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Declaration of interest mixed methods approach in pain research. J Pain Res 2021;
14: 2501e11
The authors declare that they have no conflicts of interest. € rster M, Binder A. Subgrouping of patients with
7. Baron R, Fo
neuropathic pain according to pain-related sensory ab-
Appendix A. Supplementary data normalities: a first step to a stratified treatment approach.
Lancet Neurol 2012; 11: 999e1005
Supplementary data to this article can be found online at
8. Yarnitsky D. Quantitative sensory testing. Muscle Nerve
https://doi.org/10.1016/j.bja.2022.07.001.
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9. Blankenburg M, Boekens H, Hechler T, et al. Reference
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J, McGrath PJ, Finley GA, Walco GA. Pediatric chronic
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doi: 10.1016/j.bja.2022.07.001
Advance Access Publication Date: 13 August 2022
© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Periarticular vasoconstrictor infiltration: a novel technique for

chemical vasoconstriction in major orthopaedic surgery
Vicente Roques Escolar1,2, Pablo Oliver-Fornies3,4,5,* and Mario Fajardo Perez5
1
Department of Anesthesiology, Critical Care and Pain Medicine, Hospital Clı́nico Universitario Virgen de la Arrixaca,
Murcia, Spain, 2Quiron-Salud, Murcia, Spain, 3Department of Anesthesiology, Critical Care and Pain Medicine, Mostoles
University Hospital, Madrid, Spain, 4Aragon Institute for Health Research, Aragon Institute for Health Research
(IISAragon), Zaragoza, Spain and 5Morphological Madrid Research Center (MoMaRC), Ultradissection Spain EchoTraining
School, Madrid, Spain
*Corresponding author. E-mail: pablo.oliver.fornies@gmail.com

Keywords: chemical vasoconstriction; epinephrine; haemostasis; orthopaedic surgery; regional anaesthesia

EditordIn 1987, a tumescent local anaesthesia technique was
described for liposuction.1 This approach uses lidocaine and
epinephrine to establish a Bier block with haemostatic
control, wherever the surgical dissection occurs.1 Lalonde2
extended the use of tumescent local anaesthesia to hand
surgery known as ‘wide awake local anaesthesia with no
tourniquet’ (WALANT). The presumed risks associated with
this technique, such as local anaesthetic systemic toxicity or
vasoconstrictor-induced ischaemia, have been negligible.3,4
Because of its advantages in cost savings in the outpatient
setting, WALANT has become increasingly popular, and its
indications now include upper extremity, clavicle, foot, and
ankle surgeries.5
We now present a novel vasoconstrictor-induced tech-
nique, known as the periarticular vasoconstrictor infiltration
(PVI) technique. PVI is a surgical-anaesthetic technique used to
 e98 - Correspondence

create a ‘bloodless’ field after injections of epinephrine at
multiple points (subcutaneous, intracapsular, and deep artic-
ular system of blood vessels). We explored the suitability of
vasoconstriction performed by epinephrine administration for
major orthopaedic surgery. We used PVI on patients (ASA
physical status 1e3) undergoing elective orthopaedic surgeries
including hip arthroplasty, knee arthroplasty, arthroscopy and
arthroplasty shoulder surgery, and lumbar arthrodesis.
Following the principles of WALANT, our recommenda-
tions for PVI are as follows. Firstly, patients receive general or
spinal anaesthesia, as appropriate, for the surgery. Then,
with monitoring and strict aseptic precautions, multiple-site
ultrasound-guided injections are performed using a 22 gauge
needle 15e30 min before the surgical incision. We inject a
total volume of 120e150 ml of a mixture, including 0.9% sa-
line and 1:200 000e1:400 000 epinephrine, near the blood
vessels of the joints as explained in Fig 1 and Supplementary
Figure S1. If patients have cardiac disease, we consider more
dilute solutions up to 1:1 000 000 epinephrine, which also
provides effective haemostasis.3 In patients undergoing

Fig 1. Description of the periarticular vasoconstrictor infiltration technique for lumbar spine surgery (a, b, and c) and shoulder surgery (d,
and e). At the top of the figure, we describe the anatomy of lumbar spine (a); the injections of the two-step performance (c) at the
retrolaminar space, thoracolumbar fascia, supraspinous ligament and on the incision site; and the distribution of the blood vessels (b). At
the bottom of the collage, we describe the anatomy of the shoulder and blood vessels (d), the injections of four-step performance (e)
interpectoral plane, around the circumflex artery within the deltopectoral groove, intra-articular and on the surgical dissection plane.

lumbar spine surgery, we perform bilateral injections in the
retrolaminar space, the thoracolumbar fascia, the supra-
spinous ligament, and the surgical site. For shoulder surgery,
we inject into the interpectoral plane, around the circumflex
artery within the deltopectoral groove, the surgical site, and
the intra-articular site. For hip arthroplasty, we perform
multiple-site injections following the Pericapsular Nerve
Group (PENG) block approach to target four points: the iliop-
soas muscle, neck of the femur, surgical dissection area, and
the intra-articular site.6 For knee surgery, we inject into the
superior and inferior genicular nerves, posterior capsule,
surgical site, and the intra-articular site. We performed
additional ultrasound-guided regional nerve blocks recom-
mended for each surgery. However, we hypothesise that
adding local anaesthetic to the PVI technique will improve
postoperative pain and obviate these additional blocks. The
PVI technique has been fully integrated into our hospital’s
routine clinical practice. Written informed consent was pro-
vided by all patients undergoing this technique. To date, a
total of more than 100 cases of the aforementioned surgeries
have received PVI with satisfactory results (see Fig 1 online
video).
Supplementary video related to this article can be found at
https://doi.org/10.1016/j.bja.2022.07.003
Significant blood loss continues to be a common surgical
risk in major orthopaedic surgeries, with recognised costs and
complications. For total hip or knee replacement, the esti-
mated blood loss is 726e1768 ml.7 The most significant
advantage of PVI is a reduction in total surgical bleeding to
<100 ml. This is remarkable in those surgeries in which a
tourniquet cannot be used. More than 90% of surgeons
routinely use tourniquets for knee surgery.8 However, tourni-
quet use has been associated with increased risks of post-
operative pain and venous thromboembolism.8 By using PVI to
establish haemostasis, we have eliminated the use of a prox-
imal tourniquet in knee surgery. However, patients should be
warned about two common complications: vasovagal syncope
and trembling.3 Other potential complications of this tech-
nique are accidental vascular puncture or infection. Aseptic
precautions and an aspiration test for blood with fractionated
injection should always be used. Complications secondary to
intravascular epinephrine injection can be treated with
administration of phentolamine, a competitive inhibitor of
alpha-adrenergic receptors.1
PVI is associated with reduced intraoperative and post-
operative blood loss and avoids the side-effects caused by use
of a tourniquet. Costs related to equipment used are similar
to those of regional blocks. Thus, we consider PVI to be a cost-
effective technique with benefits that outweigh the risks of
the increased number of punctures and the time needed. In
addition, we have not recorded major cardiovascular com-
plications, such as acute myocardial infarction or cardiac
arrest. We have observed infrequent minor cardiovascular
complications, such as hypertension or tachycardia. We
hypothesise that the multiple-site technique and the local
vasoconstriction itself minimise systemic absorption of
epinephrine which may explain the low incidence of hae-
modynamic instability. Contraindications include drug al-
lergy and local infection. Caution is also advised in patients
with compromised peripheral circulation, renal failure, and
connective tissue disease.5 Peripheral necrosis is a feared
potential complication after epinephrine injection but has
now disappeared, and was associated with the use of pro-
caine, which is now obsolete.4
Correspondence - e99
Local infiltration anaesthesia is another analgesia approach
that has become increasingly popular. Although this approach
usually involves intraoperative injection by surgeons, PVI can
be performed in advance by anaesthesiologists. Thereby, the
maximal vasoconstrictor effect of epinephrine occurs before
surgery.3 Use of epinephrine for local infiltration anaesthesia is
variable with concentrations from 1:200 000 to 1:100.9,10 In
contrast, PVI is performed under ultrasound guidance, which
may improve safety. The generalisability of this promising
technique remains unknown. We plan to include local anaes-
thetics in the mixture injected to provide motor-sparing anal-
gesia in the future. Currently, the PVI technique provides a
bloodless field for major orthopaedic surgeries.
Acknowledgements
The authors acknowledge the Department of Traumatology
and Orthopedic surgery of the University Hospital Reina Sofia
and Virgen de la Arrixaca (Murcia, Spain).
Declaration of interest
The authors declare that they have no conflict of interest.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.bja.2022.07.003.
References
1. Lalonde DH. Conceptual origins, current practice, and
views of wide awake hand surgery. J Hand Surg Eur 2017;
42: 886e95
2. Lalonde DH. Hole-in-one” local anesthesia for wide-awake
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3. Lalonde D. Minimally invasive anesthesia in wide awake
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4. Khudr J, Hughes L, Younis F. The what, why and when of
wide awake local anaesthesia no tourniquet surgery. Br J
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5. Kurtzman JS, Etcheson JI, Koehler SM. Wide-awake local
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© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
Preoperative fasting guidelines in National Health Service England
Trusts: a thirst for progress
Rebecca Sands, Robert Wiltshire and Peter Isherwood*
University Hospitals Dorset NHS Foundation Trust, Bournemouth, Dorset, UK
*Corresponding author. E-mail: peter.isherwood@uhd.nhs.uk
Keywords: anaesthesia; fasting; fluid intake; nil-by-mouth; patient experience; postoperative nausea and vomiting;
preoperative care
EditordOral intake before elective adult surgery remains a
research feast and an improvement famine.1 To explore this
issue between June and December 2021, we submitted freedom
of information (FOI) requests to all acute National Health
Service England Hospital Trusts via email (Supplementary
material) asking if they would please share their guidelines for
food and fluid intake (or starvation) before adult elective
surgery. Whilst FOI requests have been used before to support
published literature,2 we believe this is the first occasion in
which this strategy has been used to request a large sample of
practice guidelines to explore national practice for a given topic.
The human right to drinking water3 is suspended preop-
eratively for adult patients undergoing elective surgery on the
premise of reducing the risk of pulmonary aspiration of gastric
contents according to national guidelines.4,5 This has never
been proved to improve patient outcome or experience. Not
only is there no evidence to support our current approach to
water restriction before adult elective surgery, but there is
evidence that it can be harmful. Water deprivation leads to
increased postoperative nausea and vomiting and decreased
patient satisfaction. A 2018 study showed a significant reduc-
tion in postoperative nausea and vomiting and no increased
risk of aspiration or adverse outcome rates when adult pa-
tients undergoing day case elective surgery were allowed to
drink clear fluids up to the point of being sent for surgery.6
This retrospective study included a total of 11 500 patients,
the largest study of preoperative fluid management in adult
surgical patients to date. This, coupled with other publica-
tions,1,7,8 has resulted in calls for revision of current national
guidelines9 as there is now a strong argument that our current
guidelines are not putting the interests of patients first.
In August 2020 the UK National Institute for Health and
Clinical Excellence (NICE) published an evidence review of
preoperative practice acknowledging the variation of practice
and the negative consequences of prolonged fasting times.5
They included one Cochrane review focussed on preoperative
carbohydrate loading and a further 19 RCTs. Most of these RCTs
studied the effects of preoperative carbohydrate
randomized, comparative noninferiority study involving
99 patients. J Shoulder Elb Surg 2019; 28: 212e9
doi: 10.1016/j.bja.2022.07.003
Advance Access Publication Date: 13 August 2022
supplementation and none had more than 100 patients in
either arm, with most having far fewer. Although timing of
preoperative fluids was not the focus of these trials, the authors
suggested a 2 h cut-off for clear fluids preoperatively based
purely on their own expert opinion. However, this review did
not consider the largest study to date referenced above because
of NICE criteria.
Local audits in our centre have shown starvation times of
up to 8 h without water for adult elective surgical patients, and
our centre is not an outlier as current literature suggests this is
commonplace.1 We identified current national recommenda-
tions from the Association of Anaesthetists and NICE stating a
minimum of 2 h abstinence of water before adult elective
surgery as barriers to local improvement.
Our FOI requests received 147 responses from requests sent
to 197 trusts (74.6%). These identified 110 trusts providing
anaesthesia services for adult elective patients of which 104
have a guideline and 100 were prepared to share their guide-
line. The results of reviewing these guidelines revealed that 21
out of 100 trusts now have preoperative intake guidelines that
allow water after the 2 h cut-off recommended by current
national guidance and 15 trusts allow water to be sipped up to
the point of sending for the patient for theatre (including those
with sip until send, 30 ml h 1, 50 ml 1, 200 ml 1) (Fig 1). None of
these trusts are reporting increased rates of adverse events in
current literature or safety publications. This variation in na-
tional practice with 21% of trusts directly contradicting na-
tional guidance for preoperative fluid intake questions the
validity of current national guidance.
There is more consistency in the national approach to
timing of last solid food before surgery, with 97% of re-
spondents producing guidelines adopting the national rec-
ommendations of 6 h, although two trusts still advocate an
overnight fast for all adult elective surgeries. There are several
trusts that allow small amounts of milk to be taken with tea
and coffee up to 2 h before theatre included in their ‘clear’ fluid
guidelines, which differs from national recommendations.