PRINTER-FRIENDLY VERSION AVAILABLE AT ANESTHESIOLOGYNEWS.

COM

International Roundtable:
7 Regional Anesthesia Questions

W
e invited a member of our editorial advisory board, Admir Hadzic, MD, PhD,
A
ll

to select a group of international experts and ask them seven questions of

rig

Co
ht

his own choosing. (Note that not everyone answered all of the questions.)
py
s

rig ed.
re

ht
se
rv

ADMIR HADZIC, MD, PHD ANA M. LOPEZ, MD, PHD, DESA

20

Anesthesiologist Consultant, Anesthesiology

23
Re

Department of Anesthesiology Department of Anesthesiology

M
pr

Ziekenhuis Oost-Limburg ZOL Ziekenhuis Oost-Limburg ZOL

cM
od

Genk, Belgium Genk, Belgium

Founder, NYSORA
uc

ah in w
tio

on

FRANKLIN CHIAO, MD, MBA, MS, MSC, LAC, PETER MERJAVY, MD, PHD, EDRA, FRCA, CETC
n

Pu

FASA Consultant Anaesthetist and Acute Pain Lead

Craigavon Area University Teaching Hospital
bl

Chief of Pediatric Anesthesia, Medical Director

Portadown, Northern Ireland
is

Associate Professor of Anesthesiology

ho

hi

WMC Network Honorary Associate Professor

ng
le

Ardsley, N.Y. University of East Anglia

or

Norwich, England
G
ro

MICHAEL ROBERT FETTIPLACE, MD, PHD

in

AMAR SALTI, MD, EDRA

up
pa

Instructor in Anaesthesia
Department of Anaesthesia Consultant, Anesthesia and Pain Management
un ou
rt

Harvard Medical School Cleveland Clinic Abu Dhabi

w

le

Assistant in Anesthesia United Arab Emirates

ith

ss

Department of Anesthesia, Critical Care and Pain Medicine Adjunct Clinical Professor
ot

Massachusetts General Hospital Cleveland Clinic Lerner College of Medicine

he

Cleveland
tp

Boston
rw
er

JASPER GEVAERT, MD YOUSSEF TFAILI, MD

is
m

Anesthesiology Resident
is

Anesthesiology Resident
no
si

Department of Anesthesiology Department of Anesthesiology

on

Ziekenhuis Oost-Limburg ZOL

te

Ziekenhuis Oost-Limburg ZOL

Genk, Belgium
d.
is

Genk, Belgium
pr
oh

OLIVER KNOPS, MD JEFF L. XU, MD, FASA

ib

Anesthesiology Resident Chief

ite

Department of Anesthesiology Division of Regional Anesthesia and Acute Pain Management

d.

Ziekenhuis Oost-Limburg ZOL Program Director

Genk, Belgium Regional Anesthesiology and
University Hospital Ghent Acute Pain Medicine Fellowship
Ghent, Belgium Associate Professor of Clinical Anesthesiology
Department of Anesthesiology
Westchester Medical Center/New York Medical College
Valhalla, N.Y.

The participants reported no relevant financial disclosures.

ANESTHESIOLOGY NEWS SPECIAL EDITION 2023 17

 1 Should regional anesthesia and nerve blocks be standardized, considering the
current lack of standards compared with the well-defined guidelines for general
anesthesia administration, which encompass dosing, patient monitoring and
indications?
Chiao: I strongly believe as any body of knowledge
advances and grows, there comes a time when standardiza-
tion is both a natural and necessary evolution. The mere fact
that something is standardized does not mean that innova-
tion and flexibility are lost. I like to use sports analogies, as
A
I am a very involved fan of tennis. When the game of tennis
ll
started, there were not really standards, but everyone was
rig
Co
playing within some framework. Eventually,
ht
py
racquet size and balls were standardized.
s
rig ed.
Nevertheless, we still see variation as part of ‘The mere fact
re
the standard, as players use one-handed or
ht
se
that something is
two-handed backhands and racquet materi-
rv
als have improved. standardized does not
20
Standards are also a way to understand mean that innovation
23
Re
complex fields more easily. There is this
and flexibility are lost.’
M
pr
baseline practice (or standard) that peo-
cM
od
ple expect, so adding more complexity on —Franklin Chiao,
top of this is easier to do. It is also a mat- MD, MBA, MS, MSc, LAc, FASA
uc
ah in w
ter of patient safety, as transfers of care and
tio
on
patient handoffs become easier because
n
Pu
the staff accepting the patient understands better what
bl
intervention or block the patient had. Handoffs must still be
is
done properly, of course.
ho
hi
Sometimes there is not really enough evidence for a
ng
le
standard to smoothly be accepted or created and, in this
or
case, longer periods of time may serve to catalyze the
ro
in
development of standards. In regional anesthesia, I see
up
both of these situations occurring. Evidence for which type
of block is to be used for which surgery has a large body
of research, but the evidence for which needle or needle
length, for example, often has scant evidence. Neverthe-
less, we are all not using spinal needles or intravenous
catheters for our needle techniques. Similarly, wearing ster-
ile gloves seems like an evidence-based practice, but the
actual evidence for infection sources can be scarce.
Lastly, as the chair of the ASA Professional Liability
Committee, we see cases where the standard of practice
is easy to identify or sometimes hard to identify. If there are
standards, it can be easier to make a clear determination if
the standard of care was met. Often standards are looked
at around the region of the practice location where anes-
thesia was given, but if the national and regional standards
become more similar, reviewing and testifying as an expert
witness should be easier as well.
Fettiplace: Anesthesia is both art and science, and “one
size fits all” is too constrictive for most practitioners. How-
ever, standardization of techniques can improve safety, as
was seen in general anesthesia with standardized monitor-
ing, unit-based doses of medication, and feedback in the
form of minimum alveolar anesthetic concentration. Regional
anesthesia utilizes similar concepts, but with the rapid evo-
lution of the field over the past 15 years, there is room to
improve. In particular, standardization of nomenclature,1
18 ANESTHESIOLOGYNEWS.COM
better dosing recommendations2 and continued focus on
evidence-based practice would undoubtedly improve com-
munication among providers and elevate patient care.
Gevaert: In my experience at NYSORA, I’ve observed
that all regional blocks follow a standardized approach,
with each surgical procedure consistently using the same
technique. This not only establishes a clear framework, but
also enables individuals to become profi-
cient in each specific technique. Without
standardization, it becomes challenging
to achieve mastery in certain techniques.
In contrast, my previous centers where I
trained lacked standardization for regional
anesthesia, resulting in techniques varying
depending on the anesthesiologist. Addi-
tionally, older anesthesiologists rarely per-
formed nerve blocks.
Knops: Something I often hear during res-
idency is that multiple roads lead to Rome, a
saying I can certainly agree with. I do, how-
ever, believe that a basic framework concerning the indi-
cations and standardization of patient monitoring would be
beneficial to ensure safe and appropriate care. Standard-
ization creates an environment less prone to mistakes and
reduces miscommunication, as everyone involved can famil-
iarize themselves with the same procedure. As a novice in
locoregional anesthesia, I feel that standardized procedures
pa
definitely enabled me to progress faster than I would’ve if
un ou
every staff member taught their own version.
rt
Lastly, I feel that clear guidelines could encourage
w
le
ith
anesthesiologists who are less familiar with locoregional
ss
techniques to consider implementing them more in their
ot
hospital.
he
tp
Lopez: Yes, although the requirements for patient moni-
rw
er
toring in regional anesthesia are standardized in the same
is
m
way as for general anesthesia. In terms of indications, tech-
e
is
niques and medications, I believe that standardization is
no
si
on
necessary, at least at the institutional level. Currently, there
te
are no official recommendations regarding these matters.
d.
is
Standardization serves as the foundation for a safe work-
pr
ing environment, as it enhances efficiency, reduces errors
oh
and facilitates proficiency in regional techniques. There-
ib
fore, it would be advantageous to establish standardized
ite
indications, techniques and medications for each regional
d.
anesthesia/analgesia technique. This would foster greater
trust from the surgical team and colleagues, enabling a sys-
tematic administration of nerve blocks. Importantly, it would
also help address the existing problem of limited patient
access to regional anesthesia.
The standardization of techniques would also contribute
to improving the quality of evidence in research. Currently,
the heterogeneity of protocols and terminology makes it
challenging to compare studies effectively.
 Merjavy: Regional anesthesia and nerve blocks play a
crucial role in modern anesthesia practice. However, the
current lack of standardized guidelines for their adminis-
tration is concerning. It is imperative to establish clear and
comprehensive standards for regional anesthesia, simi-
lar to the well-defined guidelines already in place for gen-
eral anesthesia. Standardization of regional anesthesia and
nerve blocks would ensure consistent and optimal patient
care across healthcare settings. Clear dosing guidelines
would help minimize the risk for overdosing, ensuring
effective pain control without adverse effects. Moreover,
A
standardized patient monitoring protocols during regional
ll
anesthesia procedures would enhance patient safety and
rig
Co
allow for early detection of complications.
ht
py
Standardization would also address the variability in
s
rig ed.
indications for regional anesthesia, providing clinicians
re
with clear criteria for patient selection. This would promote
ht
se
evidence-based decision making, optimizing patient out-
rv
comes and reducing unnecessary utilization of regional
20
anesthesia techniques.
23
Re
Clear guidelines would facilitate the
‘Anesthesia is both art and
M
pr
education and training of anesthetists in
cM
od
regional anesthesia techniques, ensur- science, and “one size fits
ing minimal competencies, knowledge
uc
ah in w
all” is too constrictive for
and skills. Furthermore, standardiza-
tio
on
tion would enable effective communica- most practitioners. However, component of perioperative care. Stan-
n
Pu
tion and collaboration among healthcare standardization of techniques dardizing regional anesthesia and nerve
bl
teams, enhancing the continuity of care
can improve safety….’
is
and reducing the potential for errors or
ho
hi
misunderstandings. The development of —Michael Robert Fettiplace, MD, PhD Similarity, ASRA (American Society of
ng
le
standardized regional anesthesia proto-
or
cols could potentially improve resource
ro
in
allocation. This could lead to cost savings and increased
up
pa
efficiency within healthcare systems.
un ou
Salti: Yes, regional anesthesia and nerve blocks should
be standardized, given the current lack of clear guidelines
2 In the era of ultrasound, which has become the tacit standard for peripheral nerve
blocks due to its ability to provide visual information about the needle–nerve
relationship, does nerve stimulation still hold value?
Chiao: I absolutely feel that nerve stimulation is a type
of triple-check safety measure for performing nerve blocks.
We traditionally have understood our anatomic landmarks,
and now are able to use ultrasound visualization to recog-
nize patterns where we should inject local anesthesia.
Ultrasound is a double check of our identification of
landmarks. Nerve stimulation is an additional safety mea-
sure. With an expected physical movement from the nerve
stimulation, we can have an added confidence that this
location is the correct one. Moreover, we can identify the
proximity to the epineurium and potentially reduce nerve
injury. By identifying the nerve stimulation at 0.6 mA and
then finding no muscle movement at 0.5 mA, animal mod-
els have shown we are more than likely not in the epineu-
rium, so injection at this location is very safe.
Lastly, convenience is a major factor in deciding which
and standards compared with the well-defined protocols for
general anesthesia administration. The implementation of
standardized recommendations and guidelines is crucial to
ensure consistent and safe practices in regional anesthesia.
Currently, there are significant discrepancies in the
way regional anesthesia and nerve blocks are performed
across different healthcare facilities and even among indi-
vidual practitioners. This lack of standardization can lead
to variations in dosing, patient monitoring and indications,
potentially compromising patient safety and outcomes.
By establishing clear standards for regional anesthesia
and nerve blocks, we can enhance patient care by promot-
ing uniformity in practice.
Tfaili: Absolutely, without a doubt. Regrettably, there is
no consensus on specific guidelines pertaining to regional
anesthesia. The existing information is largely based on
individual opinions rather than standardized recommen-
dations. This poses a significant challenge in establish-
ing uniform clinical practices, unlike the case with general
anesthesia. Furthermore, the field of
anesthesia research suffers from a gen-
eral scarcity of funding, particularly for
projects related to regional anesthesia.
Xu: Regional anesthesia has been
playing a critical role as a fundamental
block procedures is definitely essential
for patient care, education and research.
Regional Anesthesia and Pain Medicine)
and ESRA (European Society of Regional
Anaesthesia and Pain Therapy) have made great efforts
and done remarkable work on standardizing nomenclature
in regional anesthesia, which is a very meaningful step for
rt
our regional anesthesia subspecialty.
w
le
ith
ss
ot
he
tp
rw
er
is
m
e
is
no
si
on
safety measures should be added to a procedure. Fortu-
te
nately, nerve stimulators are compact, fast and easy to use.
d.
is
It is not a particularly onerous or time-consuming task to
pr
use one, either. Nerve stimulators, although uncommonly
oh
used in sensory-only nerve blocks, can still cause paresthe-
ib
sia and indicate which area one should be in. I, therefore,
ite
routinely and primarily use nerve stimulation with periph-
d.
eral nerve motor blocks.
Fettiplace: As detailed by others,3 there are occasions
where ultrasound visualization breaks down, particularly
in obese patients, deep blocks or challenging anatomy. In
these settings, nerve stimulation can provide information
to improve safety. It can also help with identification of ner-
vous tissue that may be difficult to differentiate visually on
ultrasound (e.g., nerve to vastus medialis).
Gevaert: I believe having an additional failsafe is
ANESTHESIOLOGY NEWS SPECIAL EDITION 2023 19
beneficial, but if I had to make a choice, I would pre-
fer ultrasound guidance for regional blocks. I feel confi-
dent and familiar with using ultrasound, and it has become
widely accessible in recent times. While I don’t think nerve
stimulation should be completely disregarded, if I had to
select one method, ultrasound would be my preference.
However, I must admit that I am not fully aware of the cur-
rent evidence regarding its additional value.
Knops: Ultrasound plays a pivotal role in peripheral
nerve block procedures. It is, however, a technique which
is very operator dependent. At the time of injection, you’re
A
still limited to a two-dimensional image. The hand–eye
ll
coordination required to continuously visualize your nee-
rig
Co
dle as well as differentiating tissue on ultrasound require
ht
py
a certain amount of practice. Even for more experienced
s
rig ed.
practitioners, this can still be challenging when an optimal
re
image cannot be acquired, such as in obese patients, or
ht
se
when ideal positioning isn’t possible. I believe nerve stim-
rv
ulation to be an easy and time-efficient extra safety mea-
20
sure, where the advantage vastly outweighs the cost.
23
Re
Lopez: Indeed, nerve stimulation continues to offer valu-
M
pr
able insights that complement the information
cM
od
derived from ultrasound in peripheral nerve
blocks. This combined approach proves par- ‘While I don’t think
uc
ah in w
ticularly beneficial when the ultrasound image nerve stimulation
tio
on
is suboptimal. However, the primary objec-
n
should be completely dures where achieving a successful block is
Pu
tive of nerve stimulation is to enhance safety.
disregarded, if I had critical, such as complex surgeries or cases
bl
It serves as an early warning system, notify-
is
ing practitioners of inadvertent needle–nerve to select one method, where patient factors limit the use of alterna-
ho
hi
contact and aiding in the prevention of intra-
ng
le
neural injection. ultrasound would
or
In educational institutions, these advan- be my preference.’
ro
tages become even more significant as the
—Jasper Gevaert, MD
training process may not always provide a
perfect view of the needle. Additionally, nerve
stimulation imparts an additional layer of ana-
tomic knowledge and understanding of nerve block proce-
dures to residents.
Merjavy: Although real-time ultrasound guidance has
become the widely accepted gold standard for perform-
ing peripheral nerve blocks, there are several indications
where the combination of ultrasound and nerve stimulation
may provide added benefit.
1. Using nerve stimulation (NS) as a “rule out” tool
helps identify the close proximity of the needle tip
to the nerve or plexus when visual confirmation on
the ultrasound screen is not available, especially for
novices or occasional blockers who may not maintain
needle visibility throughout the entire procedure.
2. Using NS as a “rule in” tool helps identify the nerve/
plexus in greater depth when a low-frequency
curvilinear probe with limited resolution is used, such
as in lumbar plexus, parasacral or proximal sciatic
nerve blocks. This can be particularly helpful in
20 ANESTHESIOLOGYNEWS.COM
situations where visibility on the ultrasound screen
may be limited due to significant edema, hematoma,
subcutaneous emphysema, etc.
3. In the presence of peripheral nerve/plexus anatomic
variations, NS can help identify the correct nerve
structure, such as C5 running through or medially
to the anterior scalene muscle, joined median and
musculocutaneous nerves at the axilla, Martin-Gruber
anastomosis at the forearm, etc.
4. NS can occasionally be used to identify the fascial
plane by observing muscle contractions directly
stimulated by the NS needle and the loss of muscle
twitch when entering the interfascial plane.
Salti: While ultrasound has revolutionized the field of
regional anesthesia by enhancing precision and reducing
complications, there are specific scenarios where nerve
stimulation continues to hold value. Particularly for deep
blocks, where visibility with ultrasound may be limited or
challenging, nerve stimulation can be a useful adjunct.
In certain anatomic regions or with certain patient popu-
lations, deep nerve structures may be challenging to visu-
alize clearly using ultrasound alone. In such
cases, nerve stimulation can provide addi-
tional feedback and confirm the accurate
placement of the needle in proximity to the
nerve. This is especially relevant for proce-
tive techniques.
Tfaili: I agree that nerve stimulation still
holds value in clinical practice. Nerve stimu-
in
lation serves as an additional confirmatory
up
pa
step, enhancing the accuracy of the nerve
block. This technique can be particularly help-
un ou
rt
ful when high-quality ultrasound machines
w
le
are not available. In Lebanon, while some centers pos-
ith
ss
sess state-of-the-art ultrasound machines, it is worth not-
ot
ing that many centers do not have ultrasound equipment
he
tp
at all. In such cases, relying on nerve stimulation can be a
rw
er
practical and effective alternative for performing regional
is
m
anesthesia.
e
is
Xu: Nowadays, the majority of nerve blocks are per-
no
si
on
formed under ultrasound guidance. However, nerve stimu-
te
lation still holds great value to identify the target nerves in
d.
is
many clinical situations, such as anatomic variations, post-
pr
surgical anatomic change, deep location with blurred ultra-
oh
sound images, etc. In addition, studies have shown that
ib
combined techniques of ultrasound guidance and nerve
ite
stimulation decreased the risk for nerve injury.
d.
 3 Should the routine use of ultrasound probe covers and sterile gloves be implemented
for nerve blocks and ultrasound-guided peripheral vascular access procedures?
Chiao: I once had a director of a surgery center ask
me, “Do you think we should use a probe cover and ster-
ile gloves?” I can understand how this can be seen as con-
troversial, but I recommend ultrasound probe covers and
sterile gloves. While these additional measures do incur
an immediate cost, there are few other costs to using this
extra measure. We would all be less than truthful if we
said we had never picked up an ultrasound probe that
A
was dirty or had something smeared on it prior to doing
ll
a block. Although the risk for infection from a peripheral
rig
Co
nerve block is low, why take the risk? What if hepatitis B
ht
py
was transferred to a patient during a nerve block? It would
s
rig ed.
be hard to forgive ourselves for not using a
re
probe cover and sterile gloves.
ht
se
Moreover, for peripheral nerve cathe- ‘Standardization
rv
ters or long-term vascular access cathe- an environment less prone materials. Consistency would be in order.
20
ters, the risk for infection goes up as each
to mistakes and reduces
23
Re
day passes, so for these procedures, I also
M
miscommunication, as
pr
use a mask, gown and face mask as well.
cM
od
Furthermore, we have to ask ourselves everyone involved can
what impression are we giving to patients
uc
ah in w
if we place a probe on without a cover? familiarize themselves
tio
on
Although most patients do not know what with the same procedure.’
n
Pu
is clean and what is not, some do have
—Oliver Knops, MD
bl
some understanding.
is
A colleague of mine started plac-
ho
hi
ing a labor epidural without a mask and
ng
le
coughed in the middle of the procedure. Several days later,
or
the patient was found to have an epidural infection, and
ro
in
she reported that the anesthesiologist did not wear a mask.
up
pa
There could have been several sources, but the anesthesi-
un ou
ologist was implicated as the cause of the infection for not
rt
wearing a mask.
Fettiplace: The likelihood of infection is low with
regional blocks (particularly in the setting of acidic local
anesthetic mixtures). However, low-level decontamination
of ultrasound probes with alcohol or chlorhexidine wipes
does not adequately remove contaminants. As such, best
practice guidelines from infection control societies4 and
radiology societies5 advise use of probe covers for all inva-
sive procedures. Given the prevalence of ultrasound use
in regional anesthesia, regionalists should consider these
“best practices” and regional societies should provide
practice recommendations to improve infection prevention.
Gevaert: I believe that this choice varies depending on
the specific procedure and the level of sterility required.
For nerve blocks, I believe we should utilize sterile probe
covers and gloves. However, for peripheral vascular
access, disposable non-sterile gloves may be sufficient.
In the case of arterial access and deep catheters, using a
probe cover to minimize the risk for endocarditis and other
complications is preferred. Generally, for most procedures,
I would use both sterile probe covers and gloves, except
perhaps for peripheral venous access.
It’s important to note that inadequate sterilization of the
probe can pose a risk to patient safety, especially if there
is contamination with blood. Considering the challenges of
maintaining thorough sterilization in a busy practice, I vote
for using sterile probe covers.
Knops: Theoretically it makes sense to utilize sterile
material when performing nerve blocks. Needles penetrate
the skin barrier, traveling to deeper tissue, creating a pos-
sible path for pathogens. The majority of the recommen-
dations for the use of sterile gloves during nerve blocks
is based on expert consensus.6 The same can be said for
ultrasound-guided peripheral vascular access. The CDC
recommends the use of sterile gloves when placing arte-
rial, central and midline catheters. However, the use of ster-
ile gloves for peripheral venous access
isn’t recommended.7 The ultrasound aspect
creates shouldn’t really affect the use of sterile
I must admit that I’m unsure if the avail-
able evidence is sufficiently compelling to
support the claim that the use of probe
covers and sterile gloves significantly
reduces infection rate. Cost-effectiveness
should also be considered.
Lopez: For nerve blocks, they should
definitely be used. However, when it comes
to peripheral vascular access, their routine
use is not widely established. I personally
employ probe covers and sterile gloves for
tasks such as arterial line placement and difficult IV access.
Nevertheless, for routine percutaneous IV access, following
the current aseptic guidelines should be adequate.
Merjavy: There is strong evidence indicating the transmis-
sion of infections through both ultrasound probes and ultra-
sound gel. Therefore, it is considered best practice to use
w
le
ith
sterile ultrasound gel in conjunction with a sterile ultrasound
ss
cover and sterile gloves. This approach helps prevent poten-
ot
tial harm to patients who undergo ultrasound-guided periph-
he
tp
eral nerve blocks. Applying the same high standard of aseptic
rw
er
behavior for difficult IV access under ultrasound guidance is
is
m
logical and reinforces the aseptic practices for end users.
e
is
Salti: Yes, the routine use of ultrasound probe covers
no
si
on
and sterile gloves should be implemented for nerve blocks
te
and ultrasound-guided peripheral vascular access proce-
d.
is
dures. These practices contribute to maintaining a high
pr
level of patient safety and infection control.
oh
Ultrasound probe covers serve as a physical barrier, pre-
ib
venting direct contact between the patient’s skin and the
ite
ultrasound probe. By using probe covers, the risk for cross-
d.
contamination and transmission of infectious agents is sig-
nificantly reduced. This is particularly important in invasive
procedures where the skin barrier is breached, such as
nerve blocks and vascular access procedures.
Sterile gloves are an essential component of the asep-
tic technique during invasive procedures. They provide a
protective barrier between the healthcare provider and the
patient, minimizing the risk for introducing microorganisms
into the procedure site.
ANESTHESIOLOGY NEWS SPECIAL EDITION 2023 21
 Tfaili: In Lebanon, it is common practice for larger cen-
ters to employ sterile gloves and probe covers during
regional anesthesia procedures. However, there is a lack
of data providing specific guidance on this matter, leaving
clinicians to make individual decisions based on their own
judgment. It is important to note that the level of sterility
required may vary depending on the specific block being
performed. For instance, the femoral nerve block area of
injection is typically considered to be less clean compared
4
A
Are there any specific benefits of peripheral nerve blocks over WALANT anesthesia
ll
(wide-awake local anesthesia no tourniquet) for peripheral limb surgery?
rig
Co
ht
py
Chiao: My understanding of WALANT anesthesia is that
s
rig ed.
it is usually for hand surgery and usually lidocaine or bupi-
re
vacaine is utilized. If the extent of the hand surgery is lim-
ht
se
ited and the local anesthesia covers the surgical area, I
rv
think the benefit of a peripheral nerve block is limited.
20
If only lidocaine is used for the WALANT, I could see a
23
Re
peripheral nerve block with a long-acting local anesthetic
M
pr
having more analgesic benefits than simply lidocaine,
cM
od
unless the extent of the surgery is minimal.
If there is sufficient preoperative area to perform periph-
uc
ah in w
eral nerve blocks for peripheral limb surgery, this could be
tio
on
used to save on OR time, as the surgeon could skip giving
n
Pu
their own local anesthetic as the patient would come to the
bl
OR with a working peripheral nerve block already placed.
is
Fettiplace: WALANT surgery is a technique for hand sur-
ho
hi
gery that involves no sedation and an awake cooperative
ng
le
patient. The major benefit is avoidance of general anesthe-
or
sia leading to faster workflow, decreased
ro
in
nausea, less medicine/supplies used and
‘Nerve stimulation continues
overall cost savings. Peripheral nerve
blocks provide many of the same ben- to offer valuable insights that sound guidance or using anatomic
efits but likely with broader coverage of complement the information landmarks. Many regional anesthe-
surgical sites. In an ideal practice, these
benefits may facilitate more rapid turn- derived from ultrasound in
over by preventing intraoperative delays peripheral nerve blocks.’
while waiting for local anesthesia to take
effect. —Ana M. Lopez, MD, PhD, DESA
Gevaert: In my opinion, I find
WALANT anesthesia to be a messy pro-
cedure. It does not involve targeting a specific nerve,
which increases the risk for inadvertently hitting vascular
structures or nerves, since ultrasound guidance is not uti-
lized. While WALANT anesthesia may still effectively serve
its purpose, I believe it lacks the precision and specificity
that nerve blocks offer. To me, it feels like using a bazooka
to kill a fly. Personally, I consider nerve blocks to be a
more elegant anesthesia technique.
Knops: If you want to put dressing on your salad, it
makes sense to take a bottle and pour some on, rather
than throwing a bucket over your counter. Sure, some of
it will hit the salad, but it would also be all over your coun-
ter, with the risk for it dripping into places it doesn’t belong.
Even small volumes of local anesthetic can cause
unpleasant sensations for patients. By specifically targeting
nerves, duration of effect can be extended while volume of
22 ANESTHESIOLOGYNEWS.COM
with regions such as the axillary or ankle blocks. There-
fore, clinicians must exercise their discretion and consider
the cleanliness requirements specific to each block when
implementing sterility measures.
Xu: As clinicians, our goal is to provide the best care
with the lowest-risk maneuvers whenever we can. I would
agree to use ultrasound probe covers and sterile gloves
for nerve blocks and ultrasound-guided peripheral vascular
access procedures routinely.
local anesthetic and risk for any adverse systemic effects
can be reduced.
Lopez: I believe that the visualization of peripheral
nerves is within reach for most medical centers that carry
out a substantial number of orthopedic procedures. In such
instances, selective distal blocks, utilizing a small volume
of local anesthetic, prove to be more efficient and ele-
gant. These blocks are equally effective in providing pain
relief while preserving the motor function of the limb. Addi-
tionally, the option to select and combine different local
anesthetics allows customization to match the duration
of surgery and ensure optimal postoperative analgesia.
While the surgical team’s preferences play a role, I firmly
believe that peripheral nerve blocks surpass WALANT
anesthesia in terms of versatility. The use of a tourniquet
and additional sedation is optional, depending on surgical
requirements and patient preferences.
Merjavy: “WALANT anesthesia” is a
term commonly used to describe the infil-
up
pa
tration of local anesthetic under ultra-
un ou
rt
w
le
sia techniques are routinely employed
ith
ss
worldwide on a daily basis in patients
ot
without any sedation, allowing for a “wide
he
tp
awake” state, by injecting the local anes-
rw
er
thetic close to nerves or nerve plexuses.
is
m
The decision to use a pneumatic tourni-
e
is
quet is at the discretion of the surgeon
no
si
on
performing the surgery.
te
Peripheral nerve blocks offer several advantages over
d.
is
local anesthetic infiltration:
pr
• Nerve blocks can be administered in a block room,
oh
ensuring high efficiency of the surgical list by employing
ib
parallel processing.
ite
• Prior to the patient entering the operating theatre,
d.
the adequacy of nerve blocks can be assessed by
an anesthesiologist, who can supplement them with
additional local anesthetic injections if necessary.
• Nerve blocks provide longer-lasting analgesia after
surgery compared with infiltration.
• By selecting the appropriate site for the nerve block,
motor block of the upper or lower limb can be either
induced or avoided.
• Nerve blocks do not impact tissue edema in the surgical
 field, unlike local anesthetic infiltration.
• If needed, the surgeon can always inject a solution
containing adrenaline, including saline with adrenaline.
Note: It’s worth mentioning that
“WALANT anesthesia” may not be a uni-
versally recognized term, and its usage ‘Peripheral nerve blocks offer of local anesthetics. This is because of
may vary in different regions or medical several advantages over
contexts.
Salti: Yes, there are specific benefits of local anesthetic infiltration.’
peripheral nerve blocks over general anes-
—Peter Merjavy,
thesia, such as WALANT anesthesia, for MD, PhD, EDRA, FRCA, CETC
A
peripheral limb surgery. One significant
ll
advantage is the ability to achieve stronger
rig
Co
motor blocks when needed through regional nerve blocks.
ht
py
Peripheral nerve blocks target specific nerves in the
s
rig ed.
limb being operated on, allowing for selective and precise
re
anesthesia. By directly blocking nerve conduction, regional
ht
se
nerve blocks can provide excellent pain relief and mus-
rv
cle relaxation in the surgical area. This can be particularly
20
23
Re
5 Should the use of ultrasound in regional anesthesia be mandated with a
M
pr
cM
od
certification process to ensure minimal competence standards?
uc
ah in w
Chiao: Certification is a tricky topic. Certification itself
tio
on
implies a minimum or basic set of knowledge and experi-
n
Pu
ence was reached. However, certification without some mea-
bl
sure of continuing certification could mean this skill set was
is
lost over time. Moreover, there are those without certification
ho
hi
who may be more qualified than those with it and sufficiently
ng
le
capable of doing these ultrasound-guided blocks.
or
From a professional liability perspective, the area gets
ro
in
murky. For example, without certification, if someone performs
up
pa
an ultrasound-guided block and there is an adverse outcome,
could their lack of certification adversely affect them?
Fettiplace: Absolutely. Ultrasound-based regional anes-
thesia reduces complications. According to the Accred-
itation Council for Graduate Medical Education (ACGME),
regional anesthesia fellows “must demonstrate compe-
tence in bedside point-of-care ultrasound for use in place-
ment and management of neuraxial and peripheral blocks.”
These recommendations are nebulous to provide flexibility
to programs and trainees. More recent expert recommen-
dations advise that practitioners should be able to identify
standardized views and standardized structures to demon-
strate competence, which will likely improve safety.8
Gevaert: In my opinion, I believe it is essential to make
ultrasound training a requirement in the regional anes-
thesia training program—similar to how intubation and
other technical skills are evaluated in general anesthe-
sia training. However, the operators must possess skills in
using this technology to minimize risks to the patient. The
requirements should not be overly stringent, as it could
discourage practitioners from utilizing ultrasound alto-
gether. If ultrasound use is discouraged, would it hamper
the efforts for its more widespread use? Finding the right
balance will encourage the adoption of ultrasound while
ensuring that anesthesiologists receive adequate training
in its application.
beneficial in complex procedures or cases where precise
motor control is required.
Tfaili: Indeed, WALANT anesthesia can be utilized,
but it may carry a higher risk for sys-
temic toxicity associated with the use
the significantly higher doses and vol-
umes employed in WALANT anesthesia
compared with peripheral nerve blocks.
For instance, an ankle block typically
requires 10 to 15 mL of local anesthetic,
whereas using WALANT anesthesia
to anesthetize the ankle would neces-
sitate 30 to 40 mL of local anesthetics, along with the
addition of epinephrine for hemostasis. The increased
dosage and volume in WALANT anesthesia contribute to
an elevated potential for systemic toxicity, and clinicians
must exercise caution and closely monitor patients when
employing this technique.
Knops: Like any anesthetic technique, sufficient mastery
should be acquired before practicing locoregional blocks
without supervision. I’m not sure if a separate certification
process is the way to go. There’s no certification process
for intubating a patient or placing a central venous line,
either. I believe that during residency, locoregional tech-
niques should be addressed more, providing a graduated
anesthesiologist with a broader basic skill set.
Lopez: In my view, upon achieving board certification, all
anesthesiology residents should demonstrate the ability to
un ou
safely perform a range of basic ultrasound-guided locore-
rt
gional anesthetic techniques. This would enhance patient
w
le
ith
access to locoregional anesthesia. However, for more spe-
ss
cialized techniques, comprehensive training with standard-
ot
ized content is essential.
he
tp
Regarding the utilization of ultrasound, I would propose
rw
er
two levels of education. The first level would be a “univer-
is
m
sal” training applicable to all residents, covering not only
e
is
regional anesthesia but also point-of-care ultrasound. The
no
si
on
second level would focus on more advanced applications,
te
education and research and should be conducted by certi-
d.
is
fied experts in the respective fields.
pr
Merjavy: Indeed, we are familiar with Grady Booch’s
oh
famous quote: “A fool with a tool is still a fool.” Ultrasound
ib
machines have undoubtedly evolved, offering improved
ite
quality and user-friendliness with each passing year. How-
d.
ever, comprehending the principles of ultrasound guidance
necessitates specific training to ensure the successful and
safe diagnostic or therapeutic use of ultrasound. The certi-
fication process for demonstrating minimal competencies
should adhere to a similar structure to other well-established
pathways in anesthesiology, such as airway management or
neuraxial techniques in obstetrics. This approach ensures
that practitioners acquire the necessary skills and knowledge
to effectively utilize ultrasound technology in their practice.
ANESTHESIOLOGY NEWS SPECIAL EDITION 2023 23
 Salti: Ultrasound-guided regional anesthesia has
become a valuable tool in improving procedural accuracy,
efficacy and patient safety. However, pro-
ficiency in ultrasound interpretation and
application is essential to maximize its ‘By mandating a
benefits and minimize potential risks. certification process,
By mandating a certification process,
healthcare providers would be required healthcare providers would
to demonstrate a minimum level of com- be required to demonstrate
petence in ultrasound-guided regional
a minimum level of
anesthesia. This process would ensure
A
that practitioners have received adequate competence in ultrasound-
ll
training, possess the necessary knowl- guided regional anesthesia.’ practice, many other factors must be con-
rig
Co
edge and skills, and can consistently
ht
py
perform these procedures safely and —Amar Salti, MD, EDRA
s
rig ed.
effectively.
re
Tfaili: It may not be necessary to man-
ht
se
date a certificate specifically for the use of ultrasound in
rv
regional anesthesia. However, it is crucial to establish a
20
standardized and structured training process for healthcare
23
Re
professionals to ensure competency in ultrasound-guided
M
pr
cM
od
6 Are there any advantages of spinal anesthesia over general anesthesia for
uc
ah in w
tio
patients with hip fractures?
on
n
Pu
Chiao: There are definitely advantages to spinal anes-
bl
thesia. Historically, evidence has shown less blood loss,
is
lower mortality and fewer respiratory complications. How-
ho
hi
ever, a recent study in The New England Journal of Med-
ng
le
icine sparked controversy by implying no advantage to
or
spinal.9 That study had a set of design issues that could
affect their results. Their patient population was relatively
healthy, and there was a high rate of failure with spinal,
implying that the practitioners placing spinals may have
been poorly qualified. Regional anesthesia in general has
a huge role in patient safety, particularly in older and less
healthy patients, as it reduces the systemic impact of gen-
eral anesthetics.
Fettiplace: Taken from an alternative perspective, the
anesthesiologist is likely the most important piece of the
anesthetic procedure. Data from both REGAIN9 and RAGA10
demonstrate that in the hands of skilled anesthesiologists,
both spinal and general anesthetics can provide similar
outcomes. Based on these findings, care should be driven
by patient preference and provider comfort. However,
questions remain about the benefit of spinal versus general
in the most at-risk populations (e.g., severe dementia, pro-
found frailty and others) and for other lower-extremity sur-
geries, including elective arthroplasty and revascularization
surgeries.
Gevaert: Indeed, in fragile patients or those with severe
comorbidities such as impaired lung function or cardio-
vascular disease, spinal anesthesia can be a preferable
option. These patients often pose challenges with intu-
bation, maintaining adequate pressure, achieving optimal
analgesia and managing the potential hypotensive effects
of opioids. In such cases, spinal anesthesia offers advan-
tages in terms of safety and patient comfort. When dealing
24 ANESTHESIOLOGYNEWS.COM
techniques. This training process would focus on provid-
ing the necessary knowledge and skills to safely and effec-
tively perform ultrasound-guided regional
anesthesia.
By implementing a minimum training
requirement, clinicians can acquire the
necessary proficiency without the poten-
tial obstacles that certification might pres-
ent, such as limiting access to ultrasound
or hindering the adoption of this valuable
technique in clinical practice.
Xu: Theoretically, yes; however, in real
sidered. For example, a mandated cer-
tificate may build a barrier and eliminate
many clinicians who can provide ultra-
sound-guided nerve blocks, and this may
compromise patient care. On the other hand, ultrasound
skills are one of the mandatory components of the ACGME,
so some form of documenting minimal competence level
should be considered.
with healthy patients, the choice between spinal anesthe-
sia and general anesthesia can be debated or even left
to the patient’s preference. However, for fragile patients, I
consider spinal anesthesia a safer alternative. It allows the
anesthesiologist to focus on a more limited set of param-
eters, which in turn enhances patient safety. Additionally,
ro
in
the simplicity and reduced complexity of administering spi-
up
pa
nal anesthesia can contribute to increased comfort for the
un ou
anesthesiologist.
rt
Knops: Having provided both spinal and general anes-
w
le
ith
thesia for knee and hip replacements, a remarkable
ss
decrease in postoperative opioid usage and increase in
ot
comfort could be observed. Especially in elderly patients,
he
tp
general anesthesia presents risks, which can be avoided
rw
er
by performing spinal anesthesia, combined with sedation
is
m
if preferred. It is arguably more difficult to provide a bal-
e
is
anced sedation than conducting a controlled general anes-
no
si
on
thesia, but sedation can be tailored to the medical needs
te
and preferences of the patient. Although often reluctant at
d.
is
first, patients are generally pleased with the overall experi-
pr
ence when accompanied by the right level of sedation.
oh
Lopez: I firmly believe that spinal anesthesia offers sig-
ib
nificant advantages over general anesthesia for elderly and
ite
fragile patients with hip fractures. As such, my preference
d.
would be to administer spinal anesthesia due to its supe-
rior hemodynamic stability, faster recovery and, importantly,
reduced occurrence of postoperative respiratory compli-
cations. General anesthesia would only be administered in
cases where urgent surgery is required and spinal anesthe-
sia is contraindicated, such as in the presence of coagula-
tion issues.
Merjavy: Patients with hip fractures present a complex
clinical scenario. Typically, they are elderly individuals with
an average age of around 84 years, burdened with multiple
comorbidities. Many of them require anticoagulation due to
cardiac or neurologic conditions. Additionally, a significant
proportion of these patients resides in nursing homes and
rely on walking aids or are immobile. The 30-day mortality
rate in this patient population is notably higher compared
with those undergoing total hip or total knee replacement.
Thorough preoperative assessment and optimization by
an orthogeriatric team are crucial. However, it is important to
avoid undue delay in surgery, ideally within 24 to 48 hours,
except in rare cases with specific indications. Regional anes-
A
thesia plays a pivotal role in the manage-
ll
ment of these frail patients. The approach ‘Many studies have
rig
Co
begins with fascia iliaca compartment block,
ht
femoral nerve block or pericapsular nerve demonstrated that there and respiratory complications compared
py
s
rig ed.
group block, which can be administered in are advantages of spinal with general anesthesia.
re
the emergency department upon admission.
ht
se
anesthesia over general
Spinal anesthesia has demonstrated
rv
benefits in reducing morbidity, particularly anesthesia for patients
20
when low doses of local anesthetic are uti- with hip fractures.’
23
Re
lized. Combining low-dose spinal anesthe-
M
pr
sia with peripheral nerve blocks, often with —Jeff L. Xu, MD, FASA
cM
od
minimal or no sedation, is widely practiced
in numerous medical centers worldwide.
uc
ah in w
General anesthesia is reserved for cases where neuraxial
tio
on
techniques are contraindicated and should always be com-
n
Pu
bined with peripheral nerve blocks to provide perioperative
bl
and postoperative pain relief.
is
Salti: Spinal anesthesia offers advantages over gen-
ho
hi
eral anesthesia for patients with hip fractures, including
ng
le
or
7 What role does liposomal bupivacaine (Exparel, Pacira) play in regional anesthesia?
ro
in
up
pa
un ou
Chiao: Liposomal bupivacaine belongs in the armament
rt
of local anesthetics. It has a role in surgical field anesthe-
sia and regional anesthesia. For peripheral nerve blocks, it
extends the duration of the nerve block. This can be help-
ful when patients are expected to have severe pain or do
not want to endure any more pain than necessary. From
my experience, in the recommended doses, it lasts into
postoperative day 1. It can also allow patients to avoid any
postoperative opioids, as the extra duration of analgesia
pushes the patient through the most painful postoperative
period, whereas in other cases, they would take one or two
oxycodone doses on postoperative day 1.
Fettiplace: More generally, “What is the role of
extended-release formulations of local anesthetic?”
There isn’t convincing scientific evidence that liposo-
mal bupivacaine is superior to bupivacaine for blocks.11
However, there are anecdotal reports that targeted
use still provides a clinical benefit, so further work is
potentially merited. Other touted benefits of liposomal
bupivacaine, like limited toxicity, do not bear out in prac-
tice, with evidence of toxicity at similar rates to plain
bupivacaine.12 Alternative drugs, like bupivacaine and
meloxicam in biochronomer polymer technology (e.g., Zyn-
relef, Heron), are still incompletely studied but may yet
alter our practice.13
hemodynamic stability, reduced respiratory complications,
selective anesthesia to the affected limb, decreased sys-
temic medication requirements and shorter recovery time.
These factors contribute to improved patient outcomes
and enhanced perioperative care.
Tfaili: Certainly, avoiding airway manipulation, such as in
the case of spinal anesthesia, can have its benefits. While
the recent study by Neuman published in The New Eng-
land Journal of Medicine9 may suggest otherwise, it is
important to consider real-world clinical practice and indi-
vidual patient characteristics. In my experience, spinal
anesthesia has proven to be advantageous
for hip fracture patients, as it reduces the
risk for severe hemodynamic disturbances
In the elderly population, mechani-
cal ventilation can be a patient-harming
machine, in my opinion; and as an experi-
enced anesthesiologist, I make an effort to
minimize its use whenever possible. It is
crucial to consider each patient’s unique
needs and carefully evaluate the benefits
and risks of different anesthesia techniques
to ensure optimal outcomes.
Xu: Many studies have demonstrated that there are
advantages of spinal anesthesia over general anesthesia
for patients with hip fractures, although some studies did
not show this to be true. We routinely use spinal anesthesia
for hip fracture surgery at our institution.
Gevaert: I do not have experience with using liposomal
bupivacaine.
w
le
ith
Knops: As liposomal bupivacaine is not yet available in
ss
Belgium, I have no personal experience with its use. The
ot
benefit of liposomal bupivacaine when compared with the
he
tp
regular version would be the longer duration of effect—
rw
er
something you would normally need a catheter for. Person-
is
m
ally, I believe that the placement of catheters is a step up in
e
is
difficulty compared with a single-shot block. Furthermore,
no
si
on
catheters can dislocate or cause infection, resulting in the
te
need for hospitalization for observational purposes. As sur-
d.
is
gery is starting to shift more toward an outpatient setting,
pr
usage of liposomal bupivacaine could provide extended
oh
pain relief, without the need for a catheter and the accom-
ib
panying need for hospitalization.
ite
The current evidence for liposomal bupivacaine is
d.
somewhat ambiguous. I definitely believe that liposomal
bupivacaine could be a game changer for regional anes-
thesia. The proper indications would need to be examined
further.
Lopez: Unfortunately, my clinical experience with lipo-
somal bupivacaine is limited. I have only been involved in
a few studies that demonstrated its positive effects com-
pared with placebo and plain bupivacaine for certain nerve
blocks. However, the existing evidence suggests that the
ANESTHESIOLOGY NEWS SPECIAL EDITION 2023 25
magnitude of its effect is not particularly remarkable. None- local anesthetic from a slow-release formulation. It is pos-
theless, I do believe that liposomal bupivacaine can pro- sible that different local anesthetics may follow in the foot-
vide added benefits, especially for patients who cannot steps of liposomal bupivacaine as future advancements in
receive all components of a multimodal analgesia regimen. this field continue to unfold.
In such cases, a prolonged nerve block would be advanta- Salti: The extended duration of action offered by liposo-
geous. However, due to my lack of clinical experience with mal bupivacaine can be particularly beneficial in managing
liposomal bupivacaine, I cannot make definitive judgments postoperative pain, allowing patients to experience sus-
on its efficacy. tained relief during the critical recov-
Merjavy: It is well recognized that ery period. By reducing the reliance on
certain surgical procedures can result ‘Further studies are needed to systemic opioids, it may help minimize
in prolonged postoperative pain that clarify liposomal bupivacaine’s opioid-related side effects and improve
A

extends beyond the duration of single- patient comfort.

ll

shot nerve blocks. The placement of

efficacy and optimal techniques Liposomal bupivacaine has been
rig

Co

nerve block catheters has emerged as for utilizing it to its full potential.’ studied and utilized in various surgi-
ht

py

a potential solution for providing anal- cal procedures, including orthopedic

s

—Youssef Tfaili, MD
rig ed.

gesia lasting over 24 hours. However, surgeries, such as joint replacements

re

catheters come with their own chal- or soft tissue procedures, as well as
ht
se

lenges, including dislocation, kinking, disconnection and in certain abdominal surgeries. It offers the advantage of
rv

the potential for local anesthetic accumulation, which can providing prolonged pain control and potentially enhanc-
20

lead to side effects such as phrenic nerve block in the case ing patient satisfaction by reducing the need for rescue
23
Re

of interscalene catheters. Additionally, the use of catheters analgesics.

M
pr

is associated with increased costs. Tfaili: While I personally have not used liposomal bupi-
cM
od

Liposomal bupivacaine offers an alternative approach vacaine, I understand that there is controversy surround-
by providing longer-lasting analgesia through the slow ing its use. Liposomal bupivacaine is formulated to provide
uc

ah in w

release of local anesthetic from the liposomal carrier over a slow release of bupivacaine, which theoretically should
tio

on

several days. result in prolonged analgesia. However, further studies are

n

Pu

This principle has also been applied successfully in needed to clarify its efficacy and optimal techniques for uti-
bl

other medications, such as chemotherapy. While the use lizing liposomal bupivacaine to its full potential. It is essen-
is

of liposomal bupivacaine has already been approved for tial to stay updated on the latest research to gain a better
ho

hi

various nerve blocks or tissue infiltration, we are still in the understanding of the benefits and limitations of this formu-
ng
le

early stages of exploring the exciting potential of provid- lation and to make informed decisions regarding its use in
or

ing long-lasting analgesia through a single-shot injection of clinical practice.

ro
in

up
pa

References
un ou
rt

1. Reg Anesth Pain Med. 2021;46(7):571-580. 8. Reg Anesth Pain Med. 2022;47(2):106-112.
w

le
ith

2. Reg Anesth Pain Med. 2023;48(9):437-438. 9. N Engl J Med. 2021;385(22):2025-2035.

ss
ot

3. Anaesthesia. 2021;76(suppl 1):65-73. 10. JAMA. 2022;327(1):50-58.

he

4. Australas J Ultrasound Med. 2017;20(1):30-40. 11. Anesthesiology. 2021:134(2):147-164.

tp

rw

5. Insights Imaging. 2017;8(6):523-535. 12. Expert Opin Drug Saf. 2018;17(6):581-587.

er

is
m

6. Acta Anaesthesiol Belg. 2013;64(3):105-108. 13. Reg Anesth Pain Med. 2019;44:700-706.
e
is

7. Clin Infect Dis. 2011;52(9):1087-1099.

no
si
on

te
d.
is
pr
oh
ib
ite
d.

Copyright © 2023 McMahon Publishing, 545 West 45th Street, New York, NY 10036.
Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form.

26 ANESTHESIOLOGYNEWS.COM