Supraclavicular vs. Infraclavicular Brachial Plexus Nerve Blocks: Clinical, Pharmacological, and Anatomical Considerations

: Peripheral nerve blocks (PNB) have become standard of care for enhanced recovery pathways after surgery. For brachial plexus delivery of anesthesia, both supraclavicular (SC) and infraclavicular (IC) approaches have been shown to require less supplemental anesthesia, are performed more rapidly, have quicker onset time, and have lower rates of complications than other approaches (axillary, interscalene, etc.). Ultrasound-guidance is commonly utilized to improve outcomes, limit the need for deep sedation or general anesthesia, and reduce procedural complications. Given the SC and IC approaches are the most common approaches for brachial plexus blocks, the differences between the two have been critically evaluated in the present manuscript. Various studies have demonstrated slight favorability towards the IC approach from the standpoint of complications and safety. Two prospective RCTs found a higher incidence of complications in the SC approach – particularly Horner syndrome. The IC method appears to support a greater block distribution as well. Overall, both SC and IC brachial plexus nerve block approaches are the most effective and safe approaches, particularly under ultrasound-guidance. Given the success of the supraclavicular and infraclavicular blocks, these techniques are an important skill set for the anesthesiologist for intraoperative anesthesia and postoperative analgesia.

A Survey of Regional Anesthesia Use in Greece and the Impact of a Structured Regional Anesthesia Course on Regional Techniques Knowledge and Practice

Background: Due to the growing interest in regional anesthesia (RA) techniques and the realization of the need for formalized education in them, the Greek Chapter of the European Society of Regional Anesthesia and Pain Therapy (ESRA-Hellas) has established a structured hands-on training course held annually since 2009, which is quite popular in the community of Greek anesthesiologists. The aim of the current survey was twofold: first, to provide an overview of the current practice of RA in Greece; secondly, to evaluate the effect the aforementioned training course has on participants’ knowledge and attitude towards RA. Methods: An electronic questionnaire was uploaded on SurveyMonkey and a link giving access to the questionnaire was forwarded via email to a mailing list of 825 practicing Greek anesthesiologists held in the electronic database of ESRA Hellas. The survey was totally anonymous and no identifying information was collected throughout. It contained questions relating to the anesthesiologists’ demographic characteristics, their RA practice, and information pertaining to the RA training course. Results: A total of 424 fully completed questionnaires were received, representing an overall response rate of 51.4%. Attendants of the course are more familiar than non-attendants with the performance of peripheral nerve blocks with neurostimulation and/or ultrasound guidance (p < 0.001). Attendants are also less likely to practice exclusively general anesthesia, more likely to use peripheral blocks for lower limb surgery, and more likely to consider taking the European Diploma of RA in comparison to non-attendants (p < 0.001, p = 0.018 and p = 0.002, respectively). Both cohorts consider the course of value and agree that the main reason to use regional techniques is to ensure optimal postoperative analgesia, while the main hindrance to RA practice is the lack of relevant education in the techniques, especially those under ultrasound guidance. Regarding improvement of the course, most participants suggested devoting ampler time in hands-on ultrasound practice and application. Conclusions: Greek anesthesiologists seek educational activities in the field of RA and the course seems to fulfil the majority of attendants’ expectations. There will be further effort by the organizers to improve weaknesses of the current course and undertake further educational initiatives in the field of RA according to international recommendations.

Reliability and Quality of YouTube Videos on Ultrasound-Guided Brachial Plexus Block: A Programmatical Review

BACKGROUND

Ultrasound-guided regional anesthesia has gained popularity over the last decade. This study aimed to assess whether YouTube videos sufficiently serve as an adjunctive tool for learning how to perform an ultrasound-guided brachial plexus block (BPB).

METHODS

All YouTube videos were classified, based on their sources, as either academic, manufacturer, educational, or individual videos. The metrics, accuracy, utility, reliability (using the Journal of American Medical Association Score benchmark criteria (JAMAS)), and educational quality (using the Global Quality Score (GQS) and Brachial Plexus Block Specific Quality Score (BSQS)) were validated.

RESULTS

Here, 175 videos were included. Academic (1.19 ± 0.62, mean ± standard deviation), manufacturer (1.17 ± 0.71), and educational videos (1.15 ± 0.76) had better JAMAS accuracy and reliability than individual videos (0.26 ± 0.67) (p < 0.001). Manufacturer (11.22 ± 1.63) and educational videos (10.33 ± 3.34) had a higher BSQS than individual videos (7.32 ± 4.20) (p < 0.001). All sources weakly addressed the equipment preparation and post-procedure questions after BSQS analysis.

CONCLUSIONS

The reliability and quality of ultrasound-guided BPB videos differ depending on their source. As YouTube is a useful educational platform for learners and teachers, global societies of regional anesthesiologists should set a standard for videos.

Challenges and Variations in Emergency Medicine Residency Training of Ultrasound-guided Regional Anesthesia Techniques

BACKGROUND

Ultrasound guidance has become an integral component to procedural and diagnostic practice for the emergency physician. Whereas landmark-guided methods were used for peripheral nerve blocks in the past, the use of ultrasound has made regional anesthesia procedures faster, more successful, and feasible as a pain management modality in the emergency department. Not only the utilization, but also the teaching of ultrasound has become an essential aspect of emergency medicine residency training. Prior studies have found a substantial variation in practice and policies with regard to ultrasound-guided regional anesthesia (UGRA) and this translates to the education of both residents and fellows.

OBJECTIVES

The objective was to describe the current state of UGRA education, trends, and barriers in emergency medicine residency and ultrasound fellowship programs in the United States.

METHODS

A cross-sectional survey was conducted via the Internet utilizing the Qualtrics software platform. It was distributed to ultrasound directors and program directors of both Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) accredited emergency medicine residency programs and ultrasound fellowships. Data analysis, cross-tabulation, and subgroup analysis were performed utilizing the software.

RESULTS

We received a total of 138 responses (response rate of 66.3%). There was substantial variability with regard to implementing UGRA education. Additionally, there was a trend correlating a greater likelihood of UGRA education among programs with more than two ultrasound faculty members. Faculty training is considered to be the greatest barrier to teaching UGRA to residents and fellows.

CONCLUSION

Resident and fellow education with regard to UGRA varies significantly among individual programs. Although there are currently no ACGME or AOA guidelines, nearly all residency programs believe that this is a skill that emergency physicians should learn. With the identification of key barriers and the need for an increased number of trained faculty, pain management utilizing UGRA may become an integral part to emergency medicine resident and fellow education.

Current practice in regional anaesthesia in South America: An online survey

OBJECTIVE

A survey was conducted in order to obtain a profile of the practice of regional anesthesia in South America, and determine the limitations of its use.

METHODS

After institutional ethics committee approval, a link to an online questionnaire was sent by e-mail to anaesthesiologists in Argentina, Bolivia, Chile, Colombia, Panamá, Paraguay, Perú, and Uruguay. The questionnaire was processed anonymously.

RESULTS

A total of 1,260 completed questionnaires were received. The results showed that 97.6% of the anaesthesiologists that responded used regional anaesthesia in clinical practice, 66.9% performed peripheral nerve block (PNB) regularly, 21.6% used continuous PNB techniques, and 4.6% used stimulating catheters. The primary source of training was residency programs. As regards PNB, the most common performed were interscalene (52.3%), axillary (45.1%), femoral (43.2%), and ankle block (43%). As regards the localisation technique employed, 16% used paraesthesia, 44.2% used a peripheral nerve stimulator, and 18.1% ultrasound guidance.

CONCLUSIONS

Regional anaesthesia and PNB are commonly used among South American anaesthesiologists. Considering that each country has its own profile for use, this profile should guide training in clinical practice, especially in residency programs.

A Randomized Double-Blinded Trial on the Effects of Ultrasound Transducer Orientation on Teaching and Learning Ultrasound-Guided Regional Anesthesia

OBJECTIVES

Learning ultrasound-guided regional anesthesia skills, especially needle/ beam alignment, can be especially difficulty for trainees, who can often become frustrated. We hypothesized that teaching novices to orient the transducer and needle perpendicular to their shoulders will improve performance on a standardized task, compared to holding the transducer and needle parallel to the shoulders.

METHODS

This study compared the effects of transducer orientation on trainees' ability to complete a standardized ultrasound-guided nerve block simulation. The time to task completion and percentage of the attempt time without adequate needle visualization were measured. Participants were right-handed healthy adults with no previous ultrasound experience and were randomly assigned to training in either transducer and needle alignment in a coronal plane, parallel to the shoulders (parallel group) or transducer and needle alignment in a sagittal plane, perpendicular to the shoulders (perpendicular group). Participants used ultrasound to direct a needle to 3 targets in a standardized gelatin phantom and repeated this task 3 times. Their efforts were timed and evaluated by an assessor, who was blinded to group assignment.

RESULTS

Data were analyzed on 28 participants. The perpendicular group was able to complete the task more quickly (P < .001) and with a smaller proportion of time lost to inadequate needle visualization (P < .001).

CONCLUSIONS

Ultrasound-guided regional anesthesia trainees complete a standardized task more quickly and efficiently when instructed to hold the transducer and needle in an orientation perpendicular to their shoulders.

Ultrasound-Guided Nerve Blocks in Emergency Medicine Practice

OBJECTIVES

The purpose of this study was to investigate the current practice of ultrasound (US)-guided regional anesthesia at academic emergency departments, including education, protocols, policies, and quality assessment.

METHODS

We conducted a cross-sectional study. A questionnaire on US-guided nerve blocks was electronically sent to all emergency US directors and emergency US fellowship directors.

RESULTS

A total of 121 of 171 academic institutions with an emergency medicine residency program participated in this study, representing a 71% response rate. Eighty-four percent (95% confidence interval [CI], 77%-91%) of programs perform US-guided nerve blocks at their institutions. The most common type of nerve block performed is a forearm nerve block (ulnar, median, or radial). The most common indication for US-guided nerve blocks is fracture pain management. Only 7% (95% CI, 2%-12%) of programs have a separate credentialing pathway for US-guided nerve blocks. Regarding quality assessment review of US-guided nerve blocks, none of the programs have a separate program in place. In 57% (95% CI, 48%-66%) of programs, it is a component of the emergency US quality assessment program. Eighty-four percent (95% CI, 77%-90%) of programs do not have specific agreements with other specialty services with regard to performing US-guided nerve blocks in the emergency department. The most common educational methods used to teach US-guided nerve blocks are didactic sessions, at 67% (95% CI, 59%-75%); online resources, at 54% (95% CI, 45%-63%); and supervised training with real patients, at 48% (95% CI, 39%-57%).

CONCLUSIONS

Ultrasound-guided nerve blocks are performed at most academic emergency departments. However, there is a substantial variation in the practices and policies within these institutions.

Evaluation of a Standardized Program for Training Practicing Anesthesiologists in Ultrasound-Guided Regional Anesthesia Skills

OBJECTIVES

Practicing anesthesiologists have generally not received formal training in ultrasound-guided perineural catheter insertion. We designed this study to determine the efficacy of a standardized teaching program in this population.

METHODS

Anesthesiologists in practice for 10 years or more were recruited and enrolled to participate in a 1-day program: lectures and live-model ultrasound scanning (morning) and faculty-led iterative practice and mannequin-based simulation (afternoon). Participants were assessed and recorded while performing ultrasound-guided perineural catheter insertion at baseline, at midday (interval), and after the program (final). Videos were scored by 2 blinded reviewers using a composite tool and global rating scale. Participants were surveyed every 3 months for 1 year to report the number of procedures, efficacy of teaching methods, and implementation obstacles.

RESULTS

Thirty-two participants were enrolled and completed the program; 31 of 32 (97%) completed the 1-year follow-up. Final scores [median (10th-90th percentiles)] were 21.5 (14.5-28.0) of 30 points compared to 14.0 (9.0-20.0) at interval (P < .001 versus final) and 12.0 (8.5-17.5) at baseline (P < .001 versus final), with no difference between interval and baseline. The global rating scale showed an identical pattern. Twelve of 26 participants without previous experience performed at least 1 perineural catheter insertion after training (P < .001). However, there were no differences in the monthly average number of procedures or complications after the course when compared to baseline.

CONCLUSIONS

Practicing anesthesiologists without previous training in ultrasound-guided regional anesthesia can acquire perineural catheter insertion skills after a 1-day standardized course, but changing clinical practice remains a challenge.

A Survey of Ultrasound Training in U.S. and Canadian Chronic Pain Fellowship Programs

OBJECTIVE

To assess the current state of ultrasound training in U.S. and Canadian Chronic Pain Fellowship programs.

DESIGN

U.S. as well as Canadian chronic pain fellowship programs were contacted via email and program directors were asked to complete a survey. The surveys were completed online using a questionnaire.

SETTING

Questionnaire via email.

PATIENTS

None.

INTERVENTIONS

None.

OUTCOME

To assess the current state of ultrasound training in U.S. and Canadian Chronic Pain Fellowship programs.

MEASURES

Current teaching structure, types, and numbers of ultrasound-guided interventional pain procedures.

RESULTS

Thirty-one responses (30.7%) from the 97 U.S. and four Canadian programs surveyed. Of the 31 programs that responded, 26 offered ultrasound training; five did not. These 31 programs averaged 4.1 fellows per year, majority 96.2% of the 26 programs taught ultrasound throughout the fellowship year. The type of ultrasound training varied, with the large majority 96.2% being patient based. Among 26 programs, 96.2% used ultrasound for peripheral nerve blocks, 76.9% used ultrasound for non-axial musculoskeletal injections, and 53.8% used ultrasound for axial nerve blocks.

CONCLUSIONS

Chronic pain fellowships were teaching ultrasound-guided procedures to their fellows. The majority of the fellowships offered ultrasound training throughout the fellowship year. A majority of training was accomplished via hands-on experience with patients. Chronic pain fellows were receiving a majority of ultrasound training for peripheral nerve blocks, followed by nonaxial musculoskeletal blocks, with few axial nerve blocks being taught.

Regional anesthesia practice in Greece: A census report

Background and Aims:

Regional anesthesia (RA) techniques (central neuraxial and peripheral nerve blocks [CNBs and PNBs]) are well-established anesthesia/analgesia modalities. However, information on their nationwide use is sparse. The aim of the survey was to assess the utility of RA techniques in Greece, during 2011.

Materials and Methods:

A nationwide, cross-sectional descriptive survey was conducted (March to June, 2012), using a structured questionnaire that was sent to 128 Greek Anesthesia Departments.

Results:

Sixty-six completed questionnaires (response rate 51.56%) were analyzed. The data corresponded to 187,703 operations and represented all hospital categories and geographical regions of Greece. On the whole, RA was used in 45.5% of performed surgical procedures (85,386/187,703). Spinal anesthesia was the technique of choice (51.9% of all RA techniques), mostly preferred in orthopedics (44.8%). Epidural anesthesia/analgesia (application rate of 23.2%), was mostly used in obstetrics and gynecology (50.4%). Combined spinal-epidural and PNBs were less commonly instituted (11.24% and 13.64% of all RA techniques, respectively). Most PNBs (78.5%) were performed with a neurostimulator, while elicitation of paresthesia was used in 16% of the cases. Conversely, ultrasound guidance was quite limited (5%). The vast majority of consultant anesthesologists (94.49%) were familiar with CNBs, whereas only 46.4% were familiar with PNBs. The main reported limitations to RA application were lack of equipment (58.23%) and inadequate education/training (49.29%).

Conclusion:

Regional modalities were routinely used by Greek anesthesiologists during 2011. Neuraxial blocks, especially spinal anesthesia, were preferred over PNBs. The underutilization of certain RA techniques was attributed to lack of equipment and inadequate training.

Evidence-based medicine for ultrasound-guided regional anesthesia

Available evidence favoring the use of ultrasound for regional anesthesia is reviewed, updated, and critically assessed. Important outcome advantages include decreased time to block onset; decreased risk of local anesthetic systemic toxicity; and, depending on the outcome definition, increased block success rates. Ultrasound guidance, peripheral nerve blocks, and central neuraxial blocks are discussed.

Peripheral nerve blocks for ambulatory surgery

Peripheral nerve blocks (PNBs) provide significant improvement in postoperative analgesia and quality of recovery for ambulatory surgery. Use of continuous PNB techniques extend these benefits beyond the limited duration of single-injection PNBs. The use of ultrasound guidance has significantly improved the overall success, efficiency, and has contributed to the increased use of PNBs in the ambulatory setting. More recently, the use of ultrasound guidance has been demonstrated to decrease the risk of local anesthetic systemic toxicity. This article provides a broad overview of the indications and clinically useful aspects of the most commonly used upper and lower extremity PNBs in the ambulatory setting. Emphasis is placed on approaches that can be used for single-injection PNBs and continuous PNB techniques.