ANESTHESIE

CENTRUM ANESTHESIE

ARTIKELS

ABSTRACT 1

Incidence of iatrogenic pneumothorax after ultrasound guided supraclavicular nerve block for upper limb surgery: a single centre experience of 3641 blocks.

Vandemoortele O, Helsloot D, Van Belleghem V, Desmet M, et al. European Journal of Anaesthesiology, 2020, 37, 113

INTRODUCTION An ultrasound guided supraclavicular nerve block is one of several anaesthesia techniques to perform anaesthesia and postoperative analgesia for upper limb surgery. However, the presence of the subclavian artery and pleural cavity in the vicinity of the brachial plexus results in a possible risk for hematoma and pneumothorax. The incidence of iatrogenic pneumothorax after a supraclavicular nerve block without ultrasound is reported to vary between 0.5 and 6 percent. However, the overall incidence of pneumothorax diminishes with increasing experience and is further reduced with the use of ultrasound to an overall incidence of 0.05%.

OBJECTIVE This audit aims to demonstrate the incidence of iatrogenic pneumothorax after ultrasound guided supraclavicular nerve block in a high volume centre.

MATERIALS/METHODS A retrospective analysis was performed on all supraclavicular nerve blocks for upper limb surgery in our hospital between January 1, 2016 and November 31, 2019. All su- praclavicular nerve blocks were performed at the discretion of the attending anaesthesiologist. The overall incidence of clinically significant pneumothorax (suspected by symptoms of dyspnea or chest pain following the performance of the block and confirmed by chest X-ray) was documented.

RESULTS Between 01-01-2016 and 31-11-2019, 3641 supraclavicular nerve blocks were performed for upper limb surgery. All blocks were performed using ultrasound. 2870 blocks were performed by graduated anaesthesiologists with a variable expertise in regional anaesthesia. 771 were performed by residents. No cases of a clinically significant pneumothorax could be identified in our database. Supraclavicular nerve blocks provide excellent analgesia for upper limb surgery and are frequently used for day case surgery. Accidental pleural puncture and pneumothorax could however delay hospital discharge and increase hospital costs. The overall incidence of pneumothorax has been reported in recent years to be decreased by the use of ultrasound. Incidences lower than 0.05% have been reported (1). Our data indicate that real incidence could be even lower.

CONCLUSION Retrospective analysis of 3641 ultrasound guided supraclavicular nerve blocks indicate that this is a safe procedure and confirm previous studies indicating that the overall incidence of pneumothorax is very low (< 0.05 %).

ABSTRACT 2

Implementation of regional anesthesia guidelines in clinical practice, does it happen in real life?

Desmet M, Missant C, Reynvoet M, Lamote S et al. European Journal of Anaesthesiology, 2020, 37, 114

INTRODUCTION Clinical practice often lags behind evidence presented in the literature. Current guidelines advocate the use of low volumes of local anesthetics during peripheral nerve blocks (PNB), accept the safety of PNB performance under general anesthesia (GA) and recommend the use of combining ultrasound (US) and nerve stimulation (NS) during PNB.

OBJECTIVE This audit aims to evaluate if clinical practice has changed according to guidelines.

MATERIALS/METHODS An audit was performed on all supraclavicular (SCB) and interscalene blocks (ISB) for upper limb surgery executed in a single centre in 201 6and 2019. All blocks were performed at the discretion of the attending anesthesist. Statistical analysis using Student’s t tests and Chi square tests was performed onthe volume used, the combined use of US and NS and the performance of PNB under sedation or GA.

RESULTS In 2016 and 2019, 828 and 886 SCB were performed.There was a significant reduction of the mean volume used from 35 to 26mL (p<0.05). In 2016 both US and NS was used in 76% of cases where in 2019 this was only 37% (p<0.05). Only a small minority of patients received a PNB under GA (4 in 2016, 5 in 2019), there was a significant reduction in the use of sedatives from 2016 to 2019 (90% in 2016 vs 15% in 2019, p<0.05). In 2016 and 2019, 576 and 645 ISB were performed. There was no difference in the volume used

(19.4mLvs 18.6mL). The use of NS and US increased from 2016 to 2019 (20% vs 50%,p<0.05). ISBs were performed under general anesthesia in 46 patients in 2016 and 7 in 2019 (p<0.05), there was a significant reduction in the use of sedatives (45%vs 12%, p<0.05). Acceptance of guidelines in clinical practice is diverse. There was an increase in the use of NS combined with US for ISB but not for SCB. The fear of unexpected movement with the needle in close proximity to the pleura was the main reason for anesthesiologists not to use NS in SCB. In contrast to SCB, the volume used for ISB was already low preventing a further reduction. The logistic organization with the presence of a block room explaines the unchanged and low proportion of patients receiving a PNB under GA.

CONCLUSION Our audit demonstrates that in a high volume centre adoptation of clinical guidelines is slow or even non existent. Further research is necessary to detect the barriers that prevent implementation of clinical guidelines.

ABSTRACT 3

Comparison of the analgesic effects of perineural and intravenous dexamethasone on peripheral nerve block: a systematic review.

Piepers I, Desmet M, Van de Velde M, et al. Acta Anaesthesiologica Belgica, 2020, 71, 37-44

INTRODUCTION Perineural dexamethasone has proved to prolong the postoperative analgesia of local anesthetic peripheral nerve blocks. However, a similar increase in postoperative analgesia duration is seen with the use of intravenous dexamethasone.

OBJECTIVE The objective of this systematic review is to compare the duration of analgesia between perineural and intravenous dexamethasone as an adjuvant to a peripheral nerve block with long-acting local anesthetics.

MATERIALS/METHODS A systematic search in Medline and Scopuswas executed up to April 2020 using the following MeSH terms: dexamethasone, nerve block, brachial plexusblock, perineural. RESULTS The analgesic duration of perineural versus intravenous administration as an adjuvant to a long acting local anesthetic peripheral nerve block, was in seven trials with perineural dexamethasone significantly prolonged of which two studies were evaluated as highrisk bias. However, in five trials, no difference between perineural and intravenous dexamethasone was observed.

CONCLUSION No clinically significant difference in the analgesic duration of perineural versus intravenous administration as an adjuvant to a longacting local anesthetic peripheral nerve block could be withheld. The intravenous route is the preferred method of administration as no clinically significant analgetic advantages are seen with the perineural route, and the remaining questions exist of possible neurotoxicity with perineural dexamethasone use.

ABSTRACT 4

Regional anesthesia of the hip joint: review of regional anesthesia techniques.

Coucke C, Desmet M, Vermeylen K, et al. Acta Anaesthesiologica Belgica, 2020, 71, 7-13

INTRODUCTION As hip fractures are frequent in the frail population, multiple regional anesthesia approaches have been developed over the past years to achieve analgesia of the hip joint. Achieving optimal analgesia with opioid reduction remains challenging in this group with high morbidity and mortality. Many techniques have changed over the years due to the introduction of ultrasound and an optimisation of radiographic techniques such as MRI. There has been an upcoming interest in the fascia iliaca compartment block (FICB), local infiltration analgesia (LIA) and more recently the pericapsular nerve group block (PENGblock).

OBJECTIVE The aim of this review is to clarify the role of these techniques in hip surgery.

MATERIALS/METHODS A systematic search was performed in Medline, Embase and the Cochrane database, with the following MeSH terms: conduction anesthesia, nerve block, local Anesthesia.

RESULTS There is increasing evidence that a suprainguinal approach of the FICB is a valuable alternative for hip analgesia, as there is more success in blocking the three targeted nerves (femoral, obturator and lateral femoral cutaneous nerve), compared to the classical infra-inguinal approach. Very recently, the pericapsular nerve group block has seemed a promising option inproviding analgesia of the hip joint, compared to LIA.

CONCLUSION Both the FICB as well as the PENG block have been shown to be safe and effective analgesic options in hip fracture. However, more research is needed to determine the role of both techniques in different hip conditions.

ABSTRACT 5

Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient.

Desmet M, Bindelle S, Breebaart M, et al. Acta Anaesthesiologica Belgica, 2020, 71, 151-161

ABSTRACT In 2013, the first “Clinical guidelines for the practice of peripheral nerve blocks in the adult” were published by the Belgian Association for Regional Anesthesia (BARA) Peripheral Nerve Block working group. Since then a plethora on research has been published providing new insights in the clinical practice of peripheral nerveblocks (PNBs). The aim of this revised version is to provide anesthesiologists an update of the 2013 guidelines according to the most recent evidence in an effort to further enhance quality and safety of clinical practice. These recommendations were composed by the BARA Peripheral Nerve Blockworking group which included elected BARA boardmembers and non-board BARA all of them with an extensive experience in regional anesthesia (RA). A large-scale review of the literature regarding different topics was performed to support the guidelines by current evidence.

However, in case of limited available data, expert opinion as a result of discussion within the working group, was used as a surrogate for robust data. We would like to remind readers of this manuscript that although these guidelines are intended to optimize patient care, they do not replace sound clinical judgment and cannot ensure the avoidance of adverse outcomes. Furthermore, although great care has been taken to avoid conflict with the “Safety First Guidelines” issued by the Society for Anesthesia and Resuscitation of Belgium (SARB) and the Belgian Professional Association of Specialists in Anesthesia and Resuscitation (BSAR-APSAR), we emphasize that the “Safety First Guidelines” should be prioritized above the “Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient.”

ABSTRACT 6

Conscious sedation using dexmedetomidine during surgical paddle lead placement improves outcome in spinal cord stimulation: a case series of 25 consecutive patients.

Vanhauwaert D, Couvreur T, Vandebroek A, et al. Neuromodulation, 2020, Feb 19, DOI: 10.1111/ner.13124

OBJECTIVE Different anesthesia techniques are used for surgical implantation of paddle lead electrodes for neurostimulation through a laminectomy. We wanted to evaluate the use of dexmedetomidine as sedative for this procedure in a series of patients.

MATERIALS/METHODS Twenty-five consecutive patients received surgical implantation of a spinal cord stimulation electrode under conscious sedation using dexmedetomidine and local anesthesia. We evaluated the effects of the administered drug, the patient comfort, and the adequacy of the stimulation pattern.

RESULTS Twenty-four patients completed the procedure with only dexmedetomidine and local anesthetic. Infusion was started on average 55 minutes (sd 29) prior to incision. The mean dose of lidocaine was 430 mg (sd 95). There were no significant hemodynamic changes. Median time to reach Modified Aldrete's score postoperative was 67 minutes (sd 38). In 46% of the patients, the position of the electrode was changed guided by the feedback of the patient. More than half of the patients remember most details of the procedure. Only four patients mentioned substantial discomfort and only three would definitely not want to undergo this procedure again.

CONCLUSION Implantation of spinal cord stimulation electrodes through a surgical laminectomy using dexmedetomidine is a safe and feasible procedure with adequate comfort for patient and surgeon. This way of working increases the optimal position of the electrode resulting in the most convenient stimulation pattern and avoiding revisions.

ABSTRACT 7

The use of peripheral nerve blocks for trauma patients: a survey in Belgian emergency departments.

Puype L, Desmet M, Van Belleghem V, et al. Acta Clinica Belgica, 2020, 75, 1-41

INTRODUCTION Pain is a common symptom in the emergency department (ED). Peripheral nerve blocks (PNBs) can offer specific advantages for the trauma patient.

OBJECTIVE This study aimed to evaluate to what extent PNBs for traumapatients are performed in the Belgian EDs.

MATERIALS/METHODS This cross-sectional survey was conducted from February to July 2019. The medical chiefs of the Eds of 124 acute care hospitals in Belgium were contacted by telephone regarding the use of PNBs after trauma in their ED. The survey assessed the use of a peripheral nerve block (PNB) based on a 26-item questionnaire.These questions had items related to the type of hospital and ED.

RESULTS The response rate of the survey was 90%. In 84% of the hospitals, PNBs were performed after trauma. A similar proportion (90%) had a specific pain protocol for trauma patients. In 6% of the ED, PNBs were formally integrated in a multimodal analgesic protocol. Hip fractures were considered the main indication and ultrasound (US) was the preferred technique. However, the majority of the blocks were performed in the operating theatre (68%). According to our respondents, the main reason why they did not perform blocks in their ED, was a lack of training. Intralipid was readily available in 50% of the EDs.

CONCLUSION Although the vast majority of the hospitals perform PNBs after trauma, they are rarely incorporated in pain protocols for trauma patients. However, the majority of ED physicians are convinced of the added value of PNBs. Lack of training, time constraint and logistic challenges are the most important reasons why PNBs are not performed in Belgian EDs. Currently, the majority of PNBs are performed in the operating theatre. Providing PNBs early after arrival at the ED increasesthe quality of care and should not be delayed. Therefore, PNBs are ideally performed in the ED. Our survey demonstrated that the vast majority of ED physicians is convinced of the added value of PNBs. Although PNBs are frequently performed after trauma, they are rarely incorporated in pain protocols for trauma patients.

PRESENTATIES

ABSTRACT 8

The 10 most influential papers of 2019.

Desmet M

January 2020, ESRA Winterweek, Langefeld - Oostenrijk

ABSTRACT 9

Problem based learning discussion: conflict management in the OR.

Desmet M

January 2020, ESRA Winterweek, Langefeld - Oostenrijk