Trauma patients in the emergency department experience severe pain that is not always easy to manage. The risk of acute compartment syndrome further complicates the analgesic approach. The purpose of this review is to discuss relevant bibliography and highlight current guidelines and recommendations for the safe practice of peripheral nerve blocks in this special group of patients. According to the recent bibliography, peripheral nerve blocks are not contraindicated in patients at risk of acute compartment syndrome, as long as there is surveillance and certain recommendations are followed.

We describe the case of a 28-year-old man with Brugada syndrome who received single-shot adductor canal and sciatic nerve blocks for the management of post-operative pain related to extensive orthopedic injuries. Low-dose ropivacaine with glucocorticoid additives was administered without any EKG changes, arrhythmias, or syncopal sensations. The patient experienced pain relief for over 24 h and was monitored on telemetry with defibrillator pads as a cardiac precaution. This case adds a valuable data point in the limited canon of information on the safety and efficacy of regional anesthesia in Brugada syndrome for the perioperative physician.

BACKGROUND: Pain is a common experience in people living with cancer. Concerns around opioid prescribing have seen a move toward a multi-modality management approach, which includes interventional pain procedures.
OBJECTIVE: In this paper we discuss the interventional pain procedures used to treat cancer pain at two major tertiary centers in Australia.
RESULTS: This expert review provides practical insights on cancer pain management from healthcare providers in different specialties. These insights can be used to guide the management of a wide range of cancer pain types.
CONCLUSIONS: Furthermore, this review identifies the need for a systematic and comprehensive approach to the management of cancer pain that is broader than that of a single specialty. With recent advances in pain management procedures, an interdisciplinary approach is essential in order to provide an up to date, patient tailored approach to pain management. This review will help inform the development of a cancer pain intervention registry.

Multi-modal analgesic strategies, including regional anesthesia techniques, have been shown to contribute to a reduction in the use of opioids and associated side effects in the perioperative setting. Consequently, those so-called multi-modal approaches are recommended and have become the state of the art in perioperative medicine. In the majority of intensive care units (ICUs), however, mono-modal opioid-based analgesic strategies are still the standard of care. The evidence guiding the application of regional anesthesia in the ICU is scarce because possible complications, especially associated with neuraxial regional anesthesia techniques, are often feared in critically ill patients. However, chest and abdominal wall analgesia in particular is often insufficiently treated by opioid-based analgesic regimes. This review summarizes the available evidence and gives recommendations for peripheral regional analgesia approaches as valuable complements in the repertoire of intensive care physicians\' analgesic portfolios.

UNASSIGNED: The epidural injections used to treat lumbar radiculopathy are potentially associated with serious complications like neurological injuries and epidural abscess. The nociceptors have the unique property of being pseudo-unipolar, as its both ends are expected to be functionally same. We have hypothesized that peripheral nerve blocks given at the distal site should be able to provide pain relief. This prospective study was planned to assess the efficacy of peripheral nerve blocks in lumbar radiculopathy.
UNASSIGNED: Thirty-four patients who fit the eligibility criteria were included in this open labeled prospective preliminary study. They were administered peripheral nerve blocks at ankle level with 4 ml of 0.25% bupivacaine and 40 mg of triamcinolone.
UNASSIGNED: The outcomes measured at 15 days, 1 month, 2 months, and 3 months after the intervention were the pain intensity (Numerical Rating Scale), the Global Perceived Effect, functional status (Roland Morris Disability Questionnaire), Beck\'s Depression Inventory score, employment status, and analgesic intake.
UNASSIGNED: At 15 days, 1 month, and 2 months, 88% of the patients reported a ≥50% decrease in their pain scores and a GPE ≥6, while at 3 months 85% of the patients reported a significant decrease in their pain scores and a GPE ≥6.
UNASSIGNED: Peripheral nerve blocks are effective in the management of pain in patients with chronic lumbosacral radiculopathy. The ability to administer it in an outpatient setting, without image guidance and the absence of debilitating side effects, makes it an attractive treatment option.

UNASSIGNED: Handheld ultrasound devices have become popular among clinicians due to their affordability and compatibility with tablets and smartphones. Several handheld ultrasound devices have the capability to construct three-dimensional (3D) images using a traditional two-dimensional (2D) ultrasound transducer.
UNASSIGNED: The current study aimed to construct 3D images of common peripheral nerve and fascial plane blocks using a handheld ultrasound device with a 2D ultrasound probe.
UNASSIGNED: A total of 10 patients who were scheduled to receive ultrasound-guided peripheral nerve blocks for outpatient surgery and classified as the American Society of Anesthesiologists physical status I or II with a body mass index of ≤ 30 kg/m2 were included in the study. Patients who presented with anatomical variations during the initial ultrasound scanning were excluded.
UNASSIGNED: This study successfully constructed 3D images of 10 peripheral nerve blocks. The average time to complete each 3D scan was less than 5 seconds per attempt, with fascial plane blocks requiring twice the amount of time to complete. All the nerve blocks provided effective postoperative analgesia without complications. The 3D images were successfully captured in all patients.
UNASSIGNED: The 3D images provide clinicians with valuable information on the anatomical boundaries of the injectate that can further direct needle direction and placement of local anesthetic to achieve visual confidence of anesthetic spread.

The treatment of pain, both acute and chronic, has been a focus of medicine for generations. Physicians have tried to develop novel ways to effectively manage pain in surgical and post-surgical settings. One intervention demonstrating efficacy is nerve blocks. Single-injection peripheral nerve blocks (PNBs) are usually preferred over continuous PNBs, since they are not associated with longer lengths of stay. The challenge of single injection PNBs is their length of duration, which at present is a major limitation. Novel preparations of local anesthetics have also been studied, and these new preparations could allow for extended duration of action of anesthetics. An emerging preparation of bupivacaine, exparel, uses a multivesicular liposomal delivery system which releases medication in a steady, controlled manner. Another extended-release local anesthetic, HTX-011, consists of a combination of bupivacaine and low-dose meloxicam. Tetrodotoxin, a naturally occurring reversible site 1 sodium channel toxin derived from pufferfish and shellfish, has shown the potential to block conduction of isolated nerves. Neosaxitoxin is a more potent reversible site 1 sodium channel toxin also found in shellfish that can also block nerve conduction. These novel formulations show great promise in terms of the ability to prolong the duration of single injection PNBs. This field is still currently in development, and more researchers will need to be done to ensure the efficacy and safety of these novel formulations. These formulations could be the future of pain management if ongoing research continues to prove positive effects and low side effect profiles.

BACKGROUND: Combined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period.
METHODS: A total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate.
RESULTS: Compared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation.
CONCLUSIONS: Our pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.

Peripheral nerve blocks (PNB) have become standard of care for enhanced recovery pathways after surgery. For brachial plexus delivery of anesthesia, both supraclavicular (SC) and infraclavicular (IC) approaches have been shown to require less supplemental anesthesia, are performed more rapidly, have quicker onset time, and have lower rates of complications than other approaches (axillary, interscalene, etc.). Ultrasound-guidance is commonly utilized to improve outcomes, limit the need for deep sedation or general anesthesia, and reduce procedural complications. Given the SC and IC approaches are the most common approaches for brachial plexus blocks, the differences between the two have been critically evaluated in the present manuscript. Various studies have demonstrated slight favorability towards the IC approach from the standpoint of complications and safety. Two prospective RCTs found a higher incidence of complications in the SC approach - particularly Horner syndrome. The IC method appears to support a greater block distribution as well. Overall, both SC and IC brachial plexus nerve block approaches are the most effective and safe approaches, particularly under ultrasound-guidance. Given the success of the supraclavicular and infraclavicular blocks, these techniques are an important skill set for the anesthesiologist for intraoperative anesthesia and postoperative analgesia.