Introduction: The use of regional anesthesia (RA) by emergency physicians (EPs) is expanding in frequency and range of application as expertise in point-of-care ultrasound (POCUS) grows, but widespread use remains limited. We sought to characterize the use of RA by Canadian EPs, including practices, perspectives and barriers to use in the ED. Methods: A cross-sectional survey of Canadian EPs was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of sixteen multiple choice and numerical responses. Responses were summarized descriptively as percentages and as the median and inter quartile range (IQR) for quantitative variables. Results: The survey was completed by 149/1144 staff EPs, with a response rate of 13%. EPs used RA a median of 2 (IQR 0-4) times in the past ten shifts. The most broadly used applications were soft tissue repair (84.5% of EPs, n = 126), fracture pain management (79.2%, n = 118) and orthopedic reduction (72.5%, n = 108). EPs agreed that RA is safe to use in the ED (98.7%) and were interested in using it more frequently (78.5%). Almost all (98.0%) respondents had POCUS available, however less than half (49.0%) felt comfortable using it for RA. EPs indicated that they required more training (76.5%), a departmental protocol (47.0%), and nursing assistance (30.2%) to increase their use. Conclusion: Canadian EPs engage in limited use of RA but express an interest in expanding their use. While equipment is available, additional training, protocols, and increased support from nursing staff are modifiable factors that could facilitate uptake of RA in the ED.

Background and objective: A new posterior approach to the sciatic nerve in the subgluteal region was developed. We describe our clinical experiences on 135 consecutive patients.

Methods: All blocks were performed with a nerve stimulator (stimulation frequency 2 Hz; intensity from 1 reduced to ≤0.5 mA before application). A line was drawn from the greater trochanter to the ischial tuberosity of the femur; then, from the mid-point of this line, a second line was drawn perpendicularly and extended caudally for 4 cm: the end of this line represented the entry point of the needle. Sciatic stimulation was elicited at ≤0.5 mA; then ropivacaine 0.75% 20 mL was injected. An independent observer recorded the time from needle insertion to successful sciatic nerve stimulation (performance time), the depth of appropriate sciatic stimulation and the number of needle redirections, as well as the quality of nerve block, the discomfort during the procedure and patient acceptance.

Results: The performance time was 41 ± 25 s (mean ± SD) and the mean (SD) depth at which the sciatic nerve stimulation was found was 45 ± 10 mm. The median (range) number of needle redirections required to find the proper sciatic stimulation was 2 (1–5). The tibial response was observed in 77 patients (57%), while the common peroneal response was observed in 58 patients (43%). The degree of discomfort reported was very low and only 16 patients (12%) reported severe pain during placement of the block. The onset time (mean ± SD) of sensory and motor block was 7 ± 4 and 17 ± 13 min respectively, and the surgical procedure was completed with only the peripheral nerve block in 127 patients (94%). The same anaesthesia procedure was acceptable by 127 patients (94%) and only eight patients (6%) would prefer a different anaesthesia technique in the future.

Conclusions: The study demonstrated that the sciatic nerve can be easily blocked using this new posterior subgluteal approach, suggesting that it represents a safe and effective alternative to block the sciatic nerve at a proximal level, with the potential for reducing the discomfort experienced by the patient during block placement.

Background and objective: Unilateral paravertebral nerve blockade has been reported to produce excellent afferent nerve block, reduce the incidence of postoperative nausea and vomiting, and reduce hospital stay following inguinal hernia repair. The aim was to compare the use of bilateral paravertebral blocks to regular general anaesthesia for ventral hernia repair.

Methods: Sixty patients were prospectively allocated to receive either bilateral paravertebral nerve blockade (midazolam for block; supplemented with light intraoperative sedation if needed) or general anaesthesia for ventral hernia repair. The end-points of the study were length of hospital stay, postoperative analgesia (visual analogue scale, supplemental opioid requirement) and incidence of postoperative nausea and vomiting.

Results: The duration of hospital stay was observed to be shorter in patients handled with bilateral paravertebral nerve blockade (2.3 [SD 1.3] days) compared with patients receiving general anaesthesia (4.1 (3.0) days). Paravertebral analgesia resulted in both lower visual analogue scores and a significantly reduced need for supplemental opioid administration during the first 48 h postoperatively compared with general anaesthesia (P < 0.001). The rate of postoperative nausea and vomiting in the paravertebral nerve blockade group was only 3.3%, while 26.7% of patients in the general anaesthesia group suffered from postoperative nausea and vomiting (P < 0.05). Paravertebral nerve blockade was associated with good patient acceptance in 90% of patients.

Conclusions: Bilateral paravertebral blockade combined with light intravenous sedation was superior to general anaesthesia for ventral hernia repair. Paravertebral blockade was associated with shorter hospital stay, improved analgesia and less postoperative nausea and vomiting. It is suggested that this technique deserves more widespread use in patients undergoing ventral hernia repair.

Background and objective: Patients' perception of limb position during regional anaesthesia is frequently incorrect. The incidence and nature of this phenomenon has not yet been completely described. The aim of this prospective study was to assess phantom sensation in patients undergoing a brachial plexus block.

Methods: Axillary block was performed in 81 patients with the aid of a peripheral nerve stimulator. Immediately after the block, patients were allocated randomly to two groups (Group 1, n = 40; Group 2, n = 41) to have the blocked limb placed either on their thorax or in abduction. Fifteen minutes later, when the block was complete, the position of the limb was changed, without the knowledge of the patient, to a new position of abduction and flexion of the forearm. Patients were questioned about the new limb position. Fifteen minutes later, the limb was then transiently shown to the patient and further placed ‘blindly’ to another position. Patients were once more questioned about this new position.

Results: Correct perception was more frequently observed in both groups following the first interview. Thirty-two and 34 patients gave at least one erroneous response about their limb position when it was initially placed on the thorax or in abduction respectively. Transient visualization of the limb position did not improve the rate of correct response.

Conclusions: Patients' perception of the position of the limb after axillary block in the majority of instances was probably due to persisting sensory inputs from the shoulder joint, which is not involved in this block. This in contrast to supraclavicular or interscalene blocks. A significant number of patients experienced phantom limb sensation. They reported an arm position in fact related to the position of their arm before the axillary block.

Occipital nerve block is usually considered to be a very simple and safe regional anaesthetic technique. We describe a case of sudden unconsciousness during a lesser occipital nerve block in a patient with an occipital bone defect. A 63-year-old man complained of headache, which was localized to the right occipital region. A right lesser occipital nerve block with a local anaesthetic was performed for treatment. During the lesser occipital nerve block, the patient suddenly became disturbed and lost consciousness. Two hours after the incident, the patient was fully awake without neurological sequelae. He had previously undergone a microvascular decompression for right trigeminal neuralgia. The patient had a bone defect following craniotomy. We believed that the loss of consciousness during lesser nerve block may be due to a subarachnoid injection. Occipital nerve block is relatively contraindicated in the presence of a bone defect.

Nasal endoscopy is a valuable adjunct to the localization of the sphenopalatine ganglion. Twenty-two patients with advanced malignancies of the head and neck region whose pain was not adequately controlled with conventional medications, including oral morphine, were given nasal endoscopically guided neurolytic sphenopalatine ganglion block with six per cent phenol after a prognostic block with local anaesthetic solution. Seventeen patients had good immediate relief. One had partial relief and four had inadequate relief. On follow-up for one month, the patients had significantly lower pain intensity and the pain was more manageable with oral medication. The vicious cycle of pain was broken. This block is relatively safe and can be usefully performed as an out-patient procedure.

Background and aim We evaluated the effect of the injection technique on the onset time and efficacy of interscalene brachial plexus anaesthesia.

Methods With Ethical Committee approval and written consent, 30 patients undergoing elective shoulder acromioplasty or capsuloplasty were randomly allocated to receive interscalene brachial plexus block with 20 mL of ropivacaine 0.75% by using either a single injection (Single group, n = 15) or multiple injection (Multiple group, n = 15). Nerve blocks were placed with the aid of a nerve stimulator using short bevelled, Teflon® coated needles. The stimulation frequency was set at 2 Hz and the intensity of stimulating current, initially set at 1 mA, was gradually decreased to ≤0.5 mA after each muscular twitch was observed. In the Single group, the anaesthetic solution was slowly injected after the first muscular twitch had been observed. In the Multiple group, 6mL were injected at shoulder abduction, 6mL were njected at arm flexion, and 6ml_ at the extension of the arm.

Results Placing the block required 5min (4–8 min) in the Multiple group and 3 min (1–10 min) in the Single group (P=0.001); however, total preoperative time (from skin disinfection to complete loss of pinprick sensation from C4 to C7 with inability to elevate the limb from the operating table) was shorter in the Multiple group (15 min; range 10–28 min) than in the Single group (23 min; range 14–60 min) (P=0.03). Additional intravenous fentanyl supplementation was required in two patients of the Multiple group (13%) and eight patients of the Single group (53%) (P=0.05).

Conclusion We conclude that using a multiple injection technique shortened the preparation time and improved the quality of interscalene brachial plexus anaesthesia performed with small volumes of ropivacaine 0.75%.

An acute pain service (APS) was set up to improve pain management after operation. We attempted to reduce the length of stay in the intensive care unit (ICU) of patients undergoing major surgery and to improve their homeostasis and rehabilitation using a multimodal approach (pain relief, stress reduction, early extubation). Patient-controlled epidural analgesia (PCEA) was a keystone of this approach. If PCEA was not applicable, patients received patient-controlled intravenous analgesia (PCIA) instead. Brachial plexus blockade (BPB) was used for surgery of the upper limbs. A computer based documentation system was used to help evaluate prospectively (a) the quality of analgesia, (b) adverse effects and risks of the special pain management techniques, and (c) cost-effectiveness.

Patients receiving PCEA (n = 5.602) received a patient-titrated continuous infusion into the epidural space of either bupivacaine 0.175% or ropivacaine 0.2%, with 1 μg sufentanil mL−1 added, followed by patient-controlled boluses of 2 mL (lockout time 20 min). For patients receiving PCIA (n = 634) an initial bolus of 7.5–15 mg piritramide was given, and the subsequent bolus was 2 mg (lockout time 10 min). A continuous infusion of bupivacaine 0.25% was administered to patients receiving BPB (n = 113). The dose was titrated to a dynamic visual analogue scale (VAS) scores < 40.

The mean treatment periods were: BPB = 4.33 days, PCEA = 5.6 days, PCIA = 5.0 days. In the case of PCEA, the quality of pain relief, vigilance and satisfaction were superior compared with the PCIA method, which resulted in greater sedation and nausea. Although personal supervision was higher for the PCEA-treated patients, cost analysis revealed final savings of €91 620 for the year 1998 obviating the need for an ICU stay totalling 433 days.

Provided that PCEA is part of a fast-track protocol employing early tracheal extubation and optimal perioperative management, the associated initial higher costs will be recouped by the benefits to patients of better pain relief after surgery and fewer days subsequently spent in the ITU.

To evaluate the effects of adding low-dose fentanyl to 0.75% ropivacaine during peripheral nerve blocks, 30 ASA physical status I–II patients undergoing hallux valgus repair under combined sciatic–femoral nerve block were randomly allocated in a double-blind fashion to receive nerve block placement with 30 mL of either 0.75% ropivacaine alone (group: ropivacaine, n=15) or 0.75% ropivacaine plus fentanyl 1 μg kg−1 (group: ropivacaine–fentanyl, n=15). A blinded observer recorded haemodynamic variables and sedation, as well as the time required to achieve surgical block and the first request for analgesia. Readiness to surgery required 10 min (5–20 min) with 0.75% ropivacaine and 10 min (3–20 min) with the ropivacaine–fentanyl mixture. No differences in the degree of sedation, peripheral oxygen saturation, and haemodynamic variables were observed between the two groups. The degree of pain measured at first analgesic request, and the consumption of postoperative analgesics, was similar in the two groups, while the mean time from block placement to the first request for pain medication was 13.7 h (25–75th percentiles: 11.8–14.5 h) in the ropivacaine group and 13.9 h (25–75th percentiles: 10.5–14.5 h) in the ropivacaine–fentanyl group (P=not significant). We conclude that adding fentanyl 1 μg kg−1 to 0.75% ropivacaine did not provide clinically relevant advantages in terms of onset time, quality and duration of combined sciatic–femoral nerve block in patients undergoing elective hallux valgus repair.

Amide local anaesthetics inhibit platelet function. We hypothesized that residual anaesthetic in the epidural space could decrease efficacy of an epidural blood patch in preventing postdural puncture headache. Levobupivacaine has recently been approved for epidural anaesthesia. Its effects on coagulation have not previously been studied. The aim of this study was to determine the effects of levobupivacaine on clotting using thromboelastography. Ten ASA Class I volunteers were studied. Venous blood samples were analysed using a Haemoscope 2000D TEG analyser. Whole blood, a 50% saline control and two levobupivacaine solutions (2.5 mg mL−1 and 2.5 μg mL−1 in blood) were compared. The former reproduces that produced in the epidural space by blood (20 mL for an epidural blood patch) and levobupivacaine 0.5% (20 mL). The latter approximates plasma concentrations following epidural injection of levobupivacaine 0.5% (20 mL). P < 0.05 was considered significant. Maximum amplitude (MA), a measure of clot strength, is decreased by levobupivacaine 2.5 mg mL−1. Levobupivacaine 2.5 mg mL−1 decreases clot strength and may reduce efficacy of a prophylactic epidural blood patch.