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Background and objectivesThe paraneural sheath is a multilayered network of collagen fibers that surround the brachial plexus. Currently, there are no sonographic data on the paraneural sheath of the brachial plexus, which this study aimed to evaluate.MethodsUltrasound imaging datasets of 100 patients who received a costoclavicular brachial plexus block, using high-definition ultrasound imaging, were retrospectively reviewed. Video files, representing sonograms before and after the local anesthetic injection, from the costoclavicular space and lateral infraclavicular fossa were collated and reviewed by three experienced anesthesiologists. Frequency (yes/no) of ultrasound visualization of the paraneural sheath, septum, and the anterior and posterior compartments was assessed. Representative sonograms from the costoclavicular space and lateral infraclavicular fossa were visually correlated with archived cadaver microanatomic sections from the same location.ResultsDatasets of the 98 patients who achieved surgical anesthesia were evaluated. The paraneural sheath, septum, and the anterior and posterior compartments were visualized in 17.3%, 7.1%, 5.1% and 5.1%, respectively, at the costoclavicular space before the brachial plexus block; this contrasts (p<0.001) with their visibility post-block (94.9%, 75.5%, 75.5% and 75.5%, respectively). At the lateral infraclavicular fossa, the corresponding visibility of these structures post-block were 67.7%, 81.5%, 81.5% and 81.5%, respectively. Ultrasound images of the paraneural sheath and septum correlated well with that in the cadaver microanatomic sections.ConclusionWe have demonstrated the paraneural sheath and fascial compartments surrounding the cords of the brachial plexus at the costoclavicular space and lateral infraclavicular fossa using high-definition ultrasound imaging.Trial registration numberClinicalTrials.gov Registry (NCT04370184), (https://www.clinicaltrials.gov/).

BACKGROUND AND OBJECTIVESIt has recently been proposed that an infraclavicular brachial plexus block (BPB) at the costoclavicular (CC) space may overcome some of the limitations of the lateral sagittal (LS) approach. In this study, we hypothesized that the CC approach will produce faster onset of sensory blockade of the 4 major terminal nerves of the brachial plexus than the LS approach. METHODSForty patients undergoing elective upper extremity surgery under a BPB were randomized to receive either the LS (Gp-LS, n = 20) or CC approach (Gp-CC, n = 20) for infraclavicular BPB. Twenty-five milliliters of 0.5% ropivacaine was used for the BPB in both study groups. Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves was assessed by a blinded observer at regular intervals for 45 minutes after the block. Sensory block was assessed using a verbal rating scale (0–100) and motor block using a 3-point qualitative scale (0–2). Onset of sensory (primary outcome variable) and motor blockade was defined as the time it took to achieve a sensory verbal rating scale of 30 or less and motor grade of 1 or less, respectively. Time to readiness for surgery was defined as the time it took to achieve a sensory score of 30 or less and motor grade of 1 or less in all the 4 nerves tested. RESULTSThe overall sensory onset time (median [interquartile range]) was significantly faster (P = 0.004) in Gp-CC (10 [10–26.25] minutes) than in Gp-LS (20 [15–30] minutes). The overall sensory score was significantly lower in Gp-CC than in Gp-LS at 5 (P < 0.001), 10 (P = 001), 15 (P = 0.001), and 20 (P = 0.04) minutes after the BPB. The overall motor score was significantly lower (P = 0.009) in Gp-CC than in Gp-LS at 10 minutes after the BPB. There were more (P = 0.04) patients with complete sensory-motor blockade at 20 minutes after the BPB in Gp-CC (25%) than in Gp-LS (0%). Time to readiness for surgery was also significantly faster (P = 0.002) in Gp-CC (10 [10–26.5] minutes) than in Gp-LS (20 [15–30] minutes). CONCLUSIONSThe CC approach for infraclavicular BPB produces faster onset of sensory blockade and earlier readiness for surgery than the LS approach. CLINICAL TRIAL REGISTRATIONThis study was registered at the Centre for Clinical Trials of The Chinese University of Hong Kong, identifier CUHK_CCT00389.

Background and objectivesWhile there are several published recommendations and guidelines for trainees undertaking subspecialty Fellowships in regional anesthesia, a similar document describing a core regional anesthesia curriculum for non-fellowship trainees is less well defined. We aimed to produce an international consensus for the training and teaching of regional anesthesia that is applicable for the majority of worldwide anesthesiologists.MethodsThis anonymous, electronic Delphi study was conducted over two rounds and distributed to current and immediate past (within 5 years) directors of regional anesthesia training worldwide. The steering committee formulated an initial list of items covering nerve block techniques, learning objectives and skills assessment and volume of practice, relevant to a non-fellowship regional anesthesia curriculum. Participants scored these items in order of importance using a 10-point Likert scale, with free-text feedback. Strong consensus items were defined as highest importance (score ≥8) by ≥70% of all participants.Results469 participants/586 invitations (80.0% response) scored in round 1, and 402/469 participants (85.7% response) scored in round 2. Participants represented 66 countries. Strong consensus was reached for 8 core peripheral and neuraxial blocks and 17 items describing learning objectives and skills assessment. Volume of practice for peripheral blocks was uniformly 16–20 blocks per anatomical region, while ≥50 neuraxial blocks were considered minimum.ConclusionsThis international consensus study provides specific information for designing a non-fellowship regional anesthesia curriculum. Implementation of a standardized curriculum has benefits for patient care through improving quality of training and quality of nerve blocks.