( Anaesthesia . 2023;78(9):1129–1138) Neuraxial labor analgesia is a well-established and effective method for managing pain during labor. The initiation of analgesia through epidural or combined spinal-epidural methods can be followed by various maintenance techniques, including continuous epidural infusion, manual intermittent boluses, patient-controlled epidural analgesia (PCEA), programmed intermittent epidural bolus (PIEB), or a combination of these approaches. Adding PCEA to a continuous infusion was long-favored, demonstrating benefits such as reduced breakthrough pain incidents, lower local anesthetic consumption without compromising efficacy, and heightened patient satisfaction compared with continuous epidural infusion.

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient-controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non-inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non-inferiority of patient-controlled epidural analgesia with respect to breakthrough pain; and superiority of patient-controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient-controlled epidural analgesia-only or programmed intermittent epidural bolus groups. The patient-controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 μg.ml-1 ; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient-controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups. Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non-inferiority). Total ropivacaine consumption was lower in the PCEA-group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient-controlled epidural analgesia is non-inferior to programmed intermittent epidural bolus if equal volumes of patient-controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.

The reported case describes a patient with hereditary neuropathy with liability to pressure palsies (HNPP) requiring a neurosurgical laminotomy procedure for an arachnoid cyst with medullary compression. HNPP is a rare pathology requiring meticulous anesthetic and surgical management. We give a detailed overview of the planning, simulation, and performance of the anesthesia procedure in order to minimize all potential risk factors for perioperative nerve injury. During the preparation of this case, where the positioning was extremely challenging, we reviewed the available literature for guidance. A few papers report the use of neuraxial anesthesia in patients previously diagnosed with HNPP. No reports could be found on the management of general anesthesia and positioning for major surgery in those patients.

During the COVID-19 pandemic, multiple guidelines have been issued on hospital safety and protection measures to prevent transmission to healthcare workers and to other patients. The operating room is a high-risk environment where enhanced precautions are required. The guidelines differ and practical implementation between hospitals can also vary, according to interpretation and budget. Staff at risk may question if the local policies are sufficient and correct. This article provides an overview and theoretical background to the additional safety measures required in the operating room during a viral pandemic like the COVID-19 pandemic. This may serve as a touchstone and tool for anesthetists and OR managers.

The Peripheral Nerve Block working group of the Belgian Association for Regional Anesthesia has revised and updated the “Clinical guidelines for the practice of peripheral nerve block in the adult” which were published in 2013.

The interfascial thoracic wall blockades Pecs I and Pecs II are increasingly applied in breast and axillary surgery. Despite the clear anatomical demarcations depicted at their introduction, the clinical outcome is more variable than would be expected based upon the described anatomy. In order to elucidate factors that explain this variability, we evaluated the spread of each injection—medial Pecs I, lateral Pecs I, the deep injection of the Pecs II—separately. A correlation of in vivo landmarks and ultrasound images with ex vivo ultrasound, reconstructed anatomical planes, histology and magnetic resonance imaging. The medial Pecs I, similar to the sagittal infraclavicular block positioning with needle position medial to the pectoral branch of the thoracoacromial artery, reaches the medial and lateral pectoral nerves. The lateral Pecs I, below the lateral third of the clavicle at the level of the third rib with needle position lateral to the pectoral branch of the thoracoacromial artery, additionally spreads to the axilla and reaches the intercostobrachial nerve. The deep Pecs II injection spreads to the lateral cutaneous part of the III–VI intercostal nerves and reaches the long thoracic nerve. The variability of the Pecs anesthetic blockades is driven by the selected Pecs I approach as only the lateral approach stains the intercostobrachial nerve. The pectoral branch of the thoracoacromial artery can serve as the landmark to differentiate the needle position of the medial and lateral Pecs I block. Clin. Anat. 32:421–429, 2019. © 2019 Wiley Periodicals, Inc.

Supplemental Digital Content is available in the text

Editor, In an earlier prospective double-blind placebo-controlled randomised controlled trial (RCT), we evaluated the analgesic characteristics of the pectoral block type II (PECS II). We concluded that PECS II (30 ml levobupivacaine 0.25%) significantly reduces postsurgical pain and opioid requirements during the postanaesthesia care unit (PACU) stay compared with placebo (30 ml NaCl 0.9%) in breast cancer surgery. 1 The block is easy to implement and requires limited follow-up. Given these short-term benefits, many practitioners have adopted it in clinical practice. Persistent pain after breast cancer surgery (PPBCS) is defined as persistent neuropathic pain that lasts for more than 3 months after surgery. PPBCS is experienced by up to two-thirds of female patients. 2 The influence of PECS II on the incidence of PPBCS is unknown. We performed a questionnaire follow-up, based on the survey of Peuckmann et al. 3 to evaluate whether PECS II reduces PPBCS compared with placebo. The prevalence of PPBCS was similar in both PECS II and placebo groups. Table 1 summarises the key results; a full overview is published online; https://links.lww.com/EJA/A180. We found no reduction in pain intensity, pain frequency or number of locations in which pain is perceived. Patients who received PECS II did not require less pain therapy, nor did they consume fewer analgesics nor did they experience less sensory disturbance or discomfort.Table 1: Selection of study results with α = 0.05 and using χ2 tests or t testsPredictive factors of PPBCS development are younger age, radiotherapy, axillary lymph node dissection, pre-operative pain and acute postoperative pain. 2 Age, radiotherapy and axillary lymph node dissection were equally represented in both groups and therefore should not have influenced our results. Pre-operative pain was a risk factor we could not evaluate, as patients with pre-existing pain were excluded from the initial study. Hence, acute postoperative pain is the only risk factor in this research. Insufficient treatment of acute postoperative pain is assumed to generate central sensitisation during or immediately after surgery resulting in chronic pain. 4 In our study, patients received analgesics according to the hospital's protocol and both groups were satisfied with their pain management. Patients who received PECS II required less opioids in the PACU and a negligible amount on the ward. However, 2 years after surgery, both groups reported about 40% PPBCS presence which is consistent with large-scale studies. 3 Intriguingly, patients reported a period of approximately 4 months postsurgery in which they do not recall pain sensation related to the breast surgery. Studies with the paravertebral block also observed such pain absence up to 6 months after surgery. 5 Breast cancer surgery can result in nerve damage, trigger inflammation and lymphoedema and hence result in PPBCS despite optimal acute pain management. 3,6 Ilfeld et al. 6 investigated the benefits of a continuous versus single-injection paravertebral block for acute and chronic pain after mastectomy. Significantly, the results showed a benefit on acute pain during infusion, no difference after 3 months and a clear benefit for continuous infusion over single shot on chronic pain after 12 months with 13 versus 47% of patients experiencing pain. The difference at 12 months and not at 3 months correlates with the theory of acute inflammatory versus chronic pain. We therefore hypothesise that we could address some of the long-term effects caused by breast cancer surgery by using a continuous PECS II. Nevertheless, PPBCS is caused by several mechanisms, also nonneuropathic, and thus requires a number of strategies. 7 We therefore suggest further research to study a continuous PECS II with regimens of gabapentinoids, antidepressants and multimodal analgesia. To summarise, a single-shot PECS II reduces opioid consumption and acute postoperative pain after breast cancer surgery. However, it does not prevent the occurrence of PPBCS. Limitations of this study are the absence of a psychosocial baseline or conditioned pain modulation and the self-diagnosis of PPBCS. The population was limited to the patients enrolled in the RCT and hence not a priori powered for this follow-up study. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: funding granted by the Anaesthesiology department of GZA Sint-Augustinus, Wilrijk, Belgium. Conflicts of interest: none. Institution where the work was carried out: GZA Sint-Augustinus; Oosterveldlaan 24, 2610 Wilrijk, Belgium. The authors sincerely thank Nancy Belmans for her diligent record keeping.

A 30-year old female patient with a history of relapsing-remitting multiple sclerosis (MS) was planned for an elective cesarean section. Additionally, the patient suffered from Generalized Anxiety Disorder. After careful discussion with the patient, spinal anesthesia was chosen for the procedure. The anesthetic course was uneventful and cesarean section was without incident. No per-or post-operative complications were observed. No relapse or disease aggravation occurred in the first three months following delivery. Subsequently, a more profound MEDLINE and EMBASE literature search was conducted to review current evidence regarding safety of neuraxial anesthesia, and more specifically spinal anesthesia, in patients with MS. Neuraxial anesthesia has historically always faced considerable skepticism in this population. Current consensus, however, postulates no contra-indication for the use of neuraxial anesthesia in patients with MS. Epidural anesthesia remains the conventional neuraxial technique for purely paradigmatic reasons. A number of cases may nowadays safely benefit from a spinal technique.

The pectoral nerves (Pecs) blocks are challenging the conventional approach of basing change in practice on scientific evidence. Indeed, several practitioners have already incorporated these blocks into their practice before conclusive evidence regarding their efficacy and safety has been published. This systematic literature review examines the analgesic efficacy of Pecs type I and II blocks for their current indications. We searched publications indexed by MEDLINE, EMBASE, Cochrane Library and Google Scholar from inception to October 2016 without publication type, status, language or publication period restrictions. In addition, we searched references and citations for other relevant studies. Results from our systematic literature search show encouraging and consistent evidence that the Pecs blocks produce effective analgesia, and reduce perioperative opioid consumption as compared to control groups without regional anesthesia, as well as other regional anesthesia techniques. Furthermore, the Pecs blocks provide favorable analgesic results in a wide range of indications including regional anesthesia and pain medicine technique. The absence of block-related complications reported in the literature may suggest that the Pecs blocks are easy to apply and safe for patients.

STUDY OBJECTIVEThe aim of this clinical trial was to test the hypothesis whether adding the pectoral nerves (Pecs) block type II to the anesthetic procedure reduces opioid consumption during and after breast surgery.DESIGNA prospective randomized double blind placebo-controlled study.SETTINGA secondary hospital.PATIENTS140 breast cancer stage 1-3 patients undergoing mastectomy or tumorectomy with sentinel node or axillary node dissection.INTERVENTIONSPatients were randomized to receive either a Pecs block with levobupivacaine 0.25% (n=70) or placebo block with saline (n=70).MEASUREMENTSThe pain levels were evaluated by Numeric Rating Scale (NRS) pain scores at 15-minute intervals during the post anesthesia care unit stay time (PACU), at 2-hour intervals for the first 24h on the ward and at 4-hour intervals for the next 24h. Intraoperative and postoperative opioid consumption were recorded during the full stay. Patient satisfaction was evaluated upon discharge using a 10-point scale.MAIN RESULTSIntraoperative sufentanil requirements were comparable for the Pecs and placebo group (8.0±3.5μg and 7.8±3.0μg, P=0.730). Patients in the Pecs group experienced significantly less pain than patients in the control group (P=0.048) during their PACU stay. Furthermore, patients in the Pecs group required significant less postoperative opioids (9.16±10.15mg and 14.97±14.38mg morphine equivalent, P=0.037) and required significant fewer postsurgical opioid administration interventions than patients in the control group (P=0.045). Both patient-groups were very satisfied about their management (9.6±0.6 and 9.1±1.8 on a 10-point scale, P=0.211).CONCLUSIONSThe Pecs block reduces postsurgical opioid consumption during the PACU stay time for patients undergoing breast surgery.

We assessed the practice of obstetric anesthesia in Flanders through an on-line enquiry form and investigated the advancements by comparing the results with those of the 2004 survey. 54 (86%) structured forms were completed, representative for 94% of the accredited maternity beds in Flanders. Obstetric anesthesia is provided in all Flemish acute hospitals and 7/10 deliveries are performed nowadays with neuraxial analgesia. For labor analgesia, classical epidural remains the main neuraxial technique (62%) whereas CSE is used as default technique in 17% of the hospitals and upon indication in 21%. In half of the departments a test dose is used to validate the correct placement of the catheter, with lidocaine as the most (68%) commonly used test drug; this practice is comparable to 10 years ago. Ropivacaine (84%) with or without sufentanil is typically used as loading dose and ropivacaine with sufentanil (83%) to maintain the epidural analgesia. Patient-controlled epidural analgesia is the preferred maintenance mode (76%) for labor analgesia. CSE, with hyperbaric bupivacaine and sufentanil is the most used anesthesia protocol when caesarean section is required (47%). There is no clear preference for postoperative analgesia after cesarean section as both epidural/regional and parenteral/per os analgesia regimens are almost equally used in Flemish obstetric care.

Gastric ultrasound (GUS) is an emerging point-of-care diagnostic tool to examine stomach contents and determine pulmonary aspiration risk at the bedside.1–7 This type of assessment is useful to guide airway and/or anaesthetic management in the acute care setting, when NPO (nil per oral) status is questionable or unknown. A point-of-care ultrasound application has a well-defined purpose, aimed at improving patient outcome and is therefore focused and goal oriented; the findings need to be easily recognizable and the examination easily learnt and quickly performed at the patient’s bedside.

Purpose : The purpose of this study was to evaluate the use of an ultrasound guided femoral nerve (FN) block together with an ultrasound guided lateral femoral cutaneous nerve (LFCN) block in addition to a patient controlled intravenous analgesia (PCIA) pump with piritramide as a strategy for postoperative pain-management after primary hip arthroplasty.Methods : In a retrospective study, data recorded from 32 patients undergoing primary hip arthroplasty in 2008, before peripheral blocks were used, were compared with data from 38 patients undergoing primary hip arthroplasty in 2011, when an ultrasound guided single shot FN and LFCN block was used. As primary endpoint the total piritramide consumption after 48 hours was analyzed. A score on a visual analog pain scale at rest and during movement was included as a secondary outcome.Results : Patients receiving the peripheral nerve blocks used significantly less piritramide in comparison to the patients who received no peripheral nerve blocks (p < 0.01). Moreover, pain scores at rest and during movement were significantly lower in the group with the peripheral nerve block (p-values respectively < 0.01 and < 0.05).Conclusions : This retrospective study indicates that a FN block in combination with a LFCN block as supplementary postoperative analgesia after primary hip arthroplasty, can reduce the piritramide consumption. Furthermore, patients receiving the peripheral nerve block report lower pain scores at rest and during movement compared with the patients who did not receive a peripheral block. However, as this is a retrospective study, conclusions have to be drawn cautiously.

These guidelines, made by BARA, are, like the "Safety First Guidelines" of the SARB, clinical recomendations for a good and safe practice when performing peripheral nerve blocks (PNB). These recommendations were made according to the most recent literature and experts opinion and are therefore prone to changes due to evolution of literature. The guidelines deal with "Informed Consent", preoperative visit, monitoring, equipment and the PNB procedure itself regardless of using ultrasound or neurostimultion or both. Advise is given when combining a PNB with general anesthesia and when a catheter technique is used.

The use of locoregional anaesthesia in obstetrics in Flanders was assessed by a postal questionnaire sent to the directors of the anaesthesia departments of the 72 hospitals with an obstetric unit. 59 (82%) answers were returned. In the group of parturients who had a vaginal delivery a neuraxial technique was requested by 65% of the patients and consisted of epidural analgesia in 84%, and combined spinal epidural analgesia in 16%. Test doses are used in labour in 67%. To perform the block - spinal as well as epidural - the sitting position is somewhat preferred over the left lateral (55 versus 45%). For caesarean section general anaesthesia was used in only 5 % of the deliveries, whereas spinal, single or as a part of a CSE technique, was preferred in 80 %; the epidural technique was applied in 15%. There is no clear preference in technique for postoperative analgesia after caesarean delivery as both parenteral and epidural analgesia are used in 50% of the cases.

Eighty term parturients requesting epidural analgesia for labor pain treatment were randomly assigned to receive bupivacaine 0.125%, sufentanil 0.75 microgram/ml and epinephrine 1/800.000 by PCA modality with or without a basal rate of 3 ml/hr. A loading of 10 ml using the same mixture was administered while the PCA-demand dose consisted of 3 ml (lock out time 12 minutes). Total consumption, duration of labor, pain scores during the first and second stage of labor, maternal satisfaction and side-effects did not differ among both groups. Only when short labours were considered total consumption was lower in those treated with the demand modality only but they tended to experience more pain during the second stage. We conclude that for shortlasting labors, a low dose epidural PCA regimen results in a dose-sparing effect when compared to PCEA combined with a background infuson. For longer-lasting labors no differences between the two modalities could be observed.