ESRA UPDATES Journal Club invites leading experts in (regional) anaesthesia to select one (or more) article(s) which for him/her were/are important, interesting or changed his/her clinical practice. This choice can be a general big randomized study but can also be very personal. For this edition our choice went to Professor John McDonnell.
Father, husband & anaesthesiologist. Love Regional Anaesthesia and beating pain. Love ESRA family. Part time triathlete.
Professor John McDonnell MB, BAO, BCh, LRCP &SI, FFARCSI, Dip Med Ed, MD Galway University Hospitals, Galway, Ireland. The National University of Ireland, Galway. BreastCheck West, the National Cancer Screening Service, Galway.
It is a daunting task to be asked to discuss papers that have and continue to shape my clinical practice. When you look at the plethora of papers that could be discussed it is amazing that we would to some degree have the same thoughts. Prof. Albrecht discussed the 2022 meta-analysis paper on the choice of GA versus spinal in patients with hip fractures and the fact that we are bombared with ‘zombie papers. These too would have been in my top few papers.
The first paper I would like to discuss is some of my heroes in regional anaesthesia and was published in Reg Anesth Pain Med in July 2021. The article ‘Anatomical basis of fascial plane blocks’, Regional Anesthesia & Pain Medicine 2021;46:581-599. Chin KJ, Versyck B, Elsharkawy H, et al is a comprehensive review of anatomy of fascial planes and pharmacokinetics of the regional anaesthetic techniques used to achieve analgesia in the associated patient population. This publication is populated with excellent anatomical drawings, clinical dissections and ultrasonographic images that will aid readers. It is articles like this that bring us back to basics in terms of anatomy that not only aid understanding of how our blocks work but that serve as resources to refine older techniques and aid the propagation of newer techniques. The inclusion of the sympathetic nervous system in the review hopefully will lead to further inclusion of this important neuronal system in future research in acute pain management. This paper is an excellent follow on from previous papers by Dr. Chin such as ‘Essentials of our current understanding: abdominal wall blocks. Reg Anesth Pain Med 2017;42:133-183.
The second paper that really shapes my daily clinical practice is ‘Best practices for safety and quality in peripheral regional anaesthesia’ BJA Education, 20(10): 341-247 (2020). It is amazingly gratifying to see Dr. B. Nicholls still educating us after all these years. I know Dr. Oldman won’t mind me singling out Dr. Nicholls. He is one of my absolute heroes in regional anaesthesia and was instrumental in my education in regional anaesthetic education. This paper is a concise and informative paper on how to safely perform regional anaesthetic techniques in daily practice.
The last paper I’d like to mention is a personal anathema of mine. There has been a proliferation of pumps evident in theatres in the past number of years. Now let me state that I am a proponent of TIVA. But in terms of iontropic support / vasoactive drugs there seems to be an infusion of phenylephrine started in nearly every case nowadays. I don’t remember this drug being widely used in recent decades but it seems to be everywhere I look now. This paper ‘Intraoperative use of phenylephrine versus ephedrine and postoperative delirium: A multicenter retrospective cohort study’ by Ma H et al makes for worrying reading. This study looked at over one hundred thousand patients and while retrospective in nature has validity in the clinical setting. With an aging population the incidence of cerebro-vascular insufficiency will increase, increasing the watershed areas through routine usage of phenylephrine infusions to correct hypotension may have serious consequences for our patients and I would urge consideration as to why the patient is hypotensive prior to always reaching for the phenylephrine infusion.
The last resource that massively influences my daily practice is not actually a peer reviewed publication but rather the online youtube channel of one of my colleagues. The great thing about working with colleagues that also have academic interests is that they are a constant source of information in a variety of differing areas of anaesthesia practice. Prof. Patrick Neligan’s youtube channel while mainly directed at intensive care medicine the core ideas and lessons are totally applicable to most anaesthesia practices. I would encourage all to peruse the website for an open discussion on issues that will impact on everyone’s clinical practice at some stage.
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