Newsletter July 2020: The paper which changed my practice

Upper Extremity Regional Anesthesia: Essentials of Our Current Understanding, 2008
Neal JM, Gerancher JC, Hebl JR, et al. Reg Anesth Pain Med 2009;34:134–70

Bernardo Matias


Regional anaesthesia is a field of our speciality that has dramatically developed over recent years, in particular peripheral nerve blocks, with the widespread use of ultrasound for nerve localisation, and the evolution of both single shot and continuous techniques, including growing evidence for the use of adjuvant drugs to local anaesthetics. These procedures have several advantages, both for patients (such as improved outcomes and reduced postoperative pulmonary complications), whether they are used with analgesic or anaesthetic purpose, and organisational aspects (like decreased operating room turnover time). This has even led to the identification, by the European Board of Anaesthesiology, of “regional anaesthesia” as an independent domain of general care competencies, included in the last version of the “European Training Requirements in ANAESTHESIOLOGY”1.

Personally, one of the articles that most contributed to my fundamental knowledge in this area was “Upper Extremity Regional Anesthesia: Essentials of Our Current Understanding, 2008”. As mentioned in that publication, after “Recognising that upper extremity neural blockade represents the most frequent use of peripheral nerve blocks in most anesthesiologists’ practice, in 2001, the American Society of Regional Anesthesia and Pain Medicine (ASRA) undertook a critical review of all available English-language publications pertinent to this topic. The resulting extensive source document was synthesised into a comprehensive review article that was published in 2002.” The goal was that both the source and the review documents would be updated approximately every 5 years, and the most recent version is the mentioned article.

Arm in sling

It is a very informative publication, that “strives (1) to serve as a review of pertinent anatomy, (2) to compare the effectiveness of brachial plexus approaches and techniques, (3) to present available evidence to guide the selection of pharmacological agents, (4) to describe the complications inherent to upper extremity anaesthesia, (5) to consider pertinent perioperative issues, and (6) to identify information gaps and emphasise where we believe further study is warranted”. One of the main modifications of this issue is the increasing use of ultrasound, which improves resident learning of techniques, have fewer needle passes, less patient discomfort, and improved block success rates, compared to other methods of nerve localisation. The only major disadvantage is the time since its release, but hopefully and the updated version will be made available shortly.

With the success of this initiative, 2 other articles were published as “Essentials of Our Current Understanding”, focused on “Lower Extremity Regional Anesthesia” (initially in 2005 and updated in 20192) and “Abdominal Wall Blocks” (20173). Both try to follow the structure of the initial article, regarding relevant anatomy, procedure steps, significant safety concerns and specific indications, like the role of truncal blocks in obstetric patients, through an evidence-based approach anchored is an extensive bibliographic review.

In summary, the article “Upper Extremity Regional Anesthesia: Essentials of Our Current Understanding, 2008“ in particular, but also the whole “Essentials of Our Current Understanding” series from the Regional Anesthesia and Pain Medicine journal represent an invaluable piece of information for practitioners of all levels of expertise, whether they are beginners (with didactic images of the pertinent anatomy, including common variations), non-regional anaesthesiologists (looking to revise the most important aspects of the more commonly used blocks) or experts (searching for the current general literature available, before diving into a more particular issue of the growing body of publications on these techniques).

1. ETR Anaesthesiology 2018 (https://www.eba-uems.eu/resources/PDFS/EPD/ETR-Anaesthesiology-2018.pdf)
2. Tran DQ, et al. Reg Anesth Pain Med 2019;44:143143:143143–143180–143180
3. Chin KJ, et al. Reg Anesth Pain Med 2017;42: 133–183


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