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
Introduction: Ultrasound-guided regional anaesthesia enhances pain control, patient outcomes and lowers healthcare costs. However, teaching this skill effectively presents challenges with current training methods. Simulation-based medical education offers advantages over traditional methods. However, the use of instructional design features in ultrasound-guided regional anaesthesia simulation training has not been defined. This systematic review aimed to identify and evaluate the prevalence of various instructional design features in ultrasound-guided regional anaesthesia simulation training and their correlation with learning outcomes using a modified Kirkpatrick model.

Methods: A comprehensive literature search was conducted including studies from inception to August 2024. Eligibility criteria included randomised controlled trials; controlled before-and-after studies; and other experimental designs focusing on ultrasound-guided regional anaesthesia simulation training. Data extraction included study characteristics; simulation modalities; instructional design features; and outcomes.

Results: Of the 2023 articles identified, 62 met inclusion criteria. Common simulation modalities included live-model scanning and gel phantom models. Instructional design features such as the presence of expert instructors, repetitive practice and multiple learning strategies were prevalent, showing significant improvements across multiple outcome levels. However, fewer studies assessed behaviour (Kirkpatrick level 3) and patient outcomes (Kirkpatrick level 4).

Discussion: Ultrasound-guided regional anaesthesia simulation training incorporating specific instructional design features enhances educational outcome; this was particularly evident at lower Kirkpatrick levels. Optimal combinations of instructional design features for higher-level outcomes (Kirkpatrick levels 3 and 4) remain unclear. Future research should standardise outcome measurements and isolate individual instructional design features to better understand their impact on clinical practice and patient safety.

Abstract
Purpose: Chest wall trauma involving rib fractures represents an anaesthetic challenge, often resulting in high opioid requirements, hypoventilation, hypostatic pneumonia and respiratory failure. Regional anaesthesia (RA) techniques have the potential to reduce opioid consumption and maintain oxygenation. In this study we characterise a cohort of trauma patients who have received RA blocks and assess the impact of such techniques on respiratory support requirements, opioid consumption and outcomes.

Methods: We retrospectively collected data from all patients with chest wall trauma who received RA techniques with catheter placement from October 2018 to August 2022.

Results: Data from 187 patients was reviewed. Mean age was 64.25 years, median injury burden was 7 rib fractures and mean STUMBL score was 33.4. Erector Spinae Plane block (n = 131, 70.1%) and Serratus Anterior Plane block (n = 43, 23%) were the most used techniques. Thirty patients (16%) underwent rib fixation. RA significantly reduced the highest respiratory support requirements 24 h post-RA compared to 24 h pre-RA (p = 0.001) and lowest recorded peripheral oxygen saturations also significantly improved (91.5% pre-RA vs. 92.9% post-RA, p < 0.001). Opioid consumption significantly reduced 24 h post-RA compared to 24 h pre-RA (20.5 mg vs. 14 mg of intravenous morphine equivalents, p < 0.001). One hundred and forty-nine (79.7%) patients required ICU admission and 168 (89.8%) survived to hospital discharge.

Conclusion: Our analysis demonstrated improvement in respiratory support and reduction in opioid consumption following RA techniques in a high injury burden patient cohort. These results support RA utilisation in patients with significant chest wall trauma, especially if rib fixation is not immediately available.

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.