Regional anaesthesia: Overview

Regional Anesthesia & Pain Medicine, the official publication of the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine), is a monthly journal that publishes peer-reviewed scientific and clinical studies to advance the understanding and clinical application of regional techniques for surgical anesthesia and postoperative analgesia. Coverage includes intraoperative regional techniques, perioperative pain, chronic pain, obstetric anesthesia, paediatric anesthesia, outcome studies, and complications.

Abstract
Local anaesthetics (LAs) allow a range of procedures to be performed in interventional radiology (IR) through improving patient comfort and reducing pain. This review serves as a primer for interventional radiologists, providing an overview of commonly used LAs and practical tips for their implementation. With its quick onset time and moderate duration of action, the amide lidocaine is the most used and applicable to a variety of procedures such as biopsies and embolization. In contrast, bupivacaine and ropivacaine (both amides) have longer durations of action, and are therefore suitable for lengthy procedures and pain control post-procedurally. Procaine, an ester, may be used in cases of amide anaesthetic allergies. This review examines the clinical applications of LAs in radiology and management of their adverse effects including local anaesthetic systemic toxicity (LAST) and allergic reactions. It concludes with a discussion of LAST, emphasising techniques for early intervention and management. The role of lipid emulsion therapy and modifications to the advanced cardiac life support (ACLS) protocol are highlighted, including a discussion of other aspects such as airway management. By presenting the latest strategies to manage LAST and adverse effects, this research aims to help standardise anaesthetic management in radiology. It provides actionable steps for selecting and injecting anaesthetics, and management of complications that will be beneficial for interventional radiologists performing a diverse array of procedures.

Abstract in English, French
Purpose: Dosing and types of local anesthetic agents for spinal anesthesia in ambulatory settings vary significantly. We sought to conduct a network meta-analysis to evaluate the effect of the type and dose of local anesthetic on outcomes in patients undergoing ambulatory surgery.

Methods: After PROSPERO registration (CRD42023399356), we searched various databases for randomized controlled trials (RCTs) evaluating adult patients undergoing daycare surgery under spinal anesthesia. Most included trials focused on patients undergoing knee arthroscopy, while other covered procedures were perineal, lower abdominal, and limb surgeries. Unfortunately, we could not include trials on arthroplasty surgery owing to the lack of RCTs in this area. We used Confidence in Network Meta-Analysis (CINeMA) to assess the confidence in the estimates, and we used surface under the cumulative ranking curve (SUCRA) to determine the probability rank order. The primary outcome was the time to discharge. Intraoperative effectiveness of anesthetic, sensory, and motor blockade duration; time to first micturition; time to ambulation; and adverse effects such as urinary retention and transient neurologic symptoms (TNS) were the secondary outcomes.

Results: Overall, this study included 44 trials comprising 3,299 patients, each comprising 11 distinct agents (2-chloroprocaine, articaine, high-dose bupivacaine, low-dose bupivacaine, lidocaine, high-dose levobupivacaine, low-dose levobupivacaine, mepivacaine, prilocaine, high-dose ropivacaine, and low-dose ropivacaine). Low- to moderate-certainty evidence showed that 2-chloroprocaine, lidocaine, and mepivacaine were superior for discharge readiness, while 2-chloroprocaine ranked highest for other outcomes (sensory and motor block duration, time to first ambulation, and spontaneous voiding).

Conclusions: Evidence supports 2-chloroprocaine for short-duration spinal anesthesia in the ambulatory setting.