Explore the vast range of titles available.

The American Society of Regional Anesthesia and Pain Medicine (ASRA) periodically updates its practice advisories and associated cognitive aids. The 2020 version of the ASRA Local Anesthetic Systemic Toxicity checklist was created in response to user feedback, simulation studies and advances in medical knowledge. This report presents the 2020 version and discusses the rationale for its update.

ObjectiveLocal anesthetic-induced myotoxicity occurs consistently in animal models, yet is reported rarely in humans. Herein, we describe 3 sentinel cases of local anesthetic myotoxicity after continuous adductor canal block (ACB).Case ReportThree patients underwent total knee arthroplasty that was managed with subarachnoid block plus ACB induced with 1.5% lidocaine or 1.5% mepivacaine bolus followed by 0.2% ropivacaine at 8 mL-h. Although initial postoperative recovery was normal, each patient on either postoperative day 1 or 2 developed progressive, profound weakness of the quadriceps muscles. Clinical course, imaging, and neurophysiologic studies were consistent with myositis. The patients experienced partial to full functional recovery over the ensuing weeks to months.ConclusionsClinically apparent local anesthetic-induced myotoxicity has been documented rarely in humans undergoing non-ophthalmic surgery. We report 3 sentinel cases associated with continuous ACB.

In 2010, the American Society of Regional Anesthesia and Pain Medicine's evidence-based medicine assessment of ultrasound (US)-guided regional anesthesia (UGRA) analyzed the effect of this nerve localization technology on patient safety. That analysis focused on 4 important regional anesthesia complications: peripheral nerve injury, local anesthetic systemic toxicity (LAST), hemidiaphragmatic paresis (HDP), and pneumothorax. In the intervening 5 years, further research has allowed us to refine our original conclusions. This update reviews previous findings and critically evaluates new literature published since late 2009 that compares the patient safety attributes of UGRA with those of traditional nerve localization methods. As with the previous version of this exercise, analysis focused on randomized controlled trials that compared UGRA with an alternative neural localization method and case series of more than 500 patients. The Jadad score was used to grade individual study quality, and conclusions were graded as to strength of evidence. Of those randomized controlled trials identified by our search techniques, 28 compared the incidence of postoperative nerve symptoms, 27 assessed LAST parameters, 7 studied HDP, and 9 reported the incidence of pneumothorax. The current analysis strengthens our original conclusions that US guidance has no significant effect on the incidence of postoperative neurologic symptoms and that UGRA reduces the incidence and intensity of HDP but does so in an unpredictable manner. Conversely, emerging evidence supports the effectiveness of US guidance for reducing LAST across its clinical presentation continuum. The predicted frequency of pneumothorax has grown smaller in tandem with increased experience with US-guided supraclavicular block. This evidence-based review summarizes both the power and the limitations of UGRA as a tool for improving patient safety.Since the original 2010 publication of this analysis, evidence has continued to support the concept that ultrasound (US) guidance does not meaningfully affect the incidence of peripheral nerve injury (PNI) associated with regional anesthesia. Similar confirmatory evidence attests to US guidance reducing the incidence and intensity of hemidiaphragmatic paresis (HDP) but not eliminating it. Literature published since late 2009 reports the effective role of US guidance in reducing the incidence of local anesthetic systemic toxicity and allows calculation of a lower predicted frequency of pneumothorax associated with US-guided supraclavicular blocks.

The American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity assimilates and summarizes current knowledge regarding the prevention, diagnosis, and treatment of this potentially fatal complication. It offers evidence-based and/or expert opinion-based recommendations for all physicians and advanced practitioners who routinely administer local anesthetics in potentially toxic doses. The advisory does not address issues related to local anesthetic-related neurotoxicity, allergy, or methemoglobinemia. Recommendations are based primarily on animal and human experimental trials, case series, and case reports. When objective evidence is lacking or incomplete, recommendations are supplemented by expert opinion from the Practice Advisory Panel plus input from other experts, medical specialty groups, and open forum. Specific recommendations are offered for the prevention, diagnosis, and treatment of local anesthetic systemic toxicity.

AbstractThe American Society of Regional Anesthesia and Pain Medicine's Third Practice Advisory on local anesthetic systemic toxicity is an interim update from its 2010 advisory. The advisory focuses on new information regarding the mechanisms of lipid resuscitation, updated frequency estimates, the preventative role of ultrasound guidance, changes to case presentation patterns, and limited information related to local infiltration anesthesia and liposomal bupivacaine. In addition to emerging information, the advisory updates recommendations pertaining to prevention, recognition, and treatment of local anesthetic systemic toxicity.What’s New in This Update?This interim update summarizes recent scientific findings that have enhanced our understanding of the mechanisms that lead to lipid emulsion reversal of LAST, including rapid partitioning, direct inotropy, and post-conditioning. Since the previous practice advisory, epidemiological data have emerged that suggest a lower frequency of LAST as reported by single institutions and some registries, nevertheless a considerable number of events still occur within the general community. Contemporary case reports suggest a trend toward delayed presentation, which may mirror the increased use of ultrasound guidance (fewer intravascular injections), local infiltration techniques (slower systemic uptake), and continuous local anesthetic infusions. Small patient size and sarcopenia are additional factors that increase potential risk for LAST. An increasing number of reported events occur outside of the traditional hospital setting and involve non-anesthesiologists.

The role of ultrasound-guided regional anesthesia (UGRA) in reducing the frequency of regional anesthetic-related complications is difficult to ascertain from analyzing the limited literature on the topic. This evidence-based review critically evaluates the contributions of UGRA to improved patient safety, particularly as compared with standard nerve localization tools. Randomized controlled trials that compared UGRA with another form of neural localization and case series of more than 500 patients were used to compare safety parameters. The quality of studies and strength of evidence were graded. Of those randomized controlled trials identified by our search techniques, 22 compared the incidence of postoperative nerve symptoms, 17 assessed local anesthetic systemic toxicity parameters, and 3 studied hemidiaphragmatic paresis. Statistical proof for meaningful reduction in the frequency of extremely rare complications, such as permanent peripheral nerve injury, is likely unattainable. Although there is evidence for UGRA reducing the occurrence of vascular puncture and the frequency of hemidiaphragmatic paresis, as yet there is at best inconclusive scientific proof that these surrogate outcomes are linked to actual reduction of their associated complications, such as local anesthetic systemic toxicity or predictable diaphragmatic impairment in at-risk individuals. This evidence-based review thus strives to summarize both the power and the limitations of UGRA as a tool for improving patient safety.

Neurologic injury associated with regional anesthetic or pain medicine procedures is extremely rare. The Second American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine focuses on those complications associated with mechanical, ischemic, or neurotoxic injury of the neuraxis or peripheral nervous system. As with the first advisory, this iteration does not focus on hemorrhagic or infectious complications or local anesthetic systemic toxicity, all of which are the subjects of separate practice advisories. The current advisory offers recommendations to aid in the understanding and potential limitation of rare neurologic complications that may arise during the practice of regional anesthesia and/or interventional pain medicine.What’s NewThe Second American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine updates information that was originally presented at the Society’s first open forum on this subject (2005) and published in 2008. Portions of the second advisory were presented in an open forum (2012) and are herein updated, with attention to those topics subject to evolving knowledge since the first and second advisory conferences. The second advisory briefly summarizes recommendations that have not changed substantially. New to this iteration of the advisory is information related to the risk of nerve injury inherent to common orthopedic surgical procedures. Recommendations are expanded regarding the preventive role of various monitoring technologies such as ultrasound guidance and injection pressure monitoring. New clinical recommendations focus on emerging concerns including spinal stenosis and vertebral canal pathologies, blood pressure management during neuraxial anesthesia, administering blocks in anesthetized or deeply sedated patients, patients with preexisting neurologic disease, and inflammatory neuropathies. An updated diagnostic and treatment algorithm is presented.

ABSTRACTThe American Society of Regional Anesthesia and Pain Medicine (ASRA) periodically revises and updates its checklist for the management of local anesthetic systemic toxicity. The 2017 update replaces the 2012 version and reflects new information contained in the third ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Electronic copies of the ASRA checklist can be downloaded from the ASRA Web site (www.asra.com) for inclusion in local anesthetic toxicity rescue kits or perioperative checklist repositories.

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine’s ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.