework. Eventually, racquet size and balls were standardized. Nevertheless, we still see variation as part of the standard, as players use one-handed or two-handed backhands and racquet materials have improved.

Standards are also a way to understand complex fields more easily. There is this baseline practice (or standard) that people expect, so adding more complexity on top of this is easier to do. It is also a matter of patient safety, as transfers of care and patient handoffs become easier because the staff accepting the patient understands better what intervention or block the patient had. Handoffs must still be done properly, of course.

Sometimes there is not really enough evidence for a standard to smoothly be accepted or created and, in this case, longer periods of time may serve to catalyze the development of standards. In regional anesthesia, I see both of these situations occurring. Evidence for which type of block is to be used for which surgery has a large body of research, but the evidence for which needle or needle length, for example, often has scant evidence. Nevertheless, we are all not using spinal needles or intravenous catheters for our needle techniques. Similarly, wearing sterile gloves seems like an evidence-based practice, but the actual evidence for infection sources can be scarce.

Lastly, as the chair of the ASA Professional Liability Committee, we see cases where the standard of practice is easy to identify or sometimes hard to identify. If there are standards, it can be easier to make a clear determination if the standard of care was met. Often standards are looked at around the region of the practice location where anesthesia was given, but if the national and regional standards become more similar, reviewing and testifying as an expert witness should be easier as well.

Fettiplace: Anesthesia is both art and science, and “one size fits all” is too constrictive for most practitioners. However, standardization of techniques can improve safety, as was seen in general anesthesia with standardized monitoring, unit-based doses of medication, and feedback in the form of minimum alveolar anesthetic concentration. Regional anesthesia utilizes similar concepts, but with the rapid evolution of the field over the past 15 years, there is room to improve. In particular, standardization of nomenclature,¹ better dosing recommendations² and continued focus on evidence-based practice would undoubtedly improve communication among providers and elevate patient care.

Gevaert: In my experience at NYSORA, I’ve observed that all regional blocks follow a standardized approach, with each surgical procedure consistently using the same technique. This not only establishes a clear framework, but also enables individuals to become proficient in each specific technique. Without standardization, it becomes challenging to achieve mastery in certain techniques. In contrast, my previous centers where I trained lacked standardization for regional anesthesia, resulting in techniques varying depending on the anesthesiologist. Additionally, older anesthesiologists rarely performed nerve blocks.

Knops: Something I often hear during residency is that multiple roads lead to Rome, a saying I can certainly agree with. I do, however, believe that a basic framework concerning the indications and standardization of patient monitoring would be beneficial to ensure safe and appropriate care. Standardization creates an environment less prone to mistakes and reduces miscommunication, as everyone involved can familiarize themselves with the same procedure. As a novice in locoregional anesthesia, I feel that standardized procedures definitely enabled me to progress faster than I would’ve if every staff member taught their own version.

Lastly, I feel that clear guidelines could encourage anesthesiologists who are less familiar with locoregional techniques to consider implementing them more in their hospital.

Lopez: Yes, although the requirements for patient monitoring in regional anesthesia are standardized in the same way as for general anesthesia. In terms of indications, techniques and medications, I believe that standardization is necessary, at least at the institutional level. Currently, there are no official recommendations regarding these matters. Standardization serves as the foundation for a safe working environment, as it enhances efficiency, reduces errors and facilitates proficiency in regional techniques. Therefore, it would be advantageous to establish standardized indications, techniques and medications for each regional anesthesia/analgesia technique. This would foster greater trust from the surgical team and colleagues, enabling a systematic administration of nerve blocks. Importantly, it would also help address the existing problem of limited patient access to regional anesthesia.

The standardization of techniques would also contribute to improving the quality of evidence in research. Currently, the heterogeneity of protocols and terminology makes it challenging to compare studies effectively.

Merjavy: Regional anesthesia and nerve blocks play a crucial role in modern anesthesia practice. However, the current lack of standardized guidelines for their administration is concerning. It is imperative to establish clear and comprehensive standards for regional anesthesia, similar to the well-defined guidelines already in place for general anesthesia. Standardization of regional anesthesia and nerve blocks would ensure consistent and optimal patient care across healthcare settings. Clear dosing guidelines would help minimize the risk for overdosing, ensuring effective pain control without adverse effects. Moreover, standardized patient monitoring protocols during regional anesthesia procedures would enhance patient safety and allow for early detection of complications.

Standardization would also address the variability in indications for regional anesthesia, providing clinicians with clear criteria for patient selection. This would promote evidence-based decision making, optimizing patient outcomes and reducing unnecessary utilization of regional anesthesia techniques.

Clear guidelines would facilitate the education and training of anesthetists in regional anesthesia techniques, ensuring minimal competencies, knowledge and skills. Furthermore, standardization would enable effective communication and collaboration among healthcare teams, enhancing the continuity of care and reducing the potential for errors or misunderstandings. The development of standardized regional anesthesia protocols could potentially improve resource allocation. This could lead to cost savings and increased efficiency within healthcare systems.

Salti: Yes, regional anesthesia and nerve blocks should be standardized, given the current lack of clear guidelines and standards compared with the well-defined protocols for general anesthesia administration. The implementation of standardized recommendations and guidelines is crucial to ensure consistent and safe practices in regional anesthesia.

Currently, there are significant discrepancies in the way regional anesthesia and nerve blocks are performed across different healthcare facilities and even among individual practitioners. This lack of standardization can lead to variations in dosing, patient monitoring and indications, potentially compromising patient safety and outcomes.

By establishing clear standards for regional anesthesia and nerve blocks, we can enhance patient care by promoting uniformity in practice.

Tfaili: Absolutely, without a doubt. Regrettably, there is no consensus on specific guidelines pertaining to regional anesthesia. The existing information is largely based on individual opinions rather than standardized recommendations. This poses a significant challenge in establishing uniform clinical practices, unlike the case with general anesthesia. Furthermore, the field of anesthesia research suffers from a general scarcity of funding, particularly for projects related to regional anesthesia.

Xu: Regional anesthesia has been playing a critical role as a fundamental component of perioperative care. Standardizing regional anesthesia and nerve block procedures is definitely essential for patient care, education and research. Similarity, ASRA (American Society of Regional Anesthesia and Pain Medicine) and ESRA (European Society of Regional Anaesthesia and Pain Therapy) have made great efforts and done remarkable work on standardizing nomenclature in regional anesthesia, which is a very meaningful step for our regional anesthesia subspecialty.

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2.In the era of ultrasound, which has become the tacit standard for peripheral nerve blocks due to its ability to provide visual information about the needle–nerve relationship, does nerve stimulation still hold value?

Chiao: I absolutely feel that nerve stimulation is a type of triple-check safety measure for performing nerve blocks. We traditionally have understood our anatomic landmarks, and now are able to use ultrasound visualization to recognize patterns where we should inject local anesthesia.

Ultrasound is a double check of our identification of landmarks. Nerve stimulation is an additional safety measure. With an expected physical movement from the nerve stimulation, we can have an added confidence that this location is the correct one. Moreover, we can identify the proximity to the epineurium and potentially reduce nerve injury. By identifying the nerve stimulation at 0.6 mA and then finding no muscle movement at 0.5 mA, animal models have shown we are more than likely not in the epineurium, so injection at this location is very safe.

Lastly, convenience is a major factor in deciding which safety measures should be added to a procedure. Fortunately, nerve stimulators are compact, fast and easy to use. It is not a particularly onerous or time-consuming task to use one, either. Nerve stimulators, although uncommonly used in sensory-only nerve blocks, can still cause paresthesia and indicate which area one should be in. I, therefore, routinely and primarily use nerve stimulation with peripheral nerve motor blocks.

Fettiplace: As detailed by others,³ there are occasions where ultrasound visualization breaks down, particularly in obese patients, deep blocks or challenging anatomy. In these settings, nerve stimulation can provide information to improve safety. It can also help with identification of nervous tissue that may be difficult to differentiate visually on ultrasound (e.g., nerve to vastus medialis).

Gevaert: I believe having an additional failsafe is beneficial, but if I had to make a choice, I would prefer ultrasound guidance for regional blocks. I feel confident and familiar with using ultrasound, and it has become widely accessible in recent times. While I don’t think nerve stimulation should be completely disregarded, if I had to select one method, ultrasound would be my preference. However, I must admit that I am not fully aware of the current evidence regarding its additional value.

Knops: Ultrasound plays a pivotal role in peripheral nerve block procedures. It is, however, a technique which is very operator dependent. At the time of injection, you’re still limited to a two-dimensional image. The hand–eye coordination required to continuously visualize your needle as well as differentiating tissue on ultrasound require a certain amount of practice. Even for more experienced practitioners, this can still be challenging when an optimal image cannot be acquired, such as in obese patients, or when ideal positioning isn’t possible. I believe nerve stimulation to be an easy and time-efficient extra safety measure, where the advantage vastly outweighs the cost.

Lopez: Indeed, nerve stimulation continues to offer valuable insights that complement the information derived from ultrasound in peripheral nerve blocks. This combined approach proves particularly beneficial when the ultrasound image is suboptimal. However, the primary objective of nerve stimulation is to enhance safety. It serves as an early warning system, notifying practitioners of inadvertent needle–nerve contact and aiding in the prevention of intraneural injection.

In educational institutions, these advantages become even more significant as the training process may not always provide a perfect view of the needle. Additionally, nerve stimulation imparts an additional layer of anatomic knowledge and understanding of nerve block procedures to residents.

Merjavy: Although real-time ultrasound guidance has become the widely accepted gold standard for performing peripheral nerve blocks, there are several indications where the combination of ultrasound and nerve stimulation may provide added benefit.

1. Using nerve stimulation (NS) as a “rule out” tool helps identify the close proximity of the needle tip to the nerve or plexus when visual confirmation on the ultrasound screen is not available, especially for novices or occasional blockers who may not maintain needle visibility throughout the entire procedure.
2. Using NS as a “rule in” tool helps identify the nerve/plexus in greater depth when a low-frequency curvilinear probe with limited resolution is used, such as in lumbar plexus, parasacral or proximal sciatic nerve blocks. This can be particularly helpful in situations where visibility on the ultrasound screen may be limited due to significant edema, hematoma, subcutaneous emphysema, etc.
3. In the presence of peripheral nerve/plexus anatomic variations, NS can help identify the correct nerve structure, such as C5 running through or medially to the anterior scalene muscle, joined median and musculocutaneous nerves at the axilla, Martin-Gruber anastomosis at the forearm, etc.

4. NS can occasionally be used to identify the fascial plane by observing muscle contractions directly stimulated by the NS needle and the loss of muscle twitch when entering the interfascial plane.

Salti: While ultrasound has revolutionized the field of regional anesthesia by enhancing precision and reducing complications, there are specific scenarios where nerve stimulation continues to hold value. Particularly for deep blocks, where visibility with ultrasound may be limited or challenging, nerve stimulation can be a useful adjunct.

In certain anatomic regions or with certain patient populations, deep nerve structures may be challenging to visualize clearly using ultrasound alone. In such cases, nerve stimulation can provide additional feedback and confirm the accurate placement of the needle in proximity to the nerve. This is especially relevant for procedures where achieving a successful block is critical, such as complex surgeries or cases where patient factors limit the use of alternative techniques.

Tfaili: I agree that nerve stimulation still holds value in clinical practice. Nerve stimulation serves as an additional confirmatory step, enhancing the accuracy of the nerve block. This technique can be particularly helpful when high-quality ultrasound machines are not available. In Lebanon, while some centers possess state-of-the-art ultrasound machines, it is worth noting that many centers do not have ultrasound equipment at all. In such cases, relying on nerve stimulation can be a practical and effective alternative for performing regional anesthesia.

Xu: Nowadays, the majority of nerve blocks are performed under ultrasound guidance. However, nerve stimulation still holds great value to identify the target nerves in many clinical situations, such as anatomic variations, postsurgical anatomic change, deep location with blurred ultrasound images, etc. In addition, studies have shown that combined techniques of ultrasound guidance and nerve stimulation decreased the risk for nerve injury.

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3.Should the routine use of ultrasound probe covers and sterile gloves be implemented for nerve blocks and ultrasound-guided peripheral vascular access procedures?

Chiao: I once had a director of a surgery center ask me, “Do you think we should use a probe cover and sterile gloves?” I can understand how this can be seen as controversial, but I recommend ultrasound probe covers and sterile gloves. While these additional measures do incur an immediate cost, there are few other costs to using this extra measure. We would all be less than truthful if we said we had never picked up an ultrasound probe that was dirty or had something smeared on it prior to doing a block. Although the risk for infection from a peripheral nerve block is low, why take the risk? What if hepatitis B was transferred to a patient during a nerve block? It would be hard to forgive ourselves for not using a probe cover and sterile gloves.

Moreover, for peripheral nerve catheters or long-term vascular access catheters, the risk for infection goes up as each day passes, so for these procedures, I also use a mask, gown and face mask as well. Furthermore, we have to ask ourselves what impression are we giving to patients if we place a probe on without a cover? Although most patients do not know what is clean and what is not, some do have some understanding.

A colleague of mine started placing a labor epidural without a mask and coughed in the middle of the procedure. Several days later, the patient was found to have an epidural infection, and she reported that the anesthesiologist did not wear a mask. There could have been several sources, but the anesthesiologist was implicated as the cause of the infection for not wearing a mask.

Fettiplace: The likelihood of infection is low with regional blocks (particularly in the setting of acidic local anesthetic mixtures). However, low-level decontamination of ultrasound probes with alcohol or chlorhexidine wipes does not adequately remove contaminants. As such, best practice guidelines from infection control societies⁴ and radiology societies⁵ advise use of probe covers for all invasive procedures. Given the prevalence of ultrasound use in regional anesthesia, regionalists should consider these “best practices” and regional societies should provide practice recommendations to improve infection prevention.

Gevaert: I believe that this choice varies depending on the specific procedure and the level of sterility required. For nerve blocks, I believe we should utilize sterile probe covers and gloves. However, for peripheral vascular access, disposable non-sterile gloves may be sufficient. In the case of arterial access and deep catheters, using a probe cover to minimize the risk for endocarditis and other complications is preferred. Generally, for most procedures, I would use both sterile probe covers and gloves, except perhaps for peripheral venous access.

It’s important to note that inadequate sterilization of the probe can pose a risk to patient safety, especially if there is contamination with blood. Considering the challenges of maintaining thorough sterilization in a busy practice, I vote for using sterile probe covers.

Knops: Theoretically it makes sense to utilize sterile material when performing nerve blocks. Needles penetrate the skin barrier, traveling to deeper tissue, creating a possible path for pathogens. The majority of the recommendations for the use of sterile gloves during nerve blocks is based on expert consensus.⁶ The same can be said for ultrasound-guided peripheral vascular access. The CDC recommends the use of sterile gloves when placing arterial, central and midline catheters. However, the use of sterile gloves for peripheral venous access isn’t recommended.⁷ The ultrasound aspect shouldn’t really affect the use of sterile materials. Consistency would be in order.

I must admit that I’m unsure if the available evidence is sufficiently compelling to support the claim that the use of probe covers and sterile gloves significantly reduces infection rate. Cost-effectiveness should also be considered.

Lopez: For nerve blocks, they should definitely be used. However, when it comes to peripheral vascular access, their routine use is not widely established. I personally employ probe covers and sterile gloves for tasks such as arterial line placement and difficult IV access. Nevertheless, for routine percutaneous IV access, following the current aseptic guidelines should be adequate.

Merjavy: There is strong evidence indicating the transmission of infections through both ultrasound probes and ultrasound gel. Therefore, it is considered best practice to use sterile ultrasound gel in conjunction with a sterile ultrasound cover and sterile gloves. This approach helps prevent potential harm to patients who undergo ultrasound-guided peripheral nerve blocks. Applying the same high standard of aseptic behavior for difficult IV access under ultrasound guidance is logical and reinforces the aseptic practices for end users.

Salti: Yes, the routine use of ultrasound probe covers and sterile gloves should be implemented for nerve blocks and ultrasound-guided peripheral vascular access procedures. These practices contribute to maintaining a high level of patient safety and infection control.

Ultrasound probe covers serve as a physical barrier, preventing direct contact between the patient’s skin and the ultrasound probe. By using probe covers, the risk for cross-contamination and transmission of infectious agents is significantly reduced. This is particularly important in invasive procedures where the skin barrier is breached, such as nerve blocks and vascular access procedures.

Sterile gloves are an essential component of the aseptic technique during invasive procedures. They provide a protective barrier between the healthcare provider and the patient, minimizing the risk for introducing microorganisms into the procedure site.

Tfaili: In Lebanon, it is common practice for larger centers to employ sterile gloves and probe covers during regional anesthesia procedures. However, there is a lack of data providing specific guidance on this matter, leaving clinicians to make individual decisions based on their own judgment. It is important to note that the level of sterility required may vary depending on the specific block being performed. For instance, the femoral nerve block area of injection is typically considered to be less clean compared with regions such as the axillary or ankle blocks. Therefore, clinicians must exercise their discretion and consider the cleanliness requirements specific to each block when implementing sterility measures.

Xu: As clinicians, our goal is to provide the best care with the lowest-risk maneuvers whenever we can. I would agree to use ultrasound probe covers and sterile gloves for nerve blocks and ultrasound-guided peripheral vascular access procedures routinely.

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4.Are there any specific benefits of peripheral nerve blocks over WALANT anesthesia (wide-awake local anesthesia no tourniquet) for peripheral limb surgery?

Chiao: My understanding of WALANT anesthesia is that it is usually for hand surgery and usually lidocaine or bupivacaine is utilized. If the extent of the hand surgery is limited and the local anesthesia covers the surgical area, I think the benefit of a peripheral nerve block is limited. If only lidocaine is used for the WALANT, I could see a peripheral nerve block with a long-acting local anesthetic having more analgesic benefits than simply lidocaine, unless the extent of the surgery is minimal.

If there is sufficient preoperative area to perform peripheral nerve blocks for peripheral limb surgery, this could be used to save on OR time, as the surgeon could skip giving their own local anesthetic as the patient would come to the OR with a working peripheral nerve block already placed.

Fettiplace: WALANT surgery is a technique for hand surgery that involves no sedation and an awake cooperative patient. The major benefit is avoidance of general anesthesia leading to faster workflow, decreased nausea, less medicine/supplies used and overall cost savings. Peripheral nerve blocks provide many of the same benefits but likely with broader coverage of surgical sites. In an ideal practice, these benefits may facilitate more rapid turnover by preventing intraoperative delays while waiting for local anesthesia to take effect.

Gevaert: In my opinion, I find WALANT anesthesia to be a messy procedure. It does not involve targeting a specific nerve, which increases the risk for inadvertently hitting vascular structures or nerves, since ultrasound guidance is not utilized. While WALANT anesthesia may still effectively serve its purpose, I believe it lacks the precision and specificity that nerve blocks offer. To me, it feels like using a bazooka to kill a fly. Personally, I consider nerve blocks to be a more elegant anesthesia technique.

Knops: If you want to put dressing on your salad, it makes sense to take a bottle and pour some on, rather than throwing a bucket over your counter. Sure, some of it will hit the salad, but it would also be all over your counter, with the risk for it dripping into places it doesn’t belong.

Even small volumes of local anesthetic can cause unpleasant sensations for patients. By specifically targeting nerves, duration of effect can be extended while volume of local anesthetic and risk for any adverse systemic effects can be reduced.

Lopez: I believe that the visualization of peripheral nerves is within reach for most medical centers that carry out a substantial number of orthopedic procedures. In such instances, selective distal blocks, utilizing a small volume of local anesthetic, prove to be more efficient and elegant. These blocks are equally effective in providing pain relief while preserving the motor function of the limb. Additionally, the option to select and combine different local anesthetics allows customization to match the duration of surgery and ensure optimal postoperative analgesia. While the surgical team’s preferences play a role, I firmly believe that peripheral nerve blocks surpass WALANT anesthesia in terms of versatility. The use of a tourniquet and additional sedation is optional, depending on surgical requirements and patient preferences.

Merjavy: “WALANT anesthesia” is a term commonly used to describe the infiltration of local anesthetic under ultrasound guidance or using anatomic landmarks. Many regional anesthesia techniques are routinely employed worldwide on a daily basis in patients without any sedation, allowing for a “wide awake” state, by injecting the local anesthetic close to nerves or nerve plexuses. The decision to use a pneumatic tourniquet is at the discretion of the surgeon performing the surgery.

Peripheral nerve blocks offer several advantages over local anesthetic infiltration:

• Nerve blocks can be administered in a block room, ensuring high efficiency of the surgical list by employing parallel processing.
• Prior to the patient entering the operating theatre, the adequacy of nerve blocks can be assessed by an anesthesiologist, who can supplement them with additional local anesthetic injections if necessary.
• Nerve blocks provide longer-lasting analgesia after surgery compared with infiltration.
• By selecting the appropriate site for the nerve block, motor block of the upper or lower limb can be either induced or avoided.
• Nerve blocks do not impact tissue edema in the surgical field, unlike local anesthetic infiltration.
• If needed, the surgeon can always inject a solution containing adrenaline, including saline with adrenaline.

Note: It’s worth mentioning that “WALANT anesthesia” may not be a universally recognized term, and its usage may vary in different regions or medical contexts.

Salti: Yes, there are specific benefits of peripheral nerve blocks over general anesthesia, such as WALANT anesthesia, for peripheral limb surgery. One significant advantage is the ability to achieve stronger motor blocks when needed through regional nerve blocks.

Peripheral nerve blocks target specific nerves in the limb being operated on, allowing for selective and precise anesthesia. By directly blocking nerve conduction, regional nerve blocks can provide excellent pain relief and muscle relaxation in the surgical area. This can be particularly beneficial in complex procedures or cases where precise motor control is required.

Tfaili: Indeed, WALANT anesthesia can be utilized, but it may carry a higher risk for systemic toxicity associated with the use of local anesthetics. This is because of the significantly higher doses and volumes employed in WALANT anesthesia compared with peripheral nerve blocks. For instance, an ankle block typically requires 10 to 15 mL of local anesthetic, whereas using WALANT anesthesia to anesthetize the ankle would necessitate 30 to 40 mL of local anesthetics, along with the addition of epinephrine for hemostasis. The increased dosage and volume in WALANT anesthesia contribute to an elevated potential for systemic toxicity, and clinicians must exercise caution and closely monitor patients when employing this technique.

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5.Should the use of ultrasound in regional anesthesia be mandated with a certification process to ensure minimal competence standards?

Chiao: Certification is a tricky topic. Certification itself implies a minimum or basic set of knowledge and experience was reached. However, certification without some measure of continuing certification could mean this skill set was lost over time. Moreover, there are those without certification who may be more qualified than those with it and sufficiently capable of doing these ultrasound-guided blocks.

From a professional liability perspective, the area gets murky. For example, without certification, if someone performs an ultrasound-guided block and there is an adverse outcome, could their lack of certification adversely affect them?

Fettiplace: Absolutely. Ultrasound-based regional anesthesia reduces complications. According to the Accreditation Council for Graduate Medical Education (ACGME), regional anesthesia fellows “must demonstrate competence in bedside point-of-care ultrasound for use in placement and management of neuraxial and peripheral blocks.” These recommendations are nebulous to provide flexibility to programs and trainees. More recent expert recommendations advise that practitioners should be able to identify standardized views and standardized structures to demonstrate competence, which will likely improve safety.⁸

Gevaert: In my opinion, I believe it is essential to make ultrasound training a requirement in the regional anesthesia training program—similar to how intubation and other technical skills are evaluated in general anesthesia training. However, the operators must possess skills in using this technology to minimize risks to the patient. The requirements should not be overly stringent, as it could discourage practitioners from utilizing ultrasound altogether. If ultrasound use is discouraged, would it hamper the efforts for its more widespread use? Finding the right balance will encourage the adoption of ultrasound while ensuring that anesthesiologists receive adequate training in its application.

Knops: Like any anesthetic technique, sufficient mastery should be acquired before practicing locoregional blocks without supervision. I’m not sure if a separate certification process is the way to go. There’s no certification process for intubating a patient or placing a central venous line, either. I believe that during residency, locoregional techniques should be addressed more, providing a graduated anesthesiologist with a broader basic skill set.

Lopez: In my view, upon achieving board certification, all anesthesiology residents should demonstrate the ability to safely perform a range of basic ultrasound-guided locoregional anesthetic techniques. This would enhance patient access to locoregional anesthesia. However, for more specialized techniques, comprehensive training with standardized content is essential.

Regarding the utilization of ultrasound, I would propose two levels of education. The first level would be a “universal” training applicable to all residents, covering not only regional anesthesia but also point-of-care ultrasound. The second level would focus on more advanced applications, education and research and should be conducted by certified experts in the respective fields.

Merjavy: Indeed, we are familiar with Grady Booch’s famous quote: “A fool with a tool is still a fool.” Ultrasound machines have undoubtedly evolved, offering improved quality and user-friendliness with each passing year. However, comprehending the principles of ultrasound guidance necessitates specific training to ensure the successful and safe diagnostic or therapeutic use of ultrasound. The certification process for demonstrating minimal competencies should adhere to a similar structure to other well-established pathways in anesthesiology, such as airway management or neuraxial techniques in obstetrics. This approach ensures that practitioners acquire the necessary skills and knowledge to effectively utilize ultrasound technology in their practice.

Salti: Ultrasound-guided regional anesthesia has become a valuable tool in improving procedural accuracy, efficacy and patient safety. However, proficiency in ultrasound interpretation and application is essential to maximize its benefits and minimize potential risks.

By mandating a certification process, healthcare providers would be required to demonstrate a minimum level of competence in ultrasound-guided regional anesthesia. This process would ensure that practitioners have received adequate training, possess the necessary knowledge and skills, and can consistently perform these procedures safely and effectively.

Tfaili: It may not be necessary to mandate a certificate specifically for the use of ultrasound in regional anesthesia. However, it is crucial to establish a standardized and structured training process for healthcare professionals to ensure competency in ultrasound-guided techniques. This training process would focus on providing the necessary knowledge and skills to safely and effectively perform ultrasound-guided regional anesthesia.

By implementing a minimum training requirement, clinicians can acquire the necessary proficiency without the potential obstacles that certification might present, such as limiting access to ultrasound or hindering the adoption of this valuable technique in clinical practice.

Xu: Theoretically, yes; however, in real practice, many other factors must be considered. For example, a mandated certificate may build a barrier and eliminate many clinicians who can provide ultrasound-guided nerve blocks, and this may compromise patient care. On the other hand, ultrasound skills are one of the mandatory components of the ACGME, so some form of documenting minimal competence level should be considered.

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6.Are there any advantages of spinal anesthesia over general anesthesia for patients with hip fractures?

Chiao: There are definitely advantages to spinal anesthesia. Historically, evidence has shown less blood loss, lower mortality and fewer respiratory complications. However, a recent study in The New England Journal of Medicine sparked controversy by implying no advantage to spinal.⁹ That study had a set of design issues that could affect their results. Their patient population was relatively healthy, and there was a high rate of failure with spinal, implying that the practitioners placing spinals may have been poorly qualified. Regional anesthesia in general has a huge role in patient safety, particularly in older and less healthy patients, as it reduces the systemic impact of general anesthetics.

Fettiplace: Taken from an alternative perspective, the anesthesiologist is likely the most important piece of the anesthetic procedure. Data from both REGAIN⁹ and RAGA¹⁰ demonstrate that in the hands of skilled anesthesiologists, both spinal and general anesthetics can provide similar outcomes. Based on these findings, care should be driven by patient preference and provider comfort. However, questions remain about the benefit of spinal versus general in the most at-risk populations (e.g., severe dementia, profound frailty and others) and for other lower-extremity surgeries, including elective arthroplasty and revascularization surgeries.

Gevaert: Indeed, in fragile patients or those with severe comorbidities such as impaired lung function or cardiovascular disease, spinal anesthesia can be a preferable option. These patients often pose challenges with intubation, maintaining adequate pressure, achieving optimal analgesia and managing the potential hypotensive effects of opioids. In such cases, spinal anesthesia offers advantages in terms of safety and patient comfort. When dealing with healthy patients, the choice between spinal anesthesia and general anesthesia can be debated or even left to the patient’s preference. However, for fragile patients, I consider spinal anesthesia a safer alternative. It allows the anesthesiologist to focus on a more limited set of parameters, which in turn enhances patient safety. Additionally, the simplicity and reduced complexity of administering spinal anesthesia can contribute to increased comfort for the anesthesiologist.

Knops: Having provided both spinal and general anesthesia for knee and hip replacements, a remarkable decrease in postoperative opioid usage and increase in comfort could be observed. Especially in elderly patients, general anesthesia presents risks, which can be avoided by performing spinal anesthesia, combined with sedation if preferred. It is arguably more difficult to provide a balanced sedation than conducting a controlled general anesthesia, but sedation can be tailored to the medical needs and preferences of the patient. Although often reluctant at first, patients are generally pleased with the overall experience when accompanied by the right level of sedation.

Lopez: I firmly believe that spinal anesthesia offers significant advantages over general anesthesia for elderly and fragile patients with hip fractures. As such, my preference would be to administer spinal anesthesia due to its superior hemodynamic stability, faster recovery and, importantly, reduced occurrence of postoperative respiratory complications. General anesthesia would only be administered in cases where urgent surgery is required and spinal anesthesia is contraindicated, such as in the presence of coagulation issues.

Merjavy: Patients with hip fractures present a complex clinical scenario. Typically, they are elderly individuals with an average age of around 84 years, burdened with multiple comorbidities. Many of them require anticoagulation due to cardiac or neurologic conditions. Additionally, a significant proportion of these patients resides in nursing homes and rely on walking aids or are immobile. The 30-day mortality rate in this patient population is notably higher compared with those undergoing total hip or total knee replacement.

Thorough preoperative assessment and optimization by an orthogeriatric team are crucial. However, it is important to avoid undue delay in surgery, ideally within 24 to 48 hours, except in rare cases with specific indications. Regional anesthesia plays a pivotal role in the management of these frail patients. The approach begins with fascia iliaca compartment block, femoral nerve block or pericapsular nerve group block, which can be administered in the emergency department upon admission.

Spinal anesthesia has demonstrated benefits in reducing morbidity, particularly when low doses of local anesthetic are utilized. Combining low-dose spinal anesthesia with peripheral nerve blocks, often with minimal or no sedation, is widely practiced in numerous medical centers worldwide. General anesthesia is reserved for cases where neuraxial techniques are contraindicated and should always be combined with peripheral nerve blocks to provide perioperative and postoperative pain relief.

Salti: Spinal anesthesia offers advantages over general anesthesia for patients with hip fractures, including hemodynamic stability, reduced respiratory complications, selective anesthesia to the affected limb, decreased systemic medication requirements and shorter recovery time. These factors contribute to improved patient outcomes and enhanced perioperative care.

Tfaili: Certainly, avoiding airway manipulation, such as in the case of spinal anesthesia, can have its benefits. While the recent study by Neuman published in The New England Journal of Medicine⁹ may suggest otherwise, it is important to consider real-world clinical practice and individual patient characteristics. In my experience, spinal anesthesia has proven to be advantageous for hip fracture patients, as it reduces the risk for severe hemodynamic disturbances and respiratory complications compared with general anesthesia.

In the elderly population, mechanical ventilation can be a patient-harming machine, in my opinion; and as an experienced anesthesiologist, I make an effort to minimize its use whenever possible. It is crucial to consider each patient’s unique needs and carefully evaluate the benefits and risks of different anesthesia techniques to ensure optimal outcomes.

Xu: Many studies have demonstrated that there are advantages of spinal anesthesia over general anesthesia for patients with hip fractures, although some studies did not show this to be true. We routinely use spinal anesthesia for hip fracture surgery at our institution.

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7.What role does liposomal bupivacaine (Exparel, Pacira) play in regional anesthesia?

Chiao: Liposomal bupivacaine belongs in the armament of local anesthetics. It has a role in surgical field anesthesia and regional anesthesia. For peripheral nerve blocks, it extends the duration of the nerve block. This can be helpful when patients are expected to have severe pain or do not want to endure any more pain than necessary. From my experience, in the recommended doses, it lasts into postoperative day 1. It can also allow patients to avoid any postoperative opioids, as the extra duration of analgesia pushes the patient through the most painful postoperative period, whereas in other cases, they would take one or two oxycodone doses on postoperative day 1.

Fettiplace: More generally, “What is the role of extended-release formulations of local anesthetic?” There isn’t convincing scientific evidence that liposomal bupivacaine is superior to bupivacaine for blocks.¹¹ However, there are anecdotal reports that targeted use still provides a clinical benefit, so further work is potentially merited. Other touted benefits of liposomal bupivacaine, like limited toxicity, do not bear out in practice, with evidence of toxicity at similar rates to plain bupivacaine.¹² Alternative drugs, like bupivacaine and meloxicam in biochronomer polymer technology (e.g., Zynrelef, Heron), are still incompletely studied but may yet alter our practice.¹³

Gevaert: I do not have experience with using liposomal bupivacaine.

Knops: As liposomal bupivacaine is not yet available in Belgium, I have no personal experience with its use. The benefit of liposomal bupivacaine when compared with the regular version would be the longer duration of effect—something you would normally need a catheter for. Personally, I believe that the placement of catheters is a step up in difficulty compared with a single-shot block. Furthermore, catheters can dislocate or cause infection, resulting in the need for hospitalization for observational purposes. As surgery is starting to shift more toward an outpatient setting, usage of liposomal bupivacaine could provide extended pain relief, without the need for a catheter and the accompanying need for hospitalization.

The current evidence for liposomal bupivacaine is somewhat ambiguous. I definitely believe that liposomal bupivacaine could be a game changer for regional anesthesia. The proper indications would need to be examined further.

Lopez: Unfortunately, my clinical experience with liposomal bupivacaine is limited. I have only been involved in a few studies that demonstrated its positive effects compared with placebo and plain bupivacaine for certain nerve blocks. However, the existing evidence suggests that the magnitude of its effect is not particularly remarkable. Nonetheless, I do believe that liposomal bupivacaine can provide added benefits, especially for patients who cannot receive all components of a multimodal analgesia regimen. In such cases, a prolonged nerve block would be advantageous. However, due to my lack of clinical experience with liposomal bupivacaine, I cannot make definitive judgments on its efficacy.

Merjavy: It is well recognized that certain surgical procedures can result in prolonged postoperative pain that extends beyond the duration of single-shot nerve blocks. The placement of nerve block catheters has emerged as a potential solution for providing analgesia lasting over 24 hours. However, catheters come with their own challenges, including dislocation, kinking, disconnection and the potential for local anesthetic accumulation, which can lead to side effects such as phrenic nerve block in the case of interscalene catheters. Additionally, the use of catheters is associated with increased costs.

Liposomal bupivacaine offers an alternative approach by providing longer-lasting analgesia through the slow release of local anesthetic from the liposomal carrier over several days.

This principle has also been applied successfully in other medications, such as chemotherapy. While the use of liposomal bupivacaine has already been approved for various nerve blocks or tissue infiltration, we are still in the early stages of exploring the exciting potential of providing long-lasting analgesia through a single-shot injection of local anesthetic from a slow-release formulation. It is possible that different local anesthetics may follow in the footsteps of liposomal bupivacaine as future advancements in this field continue to unfold.

Salti: The extended duration of action offered by liposomal bupivacaine can be particularly beneficial in managing postoperative pain, allowing patients to experience sustained relief during the critical recovery period. By reducing the reliance on systemic opioids, it may help minimize opioid-related side effects and improve patient comfort.

Liposomal bupivacaine has been studied and utilized in various surgical procedures, including orthopedic surgeries, such as joint replacements or soft tissue procedures, as well as in certain abdominal surgeries. It offers the advantage of providing prolonged pain control and potentially enhancing patient satisfaction by reducing the need for rescue analgesics.

Tfaili: While I personally have not used liposomal bupivacaine, I understand that there is controversy surrounding its use. Liposomal bupivacaine is formulated to provide a slow release of bupivacaine, which theoretically should result in prolonged analgesia. However, further studies are needed to clarify its efficacy and optimal techniques for utilizing liposomal bupivacaine to its full potential. It is essential to stay updated on the latest research to gain a better understanding of the benefits and limitations of this formulation and to make informed decisions regarding its use in clinical practice.

References

1. Reg Anesth Pain Med. 2021;46(7):571-580.
2. Reg Anesth Pain Med. 2023;48(9):437-438.
3. Anaesthesia. 2021;76(suppl 1):65-73.
4. Australas J Ultrasound Med. 2017;20(1):30-40.
5. Insights Imaging. 2017;8(6):523-535.
6. Acta Anaesthesiol Belg. 2013;64(3):105-108.
7. Clin Infect Dis. 2011;52(9):1087-1099.
8. Reg Anesth Pain Med. 2022;47(2):106-112.
9. N Engl J Med. 2021;385(22):2025-2035.
10. JAMA. 2022;327(1):50-58.
11. Anesthesiology. 2021:134(2):147-164.
12. Expert Opin Drug Saf. 2018;17(6):581-587.
13. Reg Anesth Pain Med. 2019;44:700-706.

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