| Wednesday 10 September |
| Time |
TRACK A- STUDIO N |
TRACK B- STUDIO 3+4 |
TRACK C- A1-4 |
TRACK D- STUDIO 2 |
TRACK E- A1-2 |
TRACK F- A1-3 |
TRACK G- A1-5 |
TRACK H- INFLATABLE ROOM |
| 08:00 |
08:00-09:50
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A10
NETWORKING SESSION
Update in Obstetric Anaesthesia
NETWORKING SESSION
Update in Obstetric Anaesthesia
Chairperson:
Thierry GIRARD (Deputy head of anaesthesiology) (Chairperson, Basel, Switzerland)
08:00 - 08:00
Introduction.
08:00 - 08:22
Labour epidural analgesia initiation : epidural vs CSE vs DPE.
Tatiana SIDIROPOULOU (Professor and Chair) (Keynote Speaker, Athens, Greece)
08:22 - 08:44
#48681 - FT01 Labour epidural analgesia maintenance.
Labour epidural analgesia maintenance.
Title
Labour epidural analgesia maintenance
Author
Petramay Attard Cortis MD (Melit.), DESAIC, MMEd (Dundee)
Consultant Anaesthetist and Lead Clinician – Obstetric Anaesthesia
Department of Anaesthesia, Intensive Care and Pain
Mater Dei Hospital, Msida, Malta, Europe
Petramay.cortis@gov.mt
Introduction
Labour epidural analgesia can be initiated using a classical epidural insertion technique, a dural puncture epidural (DPE) or combined spinal epidural (CSE). Once the lumbar epidural catheter is in situ, and the test dose has been given with no obvious signs of intrathecal or intravascular placement, the catheter is assumed to be in the epidural space. Maintenance of lumbar epidural labour analgesia, as opposed to a single shot epidural injection or a caudal catheter technique, has been around since the 1960s1.
The aims of labour epidural analgesia include satisfying the wish of parturients to have a pain-free delivery or one where the pain intensity is significantly controlled; mitigating the effects of labour on pre-existing maternal medical conditions, for example pre-eclampsia2 or modified WHO 3 and WHO 4 heart disease3; and ensuring optimal labour epidural function in case conversion to epidural anaesthesia is required in the peripartum period. This last aim requires regular epidural objective monitoring and proactive management, which remains the responsibility of the supervising anaesthesiologist, though may be delegated to other healthcare professionals4.
Patient expectations
The World Federation of Societies of Anaesthesiologists (WFSA) has published a Declaration on Labour Analgesia which emphasizes the right of every pregnant patient to receive analgesia for labour pain upon request5. When a patient asks for labour epidural analgesia, there is a spectrum of expectations as to what that may imply. Some request to “feel nothing” while others prefer to receive what is known as a “mobile” or “walking” epidural where mobility is somewhat retained. It is important that patient wishes are clarified and that the consent process clearly outlines what epidurals can reasonably be expected to provide, as well as the associated outcomes. When patients’ expectations are met, this is associated with increased patient satisfaction6. Parturients undergoing labour have opted for vaginal delivery, and thus, labour epidural analgesia maintenance should be designed to facilitate this.
Evidence-based maintenance regimes
An extensive systematic review and network meta-analysis from 2023 including 73 trials overall compared several modalities of labour epidural analgesia, namely continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), and patient controlled epidural bolus (PCEA) among others, alone or in combination7. Co-primary outcomes were maternal satisfaction and the need for rescue analgesia. In their conclusion, the authors interpret their overall findings as suggesting that PIEB + PCEA is the optimal mode for maintenance of labour epidural analgesia. This is supported by results showing improved analgesic efficacy of PIEB versus CEI; of PCEA having a reduced incidence of lower limb motor block, an increased rate of spontaneous vaginal delivery and a reduced caesarean section rate compared to CEI; and PIEB + PCEA compared to CEI + PCEA demonstrating lower consumption of local anaesthetics, lower incidence of lower limb motor block, increased rate of spontaneous vaginal delivery and increased maternal satisfaction.
Similarly, a Cochrane systematic review published in the same year, including 18 studies and 4590 participants, found that automated mandatory boluses were associated with a lower incidence of breakthrough pain and reduced local anaesthetic consumption, when compared to a basal infusion8. However, this review found no significant difference in the incidence of caesarean delivery, instrumental delivery, duration of labour analgesia, and neonatal Apgar scores8.
When considering the local anaesthetic to be used, most studies report on bupivacaine, levobupivacaine and/ or ropivacaine for labour epidural analgesia maintenance7,9. These are preferred over other local anaesthetics due to their relatively longer duration of action, and favourable sensory to motor block ratio9.
In relation to local anaesthetic concentration, a systematic review and network meta-analysis compared ultra-low, low, and high concentration local anaesthetics for maintenance of labour epidural analgesia10. This included 32 studies and 3665 participants. Ultra-low concentration was defined as ≤0.08% bupivacaine or equivalent; low concentration as >0.08% to ≤0.1% bupivacaine or equivalent; and high concentration as >0.1% bupivacaine or equivalent10. The authors concluded that similar or better maternal and neonatal outcomes were obtained with ultra-low concentrations of local anaesthetics in labour epidurals, as compared to the other concentrations, albeit with lower local anaesthetic consumption. These outcomes included shorter duration of the first and second stages of labour, less motor block, and higher rates of spontaneous vaginal delivery10 when ultra-low concentrations of local anaesthetics were used.
Together with local anaesthetics, adjuvants are recommended for the maintenance of labour epidural analgesia. Most commonly, lipophilic opioids8,9,10,11 are used in solutions prepared for use for labour epidural analgesia maintenance, such as fentanyl (1–3 μg/mL) and sufentanil (0.2–1 μg/mL), due to their synergistic effects. This increases safety as lower local anaesthetic doses are used12.
Other adjuvants that have been studied include the α2-receptors agonists clonidine and dexmedetomidine especially for breakthrough pain9,11,12,13; epinephrine9,11,12,13; and neostigmine11,12,13. Mainly due to associated adverse effects, these are not recommended for routine use.
Troubleshooting labour epidural analgesia
An important aspect of labour epidural analgesia maintenance is troubleshooting when things do not go according to plan. If the epidural was working well, and later fails with the parturient presenting with pain, this may be the consequence of a block that is absent, too low, patchy, or unilateral. In these cases, the flowchart outlined in the ESAIC focused guidelines for the management of the failing epidural during labour epidural analgesia can be followed4. Re-siting of a failing epidural is recommended using DPE/CSE if pain persists despite additional boluses4. On the other hand, if the epidural block is too high or too dense, then it is relevant to exclude catheter migration into the intrathecal space. If so, the relevant guidance from the Obstetric Anaesthetists' Association can be consulted14. If not, the labour epidural analgesia maintenance regime should be amended, for example, using smaller PIEB volumes, or asking the patient to refrain from pressing the PCEA within a PIEB+PCEA protocol.
Additional considerations
During labour epidural analgesia maintenance, regular monitoring of the patient’s clinical status should be performed and documented4, ideally on a modified obstetric early warning score chart to identify clinical deterioration early15. Vigilance must also be maintained for significant anaesthetic or obstetric complications, such as local anaesthetic systemic toxicity or uterine rupture with breakthrough pain, respectively.
At an institutional level, governance through regular audit and data analysis, will enhance understanding of current local protocols and outcomes, and will allow comparison with international practices.
Conclusion
Labour epidural analgesia maintenance involves a significant amount of time and attention from anaesthesiologists to be performed safely and effectively; to enhance maternal satisfaction; and to be prepared in case of the need for conversion to epidural anaesthesia. PIEB + PCEA seems to be the optimal mode for maintenance of labour epidural analgesia while utilizing ultra-low dose local anaesthetic with adjuvant lipophilic opioid solutions.
References
1. Callahan EC, Lim S, George RB. Neuraxial labor analgesia: maintenance techniques. Best Practice & Research Clinical Anaesthesiology. 2022 May 1;36(1):17-30.
2. Siddiqui MM, Banayan JM, Hofer JE. Pre-eclampsia through the eyes of the obstetrician and anesthesiologist. International Journal of Obstetric Anesthesia. 2019 Nov 1;40:140-8.
3. National Institute for Health and Care Excellence (Great Britain). Intrapartum care for women with existing medical conditions or obstetric complications and their babies. National Institute for Health and Care Excellence (NICE); 2019.
4. Brogly N, Gómez IV, Afshari A, Ekelund K, Kranke P, Weiniger CF, Lucas N, Dewandre PY, Arevalo EG, Ioscovich A, Kollmann A. ESAIC focused guidelines for the management of the failing epidural during labour epidural analgesia. European Journal of Anaesthesiology| EJA. 2025 Feb 1;42(2):96-112.
5. WFSA Obstetric Anaesthesia Committee. Declaration on Patients’ Rights to Labour Analgesia. Accessed in June 2025: https://wfsahq.org/wp-content/uploads/WFSA-Declaration-on-Patients-Rights-to-Labour-Analgesia-2.pdf
6. Mei JY, Afshar Y, Gregory KD, Kilpatrick SJ, Esakoff TF. Birth plans: what matters for birth experience satisfaction. Birth. 2016 Jun;43(2):144-50.
7. Wydall S, Zolger D, Owolabi A, Nzekwu B, Onwochei D, Desai N. Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2023 Mar;70(3):406-42.
8. Tan HS, Zeng Y, Qi Y, Sultana R, Tan CW, Sia AT, Sng BL, Siddiqui FJ. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Cochrane Database of Systematic Reviews 2023, Issue 6. Art. No.: CD011344. DOI: 10.1002/14651858.CD011344.pub3. Accessed 29 June 2025.
9. Callahan EC, Lim S, George RB. Neuraxial labor analgesia: maintenance techniques. Best Practice & Research Clinical Anaesthesiology. 2022 May 1;36(1):17-30.
10. Halliday L, Kinsella M, Shaw M, Cheyne J, Nelson SM, Kearns RJ. Comparison of ultra‐low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta‐analysis. Anaesthesia. 2022 Aug;77(8):910-8.
11. Vanderheeren MC, Van de Velde M, Roofthooft E. Initiation and maintenance of neuraxial labour analgesia: a narrative review. Best practice & research. Clinical anaesthesiology. 2024 Sep;38(3):168-75.
12. Halliday L, Nelson SM, Kearns RJ. Epidural analgesia in labor: a narrative review. International Journal of Gynecology & Obstetrics. 2022 Nov;159(2):356-64.
13. Javed UE, Bhatia K. Neuraxial analgesia in labour–initiation and maintenance techniques. Anaesthesia & Intensive Care Medicine. 2025 Mar 5.
14. Griffiths SK, Russell R, Broom MA, Devroe S, Van de Velde M, Lucas DN. Intrathecal catheter placement after inadvertent dural puncture in the obstetric population: management for labour and operative delivery. Guidelines from the Obstetric Anaesthetists' Association. Anaesthesia. 2024 Dec;79(12):1348-68.
15. Umar A, Ameh CA, Muriithi F, Mathai M. Early warning systems in obstetrics: A systematic literature review. PloS one. 2019 May 31;14(5):e0217864.
Petramay CORTIS (MALTA, Malta)
08:44 - 09:06
#48648 - FT02 Update in obstetric anaesthesia: managing the failing epidural.
Update in obstetric anaesthesia: managing the failing epidural.
Introduction
Epidural analgesia has remained the gold standard for labour analgesia over the past 30 years. Consecutive publications in the field of neuraxial analgesia have progressively improved the safety and reduced side effects of the technique:
• The decrease in local anaesthetic concentrations (1) has reduced the risk of obstetric and haemodynamic side effects.
• The use of opioid adjuvants, thanks to their synergistic effect with local anaesthetics, has helped to further decrease local anaesthetic concentrations 2.
• The introduction of new techniques involving puncture of the dura has allowed a more rapid onset of the block and improved the overall efficacy of epidural analgesia during labour, with no significant side effects or complications (3; 4).
• The development of maintenance methods using programmed intermittent epidural boluses (5), combined with patient-controlled epidural analgesia (PCEA) rescue boluses has led to better pain control after successful initiation of labour analgesia (6).
In fact, the European minimum standards in obstetric anaesthesia recommend adequate management of pain during both vaginal and caesarean delivery, at all stages of the epidural analgesia process (7).
A recent study described the protective effect of epidural analgesia on severe morbidity during delivery, especially when the epidural block was indicated for medical reasons and at an early gestational age (8). This finding highlights the importance of epidural analgesia not only for the comfort of parturients but also for their safety.
In the last 15 years, while safety concerns have progressively improved, there has been increasing focus on the efficacy of the epidural block, leading to efforts to reduce the incidence of epidural failure.
Definitions of Epidural Failure
In 2009, Agaram et al. (9) were the first to introduce the concept of inadequate pain relief with labour epidural, focusing on the onset of the block. They reported an incidence of 16.9% of inadequate block 30 minutes after epidural catheter placement. They identified cervical dilation >7 cm, opioid tolerance, history of previous failed epidural, and less experienced operators as risk factors for inadequate onset of the epidural block.
Hermanides et al. (10), in a narrative review published in 2012, were the first to mention the concept of failed epidural. However, their review presented several limitations: they included studies from various specialties beyond obstetrics; causes of failure varied; criteria for epidural block failure differed between studies; and reported incidence ranged from 5% to more than 40%, depending on the context.
In 2013, Thangamuthu et al. (11) used a standardized definition and reported an epidural failure rate of 23%, identifying risk factors such as anaesthesiologist experience and the length of catheter inserted into the epidural space. However, their definition encompassed both failure during onset and failure during maintenance.
Many authors have evaluated the causes and risk factors for breakthrough pain, as defined by Hess et al. (12) as an episode of pain in a previously functional epidural catheter. Prediction tools were developed to help clinicians prevent these breakthrough pain episodes (13).
Until now, there has been no clear definition in the literature of what constitutes a failing epidural. This is why a panel of experts in obstetric anaesthesia recently defined the concept as inadequate pain relief in a parturient with a previously functional epidural catheter that does not respond to a single epidural top-up dose (14).
Management of a Failing Epidural
Despite efforts to prevent and treat onset failure and breakthrough pain episodes, 6% to 9% of patients still experience epidural block failure requiring catheter replacement (15).
A recent meta-analysis confirmed the superiority of induction techniques involving dural puncture over conventional epidural analgesia, as well as maintenance techniques combining programmed intermittent epidural boluses with PCEA over continuous epidural infusion with PCEA in preventing breakthrough pain (6). Tan et al. (16) recently developed a score to predict breakthrough pain and guide clinicians in applying preventive measures.
Other studies have shown a reduced need for epidural catheter replacement when using the Dural Puncture Epidural (DPE) technique during labour (15).
Guidance was previously published for managing deficient onset of the epidural block during labour (17).
In 2025, a panel of European experts published a focused guideline to help clinicians manage failing epidural analgesia (14). The guideline addressed six clinical questions, covering failing epidural management for vaginal birth and intrapartum caesarean delivery, as well as human resources, organisational, and team training aspects. A systematic review was performed, but due to limited evidence, the panel formulated 11 clinical practice statements and only two formal recommendations.
An algorithm (Figure 1) was developed, recommending whether to administer a top-up dose or to replace the catheter in three situations: totally ineffective block, partially ineffective block, and lateralised block. For catheter replacement, the consensus recommended using a technique involving dural puncture (CSE or DPE).
Detection of a failing epidural is crucial for its management. Despite limited evidence, the panel recommended periodic monitoring of motor and sensory block, pain scores, and clinical status using objective scales. An interval of 2 hours was proposed for high-risk patients, though more flexible intervals could be considered for low-risk parturients. Assessment should include prior epidural function, the number of previous top-ups, motor block, and sympathetic block, using the HELP acronym (How was the Epidural functioning so far, Epidural top-ups administered before, Leg raising capacity, and Place hands on legs to assess temperature differences) (14).
Regarding human resources, the guideline emphasised the leadership role of anaesthesiologists in managing failing epidurals. However, part of the management can be delegated to trained non-anaesthesiologist healthcare professionals, considering human resource limitations in Europe (18). Maintaining adequate patient safety remains essential, and appropriate training for non-anaesthesiologist staff is recommended.
Although there is no specific evidence regarding the optimal training for obstetric teams in handling failing epidurals, evidence from crisis resource management suggests that simulation, teamwork, communication, multidisciplinary training, and fostering a safety and quality culture within departments improve outcomes (19). Consequently, the panel recommended developing local protocols for detecting and managing failing epidurals, alongside simulation-based training to enhance protocol adherence and awareness among healthcare professionals and patients.
Management of a Failing Epidural in the Context of Intrapartum Caesarean Delivery
To address this scenario, the panel formulated recommendations on converting epidural analgesia to anaesthesia and assessing the block to recognise failed conversion—either before surgery begins or intraoperatively. This guidance aims to assist clinicians in managing such situations. Based on criteria described by Yoon et al. (20)—including the level of urgency, the prior effectiveness of the epidural block, the time since the last epidural bolus, and maternal condition—an algorithm was created (Figure 2).
The experts recommended that early and proactive management of a failing epidural facilitates successful conversion of analgesia to anaesthesia for intrapartum caesarean delivery.
Conclusion and Future Perspectives
The introduction of the "failing epidural" concept during labour represents an important advancement in labour analgesia management. It provides clinicians with a systematic approach to addressing inadequate epidural analgesia. The focused guideline helps differentiate between onset failure, breakthrough pain, and a failing epidural, offering practical guidance for management. However, the lack of robust evidence required the panel to rely on consensus-based clinical practice statements, pending future research to validate these recommendations with stronger clinical evidence.
References
1. Halliday L, Kinsella M, Shaw M, Cheyne J, Nelson SM, Kearns RJ. Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: A systematic review and network meta-analysis. Anaesthesia 2022;77:910-918.
2. Cavens L, Roofthooft E. Neuraxial labor analgesia: Is there a place for neuraxial adjuvants beyond opioids. Best Practice & Research Clinical Anaesthesiology 2022;36:31-36.
3. Guasch E, Brogly N, Gilsanz F. Combined spinal epidural for labour analgesia and caesarean section: Indications and recommendations. Curr Opin Anaesthesiol 2020;33:284-290.
4. Singh PM, Monks DT, Bhat AD et al. Epidural analgesia versus dural puncture epidural analgesia in labouring parturients: A meta-analysis of randomised controlled trials. Br J Anaesth 2025;134:1402-1414.
5. Tan HS, Zeng Y, Qi Y et al. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Cochrane Database Syst Rev 2023;6:CD011344.
6. Wang L, Huang J, Chang X, Xia F. Effects of different neuraxial analgesia modalities on the need for physician interventions in labour: A network meta-analysis. Eur J Anaesthesiol 2024;41:411-420.
7. Guasch E, Brogly N, Mercier FJ et al. European minimum standards for obstetric analgesia and anaesthesia departments: An experts' consensus. Eur J Anaesthesiol 2020;37:1115-1125.
8. Kearns RJ, Kyzayeva A, Halliday LOE, Lawlor DA, Shaw M, Nelson SM. Epidural analgesia during labour and severe maternal morbidity: Population based study. BMJ 2024;385:e077190.
9. Agaram R, Douglas MJ, McTaggart RA, Gunka V. Inadequate pain relief with labor epidurals: A multivariate analysis of associated factors. Int J Obstet Anesth 2009;18:10-4.
10. Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: Causes and management. Br J Anaesth 2012;109:144-54.
11. Thangamuthu A, Russell IF, Purva M. Epidural failure rate using a standardised definition. Int J Obstet Anesth 2013;22:310-5.
12. Hess PE, Pratt SD, Lucas TP et al. Predictors of breakthrough pain during labor epidural analgesia. Anesth Analg 2001;93:414-8, 4th contents page.
13. Tan HS, Liu N, Sultana R et al. Prediction of breakthrough pain during labour neuraxial analgesia: Comparison of machine learning and multivariable regression approaches. Int J Obstet Anesth 2021;45:99-110.
14. Brogly N, Valbuena Gomez I, Afshari A et al. Esaic focused guidelines for the management of the failing epidural during labour epidural analgesia. Eur J Anaesthesiol 2025;42:96-112.
15. Berger AA, Jordan J, Li Y, Kowalczyk JJ, Hess PE. Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: A retrospective cohort study. Int J Obstet Anesth 2022;52:103590.
16. Tan HS, Liu N, Tan CW, Sia ATH, Sng BL. Developing the breakthrough pain risk score: An interpretable machine-learning-based risk score to predict breakthrough pain with labour epidural analgesia. Can J Anaesth 2022;69:1315-1317.
17. Guasch E, Iannuccelli F, Brogly N, Gilsanz F. Failed epidural for labor: What now? Minerva Anestesiol 2017;83:1207-1213.
18. Guasch E, Ioscovich A, Brogly N et al. Obstetric anaesthesia manpower and service provision issues (introduction and european perspective). Int J Obstet Anesth 2023;55:103647.
19. MacLennan K, Minehart RD, Vasco M, Eley VA. Simulation-based training in obstetric anesthesia: An update. Int J Obstet Anesth 2023;54:103643.
20. Yoon HJ, Do SH, Yun YJ. Comparing epidural surgical anesthesia and spinal anesthesia following epidural labor analgesia for intrapartum cesarean section: A prospective randomized controlled trial. Korean J Anesthesiol 2017;70:412-419.
Nicolas BROGLY (Madrid, Spain), Emilia GUASCH, Isabel VALBUENA GÓMEZ
09:06 - 09:28
C-section in patients with heart disease.
Malcolm BROOM (?) (Keynote Speaker, Glasgow, United Kingdom)
09:28 - 09:50
Q&A.
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08:00-09:50
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B10
NETWORKING SESSION
Exciting stuff in chronic pain
NETWORKING SESSION
Exciting stuff in chronic pain
Chairperson:
Andrzej KROL (Consultant in Anaesthesia and Pain Medicine) (Chairperson, LONDON, United Kingdom)
08:00 - 08:00
Introduction.
08:00 - 08:14
Is pain visualizable in the brain?
Luis GARCIA-LARREA (Directeur de Recherche Inserm) (Keynote Speaker, Lyon, France)
08:14 - 08:28
Neuomodulation for migraine treatment.
Sam ELDABE (Consultant Pain Medicine) (Keynote Speaker, Middlesbrough, United Kingdom)
08:28 - 08:42
Perioperative opioid use in chronic opioid users.
Patrice FORGET (Professor) (Keynote Speaker, Aberdeen, United Kingdom)
08:42 - 08:56
Modulating Glia cell activity in neuroinflammation.
Jose DE ANDRES (Tenured Professor) (Keynote Speaker, Valencia (Spain), Spain)
08:56 - 09:50
Q&A.
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08:00-08:50
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C10
SECOND OPINION BASED DISCUSSION
Prehospital blocks
SECOND OPINION BASED DISCUSSION
Prehospital blocks
Chairperson:
Lloyd TURBITT (Consultant Anaesthetist) (Chairperson, Belfast, United Kingdom)
08:00 - 08:00
Introduction.
08:00 - 08:20
Prehospital blocks in the alps.
Lukas KIRCHMAIR (Chair) (Keynote Speaker, Schwaz, Austria)
08:20 - 08:40
What do ESRA-members think of prehospital blocks.
Benjamin VOJNAR (Senior Consultant Anaesthetist) (Keynote Speaker, Marburg, Germany)
08:40 - 08:50
Q&A.
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D10
EXPERT OPINION DISCUSSION
Spinals
EXPERT OPINION DISCUSSION
Spinals
Chairperson:
Joanna TOMLINSON (School of Anatomy) (Chairperson, Bristol, United Kingdom)
08:00 - 08:00
Introduction.
08:00 - 08:15
Paresthesia during spinals - Insights from anatomy.
Xavier SALA-BLANCH (chief of orthopedics anaesthesia) (Keynote Speaker, BARCELONA, Spain)
08:15 - 08:30
#48662 - FT14 Spinal anesthesia in the ambulatory setting.
Spinal anesthesia in the ambulatory setting.
SPINAL ANESTHESIA IN THE AMBULATORY SETTING
Esperanza Ortigosa
Head of the Pain Unit at Getafe University Hospital
Professor of Medicine at the European University of Madrid
ABSTRACT
Spinal anesthesia (SA) has long been a mainstay in anesthetic practice, primarily for inpatient procedures and now is becoming more common in the ambulatory setting, particularly for select procedures and patient populations. Recent literature highlights increased interest and utilization of SA for outpatient surgeries, including orthopedic, anorectal, and minimally invasive spine procedures, as well as in pediatric populations. Advances in short-acting local anesthetics have addressed prior concerns about delayed recovery and urinary retention, making SA more adaptable to ambulatory workflows.1,2,3 .Compared to general anesthesia (GA), SA is associated with reduced postoperative pain, nausea, and opioid consumption, while facilitating same-day discharge and maintaining a low complication rate. Despite these benefits, SA remains underutilized due to lingering concerns over duration and flexibility. Nevertheless, growing clinical evidence is driving a trend toward broader adoption in ambulatory settings, confirming its safety, efficacy, and operational feasibility.
This article explores the evolving role of SA in ambulatory surgery, examining patient selection, pharmacological advances, clinical benefits, and implementation strategies for safe and effective practice.
INTRODUCTION
The paradigm shift towards outpatient surgery is driven by patient demand, hospital efficiency goals, and healthcare cost containment. In this context, anesthetic techniques that promote rapid recovery, minimal side effects, and patient satisfaction are essential. While GA remains widely used, SA offers a valuable alternative, particularly for procedures below the umbilicus. The development of short-acting spinal agents has revitalized interest in this technique for ambulatory care4.
MATERIALS AND METHODS
A systematic search was performed in PubMed, Scopus, Embase, UpToDate, and the Cochrane Library, following PRISMA-ScR guidelines. We included systematic reviews, meta-analyses, and controlled clinical trials without restrictions on publication type or language. A preliminary screening of titles and abstracts was conducted, followed by full-text evaluation to identify eligible studies. MeSH terms used included "spinal anesthesia," "ambulatory surgical procedures," "short-acting local anesthetics," and "complications of spinal anesthesia."
INDICATIONS AND SURGICAL PROCEDURES
SA is particularly suitable for short to intermediate-duration surgeries. involving the lower abdomen, pelvis, and lower extremities.
Traditionally, orthopedic patients who have benefited from SA are those undergoing procedures such as knee arthroscopy, anterior cruciate ligament repair, and foot and ankle surgeries. However, in recent years, reports have emerged on the use of SA for total joint arthroplasty in ambulatory settings. In this group, SA is associated with high rates of same-day discharge and reduced postoperative pain and nausea5. Additionally, minimally invasive spine surgeries are increasingly performed under spinal anesthesia to facilitate early mobilization and discharge6.
Some urologic procedures (such as transurethral resections and varicocelectomy), gynecologic procedures, and abdominal surgeries (including inguinal hernia repair, hemorrhoidectomy, and anal fistula repair) are also commonly performed under spinal anesthesia in the ambulatory setting. These procedures are well suited for SA due to their short duration and the possibility of using short-acting agents to enable rapid recovery7.
Careful patient selection is critical to the success of SA in the ambulatory setting. Ideal candidates include: ASA I–II patients, Body Mass Index (BMI) < 35 kg/m2. Low risk for obstructive sleep apnea or cardiovascular instabilityNo history of chronic urinary retention or neurologic disorder and Anticipated surgery duration < 90 minutes
Patient counseling is vital to align expectations regarding the anesthetic plan, recovery, and discharge criteria.
PHARMACOLOGY AND DRUG SELECTION
The choice of local anesthetic determines the duration and quality of spinal blockade. Short-acting and intermediate-acting agents are preferred for ambulatory SA due to their favorable pharmacokinetic profiles—fast onset, predictable offset, and low incidence of transient neurologic symptoms (TNS)8,9.
Local anesthetics commonly used for SA in the ambulatory setting are:
- 2-Chloroprocaine is favored for its rapid onset, short duration, and excellent recovery profile, making it particularly suitable for short-duration ambulatory procedures. It consistently demonstrates the fastest times to discharge, ambulation, and spontaneous voiding. The incidence of transient neurologic symptoms (TNS) is very low, especially with preservative-free formulations. Although rare cases of incomplete cauda equina syndrome have been reported, they are exceedingly uncommon with modern preservative-free preparations. Urinary retention is infrequent and comparable to other short-acting agents8,11.
- Prilocaine is also widely used, offering a slightly longer duration than 2-chloroprocaine but still supporting timely discharge and low TNS risk. It is suitable for procedures of intermediate duration.
- Lidocaine is effective for spinal anesthesia in ambulatory settings, but is associated with a higher risk of TNS, especially in lithotomy position, which has led to a decline in its use in favor of alternatives with better safety profiles10. Rates historically have been reported up to 20%,12 though recent data in the context of multimodal analgesia suggest a much lower incidence (<1%)10. Other side effects include hypotension, headache, backache, and, rarely, allergic reactions. Permanent neurologic injury is extremely rare.
- Mepivacaine provides a reliable block for procedures of moderate duration but may occasionally prolong recovery. The main side effect is TNS, with an incidence generally lower than lidocaine but still present (reported between 1.7% and 6.4%)12. Other side effects include hypotension, headache, and urinary retention, but these are not more frequent than with other short-acting agents. Permanent neurologic injury is rare
- Low-dose bupivacaine: The risk of TNS is very low. The main side effects are dose-dependent hypotension and urinary retention, but these are less frequent with low-dose regimens. Prolonged motor and sensory block can occur if higher doses are used, but this is minimized with ambulatory-appropriate dosing
In summary, 2-chloroprocaine is the agent of choice for most short-duration ambulatory spinal anesthetics, with prilocaine, lidocaine, and mepivacaine as additional options depending on procedure length and patient factors.
TABLE 1: Comparative table of commonly used local anesthetics for spinal anesthesia in ambulatory setting:
COMPARISON OF SPINAL ANESTHESIA AND GENERAL ANESTHESIA IN AMBULATORY SURGERY
Multiple studies and meta-analyses have compared SA and GA in the outpatient setting. SA offers several distinct advantages. While GA allows faster operating room turnover and may be preferred for upper body procedures, SA is often associated with better postoperative analgesia and fewer opioid-related side effects. The choice should be tailored based on patient characteristics, surgical site, and institutional protocols8,13,.
A multicenter observational study by Capdevila et al. (2020)7 analyzed factors influencing anesthetic choice in ambulatory settings. The study found that SA was more frequently selected for lower limb and urologic procedures, older patients, and when enhanced postoperative analgesia was prioritized. GA was preferred for shorter procedures and when rapid turnover was a concern. Institutional experience and anesthesiologist preference also played significant roles.
TABLE 2: Comparing Spinal Anesthesia and General Anesthesia
ADVANTAGES OF SPINAL ANESTHESIA IN THE AMBULATORY SETTING
SA presents several benefits over general anesthesia, particularly in fast-track surgical environments:
• Superior postoperative analgesia, reducing reliance on systemic opioids
• Decreased incidence of postoperative nausea and vomiting (PONV)
• Minimal airway manipulation, reducing the risk of sore throat and respiratory complications
• Faster cognitive recovery compared to general anesthesia
• Cost savings through reduced PACU time and resource utilization2,13
A study by Camponovo et al3. demonstrated that SA with chloroprocaine significantly reduced time to discharge readiness compared to GA for knee arthroscopy. Similar results were reported in a recent cohort by Tasso et al14, where patients undergoing knee arthroscopy under chloroprocaine spinal anesthesia achieved early ambulation and same-day discharge with minimal complications.
CHALLENGES AND LIMITATIONS OF SPINAL ANESTHESIA IN THE AMBULATORY SETTING
Despite its advantages, there are several limitations
• Urinary retention: Although rare with low-dose short-acting agents, it remains a concern. Strategies include limiting block height, avoiding fluid overload, and promoting early mobilization 13.
• Delayed ambulation: Motor recovery time must be closely monitored. Using low-dose and short-acting agents supports quicker ambulation.
• Post-dural puncture headache: Incidence is low with modern pencil-point needles (25G or 27G) 2.
• Block failure or insufficient level: Proper technique and anatomical familiarity are essential. Always prepare for conversion to general anesthesia if needed.
MONITORING AND DISCHARGE CRITERIA
Outpatient spinal anesthesia requires well-defined monitoring protocols and discharge criteria. Patients should:
• Achieve full motor recovery (modified Bromage score 0)
• Be able to ambulate with minimal assistance
• Have stable vital signs and pain control
• Tolerate oral fluids
• Urinate spontaneously or be at low risk for urinary retention (voiding is not mandatory in all protocols)2,13
EVIDENCE AND META-ANALYSES
A 2016 Cochrane meta-analysis by Guay et al1 compared SA versus GA in hip fracture repair and found no significant difference in unplanned hospital admissions, postoperative complications, or mortality rates. Importantly, SA was associated with reduced risk of deep vein thrombosis and improved analgesia in some subgroups.
A more recent and comprehensive Bayesian network meta-analysis by Singh et al8. (2025) evaluated 48 randomized controlled trials involving ambulatory non-arthroplasty surgery. The study concluded that chloroprocaine and prilocaine offered the best balance of rapid recovery, low urinary retention, and minimal transient neurologic symptoms. Specifically, chloroprocaine ranked highest in terms of early ambulation and readiness for discharge, whereas prilocaine provided a slightly longer analgesic window with acceptable safety . These findings reinforce the preferential use of these agents in outpatient SA.
Clinical studies have confirmed the safety and effectiveness of intrathecal chloroprocaine for outpatient orthopedic procedures. For example, in a prospective cohort by Tasso et al15, patients undergoing knee arthroscopy achieved early ambulation and same-day discharge, with excellent recovery profiles and high levels of patient satisfaction.
CONCLUSION
Spinal anesthesia, when tailored appropriately, is a safe, effective, and patient-friendly technique for ambulatory surgery. With careful selection, optimized pharmacology, and standardized protocols, it can enhance surgical efficiency and improve patient outcomes. As outpatient procedures continue to rise, spinal anesthesia will play an increasingly pivotal role in modern anesthetic practice.
REFERENCES
1. Guay J, Nishimori M, Kopp SL. Spinal versus general anaesthesia for hip fracture repair in adults. Cochrane Database Syst Rev. 2016;2(2):CD001159.
2. Bader AM, Datta S. Spinal anesthesia for outpatient surgery. Anesth Analg. 1992;74(4):394–398.
3. Camponovo C, Wulf H, Ghisi D, Fanelli A. Intrathecal chloroprocaine: A review of the clinical literature. Reg Anesth Pain Med. 2010;35(6):556–564.
4. Stewart J, Gasanova I, Joshi GP. Spinal anesthesia for ambulatory surgery: current controversies and concerns. Curr Opin Anaesthesiol. 2020 Dec;33(6):746-752.
5. Calkins TE, Johnson EP, Eason RR, Mihalko WM, Ford MC. Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study. J Arthroplasty. 2024 Jun;39(6):1463-1467.
6. Garg B, Ahuja K, Sharan AD. Regional Anesthesia for Spine Surgery. J Am Acad Orthop Surg. 2022 Sep 1;30(17):809-819.
7. Capdevila X, Aveline C, Delaunay L, Bouaziz H, Zetlaoui P, Choquet O, Jouffroy L, Herman-Demars H, Bonnet F. Factors Determining the Choice of Spinal Versus General Anesthesia in Patients Undergoing Ambulatory Surgery: Results of a Multicenter Observational Study. Adv Ther. 2020 Jan;37(1):527-540.
8. Singh NP, Siddiqui NT, Makkar JK, Guffey R, Singh PM. Optimal local anesthetic for spinal anesthesia in patients undergoing ambulatory non-arthroplasty surgery: a systematic review and Bayesian network meta-analysis of randomized controlled trials. Can J Anaesth. 2025 Apr;72(4):550-566.
9. Wulf H, Hampl K, Steinfeldt T. Speed spinal anesthesia revisited: new drugs and their clinical effects. Curr Opin Anaesthesiol. 2013 Oct;26(5):613-20.
10. Amaral S, Chen E, Kumar AH, MacLeod DB, Bullock WM, Ray N, Manning E, Martinez-Wilson H, Dooley J, Ohlendorf B, Gadsden J. Incidence of transient neurologic symptoms in patients receiving lidocaine spinal anesthesia for outpatient joint arthroplasty. Reg Anesth Pain Med. 2025 Apr 29:rapm-2025-106541.
11. Goldblum E, Atchabahian A. The use of 2-chloroprocaine for spinal anaesthesia. Acta Anaesthesiol Scand. 2013 May;57(5):545-52.
12. YaDeau JT, Liguori GA, Zayas VM. The incidence of transient neurologic symptoms after spinal anesthesia with mepivacaine. Anesth Analg. 2005 Sep;101(3):661-665
13. Schubert AK, Wiesmann T, Wulf H, Dinges HC. Spinal Anesthesia in Ambulatory Surgery. Best Pract Res Clin Anaesthesiol. 2023;37(2):109–12
14. Tasso F, Monteleone G, Biamino C, et al. Use of Chloroprocaine in Orthopedic Day Surgery: A Brief Report in a Cohort of Patients Undergoing Knee Arthroscopy. Eur Rev Med Pharmacol Sci. 2023;27(23):11566–11573.
Esperanza ORTIGOSA (Madrid, Spain)
08:30 - 08:45
Unresolved issues for postspinal headache.
Vishal UPPAL (Professor) (Keynote Speaker, Halifax, Canada, Canada)
08:45 - 08:50
Q&A.
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08:00-09:50
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E10
NETWORKING SESSION
Prospect Session
NETWORKING SESSION
Prospect Session
Chairperson:
Narinder RAWAL (Mentor PhD students, research collaboration) (Chairperson, Stockholm, Sweden)
08:00 - 08:00
Introduction.
08:00 - 08:22
Oesophagectomy.
Esther POGATZKI ZAHN (Full Professor) (Keynote Speaker, Muenster, Germany)
08:22 - 08:44
New and update recommendations for abdominal surgery.
Geertrui DEWINTER (anesthetist) (Keynote Speaker, leuven, Belgium)
08:44 - 09:06
#48629 - FT27 Open colorectal surgery.
Open colorectal surgery.
Open colorectal surgery - An update of the systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations
Axel R. Sauter(*)
On behalf of the PROSPECT Working group of the European Society of Regional Anaesthesia Pain therapy (ESRA)
(*) Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo,
Norway and Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
Background:
Despite advancements in surgical techniques, open colectomy remains commonplace and is often associated with significant postoperative pain.[1] In 2016, the PROcedure SPECific POSToperative Pain Management (PROSPECT) group published recommendations based on a systematic review.[2] The group aimed to update these recommendations by evaluating recent evidence and formulating new guidance for optimal pain control following open colectomy, in line with the PROSPECT approach.
Methods:
A systematic review was conducted using the established PROSPECT methodology. Randomised controlled trials and systematic reviews published in English between 2016 and 2022 were examined. The studies investigated the impact of analgesic, anaesthetic or surgical strategies on postoperative pain following open colectomy. The primary outcome of interest was pain intensity.
Results:
The original 2016 review included 93 studies. Of the 842 additional records examined, 13 new studies met the inclusion criteria and were analysed. Effective intra- and postoperative strategies included the use of paracetamol and epidural analgesia. Where epidural analgesia is contraindicated or impracticable, suitable alternatives include intravenous lidocaine, a bilateral transversus abdominis plane (TAP) block or a continuous pre-peritoneal infusion postoperatively. Safety must be emphasised: the simultaneous use of local anaesthetics via multiple routes should be avoided, and careful dosing with appropriate monitoring is critical to minimise toxicity. For colonic procedures, administrating cyclo-oxygenase-2 (COX-2) inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs) during the intraoperative and postoperative periods is also recommended.
Conclusion:
The updated review identified an evidence-based analgesic regimen for patients undergoing open colorectal surgery.[3]
References:
1. Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology 2013; 118: 934-44.
2. Joshi GP, Bonnet F, Kehlet H Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis 2013; 15: 146-55.
3. Uten T, Chesnais M, van de Velde M, Raeder J, Beloeil H Pain management after open colorectal surgery: An update of the systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol 2024; 41: 363-6.
Axel SAUTER (Oslo, Norway)
09:06 - 09:28
#48404 - FT26 Postoperative analgesia after cesarean section: an update.
Postoperative analgesia after cesarean section: an update.
Postoperative Analgesia after Cesarean Section: an Update
Chalotte De Loecker, MD1, Eva Roofthooft, MD, PhD2, Marc Van de Velde, MD, PhD, ESRA-DRA, FESAIC3
1 Trainee, Department of Anesthesiology, UZ Leuven, Leuven, Belgium
2 Consultant Anesthetist, Department of Anesthesiology, Ziekenhuis aan de Stroom (ZAS) Sint-Augustinus and Sint-Vicentius, Antwerp, Belgium
3 Professor, Department of Cardiovascular Sciences, KULeuven and Consultant, Department of Anesthesiology, UZ Leuven, Leuven, Belgium
Adress correspondence: marc.vandevelde@uzleuven.be
Introduction
Worldwide, the cesarean section rate continues to rise and is estimated to reach a staggering global 30% by 2030 (1). In some areas even rates peaking above 50% are expected, such as in the southern parts of the American continent (1). As a result, cesarean section is worldwide the most performed surgical intervention. Additionally, it is also the most performed intervention out of hours, exposing patients to potentially suboptimal care. Given the increasing frequency of cesarean delivery, the burden on our health care systems is increasing due to increasing cost, increasing demands on staffing and slower functional recovery. Enhanced recovery programs after cesarean section (ERAC) can reduce the impact of surgical delivery allowing more rapid recovery (2). Crucial in ERAC is effective and safe postoperative analgesia. This requires standardized, evidence-based protocols which are easy to implement during normal working hours and also out of hours when less experienced staff is present. The current narrative review describes the current procedure specific (PROSPECT) recommendations for pain relief after cesarean section (3,4).
Enhanced Recovery After Cesarean (ERAC)
Enhanced Recovery After Surgery (ERAS) has revolutionized surgical care for patients. The seminal publication by Kehlet et al. on ERAS in laparoscopic colonic surgery in frail and elderly patients introduced a care bundle which focussed on early mobilisation, early feeding and intensified peri-operative, mulitmodal analgesia (5). Multimodal interventions in the pre-, per- and postoperative period try to control the peri-operative stress response and improve convalescense (6). ERAS guidelines have been introduced for many surgical interventions since this initial publication. The implementation of ERAS care bundles has consistently shown reduced morbidity and mortality, reduced lenght of stay and improved peri-operative outcomes (7). Therefore, implementation of ERAS for cesarean section is crucial to improve outcome after cesarean delivery. In recent years several care bundles were introduced, the so-called ERAC bundles (8).
A crucial element of the care bundle is good quality postoperative analgesia minimizing opioid administration. Optimal pain relief comes with a firm protocol that is procedure specific and evidence based (9). PROSPECT has published numerous recommendations in recent years (www.postoppain.org) for a large variety of surgical interventions (10-18), using a well described methodology (19).
Postoperative analgesia after Cesarean Section: PROSPECT recommendations explained
The PROSPECT group has published two PROSPECT guidelines with recommendations for postoperative analgesia after cesarean. The initial guideline was published on the PROSPECT website in 2014 (20). The most recent recommendation was published in 2021 including scientific evidence up to 2020 (18). A short update was published in 2023 (21). Currently, the group is preparing a third version of the recommendations, which will be released later in 2025.
In total 325 studies were included in the two versions of the recommendation and the short update of 2023, spanning the literature up untill 2022.
Based on the analysis of these papers and following a Delphi process as described in the PROSPECT methodology, a multimodal analgesia strategy is proposed. Firstly, paracetamol and non steroidal anti-inflammatory agents (NSAIDs) are recommended intraoperatively and postoperatively. Simultanuous and systematic administration is recommended intravenously or orally for at least 48-72 hours. NSAIDs are relatively contraindicated in preeclampsia, thrombocytopenia and following major obstetric hemorrhage. However, these contraindications are relative and in UZ Leuven and ZAS Antwerp, NSAIDs are given liberally also in these situations.
The PROSPECT group also recommends the intravenous, intraoperative administration of 5-10 mg dexamethasone (or similar dose of glucocoticosteroid) following delivery of the baby. It has demonstrated analgesic efficacy in cesarean section (22), in many other surgical interventions (23,24) and has other beneficial effects such as prevention of postoperative nausea and vomiting (PONV) (25).
The use of intrathecal or epidural long-acting opioids such as morphine is recommended. It is suggested that at elective cesarean performed under spinal anesthesia, an intrathecal dose of 50-100 mcg morphine is administered. At unplanned cesarean delivery with a labor epidural catheter in place, it is suggested to administer epidural morphine in a dose of 1.5 to 3.0 mg. Recent evidence seemt to re-affirm the excellent effects of neuraxial long-acting morphine (26). However, neuraxial morphine comes with more pruritus and PONV and potentially (low risk) can cause respiratory depression up to 24hours after injection. Therefore, careful respiration and sedation monitoring is recommended making implementation of this strategy somewhat more complex.
When neuraxial morphine is not used, several regional techniques have shown to produce equivalent analgesic efficacy and opioid sparing effects (27-29). Therefore, PROSPECT recommends, as alternatives to neuraxial morphine, single shot or continuous local anesthetic wound infiltration or fascial plane blocks such as the transversus abdominis plane block (TAP) and quadratus lumborum block (QL). In the 2023 short update, also the erector spinae block (ESP) was recommended. In recent years studies have also been published supporting the transversus fascia plane block and the ilioinguinal-iliohypogastric nerve block (30,31). It must however be made clear that combining neuraxial morphine with a peripheral regional technique has no added value.
Finally, PROSPECT recommends the non-closure of the peritoneum, the Joel-Cohen type of incision and the use of postoperative abdominal binders. Transcutaneuous electrical nerve stimulation (TENS) is suggested as an analgesic adjunct.
Opioids should be reserved for rescue analgesia and routine use should be avoided.
Implementation of the PROSPECT protocol at UZ Leuven was succesful and a 4 month audit revealed excellent levels of analgesia and highly satisfied patients (32)
Conclusions
The strenght of the PROSPECT guidelines is the integration of a systematic review of the literature combined with a clinical evaluation of benefits and side-effects of each intervention performed by specialists from surgery and anesthesia. More importantly, the evidence and recommendations are procedure specific making the PROSPECT guidelines unique. The cesarean section guideline provides the clinician with clear guidance on what is effective and what is not. In 2025 an update will be published most likely adding more blocks to the armamentarium of the clinician.
References
1. Trends and projections of caesarean section rates: global and regional estimates. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. BMJ Global Health 2021 6:e005671. doi:10.1136/bmjgh-2021-005671.
2. Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis. Sultan P, Sharawi N, Blake L, Habib AS, Brookfield KF, Carvalho B.Anaesth Crit Care Pain Med. 2021; 100935. doi: 10.1016/j.accpm.2021.100935.
3. PROSPECT guideline for elective caesarean section: an updated systematic review and procedure-specific postoperative pain management recommendations. E Roofthooft, G P Joshi, N Rawal, M Van de Velde, on behalf of the PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (ESRA) and supported by the Obstetric Anaesthetists’ Association (OAA). Anaesthesia 2021; 76, 665 – 680. doi:10.1111/anae.15339
4. PROSPECT guideline for elective caesarean section: an update. E. Roofthooft, G.P. Joshi, N. Rawal, M. Van de Velde. Anaesthesia 2023; 78, 1170-1171.
5. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H.Lancet. 1995 Mar 25;345(8952):763-4. doi: 10.1016/s0140-6736(95)90643-6.
6. Multimodal approach to control postoperative pathophysiology and rehabilitation. H. Kehlet. Brit J Anaesth 1997; 78, 606-617.
7. Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials. Sauro KM, Smith C, Ibadin S, Thomas A, Ganshorn H, Bakunda L, Bajgain B, Bisch SP, Nelson G. JAMA Netw Open. 2024 Jun 3;7(6):e2417310. doi: 10.1001/jamanetworkopen.2024.17310.
8. Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean. Bollag L, Lim G, Sultan P, Habib AS, Landau R, Zakowski M, Tiouririne M, Bhambhani S, Carvalho B. Anesth Analg. 2021 May 1;132(5):1362-1377. doi: 10.1213/ANE.0000000000005257.
9. A critical approach to research on perioperative pain management. Joshi GP, Beloeil H, Lobo DN, Pogatzki-Zahn EM, Sauter AR, Van de Velde M, Wu CL, Kehlet H; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy. Br J Anaesth. 2025 Mar;134(3):621-626. doi: 10.1016/j.bja.2024.11.004.
10. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Lavand'homme PM, Kehlet H, Rawal N, Joshi GP; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (ESRA).Eur J Anaesthesiol. 2022 Sep 1;39(9):743-757. doi: 10.1097/EJA.0000000000001691. Epub 2022
11. Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, Raeder J; PROSPECT Working Group* and the European Society of Regional Anaesthesia and Pain Therapy.Anaesthesia. 2021 Aug;76(8):1082-1097. doi: 10.1111/anae.15498. Epub 2021 May 20.
12. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations.Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M; PROSPECT Working Group *of the European Society of Regional Anaesthesia and Pain Therapy.Anaesthesia. 2022 Mar;77(3):311-325. doi: 10.1111/anae.15609. Epub 2021 Nov 5.
13. PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations. Aldamluji N, Burgess A, Pogatzki-Zahn E, Raeder J, Beloeil H; PROSPECT Working Group collaborators*.Anaesthesia. 2021 Jul;76(7):947-961. doi: 10.1111/anae.15299. Epub 2020 Nov 17.
14. Pain management after elective craniotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Mestdagh FP, Lavand'homme PM, Pirard G, Joshi GP, Sauter AR, Van de Velde M; PROSPECT Working Group∗ of the European Society of Regional Anaesthesia and Pain Therapy (ESRA).Eur J Anaesthesiol. 2023 Oct 1;40(10):747-757. doi: 10.1097/EJA.0000000000001877.
15. Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Maeßen T, Korir N, Van de Velde M, Kennes J, Pogatzki-Zahn E, Joshi GP; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy.Eur J Anaesthesiol. 2023 Oct 1;40(10):758-768. doi: 10.1097/EJA.0000000000001881.
16. Acute pain management after vaginal delivery with perineal tears or episiotomy. Luxey X, Lemoine A, Dewinter G, Joshi GP, Le Ray C, Raeder J, Van de Velde M, Bonnet MP; PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy.Reg Anesth Pain Med. 2024 Jun 14:rapm-2024-105478. doi: 10.1136/rapm-2024-105478.
17. Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR; PROSPECT Working Group.Reg Anesth Pain Med. 2024 Sep 2;49(9):635-641.
18. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Roofthooft E, Joshi GP, Rawal N, Van de Velde M; PROSPECT Working Group* of the European Society of Regional Anaesthesia and Pain Therapy and supported by the Obstetric Anaesthetists’ Association.Anaesthesia. 2021 May;76(5):665-680. doi: 10.1111/anae.15339.
19. PROSPECT methodology for developing procedure-specific pain management recommendations: an update. Joshi GP, Albrecht E, Van de Velde M, Kehlet H, Lobo DN; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy.Anaesthesia. 2023 Nov;78(11):1386-1392. doi: 10.1111/anae.16135.
20. www.postoppain.org/cesarean section (ESRA and PROSPECT website)
21. PROSPECT guideline for elective caesarean section: an update and reply. Roofthooft E, Joshi GP, Rawal N, Van de Velde M; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy.Anaesthesia. 2023 Sep;78(9):1176-1177. doi: 10.1111/anae.16075. Epub 2023 Jun 30.
22. The analgesic efficacy of intravenous dexamethasone for post-caesarean pain: A systematic review with meta-analysis and trial sequential analysis. Singh, Narinder Pal; Makkar, Jeetinder Kaur; Yadav, Neha; et al. European Journal of Anaesthesiology. 39(6):498-510, June 2022.
23. High dose dexamethasone in high pain responders undergoing total hip arthroplasty: A randomized controlled trial. Nielsen, Niklas I.; Kehlet, Henrik; Gromov, Kirill et al. European Journal of Anaesthesiology. 40(10):737-746, October 2023.
24. Comparison of intravenous versus perineural dexamethasone as a local anaesthetic adjunct for peripheral nerve blocks in the lower limb: A meta-analysis and systematic review. Desai, Neel; Pararajasingham, Suji; Onwochei, Desire; et al. European Journal of Anaesthesiology. 41(10):749-759, October 2024.
25. Dexamethasone for the treatment of established postoperative nausea and vomiting: A randomised dose finding trial. Czarnetzki, Christoph; Albrecht, Eric; Desmeules, Jules; et al. European Journal of Anaesthesiology. 39(6):549-557, June 2022.
26. The implementation of intrathecal morphine for caesarean delivery into clinical practice, and assessment of its impact on patient-reported quality of recovery using the ObsQoR-10-Dutch scale: A single-centre cohort study. van den Bosch, Oscar F.C.; Rijsdijk, Mienke; Rosier, Suzanne E.; et al. European Journal of Anaesthesiology. 42(4):332-339, April 2025.
27. Transversus abdominis plane block versus local anaesthetic wound infiltration for analgesia after caesarean section: A systematic review and meta-analysis with trial sequential analysis. Grape, Sina; Kirkham, Kyle Robert; Albrecht, Eric. European Journal of Anaesthesiology. 39(3):244-251, March 2022.
28. Posteromedial quadratus lumborum block versus wound infiltration after caesarean section: A randomised, double-blind, controlled study. Stopar-Pintaric, Tatjana; Blajic, Iva; Visic, Uros; et al. European Journal of Anaesthesiology. 38:S138-S144, August 2021.
29. Local anaesthetic wound infiltration for postcaesarean section analgesia: A systematic review and meta-analysis. Adesope, Oluwaseyi; Ituk, Unyime; Habib, Ashraf S. European Journal of Anaesthesiology. 33(10):731-742, October 2016.
30. Ultrasound-guided transversalis fascia plane block or transversus abdominis plane block for recovery after caesarean section: A randomised clinical trial. Pinarbaşi, Ahmet; Altiparmak, Başak; Korkmaz Toker, Melike; et al. European Journal of Anaesthesiology. 41(10):769-778, October 2024.
31. The analgesic effectiveness of ilioinguinal-iliohypogastric block for caesarean delivery: A meta-analysis and trial sequential analysis. Singh, Narinder P.; Makkar, Jeetinder K.; Bhatia, Nidhi; et al. European Journal of Anaesthesiology. 38:S87-S96, August 2021.
32. Postoperative Pain after Cesarean Section: an Audit of Practice after Implementation of the PROSPECT recommendations. Nooshin Gharae, Eva Roofthooft, Nicoletta Fileticci, Sarah Devroe, Philippe Vanhove, Steffen Rex, Marc Van de Velde. Acta Anaesthesiologica Belgica 2021; 72, 109-113.
Charlotte DE LOECKER, Eva ROOFTHOOFT, Marc VAN DE VELDE (Leuven, Belgium)
09:28 - 09:50
Q&A.
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F10
PANEL DISCUSSION
Cold inside
PANEL DISCUSSION
Cold inside
Chairperson:
Gaurav CHHABRA (Consultant) (Chairperson, Bristol, United Kingdom)
08:00 - 08:00
Introduction.
08:00 - 08:25
Cryoanalgesia in the treatment of acute pain related to surgical procedures.
Michal BUT (Consultant pain clinic) (Keynote Speaker, Koszalin, Poland)
08:25 - 08:50
Cryoanalgesia for peripheral nerves : spasticity, neuromas and more.
Matthieu CACHEMAILLE (Médecin chef) (Keynote Speaker, Geneva, Switzerland)
08:50 - 09:15
Cryoanalgesia of the joints.
Pasquale DE NEGRI (Director of Dept) (Keynote Speaker, Caserta, Italy)
09:15 - 09:25
Q&A.
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08:00-09:50
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H10
SIMULATION TRAININGS
SIMULATION TRAININGS
Demonstrators:
Josip AZMAN (Consultant) (Demonstrator, Linkoping, Sweden), Vedran FRKOVIC (Senior Consultant in Anaesthesiology and pain medicine) (Demonstrator, Linkoping/ Sweden, Sweden), Lara RIBEIRO (Anesthesiologist Consultant) (Demonstrator, Braga-Portugal, Portugal), Roman ZUERCHER (Senior Consultant) (Demonstrator, Basel, Switzerland)
This interactive, simulation-based learning experience allows you to explore the complications of regional anaesthesia in a fun and engaging way! Covering several challenging daily clinical situations and crisis management cases from the fields of trauma, orthopaedics and obstetrics, it combines all kinds of simulation to provide an excellent learning resource.
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C10.1
ASK THE EXPERT
A full stomach
ASK THE EXPERT
A full stomach
Chairperson:
Peter VAN DE PUTTE (Consultant) (Chairperson, Bonheiden, Belgium)
09:00 - 10:00
Introduction.
09:00 - 10:00
How gastric POCUS changed my worklist.
Barbara RUPNIK (Consultant anesthetist) (Keynote Speaker, Zurich, Switzerland)
09:00 - 10:00
Q&A.
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D10.1
EXPERT OPINION DISCUSSION
Hygienic standards
EXPERT OPINION DISCUSSION
Hygienic standards
Chairperson:
Nuala LUCAS (Speaker) (Chairperson, London, United Kingdom)
09:00 - 09:00
Introduction.
09:00 - 09:15
Infectious complications: The current estimates.
Peter MARHOFER (Director of Paediatric Anaesthesia and Intensive Care Medicine) (Keynote Speaker, Vienna, Austria)
09:15 - 09:30
#48378 - FT16 Hygienic standards and environmental concerns.
Hygienic standards and environmental concerns.
Hygienic standards and environmental concerns
Vivian H. Y. Ip MBChB FRCA
Clinical Professor,
Department of Anesthesia, Perioperative, and Pain Medicine
University of Calgary
Calgary
Alberta
Canada
Email: hip@ualberta.ca
Conflict of Interests:
Dr. Vivian Ip is the Chair of the Environmental Sustainability Section, the Chair of the Regional Anesthesia Section at the Canadian Anesthesiologists’ Society, and the Advisor of the Green Anesthesia Special Interests Group at the American Society of Regional Anesthesia and Pain Medicine.
Word count = 1333
References = 22
Introduction
Regional anesthesia has been practiced for over a decade, the infection complications have reduced significantly with the evolution of infection control and prevention practices.1 Institutional protocols as well as vigilant surveillance and audits ensure infection control and prevention practice standards are upheld. Nowadays, the infectious complications of regional anesthesia in acute pain medicine in terms of neuraxial or peripheral nerve blocks are very rare.1
Nonetheless, there is always a dual challenge in healthcare with infection prevention and environmental impact. While infection prevention practice can be resource intensive, especially without consideration on the environmental sustainability and promote responsible use of resource. High-income countries often possess an abundance of resources, which can lead practitioners to overlook the critical need for responsible resource use. These resources are, in fact, costly and finite, as well as the potential to generate a substantial waste and carbon footprint. With the healthcare industry contributing a significant amount of net global carbon dioxide emission, and if healthcare were a country, it would rank the 5th largest emission of carbon dioxide in the world, there should be an evaluation of how this can be improved. Ironically, the environmental impact affects the health of humanity, considerations of responsible use of resource, while balancing patient safety is paramount. This expert opinion discussion aims to outline the strategies in clinical practice to be ‘clean and green’ in regional anesthesia.
The scale of the problem: Infection rate in regional anesthesia versus the environmental impact of healthcare
A recent review investigated the pooled estimate of overall infectious complications following all central neuraxial block was 9/100000 (95%CI: 5, 13/100000), central neuraxial infections following all central neuraxial block was estimated to be 2/100000 (95% CI: 1,3/100000), and even rarer following spinal anesthesia at 1/100000 (95% CI: 1,2/100000). Even rarer is the infection rate reported in the obstetric population with an overall infection rate of 1/100000 (95% CI: 1,3/100000) and central neuraxial injections at 4/1000000) (95% CI: 0.3, 1/100000) following all central neuraxial blocks.1 For peripheral nerve blocks, the reported rate of infections complications was slightly higher at 1.8%. (95% CI 1.2, 2.5/100) (Selvamani) A 10-year cohort study review of ultrasound-guided nerve block using non-sterile gel, sterile transparent film barrier and disinfect ultrasound transducer in between uses fount no infection rate in 7476 patients.2 Another study found no significant infection in 211 femoral nerve catheters.3 A large retrospective review of 9649 patients reported zero infections in the lumbar plexus catheters.4
Regarding environmental sustainability, healthcare industry contributes 4.6% of the global net carbon emissions.5 Recently, the “United Nations Environment Program” issued a stern statement urging immediate action to curb carbon emissions to prevent catastrophic temperature spikes and mitigate the worst impacts of climate change. To stay on track for limiting global temperature rise to 1.5°C (34.7°F), carbon emissions must decrease by 42% by 2030 and by 57% by 2035.6 Failure to act could lead to a temperature rise of 2.6–3.1°C (36.7–37.6°F). In 2023, annual global temperatures reached a record high of 1.45°C, and if current policies persist, the world is on track for a 2.7°C increase by 2100.6 Sadly, anthropogenic emissions continue to increase globally and a reverse course to maintain, minimise greenhouse gas emissions seems impossible.
Hygienic Standards in RA
Recently, ASRA Pain Medicine produced an excellent guideline on infection control in both acute and chronic pain practice.7 The article contains several procedural recommendations with the associated level of evidence. The only Grade A evidence is that preoperative antibiotic prophylaxis given 1 hour prior to surgical incision for invasive procedures, as there is strong certainty suggesting preoperative antibiotic prophylaxis reduces risk of surgical site infection. Although these types of invasive procedures tend to refer to chronic pain. For acute pain procedural recommendations, most are of grade B evidence, with the more robust and consistent evidence to prevent infection being hand hygiene, the use of chlorhexidine in alcohol, and the aseptic non-touch techniques (ANTT).7-8
In the ASRA Pain Medicine infection consensus guideline, it states that all procedural staff should perform hand hygiene prior to the first case of the day, before and after glove use, before and after patient contact, and any time hands are visibly soiled. Hand hygiene with skin antisepsis is a key component, and the single most important basic preventative measure that significantly reduce hospital-acquired infections with high certainty.7, 9
Another area with great certainty is the use of chlorhexidine in alcohol for preparation of the procedural site. A Cochrane meta-analysis in 2015 showed that preoperative skin preparation with chlorhexidine in alcohol was associated with lower infection rates after clean surgeries.10
Furthermore, the ANTT clinical procedure guideline has been incorporated into many institutional protocols globally. It is a specific type of aseptic technique with a unique theory and practice framework to improve and standardize aseptic technique for all clinical procedures. This technique ensures that only uncontaminated equipment and fluids come into contact with susceptible body sites and is also endorsed by NICE in the UK.8, 11
Upon examination of the outbreak investigations with bacterial meningitis amongst patients undergoing spinal procedures where healthcare providers did not wear a face mask, the organism causing the infection was traced back to the respiratory flora of the unmasked provider. This provides strong epidemiological evidence to advocate for all personnel in the immediate area as well as the person performing the neuraxial blocks, when catheter or injection of drug into the spinal canal or subdural space, should wear a surgical face mask to minimise the risk of droplet transmission.12-13
Environmental considerations in regional anesthesia in the context of infection prevention
The main concern is overuse of resources in practices that are considered to reduce infection rate but not supported by robust evidence. Without responsible use of resource to minimize waste generation, energy used to process reusable attires and equipment, as well as medication waste, it leaves a significant carbon footprint without meaningful clinical impact. There is also a myth that disposable equipment reduces infection risks compared to reusable supplies. Reusable supplies and equipment do not increase risk of infection when adequate sterilization is the key. A recent systematic review included 9 studies including more than 45,000 cases demonstrated no significant difference in surgical site infection rates between the reusable and disposable groups. At the same time, reusable surgical headwear significantly lowers the carbon footprint than disposable alternatives.14
Studies have shown that there is no difference between reusable or disposable supplies to reduce the risk of surgical site infection in orthopedic and spinal surgery,15 coronary artery surgery,16 intensive care unit.17 However, reusable supplies generate much less carbon emission.18-20
Another strategy to reduce waste and emissions is creative thinking of ‘doing more with less’. One example is using alcohol-based hand rub between patients. This approach is advocated by the hand hygiene liaison group, limits the use of resources, saves water, towels and energy used compared to handwashing.21, 22
Fine balance
While clinical guidelines are essential to provide valuable guidance on clinical practice, some recommendations lack robust evidence. Yet, once published as a guideline, they may be followed rigidly without assessment or consideration of the level of evidence. Though guidelines are meant to inform rather than replace clinical judgement, this concept might be overlooked.
Furthermore, there will be a point where diminishing returns are reached whereby adding more resources and intervention while holding other factors constant will not result in reduction in infection rates. The financial and social cost can then become disproportionally high compared to clinical benefits. It is important to realize that resource is finite and a greater harm and significant negative impact on society, such as more frequent and intense weather events, may be caused by trying to achieve a relatively small gain. Furthermore, better financial and resource allocation to other parts of healthcare may yield greater clinical benefits, for example, allocate funding on climate resiliency.
Conclusion
Therefore, looking ahead, there needs to be a raise in awareness and education, while drafting policy that balances infection prevention taking account of responsible use of resources without compromising patient safety.
Reference
1. Selvamani BJ, Kalagara H, Volk T et al. Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk. Reg Anesth Pain Med 2024 doi:10.1136/rapm-2024-105496.
2. Alakkad H, Naeeni A, Chan VWS, et al. Infection related to ultrasound- guided single- injection peripheral nerve blockade: a decade of experience at toronto Western hospital. Reg Anesth Pain Med 2015;40:82–4. 222
3. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg 2001;93:1045–9.
4. Njathi CW, Johnson RL, Laughlin RS, et al. Complications After Continuous Posterior Lumbar Plexus Blockade for Total Hip Arthroplasty: A Retrospective Cohort Study. Reg Anesth Pain Med 2017;42:446–50.
5. The Lancet Digital Health. Curbing the carbon footprint of health care. Curbing the carbon footprint of health care (Accessed May 25, 2025)
6. United Nation Environment programme. Emissions gap report 2024. 2024 (Oct) Emissions Gap Report 2024 | UNEP - UN Environment Programme (Accessed Nov 6, 2025)
7. Provenzano DA, et al. ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine. Reg Anesth Pain Med 2025;0:1-50
8. ANTT Clinical Practice Framework. ANTT Practice Framework (Accessed May 25, 2025)
9. Simmons CG, Hennigan AW, Loyd JM, et al. Patient safety in anesthesia: hand hygiene and perioperative infection control. Current Anesthesiology reports 2022;12:493-500.
10. Torres de Araujo Azi LM, Fonseca NM, Linard LG. SBA 2020: Regional anesthesia safety recommendations update. Braz J Anesthesiol 2020;70:398-418.
11. National Institute for Health and Care Excellence. Healthcare-associated infections: prevention and control in primary and community care. Recommendations | Healthcare-associated infections: prevention and control in primary and community care | Guidance | NICE (Accessed May 25, 2025)
12. Use of Surgical Masks in the Operating Room: A Review of the Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2013 Nov 19. APPENDIX 8, Summary of Recommendations by Source. Available from: https://www.ncbi.nlm.nih.gov/books/NBK195770/Teare L, Cookson B, Stone S. Hand hygiene.
13. Smith C, King W, O’Brien D, et al. Masks, gowns, and caps for interventional spine pain procedures. Pain Medicine 2018;19(6):1293-1294.
14. Gumera A, Mil M, Hains L, et al. Reusable surgical headwear has a rduced carbon footprint and matches disposables regarding surgical site infection: a systematic review and meta-analysis. The J of hospital infection 2024;152:164-172.
15. Kieser DC, Wyatt MC, Beswick A, et al. Does the type of surgical drape (disposable versus non-disposable) affect the risk of subsequent surgical site infection. J Orthop 2018;15(2):566-570.
16. Bellchambers J, Harris JM, Cullinan P, et al. A prospective study of wound infection in coronary artery surgery. Eur J Cardiothorac Sug 1999;15(1):45-50.
17. Albert NM, Slifcak E, Roach JD, Bena JF, Horvath G, Wilson S, Van Den Bossche R, Vargas N, Rhoades V, Hartig KM, Lachiewicz H, Murray T. Infection rates in intensive care units by electrocardiographic lead wire type: disposable vs reusable. Am J Crit Care. 2014 Nov;23(6):460-7; quiz 468. doi: 10.4037/ajcc2014362. PMID: 25362669.
18. Donahue LM, Petit HJ, Thiel CL, Sullivan GA, Gulack BC, Shah AN. A Life Cycle Assessment of Reusable and Disposable Surgical Caps. J Surg Res. 2024 Jul;299:112-119. doi: 10.1016/j.jss.2024.04.007. Epub 2024 May 14. PMID: 38749314.
19. Vozzola E, Overcash M, Griffing E. Environmental considerations in the selection of isolation gowns: a life cycle assessment of reusable and disposable alternatives. Am J Inf Cont 2018; 46: 881–6. https://doi.org/10.1016/j.ajic.2018.02.002
20. Overcash M. A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012. Anesth Analg 2012; 114: 1055–66.
21. Teare L, Cookson B, Stone S. Use alcohol hand rubs between patients: they reduce the transmission of infection. BMJ 2001; 323: 411–2. https://doi.org/10.1136/bmj.323.7310.411 (Accessed May 29, 2025)
22. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002; 23: S3–40. https://doi.org/10.1086/503164
Vivian IP (Calgary, Canada)
09:30 - 09:45
Hygienic standards: ASRA guidelines.
David PROVENZANO (Faculty) (Keynote Speaker, Bridgeville, USA)
09:45 - 09:50
Q&A.
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G10
PANEL DISCUSSION
The ESRA AI Working Group
PANEL DISCUSSION
The ESRA AI Working Group
Chairperson:
James BOWNESS (Consultant Anaesthetist) (Chairperson, London, United Kingdom)
Panelists:
Steve COPPENS (Head of Clinic) (Panelist, Leuven, Belgium), Bernard DELVAUX (Staff Anesthesiologist) (Panelist, Quincy-Sous-Sénart, France), Dan Sebastian DIRZU (consultant, head of department) (Panelist, Cluj-Napoca, Romania), Dmytro DMYTRIIEV (chief of pain medicine department) (Panelist, Vinnitsa, Ukraine), David HEWSON (Anaesthesia) (Panelist, Nottingham, United Kingdom), Eleni MOKA (faculty) (Panelist, Thessaloniki, Greece, Greece), Vicente ROQUES (Anesthesiologist consultant) (Panelist, Murcia. Spain, Spain)
The ESRA AI Working Group has been formed to support the development and appropriate adoption of AI in regional anaesthesia and point-of-care ultrasound.
09:00 - 09:50
Background of the ESRA AI working group.
Fani ALEVROGIANNI (Resident) (Keynote Speaker, Athens, Greece)
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F10.1
TIPS & TRICKS
Stay calm when the airway is tough
TIPS & TRICKS
Stay calm when the airway is tough
Chairperson:
Kamen VLASSAKOV (Chief,Division of Regional&Orthopedic Anesthesiology;Director,Regional Anesthesiology Fellowship) (Chairperson, Boston, USA)
09:30 - 10:00
Introduction.
09:30 - 10:00
RA techniques for awake fibreoptic intubation.
Kariem EL BOGHDADLY (Consultant) (Keynote Speaker, London, United Kingdom)
09:30 - 10:00
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COFFEE BREAK
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A11
NETWORKING SESSION
Updates on Caesarean section
NETWORKING SESSION
Updates on Caesarean section
Chairperson:
Tatiana SIDIROPOULOU (Professor and Chair) (Chairperson, Athens, Greece)
10:30 - 10:30
Introduction.
10:30 - 10:52
Preventing hypotention during spinals.
Thierry GIRARD (Deputy head of anaesthesiology) (Keynote Speaker, Basel, Switzerland)
10:52 - 11:14
Adjuvant drugs for spinal anaesthesia.
Sarah DEVROE (Head of clinic) (Keynote Speaker, Leuven, Belgium)
11:14 - 11:36
The anaesthetist's role in enhanced recovery.
Nuala LUCAS (Speaker) (Keynote Speaker, London, United Kingdom)
11:36 - 11:58
Analgesia after CS when intrathecal opioids haven’t been used.
Neel DESAI (Consultant in Anaesthetics) (Keynote Speaker, London, United Kingdom)
11:58 - 12:20
Q&A.
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10:30-11:20
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B11
EXPERT OPINION DISCUSSION
Multidisciplinary teams are key for success in chronic pain
EXPERT OPINION DISCUSSION
Multidisciplinary teams are key for success in chronic pain
Chairperson:
Gaurav CHHABRA (Consultant) (Chairperson, Bristol, United Kingdom)
10:30 - 10:30
Introduction.
10:30 - 10:42
Case presentation.
Gaurav CHHABRA (Consultant) (Keynote Speaker, Bristol, United Kingdom)
10:42 - 10:54
Progressing with SCS: Methods to Ensure Long-Term Outcomes.
David PROVENZANO (Faculty) (Keynote Speaker, Bridgeville, USA)
10:54 - 11:06
SCS.
Ashish GULVE (Consultant in Pain Medicine) (Keynote Speaker, Middlesbrough, United Kingdom)
11:06 - 11:18
Psychologic assessment preimplant.
Sarah LOVE-JONES (Anaesthesiology) (Keynote Speaker, Bristol, United Kingdom)
11:18 - 11:20
Q&A.
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C11
LIVE DEMONSTRATION
Blocks above the clavicle
LIVE DEMONSTRATION
Blocks above the clavicle
Demonstrators:
eric ALBRECHT (Program director of regional anaesthesia) (Demonstrator, Lausanne, Switzerland), Sebastien BLOC (Anesthésiste Réanimateur) (Demonstrator, Paris, France)
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D11
REFRESHING YOUR KNOWLEDGE
Rebound pain
REFRESHING YOUR KNOWLEDGE
Rebound pain
Chairperson:
Lukas KIRCHMAIR (Chair) (Chairperson, Schwaz, Austria)
10:30 - 10:30
Introduction.
10:30 - 10:50
#48665 - FT17 Rebound pain -a misnomer?
Rebound pain -a misnomer?
Several studies on rebound pain after peripheral nerve blocks are published in the last few years. Rebound pain is a commonly used term to describe strong pain at resolution of peripheral nerve blocks. There is however no formal definition or firm consensus of rebound pain. It is therefore unclear whether authors of different papers are describing the exact same phenomenon. The mechanisms behind rebound pain are also unclear. An important question is whether it simply represents unmasking of the expected nociceptive response after surgery in the absence of adequate analgesia, or if it represents an exaggerated nociceptive response due to a still poorly understood response to the peripheral nerve block itself. In other words: Is rebound pain an actual phenomenon or is it more likely a misnomer, leading to misunderstanding and confusion?
For patients, strong pain at block resolution can cause considerable discomfort and fear and may diminish the overall benefits of the block. This is especially important after ambulatory surgery, when patients find themselves discharged and without professional care givers at block resolution. For these patients rebound pain may increase the need for unplanned healthcare resource utilisation after discharge (1, 2)
Rebound pain is usually referred to as acute postoperative pain after resolution of the sensory nerve block caused by regional anaesthesia. It is also described as an abrupt sensation of clinically significant pain after a long pain free period. Rebound pain is more often reported after dense sensory nerve blocks in contrast to fascial plane blocks like transverse abdominal plane block, erector spinae plane block and quadratus lumborum block, and is often accompanied by an increase in analgesic consumption (3). Some studies use a cut off value of NRS score 7 for what they refer to as rebound pain, others use NRS 8-10 (4, 5). Another suggested and more precise definition is a mild pain of NRS score less than 4 while the nerve block is working that transition to severe pain represented as a NRS pain score equal or above 7 after block resolution (6).
Regardless of whether rebound pain represents a specific phenomenon or not, we do know that a large percentage of patients experience strong pain upon nerve block resolution (7). The incidence is however unknown and varies according to type of surgery and the presence of risk factors for rebound pain. In a retrospective cohort study by Barry and colleagues published in 2020, almost 50% of the patients experienced rebound pain at block resolution after peripheral nerve blocks for a mix of ambulatory surgical procedures (6). In other studies, the reported incidence varies greatly between 9% and 80% (2, 7-11).
Even though rebound pain is poorly understood, several mechanisms are suggested in the literature. One predominant hypothesis is that rebound pain occurs due to the sudden return of nociceptive sensation as the nerve block wears off. The pain aligns with the expected nociceptive pain response after surgery when adequate pre-emptive and multimodal analgesia is not provided (12).
The transition from complete absence of pain when the nerve block is working to a sudden and intense pain from previously suppressed nociceptive signals at block resolution may reduce pain tolerance. Psychological factors like anxiety, fear and fatigue may additionally increase the sensed pain.
The inflammatory response to surgery seems to be important for the strong pain at block resolution. Peripheral nerve blocks stop the transmission of nociceptive input to the spinal cord and higher brain areas and therefore may inhibit central sensitisation when the block is working (13). Peripheral nerve blocks like for example brachial plexus blocks may have a small anti-inflammatory effect due to its ability to increase peripheral circulation and thus potentially increase the “washing out” of inflammatory mediators (14). However, the potential anti-inflammatory effect on a remote surgical site seems to be minor and the inflammatory process will continue in the absence of systemic anti-inflammatory prophylaxis (15). An ongoing inflammation at the surgical site may result in sensitisation of peripheral nociceptors. When the nerve block wears off, the patients may be in a state of strong peripheral and central sensitisation from systemic inflammatory mediators. Anti-inflammatory prophylaxis with etoricoxib seems to reduce opioid consumption after surgery, the addition of dexamethasone increases nerve block duration and reduces pain scores (14). The significant effect of dexamethasone to reduce rebound pain strengthens the importance of the inflammatory reaction (8, 10).
Hyperalgesia, possibly induced by local anaesthetics, has been suggested to contribute to rebound pain after peripheral nerve blocks as rebound pain is often described as a burning sensation. Some studies indicate that a few patients experience hyperalgesia in the aftermath of a nerve block. Transient heat hyperalgesia without hyperalgesia to mechanical stimuli has been demonstrated after sciatic nerve blocks in rats (16,17), but it is important to remember that hyperalgesia to heat stimuli is a normal response to tissue trauma also in the absence of regional anaesthesia (3). The use of regional anaesthesia contribute to reduced perioperative opioid consumption, and as such theoretically prevents opioid-induced hyperalgesia (18).
Another theory of rebound pain considers it a reversible nerve injury due to neurotoxicity from potent solutions of local anaesthetics or secondary to nerve injury caused by intrafascicular injection of local anaesthetics or possibly by needle trauma. Another possible cause of transient nerve injury suggested is ischemia caused by compression by local anaesthetics or local vasoconstriction due to local anaesthetics or adjuvants (19). The counterargument to this is that rebound pain only lasts a few hours, significantly shorter than one would expect after nerve injuries.
Several factors that increase the risk of rebound pain after peripheral nerve blocks have been identified. Among them are the presence of preoperative pain, young age, female gender, surgery involving bone and the absence of perioperative multimodal analgesia (3, 6, 9). The absence of perioperative intravenous dexamethasone is highlighted as one of the most important risk factors of rebound pain (6).
There are several strategies to reduce rebound pain at block resolution. First, it is important with thorough and repeated patient information, both regarding block offset and expected post-surgical pain. Second, the use of multimodal and prophylactic analgesia is important. Analgesic medication should consist of anti-inflammatory prophylaxis combined with paracetamol and opioids and be initiated in a timely manner. It is important to instruct the patients to take analgesics earlier rather than later when the nerve block is expected to resolve. Third, as nociceptive input and pain generally declines consistently during the hours after surgery, measures to prolong the duration of the nerve block are thought to reduce rebound pain (10, 20-22). This can be achieved by intravenous, oral or perineural adjuvants or by continuous nerve block catheters. It is important to remember that many potential adjuvants are not licenced for perineural use. Oral and intravenous dexamethasone are shown to prolong nerve block duration and significantly reduce rebound pain (8, 10, 23). Perineural clonidine and dexmedetomidine prolong nerve block duration, but are not shown to reduce rebound pain, and are associated with side-effects like sedation, bradycardia and dizziness (19). Intravenous ketamine has shown conflicting results while intravenous magnesium has recently been suggested to prolong nerve block duration and reduce rebound pain (8, 11,24,25).
To conclude, it is not clear if rebound pain is simply a fancy word for poor management of postoperative pain, or if it represents increased pain due to some aspect of the nerve block itself. There are several ongoing studies that hopefully will help us better understand the mechanisms of rebound pain in the future. Regardless of whether rebound pain represents a specific physiological phenomenon or simply the expected nociceptive pain as the nerve block wears off, it is important to explore strategies to reduce the strong pain at block resolution. Literature on this topic published in the last few years singles out intravenous dexamethasone as probably the most important action to reduce this pain and should be combined with a well-timed multimodal analgesic strategy and thorough patient information.
References:
1. Sunderland S, Yarnold CH, Head SJ, Osborn JA, Purssell A, Peel JK, et al. Regional Versus General Anesthesia and the Incidence of Unplanned Health Care Resource Utilization for Postoperative Pain After Wrist Fracture Surgery: Results From a Retrospective Quality Improvement Project. Reg Anesth Pain Med. 2016;41(1):22-7.
2. Lavand'homme P. Rebound pain after regional anesthesia in the ambulatory patient. Curr Opin Anaesthesiol. 2018;31(6):679-84.
3. Munoz-Leyva F, Cubillos J, Chin KJ. Managing rebound pain after regional anesthesia. Korean J Anesthesiol. 2020;73(5):372-83.
4. Yin W, Luo D, Mi H, Ren Z, Li L, Fan Z, et al. Rebound Pain After Peripheral Nerve Block: A Review. Drugs. 2025.
5. Yang ZS, Lai HC, Jhou HJ, Chan WH, Chen PH. Rebound pain prevention after peripheral nerve block: A network meta-analysis comparing intravenous, perineural dexamethasone, and control. J Clin Anesth. 2024;99:111657.
6. Barry GS, Bailey JG, Sardinha J, Brousseau P, Uppal V. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery. Br J Anaesth. 2021;126(4):862-71.
7. Holmberg A, Sauter AR, Klaastad O, Draegni T, Raeder JC. Pre-operative brachial plexus block compared with an identical block performed at the end of surgery: a prospective, double-blind, randomised clinical trial. Anaesthesia. 2017;72(8):967-77.
8. Touil N, Pavlopoulou A, Barbier O, Libouton X, Lavand'homme P. Evaluation of intraoperative ketamine on the prevention of severe rebound pain upon cessation of peripheral nerve block: a prospective randomised, double-blind, placebo-controlled study. Br J Anaesth. 2022;128(4):734-41.
9. Sort R, Brorson S, Gogenur I, Nielsen JK, Moller AM. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study. Acta Anaesthesiol Scand. 2019;63(3):396-402.
10. Holmberg A, Hassellund SS, Draegni T, Nordby A, Ottesen FS, Gulestol A, et al. Analgesic effect of intravenous dexamethasone after volar plate surgery for distal radius fracture with brachial plexus block anaesthesia: a prospective, double-blind randomised clinical trial(). Anaesthesia. 2020;75(11):1448-60.
11. Jeng CL. (April 15, 2025). Overview of peripheral nerve blocks. In: UpToDate, Maniker R (Ed), Wolters Kluwer. (Accessed: June 20, 2025).
12. Hamilton DL. Rebound pain: distinct pain phenomenon or nonentity? Br J Anaesth. 2021;126(4):761-3.
13. Cruz FF, Rocco PR, Pelosi P. Anti-inflammatory properties of anesthetic agents. Crit Care. 2017;21(1):67.
14. Holmberg A. (2021). Plexus brachialis anaesthesia: Optimising clinical factors. Thesis PhD, University of Oslo. DUO Viten arkiv. http://urn.nb.no/URN:NBN:no-88636
15. Perniola A, Magnuson A, Axelsson K, Gupta A. Intraperitoneal local anesthetics have predominant local analgesic effect: a randomized, double-blind study. Anesthesiology. 2014;121(2):352-61.
16. Kolarczyk LM, Williams BA. Transient heat hyperalgesia during resolution of ropivacaine sciatic nerve block in the rat. Reg Anesth Pain Med. 2011;36(3):220-4.
17. Janda A, Lydic R, Welch KB, Brummett CM. Thermal hyperalgesia after sciatic nerve block in rat is transient and clinically insignificant. Reg Anesth Pain Med. 2013;38(2):151-4.
18. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145-61.
19. Murphy KJ, O'Donnell B. Rebound Pain-Management Strategies for Transitional Analgesia: A Narrative Review. J Clin Med. 2025;14(3).
20. Barrio J, Madrid E, Gil E, Richart MT, Sanchez de Meras A. Influence of sensory block duration on rebound pain after outpatient orthopaedic foot surgery under popliteal sciatic nerve block: an observational study. Anaesthesia. 2025;80(5):582-3.
21. Williams BA, Bottegal MT, Kentor ML, Irrgang JJ, Williams JP. Rebound pain scores as a function of femoral nerve block duration after anterior cruciate ligament reconstruction: retrospective analysis of a prospective, randomized clinical trial. Reg Anesth Pain Med. 2007;32(3):186-92.
22. Luebbert E, Rosenblatt MA. Postoperative Rebound Pain: Our Current Understanding About the Role of Regional Anesthesia and Multimodal Approaches in Prevention and Treatment. Curr Pain Headache Rep. 2023;27(9):449-54.
23. Maagaard M, Plambech MZ, Funder KS, Schou NK, Molgaard AK, Stormholt ER, et al. The effect of oral dexamethasone on duration of analgesia after upper limb surgery under infraclavicular brachial plexus block: a randomised controlled trial. Anaesthesia. 2023;78(12):1465-71.
24. Li Q, Tian S, Zhang L, Chai D, Liu J, Sheng F, et al. S-Ketamine Reduces the Risk of Rebound Pain in Patients Following Total Knee Arthroplasty: A Randomized Controlled Trial. Drug Des Devel Ther. 2025;19:2315-27.
25. Soeding P, Morris A, Soeding A, Hoy G. Effect of intravenous magnesium on post-operative pain following Latarjet shoulder reconstruction. Shoulder Elbow. 2024;16(1):46-52.
Anne HOLMBERG (Oslo, Norway), Sverre NARVERUD
10:50 - 11:00
Q&A.
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E11
REFRESHING YOUR KNOWLEDGE
Words like medicine
REFRESHING YOUR KNOWLEDGE
Words like medicine
Chairperson:
Oya Yalcin COK (EDRA Part I Vice Chair, EDRA Examiner, lecturer, instructor) (Chairperson, Türkiye, USA)
10:30 - 10:30
Introduction.
10:30 - 10:50
#48691 - FT28 Words like medicine.
Words like medicine.
Patient comfort and communication.
Introduction
Modern healthcare systems, particularly under financial and organizational pressure, tend to focus on efficiency and standardization. Protocols, care pathways, and checklists improve safety and consistency, but can inadvertently reduce patient encounters to technical transactions. This shift often overlooks a fundamental truth: the context in which care is delivered has a powerful impact on clinical outcomes. (1,2)
Pain is not merely a sensory experience; it is a subjective, multifactorial phenomenon shaped by individual expectations, emotional states, prior experiences, and environmental cues. Contextual factors (CFs) and clinician communication modulate pain perception—sometimes amplifying it through nocebo effects, sometimes reducing it via placebo mechanisms or hypnotic techniques. Understanding and applying these principles enables clinicians to enhance patient comfort, reduce medication reliance, and improve outcomes, often without additional time or cost.
Contextual factors
Pain is best understood as a biopsychosocial phenomenon. Beyond nociception, it is influenced by a complex interplay of physical, emotional, cognitive, and social dimensions. The environment and interpersonal cues surrounding an intervention—the contextual factors—can significantly influence a patient’s experience of pain and healing. (3,4) CFs include:
• Physical environment: design, noise, lighting, smell
• Clinician behavior: tone of voice, body language, facial expression
• Communication: verbal and non-verbal suggestions, explanations, and framing
• Symbols of care: white coats, monitors, infusion bags, equipment
• Patient factors: prior experiences, anxiety levels, expectations
CFs are omnipresent and unavoidable in every healthcare interaction. They can induce beneficial placebo effects or harmful nocebo responses, depending on how they are perceived by the patient.
The therapeutic power of placebo effects
Placebos—interventions with no pharmacological activity—can nevertheless produce real, measurable improvements in pain, function, and well-being. These effects are not limited to “sugar pills” but are elicited primarily through meaning, expectation, and interpersonal connection.
Key components of a strong placebo response include:
• A clear and reassuring explanation from a trusted clinician
• The patient feeling seen, heard, and cared for
• The patient actively participating in their care
The placebo effect is, at its core, a contextual and communicative phenomenon. (5) For example, a study by Thomas (1987) found that 64% of patients with unexplained symptoms improved when the general practitioner gave a positive, confident diagnosis and reassurance. In contrast, only 39% improved when the GP expressed diagnostic uncertainty. (6)
Placebo responses also occur at the physiological level. Neuroimaging studies reveal that verbal suggestions of pain relief can activate the prefrontal cortex, periaqueductal gray, and endogenous opioid systems, leading to reduced pain perception and enhanced well-being.
Placebo mechanisms thus represent active ingredients of the clinician–patient interaction, whether or not a medical intervention is performed.
The Nocebo effect: when words harm
In contrast, nocebo effects occur when negative expectations or communication worsen symptoms or outcomes. Like placebo effects, they are contextually and neurobiologically mediated.
Examples of nocebo effects include:
• Worsened pain after being warned about possible side effects
• Increased anxiety during informed consent procedures
• Increased nausea or dizziness after hearing others talk about them
• Heightened pain due to repeated verbal focus on “pain scores”
A study showed that patients who were warned that a drug might cause erectile dysfunction were more likely to report it (32%) than those who were not (13%). (7) Similarly, during epidural needle insertion, patients who were told “this might hurt a bit” reported significantly more discomfort than those receiving neutral or positive suggestions. (8)
Nocebo responses are not imagined—they are accompanied by real biological changes, including, activation of cholecystokinin (CCK), a neuropeptide that mediates the nocebo hyperalgesic response and is an anxiogenic stimulus. (9)
Unfortunately, many nocebo triggers are embedded in routine clinical communication. The language used by clinicians, the expression on their face, or the tone of a warning can prime patients for pain and anxiety. This is particularly problematic in high-stress or ambiguous settings like emergency departments or surgery.
Expectations
Expectations, not the drug alone, drives therapeutic efficacy. A compelling line of research has examined the difference between open (announced) versus hidden (concealed) treatment administration. (10-12) These studies reveal the critical role of expectations:
• Morphine, when administered openly with verbal reassurance, produced robust pain relief.
• The same dose, when administered without the patient’s knowledge, produced significantly less analgesia.
• In contrast, saline placebo, when given with confident verbal suggestion, often outperformed hidden morphine.
The role of language in pain perception
Language is a powerful modulator of pain. Even well-intentioned statements can have unintended negative consequences. Examples include:
Traditional Phrase Alternative
“This may hurt a bit.” “Some people feel a sensation—let me know how you experience it.”
“We’re going to inject the anesthetic now.” “You may notice a cooling or warming feeling.”
“Don’t worry.” “You’re doing great, and I’ll guide you through this.”
Words direct attention. Saying “we’re going to monitor your pain closely” reinforces the presence of pain. In contrast, asking “What helps you feel more comfortable?” shifts focus toward comfort and control. Repeatedly asking patients to rate pain (e.g., “What’s your pain on a scale from 1–10?”) reinforces vigilance and may lead to a cycle of expectation and amplification. (13)
Stress and suggestibility
When under severe stress patients often enter an altered state of awareness marked by increased suggestibility and focused attention. This state resembles natural hypnosis and opens the door to both helpful and harmful suggestions. (14,15) In these moments it is important to realize that non-verbal communication becomes just as influential as spoken words.
Hypnotic communication
Hypnotic communication is a clinical skill set that uses language and attention techniques to reduce distress, anxiety, and pain. One well-studied method is Comfort Talk®, developed by interventional radiologist Dr. Elvira Lang. It consists of rapid rapport building, reframing language to avoid negative suggestions and guided self-hypnosis or relaxation scripts. In randomized trials of over 700 patients undergoing interventional radiology procedures, pain and anxiety were significantly lower in the intervention group, but also procedure times were shorter.(16-18)
Examples of hypnotic phrasing include:
• “You might notice your breathing becoming calmer as we continue.”
• “Some people find it helpful to focus on a pleasant place or activity.”
• “You may choose how deeply you want to relax right now.”
Such suggestions are indirect, permissive, and patient-centered, increasing the sense of control while reducing resistance. Pain is easier to tolerate when patients feel in control and safe. Even simple interventions can have profound effects:
• Offer patients a signal to pause the procedure if needed
• Let them choose a coping strategy (e.g., listening to music, holding a stress ball)
• Ask, “What has helped you during similar procedures before?”
These measures provide predictability, reduce helplessness, and enhance the patient’s belief that they can manage discomfort. The result: less pain, less anxiety, and more cooperation.
Clinical recommendations
Integrating this knowledge into daily practice does not require major system changes—just awareness, language adjustment, and intention. (19) Implementation consists of:
• Train clinicians in communication techniques that avoid nocebo language and enhance placebo potential
• Design clinical environments to convey calm, cleanliness, and trust (lighting, noise control, art, scent)
• Adjust intake questions to explore comfort and coping (e.g., “What’s important to you right now?”)
• Encourage patient participation in decisions, choices, and coping strategies
• Incorporate hypnotic communication skills into standard care, especially in procedures, emergency settings, and pain management
These strategies can reduce medication needs, shorten recovery times, and increase patient satisfaction—all while supporting the clinician–patient relationship.
Conclusion
Pain and healing are not determined solely by anatomy, pharmacology, or protocols—they are deeply influenced by meaning, expectation, and context. Every interaction between a patient and healthcare provider offers a biopsychosocial intervention with real physiological effects.
By recognizing the power of contextual factors, avoiding inadvertent nocebo effects, and incorporating elements of hypnotic communication, clinicians can significantly enhance the quality and humanity of care. These methods are grounded in neuroscience, supported by evidence, and available to every practitioner—regardless of specialty.
Ultimately, words are medicine. Let us use them wisely.
References
1. Rosenthal DI, Verghese A. Meaning and the nature of physicians’ work. New Eng J Med 2016; 375(19): 1813-15.
2. Verghese A. Culture shock – patient as icon, icon as patient. New Eng J Med 2008; 359(26): 2748-51.
3. Balint M. The doctor, his patient, and the illness. Lancet 1955; 268(6866): 683-88.
4. Miller FG, Kaptchuk TJ. The power of context: reconceptualizing the placebo effect. J Royal Soc Med 2008; 101(5): 222-25.
5. Brody H. Meaning and an overview of the placebo effect. Perspect Biol Med 2018; 61(3): 353-60.
6. Thomas KB. General practice consultations: is there any point in being positive? Br Med J (Clinical research ed) 1987; 294(6581): 1200-2.
7. Planes S, Villier C, Mallaret M. The nocebo effect of drugs. Pharmacol Res Perspect 2016; 4(2): e00208.
8. Varelmann D, Pancaro C, Cappiello EC, Camann WR. Nocebo-induced hyperalgesia during local anesthetic injection. Anesth Analg 2010; 110(3): 868-70.
9. Frisaldi E, Shaibani A, Benedetti F. Understanding the mechanism of placebo and nocebo effects. Swiss Med Wkly 2020;150:w20340
10. Levine JD, Gordon NC. Influence of the method of drug administration on analgesic response. Nature 1984; 312(5996): 755-56.
11. Benedetti F, Carlino E, Pollo A. Hidden administration of drugs. Clin Pharm Ther 2011; 90(5): 651-61.
12. Bingel U, Wanigasekera V, Wiech K, Ni Mhuircheartaigh R, Lee MC, Ploner M, Tracey I. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Trans Med 2011; 3(70): 70ra14.
13. Chooi CS, White AM, Tan SG, Dowling K, Cyna AM. Pain vs comfort scores after Caesarean section: a randomized trial. Br J Anaesth 2013; 110(5): 780-87.
14. Cheek DB. Importance of recognizing that surgical patients behave as though hypnotized. Am J Clin Hypn 1962;4:227.
15. Hansen E, Zech N. Nocebo effects and negative suggestions in daily clinical practice – forms, impact and approaches to avoid them. Front. Pharmacol. 2019;10:77. Doi: 10.3389/pharm.2019.00077.
16. Lang EV, Berbaum KS, Faintuch S, Hatsiopoulou O, Halsey N, Li X, Berbaum ML, Laser E, Baum J. Adjunctive self-hypnotic relaxation for outpatient medical procedures: a prospective randomized trial with women undergoing large core breast biopsy. Pain 2006; 126(1-3): 155-64.
17. Lang EV, Benotsch EG, Fick LJ, Lutgendorf S, Berbaum ML, Berbaum KS, Logan H, Spiegel D. Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 2000; 355(9214): 1486-90.
18. Lang EV, Berbaum KS, Pauker SG, Faintuch S, Salazar GM, Lutgendorf S, Laser E, Logan H, Spiegel D. Beneficial effects of hypnosis and adverse effects of empathic attention during percutaneous tumor treatment: when being nice does not suffice. J Vasc Interv Radiol 2008; 19(6): 897-905.
19. Aarts LAM, van Geffen GJ, Smedema EAL, Smits RM. Therapeutic communication improves patient comfort during venipuncture in children: a single-blinded intervention study. Eur J Pediatr 2023;182(9);3871-3881.
Geert-Jan VAN GEFFEN (NIjmegen, The Netherlands)
10:50 - 11:00
Q&A.
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10:30-11:00
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F11
TIPS & TRICKS
WALANT is for puppies
TIPS & TRICKS
WALANT is for puppies
Chairperson:
Mireia RODRIGUEZ PRIETO (Anesthesiologist in Orthopaedics and Trauma surgery) (Chairperson, Barcelona, Spain)
10:30 - 10:30
Introduction.
10:30 - 10:50
Blocks for hand surgery.
Lloyd TURBITT (Consultant Anaesthetist) (Keynote Speaker, Belfast, United Kingdom)
10:50 - 11:00
Q&A.
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10:30-11:25
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G11
FREE PAPER SESSION 1/8
CENTRAL NERVE BLOCKS
FREE PAPER SESSION 1/8
CENTRAL NERVE BLOCKS
Chairperson:
Wojciech GOLA (Consultant) (Chairperson, Kielce, Poland)
10:30 - 10:37
#45830 - OP19 Comparison of block characteristics and outcomes of hyperbaric versus isobaric ropivacaine in patients undergoing modified radical mastectomy under segmental thoracic spinal anaesthesia: an exploratory double-blinded randomized control trial.
OP19 Comparison of block characteristics and outcomes of hyperbaric versus isobaric ropivacaine in patients undergoing modified radical mastectomy under segmental thoracic spinal anaesthesia: an exploratory double-blinded randomized control trial.
Thoracic spinal anaesthesia (TSA) is emerging as an alternative to general anaesthesia for modified radical mastectomy (MRM) for carcinoma breast due to its favorable recovery profile. The present study aims to evaluate block characteristics and outcomes of isobaric and hyperbaric ropivacaine in TSA for the same
Sixty patients scheduled for unilateral MRM were randomly allocated to equally to; Group I: (0.75% isobaric ropivacaine-1mL) and Group H: (0.75% hyperbaric ropivacaine -1mL) along with fentanyl (25 μg) in both groups for TSA at (T4-T5) level, administered in lateral position and turned to supine immediately. The primary objective of the study was to evaluate the block onset time at T2 dermatome and secondary objectives included peak sensory loss at 10 min, intraoperative cardio-respiratory changes and post operative pain scores. Data were compared using the two-sided Student t-test, Mann-Whitney and Chi-square tests. Time of onset of sensory block (in min) at T2 level (3.00 ± 0.00 versus 3.40 ± 1.04, p = 0.04) and peak sensory loss at 10 min (C5 sensory level at 10 min, 93 % versus 60 %, p <0.001) was faster with Group H. Intraoperative hypotension occurred in 63% in group I, while only 16% in group H. 10% of patients in group I had bradycardia, while none of in group H. Intraoperative apnea occurred in 23% in group I while none of the patients in group H. Postoperative pain scores were comparable till 24 h. The hyperbaric ropivacaine (0.75%) provides faster onset of sensory blockade, better cardio-respiratory profile compared to isobaric ropivacaine (0.75%) in patients undergoing unilateral modified mastectomy for carcinoma breast under thoracic spinal anaesthesia.
Preeti GROVER, Praveen TALAWAR (Rishikesh, India), Yashwant Singh PAYAL, Deepak SINGLA, Mridul DHAR, Farhanul HUDA
10:37 - 10:44
#45837 - OP20 Comparison of postoperative pulmonary functions and outcomes in patients undergoing major open abdominal surgeries between general anaesthesia with thoracic epidural and thoracic continuous spinal anaesthesia: an exploratory randomized study.
OP20 Comparison of postoperative pulmonary functions and outcomes in patients undergoing major open abdominal surgeries between general anaesthesia with thoracic epidural and thoracic continuous spinal anaesthesia: an exploratory randomized study.
Thoracic continuous spinal anaesthesia (TCSA) re-emerged as a sole anaesthetic technique for major abdominal surgery in patients at high risk for General anaesthesia (GA), as it avoids airway manipulation and mechanical ventilation. This study compared the postoperative pulmonary function and outcomes in patients undergoing major abdominal surgery under GA with thoracic epidural anaesthesia (TEA) versus TCSA.
Sixty-four adult patients scheduled for major abdominal surgery were randomly assigned to a GA with a TEA group (n=32) or a TCSA group (n=32). GA group received a thoracic epidural catheter placed at the T9–T10 level and was induced using intravenous drugs; fentanyl (2mcg/kg), propofol (2-3mg/kg), and vecuronium (0.1mg/kg), followed by endotracheal intubation. In the TCSA group, a 25G intrathecal catheter was inserted at the same spinal level, and patients received preservative-free intrathecal drugs: ketamine (0.25 mg/kg) and midazolam (0.03 mg/kg), followed by isobaric levobupivacaine 0.5% to achieve a sensory block from T4 to L1. The primary outcome was peak expiratory flow rate (PEFR) over 72 hours. Secondary outcomes included breath-holding time (BHT), lung atelectasis, postoperative pulmonary complications, change in trans-diaphragmatic excursion, and in-hospital mortality. Data were compared using the two-sided Student t-test, Mann-Whitney and Chi-square tests. Postoperatively, PEFR significantly declined from baseline in both groups (P<0.001), with no significant difference between them (P=0.498). However, the TCSA group showed significantly better outcomes than the GA group concerning BHT on postoperative day 1 (P=0.048) and day 2 (P=0.005), reduced lung atelectasis at 1h post-op (P=0.03), and greater diaphragmatic excursion at 1 hour (P<0.001), day 1 (P<0.001), and day 2 (P<0.001). TCSA was associated with better early postoperative respiratory parameters, including breath-holding time, reduced atelectasis, and improved diaphragmatic movement. These findings suggest TCSA may offer superior respiratory outcomes in the immediate postoperative period in patients undergoing major abdominal surgery.
Gourav KUMAR, Praveen TALAWAR, Ruma THAKURIA (Dehradun, India), Gaurav JAIN, Amit GUPTA
10:44 - 10:51
#47471 - OP21 Spinal Anesthesia in Patients with Lumbar Tattoos: Case Report and Literature Review.
OP21 Spinal Anesthesia in Patients with Lumbar Tattoos: Case Report and Literature Review.
Lumbar tattoos have become increasingly common, especially among young adults. Although not considered an absolute contraindication for regional anesthesia, concerns persist regarding potential complications, including the introduction of pigment into the neuraxial space.
We report the case of a 34-year-old pregnant woman at 38 weeks with gestational diabetes, who required an emergency cesarean section. She had a large tattoo covering her entire lumbar region, leaving no unaffected skin for puncture. Spinal anesthesia was performed using a 27G needle under strict aseptic technique. The patient refused a skin incision prior to puncture. The procedure was completed without complications. However, literature highlights theoretical risks: organic tattoo pigments may be neurotoxic if introduced into the spinal canal, and ink particles may trigger localized immune responses leading to inflammation or neural damage. The phenomenon of “coring”—where a fragment of tattooed skin is carried into the spinal space by the needle—has been described. To minimize this risk, some experts recommend a small skin incision, which was not possible in this case due to patient refusal. The patient was informed of potential complications and advised to report any symptoms. She was also warned about possible risks during future MRI scans. At 6 months follow-up, the patient was contacted by telephone and reported no complications, confirming an uneventful recovery. While spinal anesthesia through tattooed skin is not absolutely contraindicated, it should be approached with caution. Informed consent, thorough risk assessment, aseptic technique, and proper documentation are essential when alternative puncture sites are unavailable. However, due to the limited data available, further reserch and continued clinical vigilance are recommended.
Bonifacio Fabricio MACHADO OLANO (MONTEVIDEO, Uruguay), Alejandra LARRE BORGES, Rosario ARMAND UGON, Cecilia CASTILLO, Cesar GRACIA FABRE, Jose Renato DE SOUSA PASSOS
10:51 - 10:58
#47715 - OP22 Combination of PENG block and low-dose spinal anesthesia in patient with fractured femoral neck and severe aortic stenosis.
OP22 Combination of PENG block and low-dose spinal anesthesia in patient with fractured femoral neck and severe aortic stenosis.
76-years old patient with severe aortic stenosis and pharyngeal carcinoma with ongoing neck radiotherapy was scheduled for hip arthroplasty due to fractured femoral neck. Intubation was high-risk due to radiotherapy and spinal anesthesia was high-risk due to aortic stenosis. We chose combination of unilateral neuraxial anesthesia with analgetic regional blockade combining pericapsular nerve group (PENG) and lateral femoral cutaneous nerve (LFCN) block under the ultrasound guidance.
Blood pressure was monitored invasively with arterial cannula placed in right radial artery. Prior to spinal anesthesia patient received a 500ml bolus of normal saline over 30 minutes following PENG and LFCN analgetic blockade using 20ml and 5ml of 0.5% levobupivacaine, respectively. Unilateral neuraxial anesthesia was performed in left lateral decubitus position with 1ml of hypobaric aqua and 1ml of 0.5% levobupivacaine (5mg), using atraumatic Whitacre needle (27G). Following neuraxial anesthesia, we observed no hypotensive episodes in the first half an hour. Afterwards, we maintained blood pressure drops within 20% from baseline (150/90mmHg) with norepinephrine and phenylephrine boluses (2.5mcg and 100mcg, respectively). The biggest hypotensive episode was observed after cementing of the prosthesis (90/50mmHg) when we initiated norepinephrine infusion in minimal doses (0.03mcg/kg/min) until the end of surgery. Following surgery patient was transferred to ICU for a 24-hour monitoring. He arrived at ICU with normal blood pressure with no additional drops, received no additional analgesia and was transferred to ward the next morning. Severe aortic stenosis is not an absolute contraindication for neuraxial anesthesia, especially in cases of unilateral block with low-dose anesthetic concentration supplemented with regional analgetic blockade. Hypotensive episodes should be addressed with vasoconstrictive medication due to peripheral vasodilatation following neuraxial anesthesia while avoiding tachycardia and with administration of normal saline boluses prior to anesthesia.
Vedran LOKOŠEK (Zagreb, Croatia), Blanka VINCELJEK, Mirela DOBRIĆ, Goran SABO
10:58 - 11:05
#48108 - OP23 Did the REGAIN and RAGA trials impact use of neuraxial anesthesia among surgical hip fracture patients? -An observational study using US claims data.
OP23 Did the REGAIN and RAGA trials impact use of neuraxial anesthesia among surgical hip fracture patients? -An observational study using US claims data.
The REGAIN and RAGA trials (published in October and December 2021) demonstrated equivalence between general and neuraxial anesthesia among surgical hip fracture cases for outcomes including postoperative delirium or a composite of death or an inability to walk at 60 days post-surgery. It is unclear to what extent these trials may have influenced decision-making on choice of anesthetic.
This retrospective study used January 2016-December 2023 US Premier Healthcare claims data on surgical hip fractures. An interrupted time series approach with segmented regression compared the pre-REGAIN/RAGA (January 2016-December 2021) to the post-REGAIN/RAGA period in monthly rates of only neuraxial anesthesia (as a proportion of surgical hip fracture performed under only general anesthesia plus those performed under only neuraxial anesthesia). Trends within each period were estimated, and their differential, including 95% confidence intervals (CIs). Additionally, we assessed trends in subgroups based on hospital teaching status and hospital hip fracture volume (dichotomized using the 75th percentile). The pre-REGAIN/RAGA period included n=23,587 (6.3%) and n=351,405 (93.7%) cases performed under neuraxial and general anesthesia, respectively. This was n=5,748 (5.2%) and n=105,588 (94.8%) for the post-REGAIN/RAGA period. Post-REGAIN/RAGA publication there was a significant decrease in use of neuraxial anesthesia in surgical hip fractures (difference in trend -0.089 CI -0.152;-0.026 p=0.0068); Figure 1. This change was not different between teaching and non-teaching hospitals (p=0.9247), while was significantly different between high-volume and non-high-volume hospitals (p=0.0225). The post-REGAIN/RAGA period coincided with significant reductions in neuraxial anesthesia use among surgical hip fracture cases. Change was irrespective of hospital teaching status but did differ based on surgical volume. These findings are particularly prudent given the ongoing discussion on optimal anesthesia type, especially regarding the selection of relevant outcomes and (known) lower odds of various perioperative complications associated with neuraxial anesthesia.
Jashvant POERAN (New York, USA), Periklis GIANNAKIS, Junying WANG, Crispiana COZOWICZ, Alexander STONE, Philipp GERNER, Jiabin LIU, Stavros G. MEMTSOUDIS
11:05 - 11:12
#48151 - OP24 The air we breathe,the risk we take: pneumoventricle following loss of resistance with air.
OP24 The air we breathe,the risk we take: pneumoventricle following loss of resistance with air.
Pneumocephalus and pneumoventricle are rare but serious complications of epidural anaesthesia, particularly following accidental dural puncture when air is used in the loss of resistance (LOR) technique. These can mimic post-dural puncture headache (PDPH), potentially delaying diagnosis and treatment. We report a rare case of pneumoventricle in a high-risk patient following inadvertent dural puncture during lumbar epidural placement.
A 46-year-old hypertensive male with a past cerebrovascular accident was posted for elective renal transplant under combined epidural and general anaesthesia. During lumbar epidural placement at L1–L2 in the sitting position, an accidental dural puncture occurred using air for LOR. The epidural catheter was re-sited at another level. Headache developed immediately and was treated with intravenous paracetamol and fluids. General anaesthesia was administered and surgery completed uneventfully. Toward the end of surgery, the epidural catheter was activated with 15 mL of 0.2% ropivacaine in 5 mL aliquots. Nine hours post-puncture (two hours post-extubation), the patient developed irritability, convulsions, hypertension with bradycardia, and respiratory arrest. He was reintubated and shifted to ICU. CT brain revealed pneumoventricle with air in the frontal horns of the lateral ventricles and basal cisterns. He was managed with intravenous midazolam, mechanical ventilation for 12 hours, and supportive care. The epidural catheter was removed 24 hours post-puncture. He was extubated successfully with full neurological recovery. Pneumoventricle following epidural dural puncture is a rare but potentially life-threatening complication. Using saline instead of air for LOR may help prevent such occurrences. Anaesthesiologists should maintain a high index of suspicion in atypical presentations and consider early neuroimaging for prompt diagnosis and intervention.
Bhuvaneswari BALASUBRAMANIAN (Nagpur, India), Prateek ARORA, Priya THAPPA, Himangi BHOKARE, Amol BHAWANE, Chandrakant MUNJEWAR
11:12 - 11:19
#48181 - OP25 Low-Dose Spinal Anesthesia in Outpatient Settings: A Prospective Cohort Study.
OP25 Low-Dose Spinal Anesthesia in Outpatient Settings: A Prospective Cohort Study.
Low-dose, short-acting spinal anesthetics are promising for early recovery in outpatient surgery, yet comparative data are scarce. This study compares their effects on block duration, mobilization, urination and adverse events.
In this prospective cohort study, 75 patients undergoing outpatient urological or proctological surgery received spinal anesthesia with 2 mL of either 40 mg Prilocaine (n=33) or 20 mg 2-Chloroprocaine (n=42). Motor blockade was assessed via the Bromage scale; sensory block was evaluated using the ice test across dermatomes. Mobilization was deemed successful if patients could walk unassisted. Adverse events—including block failure, urinary retention, hypotension, and bradycardia—were recorded. Data analysis was conducted using Microsoft Excel and IBM SPSS. The median motor block duration was significantly longer in the Prilocaine group (60 min, IQR=55) compared to the 2-Chloroprocaine group (0 min, IQR=46, p<0.001). In the latter, 61.9% of patients developed no motor block. Sensory block lasted longer in the Prilocaine group (165 min, IQR=68, p<0.001) than in the 2-Chloroprocaine group (130 min, IQR=50, p<0.001). Sensory block height was also greater in Prilocaine group, with 36.3% of patients reaching T10 or higher, compared to 2.4% in the 2-Chloroprocaine group (p<0.001). Mobilization was achieved earlier in the 2-Chloroprocaine group (107 min, IQR=48, p<0.001) versus Prilocaine group (165 min, IQR=75, p<0.001). Time to urination was shoerter with 2-Chloroprocaine group (152 min, IQR=75 vs. 215 min, IQR=25, p=0.02). One patient in the 2-Chloroprocaine group required conversion to general anesthesia. No patients experienced urinary retention requiring catheterization. Two patients in the Prilocaine group and one in the 2-Chloroprocaine group developed vasovagal syncope before spinal anesthesia administration. No significant bradycardia or hypotension was observed. Both low-dose Prilocaine and ultra-low-dose 2-Chloroprocaine were effective for spinal anesthesia. However, 20 mg of 2-Chloroprocaine resulted in significantly shorter motor and sensory blockade, allowing for faster mobilization and shorter time to spontaneous urination.
Arturs AVSTREIHS (Riga, Latvia), Janis URTANS, Edgars VASILEVSKIS, Natalija ZLOBINA, Irina EVANSA
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11:10-11:40
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D12
REFRESHING YOUR KNOWLEDGE
Phantom limb pain
REFRESHING YOUR KNOWLEDGE
Phantom limb pain
Chairperson:
Patrice FORGET (Professor) (Chairperson, Aberdeen, United Kingdom)
11:10 - 11:10
Introduction.
11:10 - 11:30
#48682 - FT18 Treatment options in phantom limb pain.
Treatment options in phantom limb pain.
Treatment Options in Phantom Limb Pain
Maria Isabel Brazão Lusitano de Freitas, Javier De Andrés Ares.
University Hospital Viamed Santa Elena, University Hospital HLA Moncloa, Madrid, Spain
Upon completion of this session, attendees will be able to discuss:
• The pathophysiology of phantom limb pain (PLP).
• Clinical evaluation of PLP and differential diagnosis.
• Pharmacological therapies for PLP.
• Interventional therapies for PLP.
• Surgical and advanced therapies for PLP.
1. Introduction
PLP is a neuropathic pain perceived in a limb or part of a limb that has been amputated, representing a form of deafferentation pain [1]. It must be distinguished from non-painful phantom sensations and residual limb (stump) pain, conditions that often coexist and complicate clinical assessment [2]. PLP affects 60–85% of amputees and typically begins within days to weeks post-amputation, though it may persist chronically [3]. With increasing rates of amputations due to vascular disease, diabetes, trauma, and conflict-related injuries, PLP poses a substantial burden on physical rehabilitation, prosthesis use, mental health, mobility, and quality of life [4].
2. Pathophysiology of PLP
PLP results from interconnected peripheral, spinal, and supraspinal mechanisms that contribute to pain generation and maintenance [5].
2.1 Peripheral Mechanisms and Stump Pain
Spontaneous ectopic neural activity near transected nerves has been demonstrated. These contribute to stump pain, which is often closely associated with PLP. Relief through peripheral nerve blocks supports the peripheral origin of some pain components [6].
2.2 Spinal Mechanisms
Loss of normal input due to amputation leads to reorganization within the spinal dorsal horn. These changes include reduced descending inhibition, abnormal DRG activity, ephaptic transmission, and the formation of perineural fibrosis. Together, these processes promote central sensitization, enhancing the perception and persistence of pain [8].
2.3 Central and Supraspinal Mechanisms
Functional neuroimaging (fMRI, MEG) has shown significant cortical reorganization involving the primary somatosensory and motor cortices, the thalamus, and brainstem. The degree of cortical remapping has been correlated with the severity and duration of PLP, reinforcing the importance of central plasticity [8,9].
3. Clinical Evaluation & Differential Diagnosis
Diagnosis is clinical, based on history and examination. Other causes must be excluded, including radicular pain, limb ischemia, neuromas (identified via Tinel’s sign), prosthesis-related issues, local infections, pressure lesions, or dermatologic conditions. Imaging, vascular assessments, and electrodiagnostic testing support diagnostic clarification.
4. Multimodal Management in the Pain Unit
Treatment should be individualized and multimodal, combining pharmacological, interventional, surgical, and non-invasive approaches [10].
4.1 Pharmacologic Therapies
• Tricyclic antidepressants (e.g., amitriptyline, nortriptyline): Enhance serotonergic and noradrenergic transmission, block sodium and NMDA channels, with low NNT in neuropathic pain.
• Anticonvulsants (gabapentin, pregabalin): Act on calcium channels to reduce excitatory neurotransmission; modest efficacy in PLP.
• SNRIs (e.g., duloxetine): Facilitate descending inhibition; supported by diabetic neuropathy data.
• Opioids: μ-receptor agonists; use is cautious due to dependency risks, though short-term benefit on cortical plasticity is suggested.
• NMDA antagonists (ketamine, memantine): Ketamine is effective in refractory cases but limited by adverse effects; memantine offers better tolerability.
• IV lidocaine: Reduces central and peripheral hyperexcitability.
• Adjuvants: Calcitonin, botulinum toxin A, and propranolol used selectively in persistent or refractory cases [11].
4.2 Interventional Therapies
• Peripheral nerve blocks: Diagnostic and therapeutic role, especially in neuroma-related pain.
• Sympathetic blocks: Conflicting evidence; some patients benefit, particularly when sympathetic involvement is suspected [12].
• Pulsed radiofrequency (PRF): Minimally invasive method targeting neuromas or DRG [13].
• Cryoneurolysis: Disrupts nerve conduction and prevents neuroma formation through localized freezing [11].
• Neuromodulation: Spinal cord stimulation, DRG stimulation, and peripheral nerve stimulation for refractory cases [17].
• Intrathecal ziconotide: A calcium channel blocker with central effects; use is limited due to neuropsychiatric side effects [14].
4.3 Surgical and Advanced Neurosurgical Therapies
• Deep brain stimulation (DBS) and thalamic stimulation: Reserved for highly refractory cases due to invasive nature and potential complications [15].
4.4 Non-Invasive Therapies
• Repetitive transcranial magnetic stimulation (rTMS): Modulates cortical excitability; supported by recent meta-analyses [9,10].
• Transcutaneous electrical nerve stimulation (TENS): Safe, cost-effective option, especially for mild to moderate PLP.
• Mirror therapy: uses visual feedback to create the illusion of movement and presence of the amputated limb. By reflecting the intact limb’s movements in a mirror, it helps to retrain the brain’s sensorimotor cortex and reduce maladaptive neuroplasticity associated with phantom limb pain. Studies have shown that can decrease pain intensity and improve functional outcomes.[16].
4.5 Novel Technologies
• Virtual Reality (VR), and Augmented Reality (AR) provide visual and sensory feedback to restore sensorimotor integration. Immersive VR has shown benefits in both symptom relief and cortical reorganization [10,16].
5. Conclusion
Phantom Limb Pain is a complex neuropathic condition resulting from maladaptive changes across the nervous system. Effective management requires a multimodal, multidisciplinary approach that includes pharmacologic, interventional, and technological strategies. Emerging therapies such as rTMS and VR offer exciting opportunities, but further research is required to validate their role in routine care. High-quality clinical trials comparing traditional and novel interventions are essential to refine treatment guidelines and improve patient outcomes.
References
1. Nikolajsen LJ, Jensen TS. Postamputation pain. In: Koltzenburg M, McMahon SB, editors. Wall and Melzack’s Textbook of Pain. 6th ed. Elsevier; 2013. p. 961–971.
2. Sherman RA, Sherman CJ. Prevalence and characteristics of chronic phantom limb pain among American veterans: results of a trial survey. Am J Phys Med. 1983;62(5):227–38.
3. Kern U, Busch V, Rockland M, Kohl M, Birklein F. Prevalence and risk factors of phantom limb pain and sensations in Germany. Schmerz. 2009;23(6):619–26.
4. Flor H. Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies. Expert Rev Neurother. 2008;8(5):809–18.
5. Jensen TS, Krebs B, Nielsen J, Rasmussen P. Immediate and long-term phantom limb pain in amputees. Pain. 1985;21(3):267–78.
6. Torsney C, MacDermott AB. Disinhibition opens the gate to pathological pain signaling in rat spinal cord. J Neurosci. 2006;26(7):1833–43.
7. Cohen SP, Villena F, Mao J. Two unusual cases of postamputation pain from OIF. J Trauma. 2007;62(3):759–61.
8. Ramachandran VS, Rogers-Ramachandran D. Phantom limbs and neural plasticity. Arch Neurol. 2000;57(3):317–20.
9. Elwenspoek MM, et al. Repetitive transcranial magnetic stimulation for PLP: systematic review. Pain. 2022;163(4):567–78.
10. Osumi M, et al. Effects of immersive VR therapy on PLP and cortical reorganization. Front Neurol. 2021;12:701411.
11. Moesker AA, Karl HW, Trescot AM. Cryoneurolysis for treatment of PLP. Pain Pract. 2014;14(1):52–56.
12. Waseff MR. Phantom pain with probable reflex sympathetic dystrophy. Reg Anesth. 1997;22(3):287–90.
13. Wilkes D, et al. Pulsed radiofrequency for lower-extremity PLP. Clin J Pain. 2008;24(8):736–39.
14. Prommer E. Ziconotide: new option for refractory pain. Drugs Today. 2006;42(6):369–78.
15. Bittar RG, et al. Deep brain stimulation for PLP. J Clin Neurosci. 2005;12(4):399–404.
16. Flor H. Mirror therapy and virtual reality: new frontiers in pain therapy. Expert Rev Neurother. 2011;11(3):315–26.
17. Jaffee S, et al. A scoping review of spinal cord stimulation for phantom limb pain. Interventional Pain Medicine. 2025;4 (1):100571.
Isabel BRAZAO (Madrid, Spain), Javier DE ANDRES ARES
11:30 - 11:40
Q&A.
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11:10-11:40
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E12
REFRESHING YOUR KNOWLEDGE
Be prepared
REFRESHING YOUR KNOWLEDGE
Be prepared
11:10 - 11:10
Introduction.
11:10 - 11:30
#48649 - FT29 Local Anesthetic Systemic Toxicity (LAST): Update in the era of high volume blocks.
Local Anesthetic Systemic Toxicity (LAST): Update in the era of high volume blocks.
Local Anesthetic Systemic Toxicity (LAST) is certainly not a new concept, with reports of systemic toxicity soon after the introduction of cocaine and procaine into clinical practice. Thankfully, neither is LAST common, with estimated rates of 1–2 in 1,000 patients receiving peripheral nerve blocks.[1, 2] What is new is that we are using higher volumes of local anesthetic (LA) due to the explosion in popularity of fascial plane blocks (FPBs).[3] Rather than aiming of the minimum effective volume, it is typical to maximize volume of LA in FPBs to obtain the largest possible distribution of sensory change. This presentation will review LAST symptoms, risk factors, prevention, treatment, and dosing of LA with specific attention to FPBs and continuous infusions.
Symptoms of LAST often vary from the classic textbook description. While central nervous system (CNS) symptoms are the most common (77% of cases) and often present first, 24% of cases presented with cardiovascular (CV) symptoms only.[4] In 43% CNS symptoms present alone, while both CNS and CV symptoms are apparent in 33% of cases. Prodromal CNS symptoms (29% of cases) include perioral numbness, tinnitus, confusion, dysarthria, dysphoria, dizziness, drowsiness, and dysgeusia.[5, 6] Other serious CNS symptoms include agitation, loss of consciousness, and seizure. Of those presenting with CNS symptoms, seizure was the most common symptom (53%).[4] Early CV toxicity can include tachycardia and hypertension, whereas increasing LA concentrations are associated with a dose dependent inhibition of cardiac conduction and contractility.[6, 7] Electrocardiography (ECG) changes that have been described include PR, QRS, and QT interval prolongation,[7, 8] as well as T-wave flattening, increased P-wave amplitude, and ST segment depression.[9]
Studies to define the maximum doses of lidocaine took place in the 1960s[9] and for bupivacaine and ropivacaine in the 1980s and 90s.[10-12] Suggested maximum doses are 2 mg·kg-1 for bupivacaine and levobupivacaine, 3 mg·kg-1 for ropivacaine, and 5 mg·kg-1 for lidocaine and mepivacaine.[8] However, there are several potential risk factors that could make patients more susceptible to developing LAST. Extremes in age (neonates, infants, and older adults) may be at higher risk due to low lean muscle mass.[6, 8] Comorbidities such as reduced cardiac output, liver dysfunction, and at a lesser extent, renal insufficiency increase the risk of LAST.[5, 6, 8] Patients with decreased alpha-1 acid glycoprotein levels (e.g. pregnancy, malnutrition) may be at increased risk due to reduced LA binding, resulting in increased free LA concentrations.[5] Certain metabolic conditions (e.g. diabetes, mitochondrial disease, carnitine deficiency) may increase risk. [5]
Prevention starts by understanding the procedural factors that increase risk of LAST. Extra care should be taken when LA is delivered by multiple routes (e.g. intravenous) or multiple providers (e.g. surgeon placed blocks).[13] Non-technical factors that reduce the risk of LAST include good communications, the immediate availability of a “LAST kit” including lipid rescue, and knowledge of LAST risk factors, prevention, and treatment.[5, 8] For these reasons, out-of-OR environments may have higher morbidity due to delays in treatment, although the highest rates of LAST are still in the hospital setting.[4] The risk of LAST varies by anatomical location of the injection. Higher blood flow areas tend have higher systemic absorption and earlier peak plasma levels (e.g. intercostal, intrapleural, penile, and paravertebral blocks).[5, 8] Injection of large volumes may have delayed onset of LAST symptoms (e.g. tumescent).[5, 8] Fascial plane blocks are associated with high rates of LAST, likely because of the high doses of LA administered into relatively richly perfused planes.[8, 14] Several cases of LAST have been reported following transversus abdominis plane (TAP) and erector spinae plane (ESP) blocks.[14] As well, several instances of total plasma concentrations exceeding toxicity limits have been observed in fascia iliaca, pectoral nerve, and TAP blocks.[14] There have been some instances where bupivacaine used in a TAP block resulted in plasma concentrations above toxic thresholds despite a dose of less than 2 mg·kg−1.[15] Continuous infusions commonly exceed recommended LA dosing, and are associated with higher rates of LAST.[16] Total plasma concentration tends to increase over the duration of the infusion, but free LA concentrations are held lower because of a rise in alpha-1 acid glycoprotein in the postsurgical phase.[8] Recommended absolute maximum for continuous infusions should be 0.4–0.5 mg·kg−1·hr−1 for bupivacaine and 0.5–0.6 mg·kg−1·hr−1for ropivacaine.[16]
In addition to understanding the procedural and patient factors, several safety modifications can reduce the risk of LAST. Maximum doses should be identified prior to beginning the procedure, calculated based on lean body weight.[17] For high volume blocks, the concentration of LA may be reduced to stay below maximum dosing recommendations while maintaining the required volume. Incremental dosing of LA, especially when combined with intermittent aspiration to check for intravascular needle tip positioning, will reduce risk of LAST.[6] Observing LA spread under ultrasound guidance will also help to avoid accidental intravascular injection. Use of inactive injectate (e.g. dextrose in water or normal saline) to observe spread, avoids inadvertent intravascular injection and maximizes injection of LA at intended needle endpoints. For areas with higher perfusion and therefore vascular uptake of LA, low-dose epinephrine (2.5 to 5 mcg·ml-1) both acts as an marker for intravascular injection and to decrease vascular uptake.[6] While perineural epinephrine use has decreased in some practices due to concerns about inadvertent intraneural injection, it appears to be effective in reducing plasma LA concentration in fascial plane blocks.[14] Mixing short and long acting LAs should be avoided, since the effect on onset time is negligible and it may increase the risk of LAST.[18, 19]
Treatment of LAST has been carefully described by the American Society of Regional Anesthesia and Pain Medicine (ASRA-PM) practice advisory.[17, 20] Early identification is essential, stopping any ongoing administration of LA, closely followed by initiating lipid rescue. For patients over 70 kg, a bolus of 100 ml of lipid emulsion should be given over 2-3 minutes followed by an infusion of 200-250 ml over 15-20 minutes. For patients under 70 kg, a bolus of 1.5 ml·kg-1 should be given over 2-3 minutes followed by an infusion of 0.25 ml·kg-1·min-1.[17, 20] If the patient remains unstable, the bolus can be repeated and the infusion rate doubled up to a maximum dose of 12 ml·kg-1. Airway management is key in cases resulting in seizure or loss of consciousness, avoiding hypercapnia and acidosis, which can potentiate LAST. Seizures should be ablated with benzodiazepines. In the case of cardiac arrest, several modifications to advanced cardiovascular life support (ACLS) algorithm should be observed. When epinephrine is used, the starting doses should be minimized (<1 mcg·ml-1). It is recommended to avoid beta blockers, calcium channel blocks, and vasopressin. No further LAs should be given, including lidocaine listed in the ACLS algorithm. Treating LAST may require a period of prolonged resuscitation, including prolonged cardiopulmonary resuscitation. If cardiac arrest does not respond to lipid emulsion therapy and resuscitation efforts, cardiopulmonary bypass should be initiated. When an episode of LAST is limited only to neurologic symptoms, the patient should be observed with cardiac monitoring for 2 hours. If there was cardiovascular instability, the patient should be monitored for 4-6 hours after the event.[17, 20]
References
1 Mörwald EE, Zubizarreta N, Cozowicz C, Poeran J, Memtsoudis SG. Incidence of Local Anesthetic Systemic Toxicity in Orthopedic Patients Receiving Peripheral Nerve Blocks. Reg Anesth Pain Med 2017; 42: 442-5. doi:10.1097/aap.0000000000000544
2 Rubin DS, Matsumoto MM, Weinberg G, Roth S. Local Anesthetic Systemic Toxicity in Total Joint Arthroplasty: Incidence and Risk Factors in the United States From the National Inpatient Sample 1998-2013. Reg Anesth Pain Med 2018; 43: 131-7. doi:10.1097/aap.0000000000000684
3 Bailey JG, Uppal V. Fascial plane blocks: moving from the expansionist to the reductionist era. Can J Anaesth 2022; 69: 1185-90. doi:10.1007/s12630-022-02309-x
4 Gitman M, Barrington MJ. Local Anesthetic Systemic Toxicity: A Review of Recent Case Reports and Registries. Reg Anesth Pain Med 2018; 43: 124-30. doi:10.1097/aap.0000000000000721
5 Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K, Weinberg G. Updates in our understanding of local anaesthetic systemic toxicity: a narrative review. Anaesthesia 2021; 76 Suppl 1: 27-39. doi:10.1111/anae.15282
6 Gitman M, Fettiplace MR, Weinberg GL, Neal JM, Barrington MJ. Local Anesthetic Systemic Toxicity: A Narrative Literature Review and Clinical Update on Prevention, Diagnosis, and Management. Plast Reconstr Surg 2019; 144: 783-95. doi:10.1097/prs.0000000000005989
7 Fettiplace MR, Weinberg G. The Mechanisms Underlying Lipid Resuscitation Therapy. Reg Anesth Pain Med 2018; 43: 138-49. doi:10.1097/aap.0000000000000719
8 El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth 2018; 11: 35-44. doi:10.2147/lra.S154512
9 Foldes FF, Molloy R, Mc NP, Koukal LR. Comparison of toxicity of intravenously given local anesthetic agents in man. J Am Med Assoc 1960; 172: 1493-8. doi:10.1001/jama.1960.03020140029007
10 Knudsen K, Beckman Suurküla M, Blomberg S, Sjövall J, Edvardsson N. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 1997; 78: 507-14. doi:10.1093/bja/78.5.507
11 Scott DB, Lee A, Fagan D, Bowler GM, Bloomfield P, Lundh R. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989; 69: 563-9.
12 Bardsley H, Gristwood R, Baker H, Watson N, Nimmo W. A comparison of the cardiovascular effects of levobupivacaine and rac-bupivacaine following intravenous administration to healthy volunteers. Br J Clin Pharmacol 1998; 46: 245-9. doi:10.1046/j.1365-2125.1998.00775.x
13 Foo I, Macfarlane AJR, Srivastava D, et al. The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety. Anaesthesia 2021; 76: 238-50. doi:10.1111/anae.15270
14 Bailey JG, Barry G, Volk T. Local anesthetic dosing for fascial plane blocks to avoid systemic toxicity: a narrative review. Can J Anaesth 2025; In press.
15 Trabelsi B, Charfi R, Bennasr L, et al. Pharmacokinetics of bupivacaine after bilateral ultrasound-guided transversus abdominis plane block following cesarean delivery under spinal anesthesia. Int J Obstet Anesth 2017; 32: 17-20. doi:10.1016/j.ijoa.2017.04.007
16 Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Regional Anesthesia & Pain Medicine 2023: rapm-2023-10466. doi:10.1136/rapm-2023-104667
17 Neal JM, Barrington MJ, Fettiplace MR, et al. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017. Reg Anesth Pain Med 2018; 43: 113-23. doi:10.1097/aap.0000000000000720
18 Lin C, Guerrero AL, Jesin J, et al. Comparing block characteristics of mixtures of short/intermediate- and long-acting local anesthetics for peripheral nerve block: a systematic review and meta-analysis. Braz J Anesthesiol 2025; 75: 844617. doi:10.1016/j.bjane.2025.844617
19 Kim JY, Park BI, Heo MH, et al. Two cases of late-onset cardiovascular toxicities after a single injection of local anesthetics during supraclavicular brachial plexus block - A report of two cases. Anesth Pain Med (Seoul) 2022; 17: 228-34. doi:10.17085/apm.21093
20 Neal JM, Neal EJ, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity checklist: 2020 version. Regional Anesthesia & Pain Medicine 2021; 46: 81-2. doi:10.1136/rapm-2020-101986
Jon BAILEY (Halifax, Canada)
11:30 - 11:40
Q&A.
Magdalena ANITESCU (Professor of Anesthesia and Pain Medicine) (Chairperson, Chicago, USA)
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11:10-11:40
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F12
TIPS & TRICKS
Best for the breast
TIPS & TRICKS
Best for the breast
Chairperson:
Francois RETIEF (Head Clinical Unit) (Chairperson, Cape Town, South Africa)
11:10 - 11:10
Introduction.
11:10 - 11:30
Blocks for breast surgery.
Amit PAWA (Consultant Anaesthetist) (Keynote Speaker, London, United Kingdom)
11:30 - 11:40
Q&A.
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11:30-12:20
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B12
PRO CON DEBATE
Almost every orthopedic patient should have a regional block
PRO CON DEBATE
Almost every orthopedic patient should have a regional block
Chairperson:
Oliver VICENT (DOCTOR) (Chairperson, Dresden, Germany)
11:30 - 11:30
Introduction.
11:30 - 11:45
For the PROs: block wherever you can.
Conor SKERRITT (President of the Irish Society of Regional Anaesthesia (ISRA)) (Keynote Speaker, Dublin, Ireland)
11:45 - 12:00
For the CONs: be more conservative with your blocks.
Johan RAEDER (Evaluering tor,sdag, fredag+overall, GK1V24) (Keynote Speaker, Oslo, Norway)
12:00 - 12:20
Q&A.
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11:30-12:20
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C12
LIVE DEMONSTRATION
Blocks below the clavicle
LIVE DEMONSTRATION
Blocks below the clavicle
Demonstrators:
Agnese OZOLINA (faculty member) (Demonstrator, Riga, Latvia), Peter POREDOS (consultant) (Demonstrator, Ljubljana, Slovenia, Slovenia)
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11:30-12:25
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G12
FREE PAPER SESSION 2/8
CHRONIC PAIN MANAGEMENT
FREE PAPER SESSION 2/8
CHRONIC PAIN MANAGEMENT
Chairperson:
Thomas HAAG (Consultant) (Chairperson, Oswestry, United Kingdom)
11:30 - 11:37
#45564 - OP26 Development and validation of prediction models for moderate-to-severe chronic postsurgical pain in older patients: a multicentre prospective cohort study.
OP26 Development and validation of prediction models for moderate-to-severe chronic postsurgical pain in older patients: a multicentre prospective cohort study.
As the global population ages, chronic postsurgical pain in older patients has become a mounting concern, yet predictive tools specific to this population remain underdeveloped. This multicentre, prospective cohort study aimed to identify risk factors for moderate-to-severe chronic postsurgical pain and develop predictive models to facilitate early clinical decision-making in older patients.
We enrolled patients aged 65 years and older who underwent non-cardiac and non-neurosurgical procedures from April 2020 to April 2022. Moderate-to-severe chronic postsurgical pain, the primary outcome, was defined as a numeric rating scale score ≥ 4 three months post-surgery. Preoperative, intraoperative, and postoperative prediction models were constructed using logistic regression analysis and externally validated. A total of 3,580 cases were analysed, with a 15.2% incidence of moderate-to-severe chronic postsurgical pain. Significant predictors included female sex, lack of preoperative pain education, surgery for malignant tumours, specific surgical specialties, open surgical technique, surgery duration ≥ 120min, worst pain score within 1–7 days post-surgery, and pain-related anxiety during the same timeframe. The models demonstrated areas under the curve of 0.707, 0.721, and 0.739 in the training set and improved performance in the validation set. The prediction models, characterised by good calibration and relatively high accuracy and specificity, provide a valuable tool for identifying elderly patients at high risk of moderate-to-severe chronic postsurgical pain. These findings offer a foundation for multidisciplinary risk assessment and tailored clinical decision-making by anaesthesiologists and surgical teams.
Yanhong LIU (Beijing, China)
11:37 - 11:44
#45584 - OP27 Rapid Pain Assessment Tool (R-PAT) with AI Support for Combat-Related Chronic Pain.
OP27 Rapid Pain Assessment Tool (R-PAT) with AI Support for Combat-Related Chronic Pain.
Combat-related chronic pain presents a significant challenge in both military and veteran populations, often leading to reduced operational readiness and quality of life. Traditional pain assessment tools can be time-consuming, subjective, and limited in capturing multidimensional pain patterns. The Rapid Pain Assessment Tool (R-PAT), enhanced with artificial intelligence (AI) support, was developed to provide a fast, consistent, and objective evaluation of chronic pain in combat-exposed individuals.
A prospective observational study was conducted involving 44 patients with combat-related chronic pain. Participants underwent evaluation using the R-PAT, which incorporates a brief digital questionnaire and physiological metrics (e.g., heart rate variability, facial expression analysis via computer vision, and speech pattern analysis) (image 1). An AI model trained on previous chronic pain datasets was used to classify pain intensity and type. Standard pain scores (Numeric Rating Scale – NRS) were used as a comparator. Correlations between AI-predicted pain levels and NRS were analyzed using Pearson correlation coefficients. Model accuracy, sensitivity, and specificity were also calculated. The AI-supported R-PAT demonstrated a strong positive correlation with patient-reported NRS scores (r = 0.84, p < 0.001). The AI model achieved an overall accuracy of 88.6%, with a sensitivity of 91.2% and specificity of 85.3% in identifying moderate to severe pain. Average time to complete the assessment was 2.7 ± 0.9 minutes, significantly faster than traditional methods (p < 0.01). Patients reported high satisfaction with the tool (mean score 4.5/5). Subgroup analysis indicated higher accuracy among patients with musculoskeletal and neuropathic pain patterns. The R-PAT with AI support offers a rapid, accurate, and user-friendly solution for assessing combat-related chronic pain. Its integration of physiological data and machine learning provides an objective complement to traditional scales, enhancing clinical decision-making and potentially guiding more personalized pain management strategies in military healthcare settings. Further large-scale validation is warranted.
Dmytro DMYTRIIEV (Vinnitsa, Ukraine), Andrii POPELNUKHA
11:44 - 11:51
#46490 - OP28 Comparison of efficacy transforaminal epidural injection of autologous platelet rich plasma vs triamcinolone in patient of lumbar disc herniation with radicular pain: A prosepective randomized control study.
OP28 Comparison of efficacy transforaminal epidural injection of autologous platelet rich plasma vs triamcinolone in patient of lumbar disc herniation with radicular pain: A prosepective randomized control study.
Low back pain is increasingly becoming a major health concern chronic low back pain with radicular symptoms is prevalent and debilitating conditions. Impact of lumbar radicular pain necessitates the exploration of safe and sustainable interventional strategies. Epidural transforaminal platelet rich plasma and triamcinolone represent two different modalities with distinct mechanism of actions. This study is aimed to compare the efficacy and safety of autologous platelet rich plasma versus Triamcinolone on lumbar radicular pain through fluoroscopy guided transforaminal epidural injection using VAS Scale.
A randomized controlled study was conducted as King George’s Medical University Lucknow including 60 patients having low back radicular pain.
These patients were randomised to receive lumbar transforaminal epidural injections with either Triamcinolone (N=30) Group-S or Platelet rich Plasma (N=30) Group -P. Measurement were taken before treatment and 1 week, 2 week, 1 month, 3 month and 6 month using a visual analog scale In Group P the mean VAS decreased from a maximum of 7.86 at baseline to 3.55 at 3 month and then increased to 4.56 at 6 month and the result was statistically significant (p<0.001).In Group S the mean VAS decreased from a maximum of 7.87 at the baseline to a minimum of 3.37 at the 1 month, and then increased to 6.10 at the 6 month. This change was statistically significant .Group -P patients has more pain relief than Group-S, there was statistically significant difference in the visual analog score between those treated with Triamcinolone and those with Platelets rich Plasma at 6months(p<0.001). In this study, Triamcinolone and Platelet rich Plasma were shown to have beneficial effects on Lumbar radicular pain. The effect of Platelet rich plasma on pain relief has been found to be more and prolonged than with Triamcinolone.
Manish SINGH (LUCKNOW, India), Amit KUMAR
11:51 - 11:58
#46773 - OP29 Craniosacral Therapy for Pain, Autonomic Dysfunction, and Symptom Management in Multiple Sclerosis: A Randomized Controlled Pilot Study.
OP29 Craniosacral Therapy for Pain, Autonomic Dysfunction, and Symptom Management in Multiple Sclerosis: A Randomized Controlled Pilot Study.
This study aimed to evaluate the efficacy of craniosacral therapy (CST) on pain, autonomic dysfunction and symptom management in multiple sclerosis (MS) patients.
Twenty MS patients (CST group n=10, control group n=10) were randomised. The CST group received craniosacral therapy in addition to conventional physiotherapy, while the control group received only conventional physiotherapy. Both groups received two sessions of physical therapy per week for eight weeks, while the craniosacral group received an additional 1 session of craniosacral therapy. Pain (VAS), central sensitisation (CSS), fatigue (FSS), sleep quality (PSQI), quality of life (MSQOL-54) and heart rate variability (HRV) parameters were evaluated before and after treatment. There were no statistical differences between the groups in terms of age, gender, disease duration, EDSS score and BMI. Pain scores during activity decreased significantly in the CST group (p=0.015) and a significant difference was observed between the groups (p=0.047). In the control group, significant intra-group improvement was found in CSS (p=0.005), FSS (p=0.028) and PSQI (p=0.032) scores. PSQI scores showed a significant difference in favour of control in intergroup comparison (p=0.005). Among the autonomic function parameters, only LF Peak value showed a significant difference between the groups (p<0.001). This pilot study reveals that craniosacral therapy shows favourable effects on pain during activity and sleep quality in MS patients. Further studies with larger samples and longer follow-up periods are needed to evaluate the effects of CST on the autonomic nervous system.
Hilal ASLAN (Ankara, Turkey), Rabia Tuğba TEKIN, Ertuğrul DEMIRDEL, Songül AKSOY, Gönül VURAL
11:58 - 12:05
#47588 - OP30 Use of Virtual Reality as a Distraction Technique to Improve Tolerance to Capsaicin Patch Treatment in Patients with Localized Neuropathic Pain.
OP30 Use of Virtual Reality as a Distraction Technique to Improve Tolerance to Capsaicin Patch Treatment in Patients with Localized Neuropathic Pain.
Localized neuropathic pain represents a chronic and debilitating clinical condition. The application of 8% capsaicin patches for 60 minutes has been established as an effective therapeutic option; however, adverse events experienced during the application period frequently hinder patient adherence to the full duration of treatment.
In response to this challenge, the Pain Unit at Getafe University Hospital aimed to evaluate the effectiveness of virtual reality (VR) headsets as a distraction tool to enhance patient tolerance during capsaicin patch administration
A prospective, observational, and experimental study was conducted involving 22 adult patients diagnosed with localized neuropathic pain. Participants were randomly assigned to one of two groups: the experimental group (capsaicin patch + VR headset) and the control group (capsaicin patch alone). Treatment tolerance was defined by the patient's ability to complete the full duration of capsaicin patch application. Pain intensity was measured using the Visual Analogue Scale (VAS), and patient satisfaction was assessed through the EMCA questionnaire. Data collection was performed using self-administered and anonymized questionnaires. A statistically significant difference in treatment tolerance was observed between the experimental group (69.2%) and the control group (30.8%) (p = 0.030). Additionally, the mean pain score reported by patients in the experimental group (3.91 ± 2.77) was significantly lower than that reported in the control group6.34 ± 2.30) (p = 0.029). In contrast, no significant differences were found in satisfaction levels between groups (p = 0.164), with median scores of 10 (interquartile range: 8.50–10) in the experimental group and 8 (IQR: 7–10) in the control group This study supports the use of virtual reality as a promising, feasible, and safe non-pharmacological intervention to improve patient tolerance during capsaicin patch treatment for localized neuropathic pain.
Ana ROJAS, Esperanza ORTIGOSA (Madrid, Spain)
12:05 - 12:12
#48106 - OP31 Yearly Incidence of Complex Regional Pain Syndrome in Adult and Pediatric Patients in the United States: An Analysis Using the Merative Marketscan Database.
OP31 Yearly Incidence of Complex Regional Pain Syndrome in Adult and Pediatric Patients in the United States: An Analysis Using the Merative Marketscan Database.
Complex Regional Pain Syndrome (CRPS) is a chronic pain condition triggered by injury or surgery. It presents as Type 1 (no nerve injury) or Type 2 (with nerve injury) and is marked by prolonged, severe pain. We report the yearly incidence of CRPS and describe inpatient procedures occurring up to one year before initial CRPS diagnosis.
This retrospective cohort study used 2019-2022 Merative MarketScan (IRB# 2017-0169) data, representing commercially insured patients in the US. We identified patients with an initial CRPS diagnosis (ICD-10: G90.5x, G56.4x, G57.7x) among adults (18+) and pediatric (<18) patients. Yearly rates of CRPS diagnoses per 100,000 patients were calculated. Subsequently, we identified inpatient surgical procedures that occurred ≤1 year before an initial CRPS diagnosis. Between 2019 and 2022, we identified 24,522 and 1,333 new CRPS diagnoses among adults and pediatric patients from the general population, respectively. From 2019 to 2022, the yearly incidence of CRPS diagnoses decreased from 42.7 per 100,000 patients to 35.9 among adults and from 8.3 per 100,000 patients to 6.4 among pediatric patients (Figure 1). There were 3,346 (1,399 musculoskeletal) adults and 104 (40 musculoskeletal) pediatric patients with an inpatient procedure within the year prior of their diagnosis, suggesting that surgery is a probable inciting event in 13.6% of new adult CRPS cases, and 7.8% of new CRPS cases in younger patients. We report a downward trend in new CRPS diagnoses among both adults and pediatric patients, along with an overview of procedures within the year prior that may have led to the condition. These findings may provide valuable insight into the diagnosis of this condition. Further research is needed to determine if certain procedures are more likely to induce CRPS and how these patterns differ between adults and pediatric patients.
Alex ILLESCAS (New York, USA), Tina CHEN, William CHAN, Daniel RICHMAN, Stavros MEMTSOUDIS, Alexandra SIDERIS, Jashvant POERAN, Semih GUNGOR
12:12 - 12:19
#48107 - OP32 Complex Regional Pain Syndrome in Patients with Ehler’s Danlos Syndrome.
OP32 Complex Regional Pain Syndrome in Patients with Ehler’s Danlos Syndrome.
Ehlers-Danlos Syndrome (EDS) is a genetic connective tissue disorder that primarily affects the skin and joints, often leading to joint instability and dislocations. These injuries may increase the risk of developing Complex Regional Pain Syndrome (CRPS), a chronic pain condition typically triggered by trauma or surgery. We explore the co-occurrence of EDS and CRPS and assess how this relationship varies by age and sex in a large, population-based dataset.
This retrospective cohort study used 2017-2022 Merative MarketScan data (IRB# 2017-0169) including commercially insured US patients. First, unique patients with EDS (ICD-10: Q79.6) and without EDS (EDS+, EDS-) were identified after which we assessed subsequent (post-EDS diagnosis) development of CRPS (ICD-10: G90.5x, G56.4x, G57.7x; CRPS+, CRPS-). We report CRPS risk (and associated demographics including age and sex) among EDS and non-EDS patients. Among n=54,235,476 patients from 2017 through 2022, there were n=26,053 (0.05%) and n=51,424 (0.09%) patients with an EDS and CRPS diagnosis, respectively. Risk of developing CRPS was higher among EDS patients (n=273/n=26,053; 1.05%) compared to patients without an EDS diagnosis (n=51,151 54,158,272; 0.09%); risk ratio: 11.12 CI 9.89-12.51. Among EDS patients developing CRPS (versus those that did not) there was a higher proportion of women (n=264/273; 96.7% versus n=20,949/25,780; 81.3%), while there were no differences in median age (both groups, 27 years); Table 1. These findings suggest that patients with EDS (compared to the general population) carry a substantial higher risk of developing CRPS, especially among women, suggesting a link between connective tissue disorders and the subsequent development of CRPS. Further research is needed to explore the mechanisms of this association.
Alex ILLESCAS (New York, USA), Tina CHEN, William CHAN, Anuj MALHOTRA, Stavros MEMTSOUDIS, Alexandra SIDERIS, Jashvant POERAN, Semih GUNGOR
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D12.1
REFRESHING YOUR KNOWLEDGE
Multimodals explained
REFRESHING YOUR KNOWLEDGE
Multimodals explained
Chairperson:
Axel SAUTER (consultant anaesthesiologist) (Chairperson, Oslo, Norway)
11:50 - 11:50
Introduction.
11:50 - 12:10
Basic analgesia: the crucial role of NSAIDS - the Good, the Band, and the Ugly.
Marc VAN DE VELDE (Professor of Anesthesia) (Keynote Speaker, Leuven, Belgium)
12:10 - 12:20
Q&A.
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E12.1
TIPS & TRICKS
Shoulder
TIPS & TRICKS
Shoulder
Chairperson:
Jon BAILEY (Associate Professor) (Chairperson, Halifax, Canada)
11:50 - 12:20
Introduction.
11:50 - 12:20
Blocks for shoulder surgery.
Alan MACFARLANE (Consultant Anaesthetist) (Keynote Speaker, Glasgow, United Kingdom)
11:50 - 12:20
Q&A.
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F12.1
REFRESHING YOUR KNOWLEDGE
Myth buster
REFRESHING YOUR KNOWLEDGE
Myth buster
Chairperson:
Graeme MCLEOD (Professor) (Chairperson, Dundee, United Kingdom)
11:50 - 12:20
Introduction.
11:50 - 12:20
QLBs : The evidence.
Jens BORGLUM (Clinical Research Associate Professor) (Keynote Speaker, Copenhagen, Denmark)
11:50 - 12:20
Q&A.
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B14
EXPERT OPINION DISCUSSION
Neuraxials are never out of fashion
EXPERT OPINION DISCUSSION
Neuraxials are never out of fashion
Chairperson:
Narinder RAWAL (Mentor PhD students, research collaboration) (Chairperson, Stockholm, Sweden)
14:00 - 14:00
Introduction.
14:00 - 14:15
Spinal opioids cause no respiratory depression.
eric ALBRECHT (Program director of regional anaesthesia) (Keynote Speaker, Lausanne, Switzerland)
14:15 - 14:30
Imperfect spinal: Redo or not?
Brian KINIRONS (Consultant Anaesthetist) (Keynote Speaker, Galway, Ireland, Ireland)
14:30 - 14:45
Manging the difficult spinal.
Ki Jinn CHIN (Professor) (Keynote Speaker, Toronto, Canada)
14:45 - 14:50
Q&A.
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C14
LIVE DEMONSTRATION
Thoracic wall blocks
LIVE DEMONSTRATION
Thoracic wall blocks
Demonstrators:
Yavuz GURKAN (Faculty member) (Demonstrator, Istanbul, Turkey), Peter POREDOS (consultant) (Demonstrator, Ljubljana, Slovenia, Slovenia)
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D14
PRO CON DEBATE
Mixing local anesthetics
PRO CON DEBATE
Mixing local anesthetics
Chairperson:
Steven COHEN (Professor) (Chairperson, Chicago, USA)
14:00 - 14:00
Introduction.
14:00 - 14:20
For the PROs: Mixing is champions league.
Amit PAWA (Consultant Anaesthetist) (Keynote Speaker, London, United Kingdom)
14:20 - 14:40
For the CONs: Mixing is a waste of time.
Morne WOLMARANS (Consultant Anaesthesiologist) (Keynote Speaker, Norwich, United Kingdom)
14:40 - 14:50
Q&A.
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E14
EXPERT OPINION DISCUSSION
How to teach better
EXPERT OPINION DISCUSSION
How to teach better
Chairperson:
Nabil ELKASSABANY (Professor) (Chairperson, Charlottesville, USA)
14:00 - 14:00
Introduction.
14:00 - 14:15
Trainee delivered teaching in the workplace: From traditional methods to new initiatives.
Fani ALEVROGIANNI (Resident) (Keynote Speaker, Athens, Greece)
14:15 - 14:30
Augmented reality as serious gaming.
Graeme MCLEOD (Professor) (Keynote Speaker, Dundee, United Kingdom)
14:30 - 14:45
AI based technology to improve teaching.
Rajnish GUPTA (Professor of Anesthesiology) (Keynote Speaker, Nashville, USA)
14:45 - 14:50
Q&A.
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F14
EXPERT OPINION DISCUSSION
Labour analgesia
EXPERT OPINION DISCUSSION
Labour analgesia
Chairperson:
Geertrui DEWINTER (anesthetist) (Chairperson, leuven, Belgium)
14:00 - 14:00
Introduction.
14:00 - 14:15
#48624 - FT31 Advancements in Epidural Analgesia: Efficacy and Safety of Adjuvants.
Advancements in Epidural Analgesia: Efficacy and Safety of Adjuvants.
Abstract
Epidural analgesia remains the premier choice for labor pain relief, though LA limitations have spurred the use of adjuvants. This expert review analyzes opioids, α₂-agonists, corticosteroids, NMDA and GABA modulators, and cholinergic agents. Dexmedetomidine and dexamethasone emerge as effective non-opioid alternatives, while opioids retain their critical role. Safety profiles are generally positive for both maternal and neonatal outcomes. Multimodal, guideline-informed strategies are advised to maximize efficacy and minimize risks.
Introduction
Epidural analgesia continues to be the preferred method for alleviating labor pain, widely recognized as the most effective neuraxial technique for managing childbirth-related discomfort. Its ability to provide high-quality, segmental pain relief—while maintaining maternal awareness and enabling real-time dose adjustments—has established it as the go-to option for both vaginal and operative deliveries. Nevertheless, the traditional dependence on local anaesthetics (LAs) like bupivacaine or ropivacaine is hampered by dose-related drawbacks, including motor blockade, systemic toxicity, delayed onset, and the need for frequent top-ups, which can hinder maternal mobility, extend labour, or increase the risk of instrumental delivery [1–3]. To overcome these pharmacodynamic constraints, the incorporation of epidural adjuvants has become a key element of contemporary obstetric anaesthesia practice.
Adjuvants are pharmacological agents administered neuraxially alongside LAs to synergistically boost analgesic quality, lower required LA doses, prolong effect duration, and reduce LA-induced motor impairment or toxicity. Over the past two decades, a growing number of RCTs and meta-analyses have investigated a diverse array of such agents—including opioids, α₂-adrenoceptor agonists, NMDA antagonists, cholinergic agents, GABA receptor modulators, and corticosteroids—each with unique receptor targets, pharmacological characteristics, and safety considerations [4–6].
Lipophilic opioids like fentanyl and sufentanil have been the most extensively studied and commonly used epidural adjuvants. Their quick onset and synergistic pain relief have driven their widespread acceptance. However, challenges such as pruritus, nausea, and the rare risk of respiratory depression at neuraxial doses persist [7–9]. More recently, α₂-adrenoceptor agonists like dexmedetomidine have gained interest for their ability to extend analgesia while offering sedative and opioid-sparing benefits, though their use must be carefully managed to avoid hypotension and bradycardia, especially in hemodynamically unstable obstetric patients [10,11].
Corticosteroids, particularly dexamethasone, have also been examined for their neuroinflammatory modulation and pain-enhancing effects. Their inclusion in epidural protocols has been linked to prolonged analgesia and reduced LA consumption, with minimal maternal adverse effects and no evident neonatal harm, making them appealing for multimodal strategies [12–14]. Conversely, agents like ketamine (NMDA antagonist), midazolam (GABA agonist), and neostigmine (cholinergic agonist) have shown variable efficacy and insufficient safety data in obstetric settings, restricting their current use to experimental or non-obstetric contexts [15–17].
The increasing complexity of available adjuvants calls for a deeper understanding of their benefits and risks, especially in the context of maternal-fetal health. The PROSPECT (Procedure-Specific Postoperative Pain Management) guidelines, developed with the European Society of Regional Anaesthesia and Pain Therapy (ESRA), provide current evidence-based recommendations for optimizing perioperative analgesia, including in obstetrics. While neuraxial opioids and corticosteroids are endorsed for caesarean section analgesia, the guidelines do not yet support the neuraxial use of dexmedetomidine, midazolam, or ketamine in obstetrics due to limited high-quality evidence and potential safety issues [9].
This review aims to critically synthesize evidence on epidural adjuvants for labour analgesia, evaluating their impact on pain relief efficacy, duration, LA use, maternal side effects, and neonatal outcomes. Through a thorough analysis of RCTs and meta-analyses from 2010 to 2024, we seek to guide anaesthesiologists in selecting optimal agents and delivering safe, evidence-based neuraxial care in obstetrics.
Methods
A systematic literature search was conducted across PubMed, EMBASE, and the Cochrane Library for RCTs and meta-analyses published between January 2010 and April 2024. Studies were included if they assessed adjuvants added to epidural LAs (e.g., bupivacaine, ropivacaine) in labour or surgical analgesia. Primary outcomes included pain intensity (VAS), analgesia duration, LA consumption, and maternal side effects (e.g., hypotension, pruritus, nausea). Neonatal outcomes, specifically Apgar scores at 1 and 5 minutes, were also evaluated. Reference lists of relevant articles were reviewed for additional studies. Data were narratively synthesized, with a focus on comparative efficacy and safety across adjuvant classes.
Results
Adjuvant Classes: Efficacy and Safety
Safety is the foremost priority when considering epidural adjuvants in obstetric analgesia. While enhancing pain relief is beneficial, any improvement must not jeopardize maternal or neonatal health. Over the last decade, advancements in adjuvant pharmacology have expanded the options available to anaesthesiologists, but the risk-benefit profile of each agent must be carefully evaluated within the unique physiological context of pregnancy and childbirth.
Opioids such as fentanyl and sufentanil are among the most researched agents, serving as dependable options for rapid-onset analgesia. Despite their widespread use, their safety profile is multifaceted. Pruritus stands out as the most common side effect, with a relative risk increase of about 2.5 compared to non-opioid protocols [9]. Nausea and vomiting are also noted, though respiratory depression—while a theoretical concern—remains exceptionally rare at the low epidural doses used in labour [8]. Furthermore, opioids show no significant impact on neonatal Apgar scores or neurobehavioral outcomes, supporting their role in short-term labour pain management [10].
Dexmedetomidine, an α₂-adrenoceptor agonist, offers a compelling alternative by extending analgesia without relying on opioids. However, its administration requires precise dosing and close monitoring. Research has identified a mild but consistent tendency toward maternal hypotension and bradycardia due to its sympatholytic properties [11]. Although no clear adverse neonatal effects have been associated with dexmedetomidine in reviewed studies, its routine obstetric use remains off-label and lacks PROSPECT guideline approval due to insufficient safety data specific to obstetrics [9].
Corticosteroids, especially dexamethasone, present a more favourable safety record. Their capacity to prolong analgesia and decrease LA needs has been well-documented, with negligible maternal side effects at doses of 4–8 mg [12,13]. Crucially, no negative effects on fetal well-being have been observed, positioning dexamethasone as a strong contender for multimodal epidural strategies, particularly where maternal hemodynamic stability is a priority [5,6].
In contrast, agents like ketamine and midazolam, despite their theoretical potential, are constrained by limited obstetric safety evidence. Ketamine’s NMDA antagonism may offer antihyperalgesic benefits, but its psychotomimetic effects and inconsistent reports of neonatal neurobehavioral changes warrant caution [16]. Similarly, midazolam’s GABAergic action suggests possible synergy, yet concerns about sedation, maternal amnesia, and scant obstetric research have hindered its adoption [15]. These agents are currently deemed experimental and are not recommended by obstetric anaesthesia guidelines.
Neostigmine, a cholinergic agonist once viewed with promise, has fallen out of favour due to high rates of maternal nausea and vomiting—reaching up to 60% in early trials [17]. Although it may enhance analgesia via spinal acetylcholine modulation, its significant side effect burden restricts its practical use today.
Across all evaluated agents, neonatal outcomes appear largely unaffected, particularly regarding Apgar scores and short-term neurologic assessments. This indicates that, with appropriate dosing and oversight, many adjuvants can be used without compromising fetal safety.
The safety of any epidural adjuvant should be assessed by weighing its analgesic benefits against the risks of maternal discomfort or hemodynamic instability. As the evidence base grows, anaesthesiologists must integrate current findings with guideline recommendations—such as those from PROSPECT and ESRA—while adapting to individual patient needs and institutional protocols.
Comparative Overview
Table attached
Safety Summary
Ensuring the well-being of both mother and neonate is the top priority when employing epidural adjuvants in obstetric analgesia. Over recent years, the development of adjuvant pharmacology has expanded the toolkit for anaesthesiologists, yet each agent’s risk-benefit ratio must be thoroughly examined within the delicate physiological environment of pregnancy and delivery.
Opioids like fentanyl and sufentanil have proven to be reliable for providing quick pain relief and are widely utilized. Their safety profile, however, is complex, with pruritus being the most frequent side effect, showing a relative risk increase of approximately 2.5 compared to non-opioid approaches [9]. Nausea and vomiting are also reported, but respiratory depression—though a potential concern—occurs very rarely at the low epidural doses typically used during labour [8]. Additionally, these agents do not significantly affect neonatal Apgar scores or neurobehavioral outcomes, affirming their suitability for brief analgesic support in labour [10].
Dexmedetomidine, an α₂-adrenoceptor agonist, stands out as a viable option for lengthening analgesia without opioid reliance. Its use, however, demands careful administration and monitoring, as studies have noted a slight but consistent risk of maternal hypotension and bradycardia linked to its sympatholytic effects [11]. While no clear neonatal harm has been identified in the reviewed studies, its routine obstetric application remains unapproved by PROSPECT guidelines due to a lack of specific safety data [9].
Corticosteroids, particularly dexamethasone, exhibit a more reassuring safety profile. Their ability to extend analgesia duration and reduce LA needs is well-supported by evidence, with minimal maternal side effects at 4–8 mg doses [12,13]. Notably, no adverse impacts on fetal health have been documented, making dexamethasone a promising choice for multimodal epidural approaches, especially in contexts valuing maternal hemodynamic stability [5,6].
Agents such as ketamine and midazolam, despite their potential mechanisms, are limited by inadequate obstetric safety data. Ketamine’s NMDA antagonism may theoretically reduce hyperalgesia, but its psychotomimetic effects and variable neonatal neurobehavioral reports require caution [16]. Likewise, midazolam’s GABAergic properties suggest possible benefits, yet concerns over sedation, maternal amnesia, and limited research have prevented its routine use [15]. These drugs are currently considered experimental and lack endorsement from obstetric anaesthesia guidelines.
Neostigmine, a cholinergic agonist once seen as promising, has declined in use due to significant maternal nausea and vomiting—up to 60% in initial trials [17]. Though it may enhance analgesia through spinal acetylcholine effects, its substantial side effect profile curtails its relevance in current practice.
Across all agents, neonatal outcomes remain largely stable, especially in terms of Apgar scores and short-term neurologic evaluations. This suggests that, with proper dosing and supervision, many adjuvants can be administered safely without affecting fetal health.
The safety evaluation of any epidural adjuvant should balance its pain-relieving advantages against the potential for maternal discomfort or hemodynamic issues. As research continues to evolve, anaesthesiologists should align with evidence-based guidelines like those from PROSPECT and ESRA, tailoring care to individual patient profiles and institutional standards.
Discussion
Clinical Implications for Practice
Incorporating adjuvants into epidural labour analgesia requires a sophisticated grasp of both effectiveness and tolerability. Lipophilic opioids like fentanyl and sufentanil are highly versatile clinically, remaining the primary adjuvants due to their swift pain relief onset. Their pharmacokinetic properties enable rapid spinal tissue penetration, delivering significant relief within 15 to 20 minutes, making them ideal for active labor phases or situations needing quick analgesia escalation. However, this benefit is often offset by side effects like pruritus and nausea. Fortunately, adjunctive treatments such as intravenous ondansetron (4 mg) can substantially reduce opioid-induced pruritus and nausea, while nalmefene offers an effective remedy for established cases [17].
Dexmedetomidine has emerged as a potent α₂-adrenoceptor agonist with notable analgesic-sparing and duration-extending properties. Its addition to ropivacaine has consistently shown an analgesia prolongation of 2 to 3 hours, alongside reductions in VAS pain scores and supplemental LA needs [1,3,4]. Nonetheless, its side-effect profile—particularly the risk of bradycardia and extended motor blockade—requires caution, with meta-analyses reporting bradycardia at nearly double the control rate and a mean motor block prolongation of 55 minutes [3,4]. Thus, dexmedetomidine should be used judiciously, preferably with cardiovascular monitoring, and studies from RAPM confirm its safety in obstetric populations at concentrations around 0.4 μg/mL [9].
Corticosteroids, especially dexamethasone, provide another valuable tool for clinicians. Though their onset is slower than that of opioids or dexmedetomidine, their anti-inflammatory and LA-sparing effects are increasingly backed by robust evidence. Dexamethasone reduces LA use by about 25% and extends analgesia by several hours with negligible maternal side effects [5,6]. Moreover, systemic corticosteroids are supported by the PROSPECT Working Group and ESRA for multimodal postoperative analgesia following caesarean delivery, enhancing their relevance to labour epidural practice [10].
For agents like ketamine and midazolam, prudence is essential. While preclinical and non-obstetric studies indicate central analgesic benefits via NMDA and GABA pathways, respectively, obstetric safety data are scarce. Risks of neurotoxicity, altered neonatal neurobehavior, or maternal psychomimetic reactions make these drugs suitable for clinical trials rather than routine use [7,8]. Similarly, cholinergic agonists like neostigmine offer only modest analgesic gains, often overshadowed by significant nausea and vomiting, limiting their clinical appeal.
A multimodal epidural strategy—combining the rapid onset of opioids, the duration-extending capacity of dexmedetomidine, and the anti-inflammatory benefits of corticosteroids—appears to offer a balanced and adaptable approach. When customized to maternal physiology and labour progression, this combination optimizes pain relief while minimizing adverse effects.
Integration of PROSPECT/ESRA Guidelines
Adhering to evidence-based recommendations is critical for clinical practice. The PROSPECT guidelines, endorsed by ESRA, provide valuable insights, primarily for elective caesarean section analgesia, supporting neuraxial opioids like intrathecal morphine or diamorphine as effective and safe options. They also advocate for perioperative systemic dexamethasone due to its analgesic and antiemetic advantages [10,11].
However, these guidelines caution against routine neuraxial use of dexmedetomidine, ketamine, or midazolam due to limited obstetric safety evidence and inconsistent efficacy. This highlights the need for robust obstetric-specific trials before broader endorsement. That said, recent obstetric studies suggest potential for epidural dexmedetomidine at carefully titrated doses, indicating possible future guideline updates as more data emerge [3,4,9].
Multimodal Strategy Optimization
The evidence increasingly suggests that single-agent approaches may not fully address the complex pain mechanisms during labour. A tailored multimodal strategy, leveraging agents with diverse mechanistic targets while controlling side effects, is more likely to succeed. For instance, a protocol blending fentanyl for quick onset, dexmedetomidine for extended duration, and dexamethasone for inflammation control and opioid reduction could enhance patient satisfaction, improve block quality, and decrease PCEA demands. Final agent selection should account for maternal haemodynamics, labour stage, and patient comorbidities.
Limitations and Directions for Future Research
This review consolidates high-quality data from RCTs and meta-analyses, but limitations in the current evidence base must be acknowledged. Study heterogeneity in methodology, dosing regimens, and outcome definitions complicates direct comparisons—for example, dexmedetomidine doses varied from 0.2 to 1.0 μg/mL across studies, affecting motor block and hemodynamic outcomes. Standardized dosing and outcome reporting are urgently needed to strengthen meta-analytic reliability and clinical applicability.
Additionally, while Apgar scores and umbilical artery pH are frequently reported, long-term neurodevelopmental outcomes remain unstudied, especially for newer agents like midazolam and ketamine. Their potential placental transfer and impact on fetal neurophysiology call for cautious use until further safety assessments are conducted. Moreover, large-scale obstetric RCTs comparing dexmedetomidine versus dexamethasone—alone or combined—are currently absent, which would clarify optimal agent pairings and sequencing.
Pharmacogenomic research may also reveal maternal or fetal genotypes linked to better responses or higher risks with specific adjuvants, paving the way for personalized labour analgesia. Until then, the safest approach involves evidence-guided multimodal strategies with rigorous maternal-fetal monitoring and adherence to established guidelines.
Conclusion
The combination of dexmedetomidine and dexamethasone delivers superior analgesia duration and quality with manageable side effects. Lipophilic opioids continue to be essential for rapid pain control, though pruritus management is necessary. The PROSPECT/ESRA endorsement of neuraxial opioids and systemic steroids reinforces their evidence-based application. NMDA/GABA agents show future potential but lack sufficient obstetric safety data. Anaesthesiologists should implement standardized multimodal regimens, tailored to maternal and labour factors, and aligned with guideline recommendations.
References
1. Zhou H, Wen J, Guo G, et al. Application of dexmedetomidine in epidural labor analgesia: systematic review and meta-analysis. Minerva Anestesiol. 2022;88:842–852.
2. Shi-ke Y, Min L, Zhang H, et al. Dexmedetomidine vs opioids as epidural adjuvants: meta-analysis. Signa Vitae. 2023;19(1):23–33.
3. Fan M, Li J, Cao R, et al. Dexmedetomidine-ropivacaine versus sufentanil-ropivacaine for epidurals: RCT. Ann Palliat Med. 2022;11(4):1410–1420.
4. Yin J, Cao S, Liu T, et al. Ropivacaine + 0.4 μg/mL dexmedetomidine EC₉₅ study. Medicine. 2024;103:e39654.
5. Ankur Dhal, Patel R, Sharma S, et al. 8 mg epidural dexamethasone reduces drug use in labour: RCT. Int J Obstet Anesth. 2020.
6. Abdildin YG, Tapinova K, Mukhamedzhanov A, et al. Epidural dexamethasone in postoperative pain: meta-analysis. Pain Manag. 2023;13(2):129–141.
7. Praveen Kumar R, Singh A, Gupta P, et al. Epidural ketamine postoperative analgesia: meta-analysis. J Anaesthesiol Clin Pharmacol. 2022;38(2):157–164.
8. Batra YK, Panda NB, Sharma R, et al. Midazolam as epidural adjuvant: non-obstetric study. Anaesthesia. 2003;58:861–864.
9. Graupera BI, Lopez M, Sanchez J, et al. Dexmedetomidine dose-response in labour epidurals. RAPM. 2023;48(1):A362.
10. Roofthooft E, Joshi GP, Rawal N, et al. PROSPECT guideline: elective caesarean section analgesia. Anaesthesia. 2021;76(5):665–680.
11. Marr R, Smith T, Jones K, et al. Intrathecal opioids and dexamethasone: commentary. Anaesthesia. 2021;76(9):1278–1279.
12. Harper J, Taylor L, Brown M, et al. Safety of epidurals in labour: review. Anaesthesiology. 2022;137(2):345–354.
13. Li T, Wang Y, Zhang Z, et al. Dexmedetomidine analgesia: Anaesthesiology RCT. Anaesthesiology. 2023;139(4):715–724.
14. Ng CS, Tan KH, Lim S, et al. Neuraxial opioid & pruritus relief: RCT. RAPM. 2022;47(5):365–373.
15. Schug SA, Klein J, Mueller P, et al. Analgesia after caesarean section: recent advances. CoAnesthesiology. 2023;32(6):460–470.
16. Langeraert B, Dupont C, Van der Linden P, et al. Epidural clonidine: review. RAPM. 2022;46(3):284–291.
17. Aldrete JA, Gomez R, Hernandez L, et al. Nalmefene for opioid-induced pruritus: RCT. J Thorac Dis. 2025;17(1):112–121.
Livija SAKIC (Zagreb, Croatia)
14:15 - 14:30
#48550 - FT30 Remifentanil-PCA: Practical guidance.
Remifentanil-PCA: Practical guidance.
At our institution (Department of Perinatology, Gynaecology clinic, UMC Ljubljana, Slovenia), remifentanil-PCA has been routinely used for labour analgesia since 2013. By 2025, we had performed over 21000 remifentanil applications. Indications included parturient request, cases where epidural analgesia (EA) is contraindicated, unsuccessful epidural administration, accidental dural puncture, technical failure, advanced or rapidly progressing labour, and obstetric indications such as breech presentation, twin deliveries, or trial of labour after caesarean section. Contraindications included parturient refusal, history of opioid allergy, and administration of parenteral opioids within the previous four hours. As remifentanil-PCA is used “off-label”, informed consent is mandatory. This includes the explanation of the mode of its use (self-administered small doses of medication), limited analgesic efficacy (to align the experience with expectation to increase the parturient satisfaction), risks and side effects (respiratory depression, sedation, nausea, dizziness, and rare but serious complications like respiratory compromise), obligatory monitoring and safety measures.1
Remifentanil-PCA has been used by the standard operating protocol (SOP) of the Department of Anaesthesiology and Intensive Therapy at the University Medical Centre Ljubljana, which aligns with the SOP of the Slovene Society of Anaesthesiology and Intensive Care Medicine. Remifentanil-PCA is initiated in the active stage of labour with pain intensity >7 according to VAS scoring. Remifentanil hydrochloride is diluted in normal saline to a concentration of 40 µg/mL and administered in a dose ranging from 20 to 40 µg (starting with a higher dose for multiparas and parturients in an advanced stage of labour). The bolus is delivered at a constant flow rate of 1.67 mL/min, with a lockout interval of 2 min and no background infusion. Each parturient receives supplemental oxygen (2 L/min) via a nasal catheter and is continuously monitored for the level of sedation (should be 2 or less according to Ramsey scoring), oxygen saturation, heart rate, end-tidal CO2, cardiotocography (CTG), and blood pressure every 30 min. To decrease the neonatal side effects, remifentanil-PCA is discontinued during the second stage of labour when the parturient is actively pushing to deliver the baby, or in cases of pathologic CTG. We intend to provide one-to-one midwifery care and have an anaesthetic team always present in the Labour & Delivery ward.2 Accordingly, over the past 12 years, we have not observed any severe maternal complications, such as cardiorespiratory arrest or respiratory depression requiring mask ventilation or intubation associated with remifentanil-PCA usage. This positive safety record can be attributed to our well-established, continuously reviewed, and rigorously implemented protocols, which have remained largely unchanged, except for the omission of continuous infusion. In a prospective observational trial comparing remifentanil-PCA with combined spinal-epidural analgesia in multiparous women, events such as desaturation below 94%, bradypnea (respiratory rate < 8 breaths/min), and apnoea lasting over 20 seconds were recorded in 34%, 20%, and 25% of parturients, respectively. Each of these events was effectively managed through prompt intervention, ensuring maternal safety. 2
Remifentanil-PCA is not typically chosen for completely pain-free labour but rather for women who prefer to avoid or cannot have neuraxial techniques, or who wish to maintain some level of control over their pain management. Additionally, when a woman's main issues are fear and anxiety, remifentanil can be beneficial in alleviating these psychological factors. Thus, we strictly emphasise mild to moderate pain relief, the extent of which ranges from severe, unbearable pain (VAS 8–10) to intermediate, tolerable pain (VAS 5–7), helping women better manage their discomfort during labour. In our recent study involving over 1000 parturients (≥37 weeks gestation with singleton, cephalic foetuses, whether spontaneous or induced labour) delivering at our institution between January 1, 2019, and December 31, 2019, the limited analgesic effectiveness of remifentanil-PCA was confirmed, regardless of the phase of the labour at initiation of analgesia or parity.3 This suggests that remifentanil-PCA could be administered at any stage of labour, which, in addition to immediate availability and rapid pain relief, increases its flexibility in clinical practice.3 This is especially valuable in rapidly progressing or advanced labour cases, where immediate epidural placement may not be feasible, and effects could be delayed.4,5
Despite limited analgesic efficacy, we generally observe good parturient satisfaction with a remifentanil analgesia.2,3 This may be attributed to lower expectations regarding pain relief among those who select remifentanil-PCA, as they are already counselled that complete pain relief with remifentanil-PCA is unlikely. In addition, women who choose remifentanil-PCA might value factors such as its immediate availability, rapid onset of self-administered analgesia, continuous midwifery support, and the euphoric and sedative effects of opioids on pain perception reduction.6 These benefits are especially advantageous for multiparas, given the typically shorter labour duration and the quicker availability and onset of analgesia with remifentanil-PCA compared to epidural analgesia.2
Remifentanil-PCA has demonstrated advantages over neuraxial analgesia in labour and delivery outcomes.7 In our cohort study of over 10,000 deliveries comparing epidural analgesia to remifentanil-PCA over 5 years, remifentanil-PCA was associated with lower rates of caesarean delivery (CD) and operative vaginal deliveries (OVD) in nulliparous women with both spontaneous and induced labour, as well as in multiparous women with spontaneous onset of labour. Moreover, remifentanil-PCA was associated with a lower incidence of operative delivery with pathologic CTG in all four studied groups. However, no differences in APGAR < 7 at 5 min, neonatal asphyxia, and NICU admission were recorded between the two analgesic techniques within any of the studied groups. Nevertheless, the associations observed in that study may not necessarily imply a causal relationship. Favourable results of non-operative delivery with remifentanil-PCA may also point to the fact that more complicated labours require EA to assist in their management. Indeed, nulliparous women with EA were older, which represents an independent risk factor for labour dystocia. The reason could be that women with normal labour progress or expectations of faster labour are more likely to choose remifentanil-PCA to avoid the potential adverse/side effects of EA. This is particularly true of multiparous women who can combine a fast delivery with rapid availability and a short use of pain relief.6 The availability of different options for pain relief, the feeling of control, and constant one-to-one care with remifentanil may furthermore enhance labour progress by increasing satisfaction and reducing stress. Lower operative vaginal delivery rates were also observed in the RESPITE study, which compared remifentanil-PCA with intramuscular pethidine. However, this difference was most likely not directly attributable to remifentanil, but rather to its lower rate of conversion to epidural anaesthesia as epidural anaesthesia itself is associated with a higher operative vaginal delivery rate.8
In our institution, remifentanil-PCA is also used for certain obstetric conditions, such as a history of previous CD, twin gestation, or a breech presentation, which may pose heightened risks for intrapartum CD with epidural analgesia. A retrospective analysis of 127 planned vaginal breech and 244 twin deliveries for the period 2013-2021 using data from the Slovenian National Perinatal Information System showed no statistically significant nor clinically relevant differences between the EA and remifentanil-PCA groups in the rates of CD in labour, postpartum haemorrhage, obstetric anal sphincter injury (OASI), APGAR score of <7 at 5 min after birth, birth asphyxia, and neonatal intensive care admission. This suggests that both EA and remifentanil-PCA are safe and comparable in terms of labour outcomes in singleton breech and twin deliveries.9
In parturient with remifentanil-PCA, the selection of anaesthetic technique for emergency CD is frequently unpredictable due to various factors, including individual patient preferences, obstetric considerations, potential contraindications to specific techniques, and the presence of labour pain, which can complicate the performance of neuraxial anaesthesia. In the study evaluating the relationship between labour analgesia modalities and types of anaesthetic techniques in categories 2 and 3 intrapartum CD, remifentanil-PCA was associated with a higher incidence of general anaesthesia in categories 2 and 3 emergency CD. The observed association might have been potentially influenced by the fact that women opting for remifentanil-PCA were often presented with either contraindications or refusal for EA. Given the higher likelihood of encountering general anaesthesia in labouring women who received remifentanil-PCA, the parturient must be counselled beforehand regarding the potential need for transition to general anaesthesia and the associated complications thereof (especially a higher likelihood of gastric paresis with the consequent risk of regurgitation and aspiration), should intrapartum CD become necessary.10
In conclusion, with 12 years of experience using remifentanil-PCA, our L&D team has gained increased confidence in its use and in preventing complications associated with its administration. We all should be aware of its limited but consistent and reliable pain relief across all stages of labour, regardless of parity. Emphasising this aspect during counselling can help align maternal expectations and enhance satisfaction with labour analgesia. Its versatility makes it an appropriate option when neuraxial analgesia is contraindicated or not preferred due to patient preferences or obstetric conditions, such as breech presentation, twin deliveries, or after a trial of labour following caesarean section. The rapid onset and immediate analgesic effects improve its clinical utility and flexibility, particularly in advanced or rapidly progressing labour. Nevertheless, the safety of remifentanil-PCA depends on cautious incremental dosing without continuous infusion, rigorous monitoring of sedation levels, and vigilant oversight by healthcare providers—ideally with the constant presence of an anaesthetic team in the labour ward.
Literature
1. Stopar-Pintaric T, Verdenik I. Regional anaesthetic techniques in 14 Slovenian obstetric units between 2013 and 2021: where are we and where are we going? Zdrav Vestn 2024;93(9-10):329-38. doi: 10.6016/ZdravVestn.3518
2. Blajic I, Zagar T, Semrl N, et al. Analgesic Efficacy of Remifentanil Patient-Controlled Analgesia versus Combined Spinal-Epidural Technique in Multiparous Women during Labour. Ginekol Pol 2021;92(11): 797–803. doi:10.5603/GP.a2021.0053
3. Stopar-Pintaric T, Vehar L, Sia AT, et al. Remifentanil patient-controlled analgesia for labour analgesia at different cervical dilations: a single centre retrospective analysis of 1045 cases. Medicina (Kaunas) 2025;61(4):675. doi: 10.3390/medicina61040675
4. Bonnet MP, Prunet C, Baillard C, et al. Anesthetic and Obstetrical Factors Associated With the Effectiveness of Epidural Analgesia for Labor Pain Relief: An Observational Population-Based Study. Reg Anesth Pain Med 2017;42(1):109–16. doi: 10.1097/AAP.0000000000000517
5. Agaram R, Douglas MJ, McTaggart RA, et al. Inadequate pain relief with labor epidurals: A multivariate analysis of associated factors. Int J Obstet Anesth 2009;18(1):10–14. doi: 10.1016/j.ijoa.2007.10.008
6. Logtenberg S, Oude Rengerink K, Verhoeven CJ, et al. Labour pain with remifentanil patient-controlled analgesia versus epidural analgesia: a randomised equivalence trial. BJOG 2017;124(4):652-60. doi: 10.1111/1471-0528.14181
7. Markova L, Lucovnik M, Verdenik I, et al. Delivery mode and neonatal morbidity after remifentanil-PCA or epidural analgesia using the Ten Groups Classification System: A 5-year single-centre analysis of more than 10 000 deliveries. Eur J Obstet Gynecol Reprod Biol 2022;277:53-56. doi: 10.1016/j.ejogrb.2022.08.011
8. Wilson MJA, MacArthur C, Hewitt CA, et al. Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. Lancet 2018;392(10148):662-72. doi: 10.1016/S0140-6736(18)31613-1
9. Lucovnik M, Verdenik I, Stopar Pintaric T. Intrapartum Cesarean Section and Perinatal Outcomes after Epidural Analgesia or Remifentanil-PCA in Breech and Twin Deliveries. Medicina (Kaunas) 2023;59(6):1026. doi: 10.3390/medicina59061026
10. Stopar Pintarič T, Pavlica M, Druškovič M, et al. Relationship between labour analgesia modalities and types of anaesthetic techniques in categories 2 and 3 intrapartum caesarean deliveries. Biomol Biomed 2024;24(5):1301-09. doi: 10.17305/bb.2024.10186
Tatjana STOPAR PINTARIC (Ljubljana, Slovenia), Pia VOVK RACMAN
14:30 - 14:45
Modern epidural maintenance techniques – infusion, bolus or both?
Nuala LUCAS (Speaker) (Keynote Speaker, London, United Kingdom)
14:45 - 14:50
Q&A.
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14:00-14:50
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G14
FREE PAPER SESSION 3/8
PAEDIATRICS
FREE PAPER SESSION 3/8
PAEDIATRICS
Chairperson:
Luc TIELENS (pediatric anesthesiology staff member) (Chairperson, Nijmegen, The Netherlands)
14:00 - 14:07
#45155 - OP33 Analgesic efficacy of ultrasound guided External Oblique Intercostal Plane Block in pediatric patients undergoing upper abdominal surgeries: A Randomized Clinical Trial.
OP33 Analgesic efficacy of ultrasound guided External Oblique Intercostal Plane Block in pediatric patients undergoing upper abdominal surgeries: A Randomized Clinical Trial.
External oblique intercostal plane block is a novel technique which targets lateral and anterior cutaneous branches of intercostal nerves from T6-T10 through a single injection. We conducted this RCT to study analgesic efficacy of ultrasound-guided External Oblique Intercostal Plane Block in pediatric patients undergoing upper abdominal surgeries.To evaluate efficacy of ultrasound-guided External Oblique Intercostal Plane Block in pediatric patients undergoing upper abdominal surgeries
This is a double-blind randomized controlled trial on pediatric patients (2 months to 7 years), ASA I and II, scheduled for upper abdominal surgeries with unilateral incisions. US-guided EOI plane block was given to all patients in group I. Any increase in HR/MAP by more than 20% intraoperatively was treated with additional fentanyl doses of 1 mcg/k and total intraoperative fentanyl consumption was noted in both groups. Intraoperatively, MAP and HR were recorded at 5, 30, 60, and 90 minutes. Pain was assessed using FLACC scale at 1, 4, 8, 16, and 24 hours and Injection Tramadol 1 mg/kg IV was given as rescue analgesia if FLACC score ≥4, and time was noted. A significant difference was noted in total intraoperative fentanyl consumption, time to first rescue analgesia, and FLACC scale at 1, 4, 8, and 24 hours postoperatively. Reduction in pain scores, decreased reliance on systemic analgesics collectively highlight effectiveness of ultrasound-guided EOI block as a valuable regional anesthesia technique for managing perioperative pain in pediatric upper abdominal surgeries
Chandni SINHA (Patna, India), Sreehari NAMBIAR
14:07 - 14:14
#45637 - OP34 Chronometry - a different point of view for the benefits of ultrasound-guided popliteal nerve block in pediatrics.
OP34 Chronometry - a different point of view for the benefits of ultrasound-guided popliteal nerve block in pediatrics.
Regarding all the benefits of ultrasound-guided regional anesthesia such as the opioid sparing effect, the safe profile, the long term analgesia and the patient comfort, we would like to also emphasize on one more positive feature, which might be underestimated and distant from medical point of view, but in fact it has a significant role in the overall anesthesia management and work organization in the operating room and this feature is chronometry. In this work we would like to compare the time for performing general anesthesia and ultrasound-guided popliteal nerve block in pediatric patients in order to analyze the time consumption in both process.
We observed total of 108 children with ankle fractures, estimated ASA I, between 7y and 17y, scheduled for surgery. We divided them into 2 groups - RA group, including 35 children - and GA group, including 73 children. Both groups underwent standard monitoring in operating room and received intravenous line for no more than 5min after entering the OR. The RA group underwent ultrasound-guided popliteal nerve block and the GA group received TIVA with propofol and fentanyl analgesia, after general anesthesia induction and placement of laryngeal mask. Chronometry analysis of total time, required for GA and RA revealed that pediatric patients, who received ultrasound-guided popliteal nerve block had
1. Three times shorter stay in the operating room after the end of surgical treatment (4min vs 12min);
2. Two times faster transfer from the recovery room to the intensive care unit (6min vs 10min);
3. Overall more than 1/3 shorter stay in the operating room from the point of view of anesthesia (22.8857min vs 34.9041min); This study proved that USG popliteal nerve block spares time, therefore - money and human resources - compared to GA as a much faster and less time consuming procedure.
Elena IVANOVA (Sofia, Bulgaria), Margarita BORISLAVOVA
14:14 - 14:21
#45639 - OP35 Efficacy of Erector Spinae Plane Block versus Caudal Block for Post-operative analgesia in paediatric surgery: A systematic review and meta-analysis.”.
OP35 Efficacy of Erector Spinae Plane Block versus Caudal Block for Post-operative analgesia in paediatric surgery: A systematic review and meta-analysis.”.
Background and Aims: Regional anaesthesia is part of multi-modal analgesia in paediatric surgery for effective pain relief. Traditional techniques like the Caudal Block (CB) and, more recently, facial plane blocks like the Erector Spinae Plane Block (ESPB) have gained popularity. This systematic review and meta-analysis compare CB and ESPB in paediatric lower abdominal and limb surgeries. It aims to clarify mixed outcomes from recent trials regarding the variability in analgesic efficacy of both techniques for future practices.
Methods: This review, registered with the International Prospective Register of Systematic Reviews (PROSPERO), includes eight randomized controlled trials comparing postoperative analgesia between ESPB and CB in paediatric lower abdominal and limb surgeries. We searched Science Direct, Google Scholar, Scopus, Proquest, and PubMed databases. The meta-analysis assessed the proportion of patients requiring rescue analgesia and post-operative pain intensity. GRADE guidelines were applied to assess the quality of evidence. Result: Eight randomised controlled trials (575 patients) were included in the review. A meta-analysis of four RCTs (217 patients) showed reduced rescue analgesia with ESPB [OR = 0.55 (95% CI: 0.31, 0.96), p<0.05], while six RCTs (360 patients) found lower pain intensity score (SMD = -0.29, 95% CI: -0.51, -0.06; p<0.05) in the ESPB group. Both outcomes exhibited considerable heterogeneity (I² = 90% for rescue analgesia, I² = 66% for pain intensity), further emphasizing the robustness of the findings. Conclusion: We conclude that ESPB provides better postoperative analgesia than CB in children undergoing lower abdominal and lower limb surgeries. ESPB reduces postoperative pain intensity scores and analgesic requirements compared to CB.
Raksha KUNDAL, Raksha KUNDAL (Jammu, India), Parveen UPPU, Vijay KUNDAL
14:21 - 14:28
#45811 - OP36 ULTRASOUND-GUIDED ERECTOR SPINAE PLANE BLOCK IN PAEDIATRIC PATIENT UNDERGOING MENINGOMYELOCOELE SURGERY: A PROSPECTIVE, RANDOMIZED CONTROLLED STUDY.
OP36 ULTRASOUND-GUIDED ERECTOR SPINAE PLANE BLOCK IN PAEDIATRIC PATIENT UNDERGOING MENINGOMYELOCOELE SURGERY: A PROSPECTIVE, RANDOMIZED CONTROLLED STUDY.
Meningomyelocele (MMC), a prevalent neural tube defect, necessitates prompt surgical correction and careful postoperative pain management, especially in pediatric populations. Traditional analgesic approaches rely heavily on opioids, which carry significant risks such as respiratory depression and delayed recovery. Ultrasound-guided erector spinae plane block (ESPB) is a relatively novel regional anesthesia technique that offers opioid-sparing, targeted analgesia. This study aimed to assess the analgesic efficacy of ESPB in children undergoing MMC repair surgery.
A prospective, randomized controlled study was conducted at King George’s Medical University, Lucknow, from June 2023 to December 2024. Seventy pediatric patients (aged 2 to 36 months) scheduled for elective MMC surgery were randomly divided into two groups: Group B received general anesthesia with ESPB using 0.5 ml/kg of 0.25% bupivacaine, while Group C received general anesthesia alone. The primary outcome was postoperative pain intensity measured by the FLACC scale at intervals of 0, 1, 2, 4, 6, 12, and 24 hours after extubation. Secondary outcomes included intraoperative fentanyl consumption, time to first rescue analgesia, intraoperative hemodynamic changes, and incidence of adverse events. Group B exhibited significantly lower FLACC scores at all assessed postoperative intervals compared to Group C (p<0.05), indicating superior analgesia. Intraoperative fentanyl consumption was significantly reduced in Group B (p<0.001), and the time to first rescue analgesia was longer compared to Group C (p<0.001). Hemodynamic parameters, particularly heart rate and mean arterial pressure, were more stable in the ESPB group. No adverse effects or complications related to the ESPB technique were observed throughout the study. Ultrasound-guided ESPB is a safe and effective technique for providing postoperative analgesia in pediatric patients undergoing meningomyelocele surgery. It significantly reduces opioid use, enhances postoperative comfort, and maintains hemodynamic stability. ESPB should be considered a valuable component of multimodal analgesia protocols in pediatric neuro-surgical care.
Prem Raj SINGH (lucknow, India), Akanksha GUPTA
14:28 - 14:35
#47003 - OP37 Straightening the curve: Comparing the effects of intravenous lidocaine infusion and liposomal bupivacaine on posterior spinal fusion for adolescent idiopathic scoliosis.
OP37 Straightening the curve: Comparing the effects of intravenous lidocaine infusion and liposomal bupivacaine on posterior spinal fusion for adolescent idiopathic scoliosis.
Multimodal analgesia is a common approach for postoperative management of posterior spinal fusion (PSF) for patients with adolescent idiopathic scoliosis (AIS). Recent studies have evaluated intraoperative intravenous lidocaine infusions (IVLI) and liposomal bupivacaine (LB) injection to optimize postoperative analgesia in pediatric spine patients. Both individual studies of IVLI and LB showed an opioid-sparing effect in children undergoing major spinal procedures compared to placebo. The aim of this study was to compare the effects of IVLI to LB injections on postoperative pain management and recovery.
A retrospective chart review was performed between April 2023 to August 2024 on 20 patients who underwent PSF for AIS. Ten patients received LB and 10 patients received IVLI intraoperatively. Data collected included demographics, ASA status, vertebral levels, surgical time, postoperative pain scores, postoperative and total opioid use, antiemetic use, and length of stay (LOS). Analysis was performed using Fisher’s Exact Test, Mann-Whitney U Test, Wilcoxon rank sum test, and t-test. There were no significant differences in age, gender, ASA status, vertebral levels between the two groups. There was a significant difference in weight between the two groups (p<0.01). There were no significant differences in hospital LOS, postoperative pain scores, and postoperative antiemetic used. There was a significant reduction in morphine milligram equivalents per kg (MME/kg) in patients who received IVLI compared to LB (p=0.01). There was also a significantly longer surgical time in the IVLI group compared to liposomal bupivacaine group (p=0.01). Though evidence supports the use of both LB and IVLI, intraoperative IVLI was associated with a significant reduction in total postoperative opioid requirement compared to LB in AIS patients undergoing PSF. A larger study is warranted to further assess the role of IVLI in these patients.
Connie LIN (Wilmington, USA), Benjamin KOA, Manish PUROHIT, Robert Scott LANG, Uzoamaka ODOEMENA, Peter GABOS, Suken SHAH, Angela SNOW
14:35 - 14:42
#47513 - OP38 Evaluation of Accuracy of Pediatric Caudal Epidural Block: An Ultrasound-Based Prospective Observational Cohort Study.
OP38 Evaluation of Accuracy of Pediatric Caudal Epidural Block: An Ultrasound-Based Prospective Observational Cohort Study.
Caudal epidural block (CEB) is widely used for perioperative analgesia in pediatric infra-umbilical surgeries.This study aimed to evaluate accuracy of landmark-guided CEB needle placement with ultrasound (US) and identify the most reliable sonographic indicators of successful placement. Ultrasound guidance (USG) can improve precision by visualizing anatomical markers like sacral canal dilatation and saline spread, but its effectiveness in confirming proper placement remains underexplored.The study focuses on assessing the first-pass success rate and identifying reliable USG signs for accurate CEB placement.
This prospective observational study was conducted at a tertiary care institute in central India after institutional ethical approval (IHEC-LOP/2020/PG/Jan/01;
CTRI/2021/06/034146). Seventy ASA I–II children aged 1–12 years scheduled for elective infra-umbilical surgeries under general anesthesia were enrolled after informed consent. CEB was performed using anatomical landmark technique, and US was used post-insertion to assess needle placement. Saline spread, sacral canal dilatation, and the pumping sign were recorded in both transverse(figure 1a) and longitudinal(figure 1b) probe orientations. First-pass success and overall success were evaluated. A total of 70 pediatric patients were included. The first-pass success rate of landmark-guided caudal epidural needle placement was 62.8%, with an overall success rate of 69%. Clear palpation of anatomical landmarks significantly improved first-pass accuracy (p < 0.05). Ultrasound revealed that transverse view, especially sacral canal dilatation and pumping sign, was most reliable for confirming correct needle placement, showing high sensitivity. The longitudinal view had higher specificity but lower sensitivity. Saline spread was less predictive when used alone. Ultrasound significantly improved placement accuracy by enabling real-time assessment, particularly with transverse sonographic markers. This study emphasizes the limitations of landmark-based pediatric caudal epidural blocks, even with experienced providers. Ultrasound, particularly transverse views identifying sacral canal dilatation and pumping sign, significantly enhances placement accuracy and safety, suggesting its routine use to reduce failure rates and improve outcomes.
Divas SINHA, Shikha JAIN (Bhopal, India), Vaishali WAINDESKAR, Zainab AHMAD, Harish KUMAR
14:42 - 14:49
#48122 - OP39 Dexmedetomidine Versus Fentanyl as Caudal Adjuvants in Pediatric Anesthesia: A Systematic Review and Meta-analysis.
OP39 Dexmedetomidine Versus Fentanyl as Caudal Adjuvants in Pediatric Anesthesia: A Systematic Review and Meta-analysis.
Caudal epidural block is commonly used in pediatric infraumbilical surgeries for postoperative analgesia. While fentanyl is traditionally employed as an adjuvant to prolong local anesthetic effect, dexmedetomidine has emerged as a promising alternative due to its analgesic and sedative properties with a potentially more favorable safety profile.
Objective: To compare the efficacy and safety of dexmedetomidine versus fentanyl as adjuvants to bupivacaine in pediatric caudal blocks.
performed a systematic review and meta-analysis in accordance with PRISMA guidelines. Databases searched included PubMed, Embase, and Cochrane Library through May 2025. We included randomized controlled trials comparing dexmedetomidine and fentanyl as adjuvants in children undergoing caudal blocks with bupivacaine. Primary outcomes were duration of analgesia, rescue analgesia requirement, postoperative sedation, and adverse effects. Risk of bias was assessed using Cochrane RoB 2. Meta-analysis was performed using RevMan 5.4, applying a random-effects model. Six randomized trials (n ≈ 340 children, ASA I–II, aged 1–12 years) were included. Dexmedetomidine significantly prolonged analgesia compared to fentanyl (mean difference ≈ +85 minutes; p < 0.001; I² ≈ 45%) and reduced the need for rescue analgesia (RR ≈ 0.25; 95% CI 0.10–0.62; I² = 0%). FLACC pain scores were consistently lower in the dexmedetomidine group. Although postoperative sedation was more pronounced with dexmedetomidine, no significant differences in bradycardia or hypotension were observed. Incidence of nausea, vomiting, and pruritus was significantly lower with dexmedetomidine (RR ≈ 0.3 and 0.2, respectively). Dexmedetomidine is associated with longer postoperative analgesia and fewer opioid-related side effects than fentanyl when used as a caudal adjuvant in children. While increased sedation warrants close monitoring, dexmedetomidine appears to be a safer and more effective alternative, supporting its use in routine pediatric anesthesia practice.
Luis Alberto RODRIGUEZ LINARES, Luis Alberto RODRIGUEZ LINARES (sao paulo, Brazil)
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14:00-14:55
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H14
SIMULATION TRAININGS
SIMULATION TRAININGS
Demonstrators:
Josip AZMAN (Consultant) (Demonstrator, Linkoping, Sweden), Clara LOBO (Medical director) (Demonstrator, Abu Dhabi, United Arab Emirates), Lara RIBEIRO (Anesthesiologist Consultant) (Demonstrator, Braga-Portugal, Portugal), Roman ZUERCHER (Senior Consultant) (Demonstrator, Basel, Switzerland)
This interactive, simulation-based learning experience allows you to explore the complications of regional anaesthesia in a fun and engaging way! Covering several challenging daily clinical situations and crisis management cases from the fields of trauma, orthopaedics and obstetrics, it combines all kinds of simulation to provide an excellent learning resource.
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COFFEE BREAK
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15:30-16:30
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A15
PANEL DISCUSSION
Tight fit
PANEL DISCUSSION
Tight fit
Chairperson:
Lloyd TURBITT (Consultant Anaesthetist) (Chairperson, Belfast, United Kingdom)
15:30 - 15:30
Introduction.
15:30 - 15:45
Pathophysiology of the compartment syndrome.
Hosim PRASAI THAPA (Consultant Anaesthetist) (Keynote Speaker, Melbourne, Australia, Australia)
15:45 - 16:00
RA is not a contraindication.
Morne WOLMARANS (Consultant Anaesthesiologist) (Keynote Speaker, Norwich, United Kingdom)
16:00 - 16:15
Mitigating factors.
Sandy KOPP (Professor of Anesthesiology and Perioperative Medicine) (Keynote Speaker, Rochester, USA)
16:15 - 16:30
Q&A.
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15:30-16:40
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B15
PANEL DISCUSSION
Spinals still rocking
PANEL DISCUSSION
Spinals still rocking
Chairperson:
Edward MARIANO (Speaker) (Chairperson, Palo Alto, USA)
15:30 - 15:30
Introduction.
15:30 - 15:45
Why it still is standard in obstetrics.
Sarah DEVROE (Head of clinic) (Keynote Speaker, Leuven, Belgium)
15:45 - 16:00
#48719 - FT07 The extra kick of continuous spinals.
The extra kick of continuous spinals.
The extra kick of continuous spinals
Danny Feike Hoogma, MD, PhD
University Hospitals of Leuven, Department of Anesthesiology, Herestraat 49, B-3000, Leuven, Belgium
University of Leuven, Biomedical Sciences Group, Department of Cardiovascular Sciences, KU Leuven, B-3000, Leuven, Belgium
University Hospitals Leuven
Department of Anesthesiology
Herestraat 49
3000, Leuven
Belgium
Danny.hoogma@uzleuven.be
Abstract
Continuous spinal anesthesia (CSA) offers a hybrid approach by combining the precision of single-shot spinal anesthesia with the flexibility of catheter-based delivery. Compared to general or single shot spinal anesthesia, CSA offers improved hemodynamic control, reduced vasopressor use, and adaptability for prolonged procedures. Particularly beneficial in elderly and comorbid patients, CSA supports a patient-centered approach and should be considered a valuable option in the high-risk population offering the “extra kick” in tailored anesthetic care.
Keywords: continuous spinal anesthesia, neuraxial block, hemodynamic stability, elderly, high-risk surgery
Introduction
Neuraxial anesthesia techniques are an integral part of the anesthesiologist’s armamentarium and can be used to provide primary anesthesia for abdominal, obstetric, vascular and lower limb surgery. Within this domain, two primary techniques are distinguished: spinal and epidural anesthesia.
Spinal anesthesia is characterized by a definitive endpoint, rapid onset, and the use of lower doses of local anesthetics to achieve a dense and reliable block. In contrast, epidural anesthesia typically requires higher doses, has a slower onset, and is associated with a higher percentage of failure and side effects (table). To combine the benefits of both, combined spinal epidural (CSE) techniques is often employed, allowing for rapid onset via spinal injection and prolonged anesthesia or analgesia through an epidural catheter. However, CSE still carries the disadvantages of epidural anesthesia, including dosing variability, side-effects and failure rates.(1, 2)
Continuous spinal anesthesia (CSA), first described by Henry Perce Dean in 1906, remains underutilized despite being around for over a century with excellent results. CSA merges the benefits of single shot spinal anesthesia (SSSA) with the flexibility of catheter-based dosing, allowing for prolonged and titratable anesthesia. This technique has been successfully applied across various surgical populations, including the frail cardiovascular or respiratory compromised patient. Despite its track record, certain patient with significant cardiovascular or pulmonary comorbidities, prolonged surgical needs, or frailty, are frequently defaulted to general anesthesia (GA). In such cases, CSA offers a tailored and underused solution.(3)
This narrative review aims to compare CSA with other techniques, highlighting its unique advantages and advocating its broader adoption, particularly in elderly, high-risk patients considered to tricky for SSSA or general anesthesia (GA).(3)
Why CSA now?
In contemporary era, the aging patient population is presenting with increasing rates of comorbidities and frailty, particularly for interventions such as hip fracture surgery.(4-6) These patients have a disproportionate impact on healthcare resources, a challenge compounded by ongoing shortages of healthcare personnel. Strategies to optimize perioperative outcomes and reduce healthcare system burden while maintaining quality of recovery are required.
CSA offers distinct advantages in this context. In elderly, frail patients undergoing hip fracture surgery, CSA has demonstrated superior hemodynamic stability compared to SSSA, CSE and potentially GA.(7, 8) The ability to incrementally titrate local anesthetics doses significantly reduces the incidence and severity of hypotension as demonstrated by multiple randomized controlled trials.(7, 9, 10) Moreover, regional anesthesia techniques, including CSA, are associated with a lower risk of respiratory complications and improved cognitive outcomes.(10) This may translate into fewer perioperative complications, reduces hospital stays and lower resource utilization.
While CSE allows rapid onset and extended duration of anesthesia via titration of the epidural catheter, it carries a notable risk of technical failure and occurrence of side effects (i.e., urinary retention, unilateral block or hypotension). These complications can delay recovery and increase resource demands.(11, 12) CSA may offer a more reliable alternative, particularly in elderly, frail patients, though high-quality comparative data are lacking. Ultimately, the choice of anesthetic technique should be individualized, with a focus on minimizing complications and facilitating early recovery. This approach aligns with current recommendations from the American Society of Anesthesiologist, which emphasize patient-centered care and risk reduction in vulnerable populations.(12)
Complications and their management
While CSA in generally safe and effective, certain complications are more relevant in elderly, frail patients undergoing procedures such as hip fracture surgery. The most notable among these are intraoperative hypotension, post-dural puncture headache (PDPH) and catheter-related issues such as dislodgement or malfunction.
Intraoperative hypotension is a frequent complication associated with neuraxial anesthesia, particularly in elderly patients with limited cardiovascular reserves. The ability to titrate local anesthetics is one of CSA’s most compelling benefits in high-risk populations. Compared to SSSA, the incidence of severe hypotension is reduced from 51% to only 8% when CSA is used.(7)
Catheter-related complications, though infrequent, can be disruptive. Issues such as dislodgement of malfunction may necessitate conversion to GA, increasing perioperative risk.(7) These challenges underscore the need for improved catheter design and insertion techniques to enhance reliability and reduce intraoperative interruptions.
PDPH is another recognized complication of CSA, though its incidence in elderly, frail patients is significantly lower than in younger adults. This reduced risk is attributed to age-related changes in dura elasticity and decreased cerebrospinal fluid pressure.(13, 14) The use of small-gauge, non-cutting (atraumatic) spinal needles and catheters further minimized the likelihood of PDPH. Clinically, PDPH presents as a postural headache (worse when upright, relieved by lying down), often accompanied by neck stiffness, nausea, photophobia, auditory symptoms (tinnitus, hearing loss). Symptoms usually develop within the first few days of the procedure and resolve spontaneously within 2 weeks. The American Academy of Pain Medicine, in its 2024 guidelines, emphasizes that PDPH should be suspected in any patient with a new, postural headache following neuraxial procedures, especially if associated with these features.(13) Conservative treatment including hydration and systemic non-opioid analgesics are generally considered sufficient. In rare instances, an epidural blood patch may be required.(13)
Despite these potential complications, the overall impact of CSA-related adverse events on recovery and resource utilization in elderly, frail patients is minimal. With appropriate techniques, equipment, and vigilance, CSA remains a safe and effective but underutilized option in this population.
Barriers to adoption & gaps
Several barriers contribute to this limited adoption, including equipment limitations, lack of familiarity, and institutional inertia. One of the primary challenges is the historical unreliability of spinal catheters, which has led to concerns about dislodgement, malfunction, and inconsistent drug delivery. These technical issues have discouraged widespread use, particularly in high-stakes surgical settings.(15) To overcome this, industry innovation is essential, modern, atraumatic, and reliable catheter systems must be developed and made widely available to support safe and effective CSA implementation.
Another significant barrier is the lack of standardized protocols and training. Many anesthesiologists are more familiar with single-shot spinal or epidural techniques, and CSA is often perceived as technically demanding or unfamiliar. This perception can be addressed through targeted education, simulation-based training, and the development of evidence-based guidelines that support CSA use in specific patient populations, such as the elderly or those with significant comorbidities.
Institutional resistance to change also plays a role. New techniques are often adopted only when they are easy to implement and perceived as low-risk. For departments already proficient in neuraxial anesthesia, CSA could be integrated relatively smoothly, provided that appropriate equipment and support are available. In this context, regional anesthesia champions can play a pivotal role by leading implementation efforts, sharing clinical experiences, and promoting CSA through research and peer education.
Finally, there is a lack of high-quality comparative data evaluating CSA against other techniques in specific populations. While existing studies suggest benefits in terms of hemodynamic stability and reduced complications, further randomized controlled trials are needed to solidify CSA’s role and guide best practices.
Conclusion
In the evolving field of regional anesthesia, CSA stands out as a precise, flexible, and patient-centered technique. Its capacity for titrated dosing, extended duration, and reduced hemodynamic disruption makes it particularly valuable in high-risk populations.
As the anesthesia community continues to value patient-specific approaches, CSA deserves renewed attention and broader application. With appropriate training, equipment, and evidence-based protocols, this once-sidelined technique is poised to deliver its full potential, an extra kick, where it's needed most.
Table: Specifics of different neuraxial techniques
Single-Shot Spinal (SSSA) Epidural Anesthesia Combined Spinal-Epidural (CSE) Continuous Spinal Anesthesia (CSA)
Onset time Rapid Slow Rapid (spinal), then slow Moderate (titrated)
Duration Fixed Adjustable Adjustable Adjustable
Block density High Variable High (spinal component) High
Hemodynamic control Poor Moderate Moderate Excellent
Ability to extend duration No Yes Yes Yes
Technical failure rate Low Moderate Low Low
CSF confirmation Yes No Yes Yes
Risk of PDPH Low Very Low Moderate Low to Moderate
Suitability for frail patients Limited Variable Variable Excellent
Reference:
1. Coppens S, Dewinter G, Hoogma DF, Raudsepp M, Vogelaerts R, Brullot L, et al. Safety and efficacy of high thoracic epidural analgesia for chest wall surgery in young adolescents. European Journal of Anaesthesiology. 2024.
2. Roofthooft E, Rawal N, Van de Velde M. Current status of the combined spinal-epidural technique in obstetrics and surgery. Best Pract Res Clin Anaesthesiol. 2023;37(2):189-98.
3. Kumar CM, Seet E. Continuous spinal technique in surgery and obstetrics. Best Pract Res Clin Anaesthesiol. 2023;37(2):139-56.
4. Sandhu MRS, Tickoo M, Bardia A. Data Science and Geriatric Anesthesia Research: Opportunity and Challenges. Clin Geriatr Med. 2025;41(1):101-16.
5. McIsaac DI, MacDonald DB, Aucoin SD. Frailty for Perioperative Clinicians: A Narrative Review. Anesth Analg. 2020;130(6):1450-60.
6. Mazarello Paes V, Ting A, Masters J, Paes MVI, Graham SM, Costa ML, et al. A systematic review of the association between early comprehensive geriatric assessment and outcomes in hip fracture care for older people. Bone Joint J. 2025;107-B(6):595-603.
7. Minville V, Fourcade O, Grousset D, Chassery C, Nguyen L, Asehnoune K, et al. Spinal anesthesia using single injection small-dose bupivacaine versus continuous catheter injection techniques for surgical repair of hip fracture in elderly patients. Anesthesia & Analgesia. 2006;102(5):1559-63.
8. Koole C, Bleeser T, Hoogma DF, Coppens S, Teunkens A, Rex S. Haemodynamic effects of continuous spinal anaesthesia versus single-shot spinal anaesthesia or general anaesthesia for hip fracture surgery: a systematic review and meta-analysis. Br J Anaesth. 2024.
9. Olsen F, Hard Af Segerstad M, Dalla K, Ricksten SE, Nellgard B. Fractional spinal anesthesia and systemic hemodynamics in frail elderly hip fracture patients. F1000Res. 2023;12:210.
10. Li P, Li X, Peng G, Deng J, Li Q. Comparative analysis of general and regional anesthesia applications in geriatric hip fracture surgery. Medicine (Baltimore). 2025;104(2):e41125.
11. Pass B, Knauf T, Knobe M, Rascher K, Bliemel C, Maslaris A, et al. Spinal anesthesia with better outcome in geriatric hip fracture surgery - An analysis of the Registry for Geriatric Trauma (ATR-DGU). Injury. 2023.
12. Sieber F, McIsaac DI, Deiner S, Azefor T, Berger M, Hughes C, et al. 2025 American Society of Anesthesiologists Practice Advisory for Perioperative Care of Older Adults Scheduled for Inpatient Surgery. Anesthesiology. 2025;142(1):22-51.
13. Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, et al. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med. 2024;49(7):471-501.
14. Kim JE, Kim SH, Han RJW, Kang MH, Kim JH. Postdural Puncture Headache Related to Procedure: Incidence and Risk Factors After Neuraxial Anesthesia and Spinal Procedures. Pain Med. 2021;22(6):1420-5.
15. Benson JS. U.S. Food and Drug Administration safety alert: cauda equina syndrome associated with use of small-bore catheters in continuous spinal anesthesia. AANA J. 1992;60(3):223.
Danny HOOGMA (Leuven, Belgium)
16:00 - 16:15
Intrathecal morphin: no extra monitoring.
Narinder RAWAL (Mentor PhD students, research collaboration) (Keynote Speaker, Stockholm, Sweden)
16:15 - 16:40
Q&A.
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15:30-16:20
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C15
LIVE DEMONSTRATION
Abdominal wall blocks
LIVE DEMONSTRATION
Abdominal wall blocks
Demonstrators:
Ashwani GUPTA (Faculty and ESRA-DRA board member and examiner) (Demonstrator, Newcastle Upon Tyne, United Kingdom), Rajnish GUPTA (Professor of Anesthesiology) (Demonstrator, Nashville, USA)
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D15
NETWORKING SESSION
Bench to bedside
NETWORKING SESSION
Bench to bedside
Chairperson:
Athina VADALOUCA (Pain and palliative care medicine) (Chairperson, Athens, Greece)
15:30 - 15:30
Introduction.
15:30 - 15:52
What is new in pathophysiology of acute postop pain.
Esther POGATZKI ZAHN (Full Professor) (Keynote Speaker, Muenster, Germany)
15:52 - 16:14
#48638 - FT20 Perioperative pain management guidelines: why don't they work?
Perioperative pain management guidelines: why don't they work?
Today, despite all the analgesic drugs and techniques available, adequate management of postoperative pain remains challenging, particularly for some patients e.g. patients presenting with preoperative chronic pain conditions or longlasting opioids intake [1]. There is evidence that the administration of analgesic treatments is sometimes inconsistent and does not reflect the best available evidence. In example, a recent analysis of perioperative pain management in 10415 patients (data extracted from 2017 until 2019) reported the use of one non-opioid analgesic in 57% of the patients and the use of two non-opioid analgesics in only 38% of the patients, while multimodal analgesia is strongly recommended from evidence-based medicine to enhance recovery [2]. Clearly, there is a gap between published recommendations and their clinical application. The principal causes of the problem are a lack of familiarity with the medical literature from practicing physicians and an inability to effectively synthetize a large body of existing literature into meaningfully beneficial clinical practice changes [3].
Perioperative guidelines have been developed to overcome the problem i.e. to provide a synthesis of existing literature and recommendations. By definition, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances” [4]. The implementation of practice guidelines is expected to reduce variations in practice, to allow for standards for measurement of clinical performance and to improve the efficacy of healthcare delivery [4]. Further, medical practice guidelines have also medicolegal implications [5]. Consequently, the field of perioperative medicine has seen a dramatic rise in clinical guidelines and consensus statements published to improve patient care [6].
Postoperative pain guidelines and their observance in practice
Two very recent surveys point out the poor observance as well as the ignorance of postoperative pain guidelines. Following a Danish survey that highlighted that 66% of women reported severe pain at any time during the first 24h after cesarean section, some authors aimed to review the standard practice for postoperative pain management in 22 Danish delivery centers [7]. All centers provided answers. Most centers relied on oral opioids in addition of paracetamol and NSAIDs. Only one center used intrathecal morphine (very low dose of 40 µg). Truncal nerve blocks were used for rescue analgesia in 73% of centers and as prophylactic analgesia in only 9% of the centers [7]. Recent guidelines on perioperative pain management for cesarean section are available from PROSPECT working group [8] and from the National Institute for Clinical Excellence (NICE guidelines released in 2021, updated in 2024). A second interesting survey piloted by the members of PROSPECT working group and colleagues was sent to ESRA and ASRA members to question the current utilization of postoperative pain guidelines. Anonymous responses from 1340 persons (56.9% from Europe) were analysed [9]. Not surprisingly the survey showed a relative underutilization of postoperative pain guidelines: only 43.8% of respondents followed available national guidelines and 38.9% used international PROSPECT guidelines in their daily practice. Some important suggestions were also made by the respondents to improve guidance: increased visibility, need to make surgeons aware of recommendations, regular update, promoting flexible guidelines to be applicable in various environments and countries, focusing guidelines on complex and challenging scenarios. The two previous examples and moreover the suggestions made by the respondents to the last survey certainly question the actual barriers to the implementation of guidelines in clinical practice and the need of adequate strategies to overcome these barriers.
Barriers to clinical guidelines implementation
Several studies have analyzed the principal barriers involved in guidelines implementation. These barriers could be classified in 3 categories which are clearly detailed and summarized in a recent review paper from De Hert [4].
Personal factors relate to the physician knowledges and attitudes. As pointed previously, ignorance about existing guidelines, national and others, and how to find them is not uncommon (prospect survey). Further, a negative attitude towards recommendations and evidence-based medicine may also exist. Some physicians think they are “cookbook medicine”, they suppress medical freedom, they are a way to control costs, they ignore patient preferences and they exclude individualized medical cares [4].
Guideline-related factors represent to date a significant barrier to their common use. These factors are well known and have been pointed out in several publications [3,4,6] . Guidelines reliability can be questioned as many have competing recommendations due to a lack of unified methodological strategy [6], they focus on expert opinions or they content recommendations that have since been contradicted by more recent clinical evidence [3]. Besides the criticism of being based on expert opinion that limits transparency, guidelines mainly rely on results from RCTs and systematic reviews usually considered as high level of evidence. The problem is that level of evidence in the majority of systematic reviews is generally low to moderate, in agreement with the quality of the included clinical studies. In example, the lack of “basic analgesic interventions” i.e. paracetamol, anti-inflammatory drugs in most of the trials aiming to assess locoregional techniques for mastectomy and for TKA requires critical appraisal and mitigates useful clinical implications [10,11]. Systematic reviews and meta-analysis also do not apply to specific populations of patients (e.g. chronic pain patients, drugs dependent patients, frailty patients with several comorbidities) [6]. Those patients who are usually excluded from RCTs on perioperative pain treatments are the most difficult ones to manage. Finally, the access to guidelines recommendations may not be easy for various reasons (limited visibility), and the guidelines presentation may be too complex (unclear and unfriendly layout, no summary provided).
External factors like organizational constraints, lack of resources, lack of time for application in busy clinical practice, and misalignment with patient expectations also preclude a current use of published guidelines [4]. Here the weight of guidelines medicolegal impact on current practice might help to better support their application at least by hospital administration and public health services [5].
Future of practice guidelines: the example of perioperative pain management guidelines
As previously stated, the overabundance of perioperative guidelines identified in the literature does not facilitate their application by practicing clinicians [3]. Consequently, there is actually a real need to improve perioperative guidelines from utility to presentation and clinical application [3,6]. It is also worth noting that in a near future, artifitial intelligence (AI) might become a real competitor to existing guidelines [12]. In 2022, an online AI chatbot (i.e. ChatGPT) was released and rapidely attracting attention. The use of AI might allow to shift from static internet information searching to dynamic knowledge gathering [12]. Currently ChatGPT seems to provide medical information of comparable quality to available static internet information. A study assessing the reliability of medical information provided by ChatGPT found a 60% agreement between guideline recommendations and AI answers [12]. Recently, the PROSPECT group (which methodology is rigorous based on critical assessment of published randomised controlled trials) has examined ChatGPT-generated recommendations for perioperative pain management across five common surgical procedures [13]. The authors compared their agreement with the PROcedure-SPECific postoperative pain managemenT (PROSPECT) recommendations. Results found persistent inaccuracies between ChatGPT versions and PROSPECT recommendations [13]. These differences might be explained by the insufficient precision of ChatGPT to identify relevant literature to extract their recommendations as well as limited capabilities to assess the relevance and quality of the information contained in the sources and references used to generate responses. However, ChatGPT is still involving [14] and in the future, it might become a provider of medical information, and even more, an adviser for health care professionnals and for the patients [12]. Therefore, it becomes mandatory to adapt the novel guidelines to the demand of physicians, focusing on easy access, readability and clinical application [3]. As an exemple, the PROSPECT working group which provides procedure-specific pain management recommendations regularly updates its methodology to further meet clinicians needs (see Table) [15].
In conclusion, several perioperative pain guidelines are available to help clinicians to improve patient recovery and outcomes. However, current reports and observations show a lack of application of existing recommendations, that strongly questions the potential barriers to guidelines implementation in daily practice. Some barriers directly rely to the guidelines themthelves (design and process) while others concern physician knowledges and attitudes. These barriers to guidelines implementation should be addressed to improve perioperative pain management.
References
1. Komann M, Baumbach P, Stamer UM, Weinmann C, Arnold C, Pogatzki-Zahn E, Meissner W: Desire to Receive More Pain Treatment - A Relevant Patient-Reported Outcome Measure to Assess Quality of Post-Operative Pain Management? Results From 79,996 Patients Enrolled in the Pain Registry QUIPS from 2016 to 2019. J Pain 2021, 22:730-738.
2. Jena PORG, Chinese POUTn, Dutch POUTn, Mexican POUTn, Serbian POUTn, Spanish POUTn, French POUTn, Italian POUTn, Swiss POUTn, Irish POUTn, et al.: Status quo of pain-related patient-reported outcomes and perioperative pain management in 10,415 patients from 10 countries: Analysis of registry data. Eur J Pain 2022, 26:2120-2140.
3. Gregory RJ, Gregory SH: Guidelines in Anesthesiology: Considering When, How, and Why. J Cardiothorac Vasc Anesth 2019, 33:2372-2373.
4. De Hert S, Paula-Garcia WN: Implementation of guidelines in clinical practice; barriers and strategies. Curr Opin Anaesthesiol 2024, 37:155-162.
5. Kranke P, Afshari A, Meybohm P, Buhre W, Wiege S, Romero CS: Decoding the meaning of medical guidelines and their medicolegal implications. Eur J Anaesthesiol 2024, 41:109-114.
6. Kehlet H, Memtsoudis SG: Perioperative care guidelines: conflicts and controversies. Br J Surg 2020, 107:1243-1244.
7. Wikkelso AJ: Postoperative pain management for caesarean section in Denmark: A survey of current clinical practice. Acta Anaesthesiol Scand 2025, 69:e70012.
8. Roofthooft E, Joshi GP, Rawal N, Van de Velde M, Anaesthesia PWGotESoR, Pain T: PROSPECT guideline for elective caesarean section: a reply. Anaesthesia 2023, 78:1173-1174.
9. Joshi G, Wu C, Moka E, Van de Velde M, Lobo D, group Pw: A survey on knowledge about PROcedure-SPEcific Postoperative Pain Management (PROSPECT) guidelines. Submitted.
10. Mija D, Kehlet H, Joshi GP: Basic analgesic use in randomised trials assessing local and regional analgesic interventions for mastectomy: a critical appraisal and clinical implications. Br J Anaesth 2023, 131:921-924.
11. Joshi GP, Stewart J, Kehlet H: Critical appraisal of randomised trials assessing regional analgesic interventions for knee arthroplasty: implications for postoperative pain guidelines development. Br J Anaesth 2022, 129:142-144.
12. Walker HL, Ghani S, Kuemmerli C, Nebiker CA, Muller BP, Raptis DA, Staubli SM: Reliability of Medical Information Provided by ChatGPT: Assessment Against Clinical Guidelines and Patient Information Quality Instrument. J Med Internet Res 2023, 25:e47479.
13. Mija D, Kehlet H, Rosero EB, Joshi GP: Evaluating the role of ChatGPT in perioperative pain management versus procedure-specific postoperative pain management (PROSPECT) recommendations. Br J Anaesth 2024, 133:1318-1320.
14. Malek MA, du Fosse N, Boon M: Evaluating the role of ChatGPT in perioperative pain management: importance of version and prompt sensitivity. Comment on Br J Anaesth 2024; 133: 1318-20. Br J Anaesth 2025, 134:1241-1243.
15. Joshi GP, Albrecht E, Van de Velde M, Kehlet H, Lobo DN, Anaesthesia PWGotESoR, Pain T: PROSPECT methodology for developing procedure-specific pain management recommendations: an update. Anaesthesia 2023, 78:1386-1392.
Patricia LAVAND'HOMME (Brussels, Belgium)
16:14 - 16:36
Effectiveness of transitional pain service.
Eleni MOKA (faculty) (Keynote Speaker, Thessaloniki, Greece, Greece)
16:36 - 16:58
Controversies regarding NSAIDs and corticosteroids.
Girish JOSHI (Professor) (Keynote Speaker, Dallas, Texas, USA, USA)
16:58 - 17:20
Q&A.
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15:30-16:20
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E15
ASK THE EXPERT
No day without POCUS
ASK THE EXPERT
No day without POCUS
Chairperson:
Andre VAN ZUNDERT (Professor and Chair Anaesthesiology) (Chairperson, Brisbane Australia, Australia)
15:30 - 15:30
Introduction.
15:30 - 16:00
POCUS integrated in daily routine.
Peter VAN DE PUTTE (Consultant) (Keynote Speaker, Bonheiden, Belgium)
16:00 - 16:20
Q&A.
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15:30-16:25
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F15
FREE PAPER SESSION 4/8
POCUS - Miscellaneous
FREE PAPER SESSION 4/8
POCUS - Miscellaneous
Chairperson:
Fabrizio FATTORINI (anesthetist) (Chairperson, Rome, Italy)
15:37 - 15:44
#46857 - OP41 Optimal Injection Sites: Sub-Epimyseal, Sub-Paraneural or Sub-Epineurial? At the level of greater trochanter.
OP41 Optimal Injection Sites: Sub-Epimyseal, Sub-Paraneural or Sub-Epineurial? At the level of greater trochanter.
Studies have demonstrated sheath surrounding the sciatic nerve is different from the epineurium
and injection inside the sheath can be differentiated from an intraneural injection.
Objectives:
1. To evaluate the existence of three separate compartment and investigate the spread pattern
of the injected dye.
2. To identify the pathways from three compartments towards the nerve fascicles and the
compartment injection in closest approximation to the fascicle
3. To evaluate the intra-muscular, vascular and neural diffusion.
In 6 Theil embalmed cadavers (12 specimens) in the prone position, Ultrasound guided injections
were performed with 10ml latex dye in three compartments; the sub-epimyseal (SEmyC), the sub-
paraneural(SPC) and the sub-epineural compartment (SEpiC) of sciatic nerve.
Each injection in 2 specimens.
Yellow dye- SEmyC; Green dye- SPC; Blue dye- SEpiC
After 2 weeks, upon cross-sections at two levels, one at the level of sciatic foramen and the second
at the level of the greater trochanter and ischial tuberosity. Images were obtained and analyzed. The SEmyC injections revealed the yellow latex occupying the entire intra-muscular compartment
and no spread towards neural elements.
In the SPN injection, the green latex was visualized in the intra-muscular compartment, the
paraneural adipose tissue at the level of the sciatic foramen and in close approximation with sacral
rami.
In the SEpiC, the blue latex occupied adipose tissue beneath the epineurium and highlighted the
fascicular components. However, no dye was visible inside the fascicle. Based on our cadaveric study, it is becoming evident the adipose tissue in the SPC and the SEpiC is
gaining prime importance for the pathways towards the sciatic nerve in reaching the fascicles. The
SEpiC injections reliably engulf the fascicles and perhaps with low volumes, but depends on the
amount of adipose tissue in the compartment.
Sandeep DIWAN, Rasika TIMANE (Nagpur, India)
15:44 - 15:51
#47278 - OP42 Pharmacokinetic characteristics of liposomal bupivacaine and mixture of liposomal bupivacaine and plain bupivacaine.
OP42 Pharmacokinetic characteristics of liposomal bupivacaine and mixture of liposomal bupivacaine and plain bupivacaine.
Liposomal bupivacaine (LB) is becoming an important drug for postoperative analgesia and has the potential to increase nerve block duration for up to 72 as the encapsulated bupivacaine is slowly released over time. However, LB may not provide adequate immediate postoperative analgesia. Several studies have shown that mixture of liposomal bupivacaine and plain bupivacaine (Mix) may provide immediate and enduring analgesia, but the pharmacokinetic characteristics have not been assessed.
To compare the pharmacokinetic profile and tolerability of liposomal bupivacaine and mixture of liposomal bupivacaine and plain bupivacaine, male rats aged 6-8 weeks were selected to receive either LB or Mix by subcutaneous injection and plasma pharmacokinetic profiles were assayed by Liquid Chromatography with tandem mass spectrometry.The present study was approved by the local ethical committee. The analysis showed that compare with LB, Mix possessed higher Cmax (2418.33±373.48 ng/ml vs. 281.13±71.54 ng/ml), shorter Tmax (0.17±0.01h vs. 0.30± 0.21h), higher AUC0-t (5293.08±307.20 h ng/ml vs. 1414.13±278.33 h ng/ml) and AUC0-∞ (5448.86±311.72 h ng/ml vs. 1469.19±279.80 h ng/ml), but shorter MRT0-∞(9.33±1.15h vs. 7.17±0.72h)(Table 1, Figure 1). This study is the first to focus on the pharmacokinetic characteristics of LB and Mix in rodent. Our results showed that Mix exhibited shorter time to peak and higher plasma concentrations, but the analgesia duration may reduce as compared to LB. The study was perfoemed in rats, it may differ from human patients, further study was needed to testify the clinical efficacy of mixture of liposomal bupivacaine and plain bupivacaine.
Kang ZHENG (Nanjing, China), Pengpeng ZHANG, Dalei ZHOU, Junjie HUANG
15:51 - 15:58
#47399 - OP43 Common errors in sample size calculations in regional anesthesia RCTs.
OP43 Common errors in sample size calculations in regional anesthesia RCTs.
Accurate sample size calculation is essential to the validity of results from randomized controlled trials (RCT), especially in the context of null findings. Currently, no systematic evaluation of sample size calculation errors exists that focuses on the regional anesthesia literature.
Among 11 RCTs published in 2025 in Regional Anesthesia and Pain Medicine (RAPM), we reviewed sample size calculation descriptions to assess appropriateness and describe common errors. Calculations were subsequently revised and compared to the original sample sizes. Among 11 included RCTs (Table 1), we identified 5 potentially erroneous sample size calculations. Errors were mostly related to: (1) arbitrary selection of effect sizes without adequate justification, (2) discrepancies between assumed and actual outcome means and variances, and (3) inappropriate use of two-sided testing when one-sided would have been sufficient. Some studies assumed opioid consumption means that were substantially higher than those ultimately observed, leading to miscalculated sample sizes. Others applied overly large effect sizes without support from existing data, resulting in underpowered trials that failed to detect clinically meaningful differences. Overpowered studies resulted when two-sided testing was inappropriately used to calculate sample size for a superiority trial. Sample size calculation errors are not uncommon in the regional anesthesia literature, and can critically undermine trial validity or lead to inconclusive results. Additionally, enrollment of more participants than necessary may expose them to procedural risks without additional scientific benefit. Improved rigor in sample size justification, including transparent reporting of assumptions and sensitivity analyses, is needed to enhance the quality and reliability of future RCTs.
Juliet ROWE (New York, NY, USA), Alex ILLESCAS, Junying WANG, Stavros MEMTSOUDIS, Jiabin LIU, Crispiana COZOWICZ, Andreas KOKÖEFER, Jashvant POERAN
15:58 - 16:05
#47400 - OP44 Neuraxial anesthesia in revision hip and knee arthroplasties stratified by prosthetic joint infection status: a trend analysis.
OP44 Neuraxial anesthesia in revision hip and knee arthroplasties stratified by prosthetic joint infection status: a trend analysis.
As primary total hip/knee arthroplasty (THA/TKA) volumes rise, revision surgeries are also increasing. While neuraxial anesthesia (NA) is well studied in primary procedures, its use in revisions, especially those due to periprosthetic joint infection (PJI), remains less understood. PJI may influence anesthesia choice due to the risks of central nervous system (CNS) infection, though evidence is limited. We examined trends in the use of NA among revision THA and TKA recipients from 2013 to 2023, stratified by PJI as indication.
Using the Premier Healthcare Database from 2013-2023, we identified 166,755 revision TKAs and 116,300 revision THAs. PJI was identified via ICD codes, and anesthesia type was classified using billing codes. The cohort was stratified by PJI status and trends were analyzed using Cochran-Armitage tests. PJI incidence rose over time for both procedure types (THA: 16.3% to 27.6%, TKA: 26.5% to 36.5%). NA use was consistently lower in PJI vs. non-PJI cases (THA: 8.9% vs. 14.1%, TKA: 10.3% vs. 18.7%; both p<0.0001). NA use declined over time in TKA revisions due to PJI (p = 0.002), remained stable in TKA revisions due to PJI (p = 0.66), and increased in THA revisions regardless of infection status (p = 0.018 and p = 0.003). Despite potential benefits, NA remains underused in revision THA/TKA, especially with PJI. This may reflect ongoing CNS infection concerns, though actual risk appears low according to the literature. These findings highlight the need for clearer guidelines and more robust evidence to support anesthesia decision-making in revision arthroplasty, particularly in PJI cases.
Juliet ROWE (New York, NY, USA), Periklis GIANNAKIS, Alex ILLESCAS, Jiabin LIU, Stavros MEMTSOUDIS, Daniel MAALOUF, Jashvant POERAN, Crispiana COZOWICZ
16:05 - 16:12
#47504 - OP45 Effects of Intrathecal Pethidine in surgical re-vascularisation of lower extremity.
OP45 Effects of Intrathecal Pethidine in surgical re-vascularisation of lower extremity.
Pethidine is the only member of the opioid family that has clinically important local anaesthetic activity in the dose range normally used for analgesia.
This study compares the effects of an intrathecal injection of pethidine combined with bupivacaine versus intrathecal bupivacaine alone in patients undergoing lower extremity
re-vasularisation surgeries.
In this prospective, randomized, controlled, double-blinded study, 46 participants scheduled for elective lower
extremity re-vascularisartion surgeries were randomly allocated into two groups. Group PD (n = 23) received an intrathecal injection of
1 mg/kg preservative-free pethidine combined with 1.5ml (7.5mg) of 0.5% hyperbaric bupivacaine, diluted with 0.9% sodium chloride saline to a total
volume of 3 mL. Group B (n = 23) received an intrathecal injection of 3 mL (15 mg) of 0.5% hyperbaric bupivacaine alone.
The primary outcome measured was the time to the first need for rescue analgesia. Secondary outcomes included spinal anesthesia
characteristics, intraoperative hemodynamic stability, and incidence of perioperative adverse events. The time to first need for rescue analgesia was significantly longer in Group PD (7.76 ± 0.79 hours) compared to Group
B (4.48 ± 0.63 hours). Differences in the onset of sensory and motor blocks between Group PD (6.39 ± 1.12 and 10.09 ± 2.23
minutes, respectively) and Group B (6.43 ± 1.99 and 9.96 ± 2.33 minutes, respectively) were statistically non-significant.
Incidence of hypotension and shivering was also less frequent in Group PD than in Group B. Intrathecal administration of 1 mg/kg pethidine plus 7.5 mg bupivacaine 0.5% provided improved spinal anesthesia, with extended postoperative analgesia, minimal intraoperative hemodynamic disturbances, and reduced incidence of shivering compared to bupivacaine alone in patients undergoing lower extremity re-vascularisation surgeries. This approach may be particularly beneficial for surgeries requiring longer time offering a cost-effective alternative to standard local anesthetics.
Jonela BURIMI (Tirana, Albania)
16:12 - 16:19
#48205 - OP46 Use of virtual reality devices during treatment of wounded soldiers: complications during and following nerve blocks under regional anesthesia.
OP46 Use of virtual reality devices during treatment of wounded soldiers: complications during and following nerve blocks under regional anesthesia.
Virtual reality (VR) headsets may complement sedation during the performance of nerve blocks, providing additional dissociative effect. On the other hand, the use of such devices may increase the risks of inadvertent nerve, vessel and lung punctures caused by patient movement, as well as augment the emetic effects of the drugs used to provide sedation. We aimed to compare such risks in a specific patient population - soldiers with blast and gunshot injuries.
Patients with blast and gunshot limb injuries undergoing surgical interventions under regional anesthesia with moderate (conscious) sedation were randomly distributed into two groups: with addition of virtual reality devices (group VR) and without them (group non-VR). Incidence of common anesthesia-related complications was compared. Chi-square test and t-test were used to calculate the statistical significance where appropriate. A total of 104 patients were included (45 in VR group and 59 in non-VR group). Clinically significant nerve damage (causing lasting muscle weakness or paresthesia) was registered in 1 patient in VR group and 2 in non-VR group (p = 0.72). Nausea was more common in the VR group (7 vs 2, p = 0.02). No vomiting was observed in either group. Undesirable patient movement during the surgical intervention, VR vs non-VR: 15 vs 18 (p = 0.75). Use of VR devices has increased the duration of preparation within the operating theater by 134 ± 35 seconds. No significant difference in propofol consumption (mg/kg/hour) was observed (VR: 4.2 ± 1.5, non-VR: 4.3 ± 1.7, p = 0.75). During treatment of combat injuries under regional anesthesia with moderate sedation, the use of virtual reality headsets does not appear to result in an increased incidence of anesthesia-related complications with an exception of manageable nausea, which is more common when VR devices are used.
Mykhailo FRANK (Kyiv, Ukraine), Dmytro SAZHYN, Natalia SEMENKO, Yurii KUCHYN, Kateryna BIELKA
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15:30-16:00
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H15
SIMULATION TRAININGS
SIMULATION TRAININGS
Demonstrators:
Josip AZMAN (Consultant) (Demonstrator, Linkoping, Sweden), Clara LOBO (Medical director) (Demonstrator, Abu Dhabi, United Arab Emirates), Lara RIBEIRO (Anesthesiologist Consultant) (Demonstrator, Braga-Portugal, Portugal), Roman ZUERCHER (Senior Consultant) (Demonstrator, Basel, Switzerland)
This interactive, simulation-based learning experience allows you to explore the complications of regional anaesthesia in a fun and engaging way! Covering several challenging daily clinical situations and crisis management cases from the fields of trauma, orthopaedics and obstetrics, it combines all kinds of simulation to provide an excellent learning resource.
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16:10-18:00
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G16
BEST FREE PAPER SESSION (RA)
BEST FREE PAPER SESSION (RA)
Chairpersons:
Thomas Fichtner BENDTSEN (Professor, consultant anaesthetist) (Chairperson, Aarhus, Denmark), Irina EVANSA (Head of Anaesthesiology, Intensive Care and Pain Department) (Chairperson, Riga, Latvia)
Examiners:
Audun STUBHAUG (Professor and consultant) (Examiner, Oslo, Norway), Michal VENGLARCIK (Head of anesthesia) (Examiner, Banska Bystrica, Slovakia)
16:10 - 16:21
#44891 - OP01 The Impact of Perineural Dexamethasone and Dexmedetomidine on Neuromonitoring in Pediatric Scoliosis Surgery.
OP01 The Impact of Perineural Dexamethasone and Dexmedetomidine on Neuromonitoring in Pediatric Scoliosis Surgery.
Maintaining neuromonitoring integrity is crucial in scoliosis surgery. This study examines the effects of perineural dexamethasone and dexmedetomidine on motor-evoked potentials (MEPs), sedation, and analgesia in pediatric patients receiving erector spinae plane block (ESPB).
This study was approved by the Bioethics Committee at Poznan University of Medical Sciences (protocol 538/23) and registered at ClinicalTrials.gov (NCT06086431). Written informed consent was obtained from all caregivers before enrollment. Ninety pediatric patients undergoing posterior spinal fusion were randomized to receive ESPB with ropivacaine alone (Control), ropivacaine + dexamethasone (DEX, 0.1 mg/kg), or ropivacaine + dexmedetomidine (DEM, 0.1 µg/kg). MEP amplitude, latency, TES stimulus strength, BIS index, postoperative analgesia, and opioid consumption were assessed. Dexamethasone significantly increased MEP amplitude (p=0.04) and reduced TES stimulus strength (p=0.04), suggesting improved neuromonitoring conditions. Dexmedetomidine did not alter MEP parameters but resulted in the lowest BIS scores (p=0.05), indicating deeper sedation, as seen in Table 1. The time to first rescue analgesia was significantly prolonged in both DEX (12.96 ± 2.03 h) and DEM (11.65 ± 2.95 h) compared to Control (5.15 ± 1.69 h; p<0.0001). Total opioid consumption was significantly lower in the DEX and DEM groups (p<0.0001), with similar reductions in postoperative pain scores (NRS). No significant differences were found in inflammatory markers or blood glucose levels. However, DEM caused 11 cases of bradycardia and 5 cases of hypotension, while no hemodynamic instability was observed in the DEX or Control groups. No nerve injuries occurred, as seen in Table 2. Dexamethasone enhances neuromonitoring while providing prolonged analgesia and opioid-sparing benefits. Dexmedetomidine offers similar pain relief but is associated with hemodynamic instability, limiting its suitability in pediatric scoliosis surgery. The choice of adjuvant should consider both intraoperative neuromonitoring requirements and patient cardiovascular stability.
Malgorzata REYSNER (Poznan, Poland), Juliusz HUBER, Tomasz REYSNER, Piotr JANUSZ, Kowalski GRZEGORZ, Przemysław DAROSZEWSKI, Katarzyna WIECZOROWSKA-TOBIS, Tomasz KOTWICKI
16:21 - 16:32
#44904 - OP02 Perineural dexamethasone for PENG block in geriatric patients undergoing Total Hip Arthroplasty: A randomized, Double-blinded Clinical Trial.
OP02 Perineural dexamethasone for PENG block in geriatric patients undergoing Total Hip Arthroplasty: A randomized, Double-blinded Clinical Trial.
Adequate postoperative analgesia is critical for elderly patients undergoing total hip arthroplasty (THA). The pericapsular nerve group (PENG) block relieves pain while preserving motor function, but its limited duration necessitates adjuncts. This study evaluates the efficacy of perineural dexamethasone in prolonging PENG block analgesia in geriatric THA patients.
This double-blinded, randomized controlled trial (RCT) was conducted at a single orthopedic center in Poland. The Bioethics Committee of Poznan University of Medical Sciences approved the study (protocol 107/2024). Written informed consent was obtained from all patients before enrollment (August 14, 2024 – January 31, 2025). The study adhered to the Declaration of Helsinki.
Sixty patients (≥65 years) undergoing total hip arthroplasty (THA) under spinal anesthesia were randomized into two groups: PENG group (PENG block with 20 mL 0.2% ropivacaine) and PENG+DEX group (PENG block with 20 mL 0.2% ropivacaine + 4 mg perineural dexamethasone).
The primary outcome was the time to first rescue opioid administration. Secondary outcomes included total opioid consumption (mEQ), pain scores (NRS), quadriceps strength (MRC scale), and adverse effects (hyperglycemia, nerve injury) over 48 hours. Dexamethasone significantly prolonged analgesia (16.0 ± 1.3 vs. 9.0 ± 1.7 hours, p < 0.0001) and reduced opioid use (0.9 ± 1.2 vs. 2.1 ± 1.4 mEQ, p = 0.0003). Pain scores were lower at 6, 12, and 24 hours (p < 0.05). Quadriceps strength remained intact in both groups. No nerve injuries were observed (p > 0.9999). Blood glucose levels at 12, 24, and 48 hours showed no significant differences between groups (p > 0.05), as seen in Table 1. Perineural dexamethasone effectively prolongs PENG block duration, reduces opioid consumption, and does not compromise motor function, nerve integrity, or glycemic control. It is a promising strategy for optimizing pain control in elderly THA patients.
Tomasz REYSNER (Poznan, Poland), Kowalski GRZEGORZ, Aleksander MULARSKI, Grochowicka MONIKA, Przemysław DAROSZEWSKI, Malgorzata REYSNER
16:32 - 16:43
#45467 - OP03 The Effect of Local Anesthetic Volume for Popliteal Plexus Block on Motor Nerve Conduction and Muscle Function in the Leg - a randomized clinical trial in healthy volunteers.
OP03 The Effect of Local Anesthetic Volume for Popliteal Plexus Block on Motor Nerve Conduction and Muscle Function in the Leg - a randomized clinical trial in healthy volunteers.
Popliteal Plexus Block (PPB) has shown moderate improvements in multimodal analgesia following total knee arthroplasty while preserving motor function. However, the optimal analgesic volume for PPB remains unknown, and concerns exist regarding potential volume-dependent motor nerve involvement. This study investigates whether increasing the volume of local anesthetic for PPB affects muscle function and motor nerve involvement.
This ethically approved RCT included 40 healthy volunteers, each receiving one active nerve block and one sham block in each leg. Participants were randomized into three PPB groups receiving 10 mL, 20 mL, or 30 mL of 1% lidocaine, with 20 observations per group. Additionally, 10 femoral nerve blocks and 10 sciatic nerve blocks were included as reference groups to confirm motor nerve involvement. The primary outcome was relative changes in maximum voluntary isometric contraction (MVIC) of ankle plantar- and dorsiflexion. Secondary outcomes included relative changes in MVIC of knee extension, relative changes in compound muscle action potential of the gastrocnemius-, anterior tibial-, vastus medialis- and vastus lateralis muscles, and frequency of saphenous nerve involvement. There were no significant differences in motor function between the three PPB groups for any MVIC measures (P≥0.1). CMAP changes did not indicate clinically relevant motor nerve involvement across PPB groups. Saphenous nerve involvement was inconsistent, affecting 40% (10 mL), 40% (20 mL), and 60% (30 mL) of cases (P=0.3), suggesting ineffective sensory block of the femoral nerve's medial knee contributions. Increasing the volume of local anesthetic for PPB does not impair muscle function or significantly involve motor nerves, supporting its motor-sparing efficacy. PPB inconsistently affects the femoral nerve's sensory contributions to the knee, emphasizing its role as an adjunct to femoral triangle or adductor canal blocks in clinical practice. Concerns of muscle impairment should not hinder future clinical trials from exploration of the optimal analgesic volume for PPB.
Johan Kløvgaard SØRENSEN (Aarhus, Denmark), Ulrik GREVSTAD, Erisela QERAMA, Line BRUUN, Lone NIKOLAJSEN, Charlotte RUNGE
16:43 - 16:54
#45501 - OP04 Duration of analgesia after supraclavicular brachial plexus block with intravenous dexamethasone and dexmedetomidine: a randomised, placebo-controlled, triple-blinded trial.
OP04 Duration of analgesia after supraclavicular brachial plexus block with intravenous dexamethasone and dexmedetomidine: a randomised, placebo-controlled, triple-blinded trial.
Intravenous dexamethasone and dexmedetomidine are two adjuncts to local anaesthetics used independently to prolong analgesia after peripheral nerve block. This randomised, controlled, triple-blinded trial tested the hypothesis that the intravenous combination of dexamethasone and dexmedetomidine would provide superior analgesia than intravenous dexamethasone alone in patients undergoing upper limb surgery with a supraclavicular brachial plexus block.
A hundred patients were randomised to receive intravenously either dexamethasone 0.15mg.kg-1 (Dexa group) or a combination of dexamethasone 0.15mg.kg-1 and dexmedetomidine 1µg.kg-1 (Dexa-Dexme group). The primary outcome was the duration of analgesia measured from the time of block procedure to first oral opioid intake. Secondary outcomes included duration of sensory and motor blocks, pains scores at rest and on movement, cumulative oral morphine consumption at 48h and incidence of hypotension episodes and bradycardia. The mean (standard deviation) duration of analgesia was 690 min (544 min) in the Dexa group and 621 min (334 min) in the Dexa-Dexme group (p=0.47). Similarly, there were no significant differences in all the secondary outcomes. In conclusion, the intravenous combination of dexamethasone and dexmedetomidine does not provide superior analgesia than intravenous dexamethasone after a supraclavicular brachial plexus block.
Eric ALBRECHT, Sina GAPE (Sion, Switzerland)
16:54 - 17:05
#45653 - OP05 Efficacy of acetaminophen with diclofenac vs. acetaminophen alone for elective post-caesarean analgesia: a systematic review and meta-analysis of randomised control trials.
OP05 Efficacy of acetaminophen with diclofenac vs. acetaminophen alone for elective post-caesarean analgesia: a systematic review and meta-analysis of randomised control trials.
Post-operative analgesia is an essential aspect for maternal recovery, ambulation, and well-being. Combining analgesics may enhance pain management, while reducing opioid use as well as postpartum depression risk. This study compares acetaminophen-diclofenac versus acetaminophen alone for post-caesarean analgesia.
A systematic search was conducted in December 2024 without date restrictions using PubMed, EMBASE, and Cochrane Central. We included studies that compared acetaminophen-diclofenac and acetaminophen alone after elective caesarean sections. The primary outcome was resting visual analogue pain scores (VAS) at various post-operative times. Risk ratios (RR) for binary and standard mean differences (SMD) for continuous outcomes were calculated using a random-effects model. I2 statistics were used to assess for heterogeneity. Five RCTs were included; 200 (47.8%) patients received acetaminophen-diclofenac, and 218 (52.2%) acetaminophen alone. Differences in resting VAS at 2-hours (SMD -0.82; 95%CI -1.52, -0.11; P=0.02), 6-hours (SMD -0.95; 95%CI -1.72, -0.18; P=0.02), 24-hours (SMD -0.61; 95%CI -1.08, -0.15; P=0.01), and morphine consumption (SMD -0.83; 95%CI -1.48, -0.17; P=0.01) were statistically significant. No significant difference was found for the side-effect of nausea/vomiting (RR 0.63; 95%CI 0.28, 1.40; P=0.25). In this meta-analysis, a significant benefit in acetaminophen-diclofenac versus acetaminophen alone was found for four of five outcomes, suggesting a possible advantage in maternal analgesic management from this combination. However, given a relatively small population, more RCTs may be needed to confirm this observation.
Elné VAN DER WESTHUYZEN (Maastricht, The Netherlands), Darja ALLEMANE, Layse MAIA DA SILVA, Giovanna GIOVACCHINI DOS SANTOS, Gabriela BOLLER BICALHO, Chukwudi ISAAC AYOGU
17:05 - 17:16
#47484 - OP06 Intrathecal morphine in minimally invasive coronary artery bypass surgery: a randomized, placebo-controlled, multicenter trial.
OP06 Intrathecal morphine in minimally invasive coronary artery bypass surgery: a randomized, placebo-controlled, multicenter trial.
Background & Aims: Minimally invasive cardiac surgery (MICS) is increasingly performed to reduce surgical trauma and enhance recovery, yet optimal strategies for postoperative pain control and patient-centered outcomes remain unclear. We hypothesized that intrathecal morphine (ITM), when added to a multimodal analgesic protocol, improves quality of recovery (QoR) following robotically-assisted minimally invasive direct coronary artery bypass (RAMIDCAB) surgery.
Methods: In this multicentre, double-blind, randomized, placebo-controlled trial, approved by the ethical committee (EudraCT 2022-003684-14), patients undergoing RAMIDCAB were randomized 1:1 to receive either ITM (5 µg/kg) with intravenous (IV) saline, or intrathecal saline with IV morphine (0.1 mg/kg) (control). All patients followed a standardized Enhanced Recovery Program (ERP). The primary endpoint was QoR-40 score at 24 hours post-extubation. Secondary endpoints included pain scores, opioid consumption, rescue analgesia, and adverse events. Results: Sixty-four patients were randomized. Compared to control, ITM did not result in a minimally clinically important improvement in the QoR-40 score at 24 or 48 hours (Figure 1). However, ITM provided significantly better postoperative analgesia in the early postoperative period (Figure 2). Cumulative opioid consumption over 24 hours was significantly lower in the ITM group (–11.9 mg morphine equivalents, p = 0.0004) (Figure 3) and fewer patients required rescue analgesia (ARR –22.2%, p = 0.02). There were no statistically significant differences in adverse events between groups. Conclusion: Although ITM did not improve overall QoR-40 scores, it significantly enhanced early postoperative analgesia and reduced opioid requirements. These findings support the integration of ITM into ERP protocols for MICS.
Marie-Camille VANDERHEEREN (Kortrijk, Belgium), Raf VAN DEN EYNDE, Wouter OOSTERLINCK, Bart EMBRECHT, Steffen REX, Danny Feike HOOGMA
17:16 - 17:27
#47508 - OP07 Regional anaesthesia for reducing the incidence of chronic post-surgical pain: Preliminary data from systematic review and network meta-analysis.
OP07 Regional anaesthesia for reducing the incidence of chronic post-surgical pain: Preliminary data from systematic review and network meta-analysis.
Chronic post-surgical pain (CPSP) is pain that develops following surgery and persists beyond 3 months. CPSP is common and challenging to manage. Preventing its development has been identified as a research priority. We aimed to assess if regional anaesthesia reduces the risk of CPSP following a range of procedures.
We conducted a PRISMA-compliant systematic review and meta-analysis of randomised controlled trials (RCT) assessing effectiveness of regional anaesthesia for prevention of CPSP, conducted between 2000 to July 2024. We restricted trials to surgeries where chronic pain is common. Outcomes included incidence of CPSP and other adverse events. We investigated effect of surgical subtype via meta-regression. We included 138 RCTs involving 16387 participants. Pairwise meta-analysis revealed regional anaesthesia reduced incidence of CPSP following mastectomy (RR=0.70; 95%CI:0.59-0.82) and thoracotomy (RR=0.77; 95%CI:0.62-0.96) relative to placebo or no regional anaesthesia. There were no significant differences for caesarean (RR=0.82; 95%CI:0.52-1.29), knee arthroplasty (RR=0.74; 95%CI:0.36-1.53), open inguinal hernia (RR=0.83; 95%CI:0.32-2.15), video assisted thoracoscopy (RR=0.77; 95%CI:0.54-1.08), major lower limb amputation (RR=0.87; 95%CI:0.54-1.40), hip arthroplasty (RR=1.23; 95%CI:0.41-3.72), sternotomy (RR=0.66; 95%CI:0.00-16037.51), craniotomy (RR=0.36; 95%CI:0.08-1.58), or open laparotomy (RR=0.77; 95%CI:0.38-1.56). Meta-regression for subgroup differences was not statistically significant however (F(10,53)=0.35, p=0.96), suggesting the effect of regional anaesthesia on CPSP was broadly consistent across surgery types. There were significantly fewer adverse events reported in regional anaesthesia arms compared to placebo or no regional anaesthesia arms in 11/43 (26%) trials that recorded adverse events. Regional anaesthesia did not significantly increase adverse events in any trials. Regional anaesthesia significantly reduces the risk of developing CPSP following mastectomy and thoracotomy. Surgery type was not significantly associated with effectiveness of regional anaesthesia in meta-regression. Regional anaesthesia may also reduce the incidence of adverse events. We will compare specific regional anaesthesia techniques and continuous local anaesthetic infusion versus single shot injection in future analysis of our data.
Martin TAYLOR-ROWAN, Iain MACTIER (Glasgow, Scotland, United Kingdom), Rachel KEARNS, Alan MACFARLANE
17:27 - 17:38
#47536 - OP08 Lumbar ESPB vs. epidural analgesia in Hip Replacement Surgery.
OP08 Lumbar ESPB vs. epidural analgesia in Hip Replacement Surgery.
Hip replacement surgery is one of the most common procedures in the elderly. The alleviation of postoperative pain should not delay or hinder patients' rehabilitation.
This study was a randomised controlled trial (RCT) conducted among patients undergoing hip replacement procedures. Each patient, without contraindications to spinal anesthesia and without an allergy to the studied drugs, who obtained written consent, was eligible to participate in this study.
In the operating theater, patients were allocated to one of the two studied groups: the continuous epidural analgesia (Epidural) group or the continuous lumbar erector spinae plane block (ESPB) group. Both procedures were performed after spinal anesthesia. A mixture containing 0.1% bupivacaine with fentanyl (2 mcg/mL) was administered at a flow rate of 5 mL/h for 24 hours. In the postoperative period, patients received patient-controlled analgesia (PCA) with oxycodone.
The main aim of this study was to examine opioid consumption with PCA pump. The other included pain severity and the Timed Up and Go test (TUG). We recruited 30 patients for each of the studied groups. As presented in the Figure, we did not observe a difference between the ESPB and Epidural groups in oxycodone consumption (11.5 [6-18] vs. 6.5 [3-15]; p = 0.12). Pain severity, both at rest and upon activity, was similar in both groups 4, 8, 24, and 48 hours following the operation. Moreover, we did not find any difference in the TUG 24 hours (29 [24-33] vs. 24 [20-27]; p = 0.12) and 48 hours (19 [16-23] vs. 26 [22-30]; p = 0.12) after the surgery. Continuous lumbar ESPB is not inferior to continuous epidural analgesia in patients undergoing scheduled hip replacement surgery in terms of pain treatment and postoperative recovery.
Michal BORYS (Lublin, Poland), Pawel KUTNIK, Aleksandra ZAKRZEWSKA-SZALAK, Justyna WASIEWICZ, Pawel PIWOWARCZYK
17:38 - 17:49
#48137 - OP09 Comparison of Quadratus Lumborum Block and Rectus Sheath Block in Postoperative Pain Management of Pediatric Patients Undergoing Laparoscopic Appendectomy.
OP09 Comparison of Quadratus Lumborum Block and Rectus Sheath Block in Postoperative Pain Management of Pediatric Patients Undergoing Laparoscopic Appendectomy.
This study aimed to compare the effects of ultrasound-guided quadratus lumborum block (QLB) and rectus sheath block (RSB) on postoperative analgesic needs, pain scores, and patient/parent satisfaction in children undergoing laparoscopic appendectomy.
After obtaining ethical approval (2022/26-15), 47 children aged 2–16 years (ASA I–II) undergoing laparoscopic appendectomy were included. After inducing general anesthesia, we randomly assigned patients to receive either QLB or RSB under ultrasound guidance before surgical incision. Both blocks were performed bilaterally with 0.4 ml/kg of 0.25% bupivacaine. Perioperative hemodynamic parameters and FLACC pain scores were recorded at postoperative 30 minutes, and 1st, 2nd, 4th, 6th, 12th, and 24th hours. We also evaluated the time to first analgesic need, total analgesic use, complications, and parental satisfaction. Twenty-four patients were assigned to the RSB group and 23 to the QLB group. There was no significant difference between groups in demographic characteristics. (p>0.05) Table 1) In the RSB group, 16 of 24 patients required postoperative analgesia, and 3 of them received two doses. Total analgesic use was 7.9 ± 6.5 mg/kg. In the QLB group, 12 of 23 patients required analgesia, with 3 receiving two doses. Total analgesic use was 6.5 ± 7.14 mg/kg (p=0.427). (Figure 1)
FLACC scores at all recorded time points were similar, and no statistically significant differences were observed (p>0.05). (Table 2) Parental satisfaction was also comparable between the groups (p=0.281). (Figure 2) No complications were reported in either group. In pediatric laparoscopic appendectomy, both ultrasound-guided QLB and RSB were similarly effective in postoperative pain management. Either block may be effectively used as part of a multimodal analgesia protocol.
Ahmet Ertuğrul DEMİR (Kahramanmaraş, Turkey), Gözen ÖKSÜZ, Gökçe GİŞİ, Mahmut ARSLAN, Feyza ÇALIŞIR, Cengizhan YAVUZ
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16:30-17:00
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C16
LIVE DEMONSTRATION
Ankle block
LIVE DEMONSTRATION
Ankle block
Demonstrators:
Corey KULL (Junior Consultant) (Demonstrator, Lausanne, Switzerland), Peter MERJAVY (Consultant Anaesthetist & Acute Pain Lead) (Demonstrator, Craigavon, United Kingdom)
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16:30-17:20
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E16
ASK THE EXPERT
Polytraumata need blocks
ASK THE EXPERT
Polytraumata need blocks
Chairperson:
Hari KALAGARA (Assistant Professor) (Chairperson, Florida, USA)
16:30 - 16:30
Introduction.
16:30 - 17:00
RA for the polytraumatized patient in ICU.
Xavier CAPDEVILA (MD, PhD, Professor, Head of department) (Keynote Speaker, Médecin, Montpellier, France)
17:00 - 17:20
Q&A.
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16:30-17:25
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F16
FREE PAPER SESSION 5/8
ULTRASOUND GUIDED (UGRA)
FREE PAPER SESSION 5/8
ULTRASOUND GUIDED (UGRA)
Chairperson:
Ivan KOSTADINOV (ESRA Council Representative) (Chairperson, Ljubljana, Slovenia)
16:30 - 16:37
#45227 - OP47 Comparison of single versus triple injection costoclavicular block in upper limb surgery: Randomised Controlled trial.
OP47 Comparison of single versus triple injection costoclavicular block in upper limb surgery: Randomised Controlled trial.
The costoclavicular approach to infraclavicular brachial plexus block focuses on the proximal infraclavicular fossa, where the medial, lateral, and posterior cords are closely situated(1). Septa in this region can restrict the spread of local anesthetic with a single injection. This study compared single versus triple aliquot injections for costoclavicular brachial plexus blocks, hypothesizing quicker onset and reduced failure rates with triple injections(2). Primary outcome: block onset time; secondary outcomes: surgical success, postoperative analgesia, and complications.
Forty-two patients undergoing upper limb surgery received either single (n=21) or triple (n=21) ultrasound-guided costoclavicular blocks using 30 mL of local anesthetic. In the triple group, the anesthetic was divided and injected near the lateral cord, medial cord, and cord junction. Blockade was assessed every 5 minutes for 30 minutes. Triple injections had a faster onset (15.71 ± 4.55 vs. 25.95 ± 3.4 minutes; p < 0.001) but longer performance time (12.05 ± 3.51 vs. 5.52 ± 1.47 minutes; p < 0.001). No differences were found in anesthesia duration, postoperative analgesia, or opioid consumption. The triple injection technique offers a faster onset of anesthesia compared to the single injection method, likely due to improved distribution of the anesthetic around the septa(3). However, the single injection approach is quicker to perform. Both techniques are comparable in terms of anesthesia duration, failure rates, and complications.
Sourav SAHA (New Delhi, India, India), Babita GUPTA, Abhishek NAGARAJAPPA, Souvik MAITRA
16:37 - 16:44
#45234 - OP48 The complementary analgesic efficacy of the deep-piriformis compartment block to pericapsular nerve group block for primary total hip arthroplasty: a prospective randomized, observer-blinded trial.
OP48 The complementary analgesic efficacy of the deep-piriformis compartment block to pericapsular nerve group block for primary total hip arthroplasty: a prospective randomized, observer-blinded trial.
The pericapsular nerve group (PENG) block has been proposed as an effective motor-sparing option for total hip arthroplasty (THA). The PENG block specifically targets the anterior hip capsule. However, it remains unclear whether the combination of a deep-piriformis compartment (DPC) block, which targets the posterior hip capsule, could enhance analgesia in patients undergoing THA.
We conducted a randomized, observer-blinded trial. One hundred patients undergoing THA were randomly assigned to either the PENG group or the PENG+DPC group, with 50 patients in each group. Before undergoing general anesthesia, patients in PENG group received PENG and lateral femoral cutaneous nerve (LFCN) block, while those in PENG+DPC group received PENG, LFCN and DPC block. The primary outcome was the static pain score at 6 hours post-surgery. The static pain score at 6 hours post-surgery was lower in the PENG+DPC group (0 [0-1]) than that in the PENG group (1 [0-2]) with a median difference of 0 (95% confidence interval, 0-1; P=0.009). Similarly, the dynamic pain score at 6 hours post- surgery, the static and dynamic pain score at 1hour post-surgery, intraoperative sufentanyl consumption and the total consumption of sufentanyl were lower in the PENG+DPC group. There were no significant differences in pain scores at other time points, motor blockade or other postoperative outcomes. No nerve block-related complications were reported during the trial. Incorporating a DPC block into the PENG block could enhance analgesia in patients undergoing THA without additional adverse effects .
Aizhong WANG (Shanghai, China)
16:44 - 16:51
#45771 - OP49 To evaluate the effectiveness of erector spinae block for micro lumber discectomy in day case surgery.
OP49 To evaluate the effectiveness of erector spinae block for micro lumber discectomy in day case surgery.
Micro-lumbar discectomy (MLD) is increasingly performed as a day-case procedure due to advancements in minimally invasive techniques [1]. Effective postoperative analgesia remains critical for early ambulation and timely discharge. Erector spinae plane block (ESPB) is a promising regional technique with growing evidence supporting its efficacy in spine surgeries [2,3]. The aim of this study is to evaluate the effectiveness of ESPB in reducing postoperative pain and opioid consumption in day-case MLD surgery under an ERAS framework.
This prospective case-control study included 60 patients (ASA: I – III) undergoing elective single level MLD. Patients were divided into two groups: ERAS-only (n=30) and ESPB + ERAS (n=30). ESPB group received a single-injection ultrasound-guided ESPB at the L3 vertebral level using 30 mL of 0.25% bupivacaine prior to induction. All patients of both groups followed ERAS protocol: preoperatively, oral paracetamol 1 g and pregabalin 25 mg; intraoperatively, IV dexamethasone 5 mg, propofol and remifentanil via TCI; postoperatively, IV diclofenac 75 mg single dose, followed by oral NSAIDs and paracetamol. Pethidine 1 mg/kg IM used as rescue analgesia. Primary outcomes were VAS scores at 2, 6, 12, and 24 hours; secondary outcomes included opioid use, time to rescue analgesia, and discharge timing. Pain scores were significantly lower in the ESPB group at all time points (VAS at 2h: 1.3 ± 0.7 vs 3.2 ± 1.1; p < 0.001). Opioid use was significantly reduced (45 ± 28 mg vs 110 ± 35 mg; p < 0.001). Rescue analgesia was delayed in the ESPB group (8 vs 3 hours; p = 0.004). No block-related complication was observed. 92% patients of ESPB + ERAS group were discharge on the same day, while 57% of ERAS only group. ESPB significantly improves postoperative analgesia, reduces opioid requirement, and enhances early recovery when integrated into ERAS for day-case MLD.
Lutful AZIZ (Dhaka, Bangladesh), Fatema AKTER, Masrufa HOSSAIN, Salah Uddin Al AZAD, Golam Ferdous ALAM, Nahida Parveen NIMMI
16:51 - 16:58
#47492 - OP50 Erector spinae plane block for postoperative analgesia in vertebral surgery: an umbrella review of systematic reviews and meta-analyses.
OP50 Erector spinae plane block for postoperative analgesia in vertebral surgery: an umbrella review of systematic reviews and meta-analyses.
The erector spinae plane (ESP) block has gained attention as a regional anesthesia technique for pain management in vertebral surgeries. Despite promising results, evidence regarding its efficacy and safety remains inconsistent. This umbrella review synthesizes data from systematic reviews (SRs) and meta-analyses to evaluate the effectiveness of the ESP block in reducing postoperative opioid consumption, pain, and postoperative nausea and vomiting (PONV).
A systematic search was conducted in CENTRAL, EMBASE, PubMed Central, and Scopus from 2016 to 2025. We included SRs and meta-analyses that investigated the use of ESP block in vertebral surgeries. Primary outcomes were opioid consumption at 24 postoperative hours (measured as milligram morphine equivalents, MME), pain scores at 12 and 24 hours, PONV incidence, and the need for additional analgesics. Quality assessment was performed using the AMSTAR 2 tool. Thirteen SRs were included. The ESP block significantly reduced opioid consumption at 24 postoperative hours (mean difference -8.70 to -18.69), although high heterogeneity was observed. Pain reduction at 12 and 24 hours was statistically significant but clinically modest, with most SRs reporting reductions of less than one point. The ESP block also significantly reduced PONV and additional analgesic use. However, most SRs were rated as critically low quality due to inadequate pre-registration and funding reporting. The ESP block demonstrates potential as a multimodal analgesia component in vertebral surgeries, reducing opioid consumption, pain intensity, and PONV. However, high heterogeneity and low methodological quality highlight the need for further research.
Alessandro DE CASSAI, Maria BISI, Marco NARDELLI (Padova, Italy), Irene PAIUSCO, Serafino TALARICO, Valentina FINCATI, Annalisa BOSCOLO, Paolo NAVALESI
16:58 - 17:05
#48136 - OP51 Continuous erector spinae catheter for rib fracture analgesia - QI Project.
OP51 Continuous erector spinae catheter for rib fracture analgesia - QI Project.
Blunt chest trauma accounts for ~15% of UK trauma admissions (~5,500 cases/year). Rib fractures carry high morbidity and up to 33% mortality. Regional analgesia can reduce complications in this cohort. Local audit demonstrated underutilisation of regional techniques in rib fracture patients in our trust. We introduced ultrasound-guided continuous erector spinae plane catheters (cESP) in our protocol as an alternative to thoracic epidural for rib fracture pain. This was combined with a departmental education programme.
Aims
• To assess the effectiveness and feasibility of introducing continuous ESP catheters in managing rib fracture pain
• To evaluate patient outcomes under current analgesia practices
This retrospective service evaluation included all adult in-patients admitted with rib fractures over two 3-month cycles. Cycles were before and after introduction of cESPs into our protocol. Ethical approval was waived by the local hospital committee. Patients were identified using the in-house trauma register and data collected from the Electronic Patient Record (EPR). Data included demographics, risk scoring (STUMBL/Battle Score), pain scores, analgesia, regional procedures, complications and admission duration. A total of 164 patients were included across two study periods. Numerical pain scores were poorly captured on EPR. Mean Battle scores were similar in both cycles (22.5 pre-cESP, 20.4 post-cESP). cESP introduction resulted in a higher proportion of patients receiving regional intervention for rib fracture pain (22% vs 14%), including patients therapeutically anticoagulated. PCA use was uncommon (11/164).
Mean battle score amongst the regional intervention cohort was lower following cESP introduction (30 vs 24).
cESP use did not adversely effect length of stay or overall complication rate but infective complications were lower. Access to regional techniques improved following cESP introduction including anticoagulated patients previously precluded. Pain score documentation remains inconsistent and requires improvement. Planned future delivery of local anaesthetic via elastometric pumps may improve mobility and length of stay.
Rajesh SHANKAR, Christopher PARNELL (Hertford, United Kingdom), Nilar MYINT, Shivani PANDYA, Vidath BALASOORIYA, Michelle ASHWELL, Tracey ROBERTSON, Camilla ZORLONI
17:05 - 17:12
#48143 - OP52 Hip arthroplasty with low concentration local anesthetic fascia iliaca block: the HALF trial.
OP52 Hip arthroplasty with low concentration local anesthetic fascia iliaca block: the HALF trial.
Suprainguinal fascia iliaca block (SIFIB) provides effective analgesia for total hip arthroplasty (THA) but often causes quadriceps weakness. We hypothesized that low concentration local anesthetic (LCLA) SIFIB using 0.075% ropivacaine would offer comparable analgesia to high concentration local anesthetic (HCLA - 0.25% ropivacaine) while better preserving quadriceps strength.
In this double-blind randomized controlled trial, 43 patients undergoing primary THA received either LCLA-SIFIB or HCLA-SIFIB (50 mL ropivacaine + epinephrine 1:200,000) (figure 1). All patients received standard spinal anesthesia (mepivacaine 2% 3.5mL + fentanyl 15mcg + morphine 100 mcg) and multimodal analgesia (standing Tylenol and celecoxib, hydromorphone PRN). Outcomes included pain scores (NRS), opioid consumption (oral morphine equivalents - OME), quadriceps strength (Oxford scale), and hospital length of stay. Groups were similar for baseline demographics (table 1). Pain scores and opioid use were similar between groups at all time points (p > 0.26). Quadriceps strength at 8 hours after spinal anesthesia was significantly better in the LCLA group (median 4 [1–5]) vs. HCLA (median 2 [0–5], p = 0.0311). A trend favoring LCLA was also seen in PACU (p = 0.0544). Strength scores were comparable by POD1 and POD2 (table 2). No differences in adverse events were observed. LCLA-SIFIB provides comparable analgesia to HCLA-SIFIB after THA, with significantly improved early quadriceps strength. These findings support LCLA-SIFIB as a promising motor-sparing regional technique for enhanced recovery in THA patients.
Divya MAHAJAN, Divya MAHAJAN (Toronto, Canada), Carlson ASANGHANWA, Javiera VARGAS, Yehoshua GLEICHER, Naveed SIDDIQUI, Sharon PEACOCK, Hermann DOS SANTOS FERNANDES
17:12 - 17:19
#48171 - OP53 Effect of Left Thoracic Erector Spinae Plane Block on Left Ventricular Functions: A Strain Echocardiography Study.
OP53 Effect of Left Thoracic Erector Spinae Plane Block on Left Ventricular Functions: A Strain Echocardiography Study.
Thoracic erector spinae plane (ESP) block is widely used for postoperative and even chronic pain management in various surgical procedures. However, limited data exist on the effects of left-sided thoracic ESP block on left ventricular (LV) function. This study aimed to evaluate the effects of thoracic ESP block on LV function.
23 patients aged 18–75 years, classified as ASA I–III and scheduled for elective thoracic surgery and had no known cardiac disease, were included in this prospective study. Ethical approval was obtained, and the study was registered with ClinicalTrials.gov before the enrollment of the first patient. After obtaining verbal and written consent, a left thoracic ESP block was performed at the T5 level using 20 ml of 0.25% bupivacaine. Hemodynamic and transthoracic echocardiographic parameters—including heart rate (HR), systolic and diastolic blood pressure (SBP and DBP), left ventricular outflow tract (LVOT) diameter, strain, cardiac output (CO), end-diastolic diameter (EDD), and end-systolic diameter (ESD)—were measured before and 15 minutes after the block. Following the block, significant decreases were observed in HR (p<0.001), SBP (p=0.004), and DBP (p=0.010), while significant increases were noted in EDD (p<0.001), ESD (p=0.019), and end-diastolic volume (p=0.002). No significant changes were detected in EF, LVOT diameter, CO, or strain (p>0.05). Left thoracic ESP block may induce measurable changes in certain cardiovascular parameters. However, its impact on clinical outcomes requires further investigation through larger-scale studies.
Ferdi GULASTI, Sevil GULASTI, Zeynep AKALIN, Yusuf BICER, Asli ERTURK, Salih COKPINAR, Sinem SARI (Aydin, Turkey)
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B16
REFRESHING YOUR KNOWLEDGE
Invest in structures
REFRESHING YOUR KNOWLEDGE
Invest in structures
Chairperson:
Sandy KOPP (Professor of Anesthesiology and Perioperative Medicine) (Chairperson, Rochester, USA)
16:50 - 16:50
Introduction.
16:50 - 17:10
Importance of transitional pain services.
Jose Alejandro AGUIRRE (Head of Ambulatory Center Europaallee) (Keynote Speaker, Zurich, Switzerland)
17:10 - 17:25
Q&A.
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17:10-18:00
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C17
LIVE DEMONSTRATION
Plantar compartment block
LIVE DEMONSTRATION
Plantar compartment block
Demonstrator:
Olivier CHOQUET (anesthetist) (Demonstrator, MONTPELLIER, France)
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17:30-18:00
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B17
REFRESHING YOUR KNOWLEDGE
Not a hangover
REFRESHING YOUR KNOWLEDGE
Not a hangover
Chairperson:
Maurizio MARCHESINI (Pain medicine Consultant) (Chairperson, OLBIA, Italy)
17:30 - 17:30
Introduction.
17:30 - 17:50
Most effective treatments for headache.
Samer NAROUZE (Professor and Chair) (Keynote Speaker, Cleveland, USA)
17:50 - 18:00
Q&A.
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17:30-18:00
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D17
TIPS & TRICKS
The future is bright
TIPS & TRICKS
The future is bright
Chairperson:
Vicente ROQUES (Anesthesiologist consultant) (Chairperson, Murcia. Spain, Spain)
17:30 - 18:00
Introduction.
17:30 - 18:00
Technology to improve trainings.
Admir HADZIC (Director) (Keynote Speaker, New York, USA)
17:30 - 18:00
Q&A.
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E17
ASK THE EXPERT
The beating heart
ASK THE EXPERT
The beating heart
Chairperson:
Agnese OZOLINA (faculty member) (Chairperson, Riga, Latvia)
17:30 - 18:00
Introduction.
17:30 - 18:00
POCUS cardiac check.
Hari KALAGARA (Assistant Professor) (Keynote Speaker, Florida, USA)
17:30 - 18:00
Q&A.
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F17
TIPS & TRICKS
ESPs do well
TIPS & TRICKS
ESPs do well
Chairperson:
Nicolas BROGLY (Anaesthesiologist) (Chairperson, Madrid, Spain)
17:30 - 17:30
Introduction.
17:30 - 18:00
How I perform a ESP that works.
Melody ANDERSON (Director of Regional Anesthesiology) (Keynote Speaker, Charlotte, USA)
18:00 - 18:00
Q&A.
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A17
OPENING CEREMONY
OPENING CEREMONY
18:15 - 18:25
Introduction.
Eleni MOKA (faculty) (Keynote Speaker, Thessaloniki, Greece, Greece)
18:25 - 18:32
Congress related topics.
Thomas VOLK (Chair) (ESRA Board, Homburg, Germany)
18:32 - 18:37
Presidential presentation & announcement of the previous year.
Eleni MOKA (faculty) (Keynote Speaker, Thessaloniki, Greece, Greece)
18:37 - 18:39
Carl Koller Award.
Andre VAN ZUNDERT (Professor and Chair Anaesthesiology) (Keynote Speaker, Brisbane Australia, Australia)
18:39 - 18:41
Recognition of Education in RA.
Nuala LUCAS (Speaker) (Keynote Speaker, London, United Kingdom), Peter MERJAVY (Consultant Anaesthetist & Acute Pain Lead) (Keynote Speaker, Craigavon, United Kingdom)
18:41 - 18:43
Recognition of Education in Pain.
Samer NAROUZE (Professor and Chair) (Keynote Speaker, Cleveland, USA)
18:43 - 18:45
Announcement regarding the Recognition of Education in Pain Medicine Award.
Fleur SLUIJTER (CEO) (Keynote Speaker, Zeist, The Netherlands)
18:45 - 18:47
Announcement regarding the Recognition of Education in Regional Anaesthesia Award.
Nick SCOTT (Consultant) (Keynote Speaker, Aberfeldy, United Kingdom)
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WELCOME RECEPTION IN THE EXHIBITION HALL
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TRACK B- STUDIO 3+4 |
TRACK C- A1-4 |
TRACK D- STUDIO 2 |
TRACK E- A1-2 |
TRACK F- A1-3 |
TRACK G- A1-5 |
TRACK H- INFLATABLE ROOM |
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A20
NETWORKING SESSION
RA wears off
NETWORKING SESSION
RA wears off
Chairperson:
Ezzat SAMY AZIZ (Professor of Anesthesia) (Chairperson, Cairo, Egypt)
08:00 - 08:00
Introduction.
08:00 - 08:22
How long does acute pain last?
Sina GRAPE (Head of Department) (Keynote Speaker, Sion, Switzerland)
08:22 - 08:44
Neuromodulation for transit.
Athmaja THOTTUNGAL (yes) (Keynote Speaker, Canterbury, United Kingdom)
08:44 - 09:06
#48683 - FT04 Pain management after abdominal surgery. How to transit an epidural.
Pain management after abdominal surgery. How to transit an epidural.
Does epidural analgesia (EDA) still have a role in postoperative pain relief after abdominal surgery?
Or have modern surgical principles and the introduction of multimodal pain relief made EDA redundant? In an editorial in BJS, Lobo and Joshi ask this inevitable question 1
For many years, EDA was the cornerstone of pain relief after abdominal surgery, and it still plays an important role in many major procedures. Unfortunately, there is a high failure rate of 15-25% with EDA, even in skilled hands and with good routines. Many patients will also require vasoactive medication and fluid overload may occur in the perioperative course due to EDA-related hypotension. Urinary retention that necessitates a bladder catheter as long as the EDA is active is common. In some patients with platelet dysfunction and coagulopathy or those on anticoagulation, epidural anesthesia may be contraindicated due to the increased risk of epidural hematoma. In addition, postoperative anticoagulation in therapeutic doses may be in conflict with removal of the EDA catheter.
At our department, we have conducted a randomized controlled trial demonstrating that a new treatment with multimodal pain analgesia was non-inferior compared to EDA with regard to overall postoperative pain during the first 6 PODs 2 in open liver surgery 3. In the intervention (non-epidural) group, patients received a non-steroidal anti-inflammatory drug (NSAIDs)(Ketorolac in our study) on postoperative days (POD) 0-2, and patient-controlled analgesia (PCA) with ketobemidone (a strong opioid). Both groups received a single dose of steroids at the start of anesthesia, and paracetamol throughout the course. In the intervention (non-epidural) group the surgical wound was infiltrated with local anesthesia. The main finding of the study was that multimodal analgesia provided the same good pain relief on POD 0-6 as EDA, (mean pain score, NRS 1.7 vs 1.6), providing non-inferiority. Not unexpectedly, EDA gave slightly better pain relief on POD 0 and 1, but thereafter multimodal pain relief was better than EDA. Another important finding was that the PCA pumps were much easier to discontinue than EDA, and the patients in the intervention group was discharged from hospital one day earlier than the EDA group, 3 vs 4 days.
The tapering of a well-functioning epidural can often be challenging following procedures enhanced recovery after surgery (ERAS) protocol enables short hospital stays. The patients with EDA have then been adapted to little or no pain, and if the tapering is too rapid, the patient will experience breakthrough pain, which can often be a reason for delayed discharge. In a retrospective study in hepato-pancreatic surgery using EDA, rebound pain occurred in nearly 30% in the patients after EDA removal, resulting in poorly controlled pain relief 4. Rebound pain is defined as a sudden and intense increase in pain after removal of a regional block or catheter. There is no easy way to avoid this phenomenon. In our unit we introduce slow-acting oxycodone on the evening at POD 2 (institutional epidural and ERAS guidelines) to facilitate the reduction of EDA, and reduce EDA infusion rate with 30% every three hours. If the patients experiences good pain relief with oral medication alone, we will try to remove EDA in the morning at POD 3 or 4. When EDA is not possible to remove because of inadequate pain control, we will consider oral medication with NSAIDs and an alpha-2 adrenergic agonist like clonidine, together with opioids and paracetamol. Some patients may need further assessment in collaboration with the acute pain team.
Early epidural removal has been reported to be successful in orthopedic surgery5 . In this study there was a significant reduction in opioid use and hospital stay in patients undergoing periacetabular osteotomy who had early catheter removal on POD1 compared to catheters removed on POD2. Patients who had their epidural catheter removed on POD1 reported significantly lower mean pain on their date of epidural removal compared with patients with epidural removal on POD2. All patients in this study received standard multimodal analgesia including oral and iv opioids, NSAIDs, aspirin and paracetamol. There were no differences in the rates of complication including readmission.
Several well-conducted RCTs have shown the similar findings as our study, and there are many alternative methods for pain relief after abdominal surgery, even after complex open surgical procedures 6. The introduction of opioid-sparing regimens with intravenous infusion of lidocaine and ketamine has received increased interest. Intrathecal morphine is also a good alternative that is easy to perform and with high rates of adequate postoperative pain relief. Furthermore, ultrasound-guided truncal blocks and abdominal wound catheter with local anesthetics have shown effective pain relief after abdominal surgery in many studies. We must not forget the surgeons either, many blocks performed by the surgeon are suitable for a majority of surgical procedures 7. At our department, we have a close and good collaboration with both urologists, and gastroenterology and transplant surgeons for the establishment of abdominal wall blocks. Together with a single dose of steroids and NSAIDs these alternative methods will give an adequate pain relief after abdominal surgery in the majority of patients.
For the future we may need a more tailored approach to pain management in selected patients undergoing complex surgery. In our opinion we will need both EDA and multimodal pain management strategies. In patients with chronic pain conditions, when NSAIDs are not recommended or in patients with an expected hospital stay of more than 5 days, EDA will often be our first option. With low risk profile (i.e. no significant renal or cardiopulmonary insufficiency, not advanced age) and minimally invasive procedures we will recommend multimodal analgesia or ultrasound guided truncal blocks were appropriate.
Due to the rapid development of new surgical techniques in abdominal surgery, studies to investigate the best way to provide postoperative pain relief to this patient group are warranted.
1. Lobo DN, Joshi GP. Pain management after abdominal surgery: requiem for epidural analgesia? Br J Surg 2024; 111 (12).
2. Hausken J, Fretland Å, Edwin B, et al. Intravenous Patient-controlled Analgesia Versus Thoracic Epidural Analgesia After Open Liver Surgery: A Prospective, Randomized, Controlled, Noninferiority Trial. Ann Surg 2019; 270 (2):193–199.
3. Fretland Å, Dagenborg VJ, Bjørnelv GMW, et al. Laparoscopic Versus Open Resection for Colorectal Liver Metastases: The OSLO-COMET Randomized Controlled Trial. Ann Surg 2018; 267 (2):199–207.
4. Kwon HJ, Kim YJ, Lee D, et al. Factors Associated With Rebound Pain After Patient-controlled Epidural Analgesia in Patients Undergoing Major Abdominal Surgery: A Retrospective Study. Clin J Pain 2022; 38 (10):632–639.
5. Cunningham DJ, Kovacs D, Norcross W, et al. The Impact of Early Epidural Discontinuation on Pain, Opioid Usage, and Length of Stay After Periacetabular Osteotomy. J Bone Joint Surg Am 2020; 102 (Suppl 2):59–65.
6. Pirie K, Traer E, Finniss D, et al. Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions. Br J Anaesth 2022; 129 (3):378–393.
7. Rawal N. Epidural analgesia for postoperative pain: Improving outcomes or adding risks? Best Pract Res Clin Anaesthesiol 2021; 35 (1):53–65.
Jon HAUSKEN (Oslo, Norway)
09:06 - 09:28
#48680 - FT03 Strong pain at nerve block resolution: How to transit a brachial plexus block.
Strong pain at nerve block resolution: How to transit a brachial plexus block.
Brachial plexus blocks provide excellent analgesia during the sensory blockade. However, the abrupt termination of the analgesic effect after single-injection techniques, often referred to as «rebound pain», is a major problem that needs consideration. Without sufficient prophylaxis, up to 50-80% of patients report strong pain (NRS 7-10) at block resolution (1-4). This pain is especially problematic in ambulatory surgery, where the patients are often discharged and at home when the nerve block wears off. Sufficient prophylactic strategies may reduce the incidence significantly (5,6).
The major strategies suggested to reduce strong pain at block resolution are to identify patients at risk, thoroughly inform all patients, use timely multimodal and prophylactic analgesia, add adjuvant medication to prolong block duration, and use continuous brachial plexus blocks when adequate. It is important to combine several strategies.
Vulnerable patients should be identified. The presence of preoperative pain, younger age, female gender, surgery involving bone, and psychosocial factors like depression or a catastrophic perception of pain are known risk factors for strong pain at block resolution (1,2,7,8).
All patients receiving brachial plexus blocks should be informed thoroughly and repeatedly regarding the expected post-surgical pain, block duration and offset, and how to manage the pain when the nerve block resolves. Whereas patients emerging from general anaesthesia usually receive titrated analgesics in the PACU, patients with a brachial plexus block usually leave the PACU pain-free. At block resolution, often in the middle of the night, the patients are usually in the ward or discharged at home without professional guidance for titration of analgesia (9,10). A perioperative plan for pain management is therefore crucial to prevent strong pain and help patients better handle the situation.
The use of multimodal and prophylactic analgesia is important. The patients should be informed about both medical and non-medical measures to reduce pain. The analgetic regime should be initiated timely and include paracetamol, anti-inflammatory prophylaxis with NSAIDs or COX-2 inhibitors, and oral rescue opioids in patients without contraindications. Other analgesics should be considered according to the expected postoperative pain. If the patients experience pain at block resolution, they should be instructed to take analgesics earlier rather than later to reduce the intensity and severity of the pain.
As nociceptive input and pain usually decline during the hours after surgery, measures to prolong the duration of the sensory block seem to reduce pain at brachial plexus block resolution (5,11-13). Current measures may include long-acting local anaesthetic solutions, the use of oral, intravenous, or perineural adjuvants, or continuous nerve block catheters.
Local anaesthetic solution should be chosen according to the expected pain after surgery. To further increase the duration of the nerve block, oral, intravenous, or perineural adjuvants could be added. Adjuvants suggested for brachial plexus blocks include adrenaline, clonidine, dexmedetomidine, ketamine, magnesium, dexamethasone and buprenorphine. Most of them are not officially approved for perineural administration (14).
Dexamethasone is so far the single most important and best documented strategy to reduce strong pain at nerve block resolution. Studies exploring the effect of dexamethasone have found only minor differences between perineural and intravenous administration. An interesting study on bilateral saphenous nerve blocks found only an inconsistent and modest block prolongation on the side with perineural dexamethasone of minor clinical importance; hence, the effect of dexamethasone seems to be mainly systemic (15). A systematic review and meta-analysis comparing perineural with intravenous dexamethasone found prolonged analgesia with the perineural approach when injected with bupivacaine (approximately 4 hours), but not with ropivacaine (16). Both iv and perineural doses of more than 8 mg of dexamethasone seem to result in similar prolongation of ropivacaine blocks (16-19). Oral dexamethasone is also shown to prolong nerve block duration and significantly reduce rebound pain (20). As the effect of perineural and intravenous dexamethasone seems to be similar, and dexamethasone is not licensed for perineural use, intravenous or oral use is recommended.
Perineural clonidine and dexmedetomidine prolong nerve block duration but are not shown to reduce pain at block resolution (6). The use is associated with side effects like sedation, bradycardia, and dizziness (6). Compared with dexamethasone for brachial plexus blocks, dexmedetomidine seems to be an inferior adjunct as it has a shorter duration of analgesia (equivalent to 2.5 hours) with more prominent side-effects (21). Therefore, dexamethasone seems to be a better alternative for most patients.
Ketamine has shown conflicting results, and it is currently unclear if it reduces the occurrence of rebound pain at block resolution (4,6,18,22), whereas intravenous magnesium has recently been suggested to prolong nerve block duration and reduce rebound pain (23). Both intravenous and perineural buprenorphine prolong the duration of postoperative analgesia, but lead to a significant increase in PONV and carry a risk of sedation and respiratory depression, which makes dexamethasone a better alternative for most patients (24).
The use of liposomal bupivacaine to prolong the duration of nerve blocks has been highly debated, and several meta-analyses have failed to show clinically relevant differences compared with conventional long-acting local anaesthetic solutions (25,26). A recently published review article by Hardrick and colleagues on liposomal bupivacaine for brachial plexus blocks shows moderately decreased pain scores on postoperative day 1 and 2 and a small reduction in postoperative opioid consumption (-3.51 OMED) compared with bupivacaine or ropivacaine. However, they concluded the differences may not be of clinical significance and that the benefits for the patients were questionable and may not justify the increased costs (27).
A well-placed nerve block catheter provides excellent analgesia for several days after surgery (7). The drawback is that the procedure is time-consuming and more challenging than a single injection technique, is more labour-intensive to manage, and the catheters have an inherent failure rate and may dislocate. Therefore, the technique is usually reserved for patients with expected strong postoperative pain for several days.
To summarise, to reduce strong pain at brachial plexus block resolution, oral or intravenous dexamethasone prolong nerve block duration, reduce inflammation and subsequently pain, and seem to be the single most important strategy to reduce pain at block resolution. Dexamethasone should be combined with thorough patient education and preventive and multimodal analgesic strategies.
References:
1. Barry GS, Bailey JG, Sardinha J, Brousseau P, Uppal V. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery. Br J Anaesth. 2021;126(4):862-71.
2. Lavand'homme P. Rebound pain after regional anesthesia in the ambulatory patient. Curr Opin Anaesthesiol. 2018;31(6):679-84.
3. Holmberg A, Sauter AR, Klaastad O, Draegni T, Raeder JC. Pre-operative brachial plexus block compared with an identical block performed at the end of surgery: a prospective, double-blind, randomised clinical trial. Anaesthesia. 2017;72(8):967-77.
4. Jeng CL. (April 15, 2025). Overview of peripheral nerve blocks. In: UpToDate, Maniker R (Ed), Wolters Kluwer. (Accessed: June 20, 2025).
5. Holmberg A, Hassellund SS, Draegni T, Nordby A, Ottesen FS, Gulestol A, et al. Analgesic effect of intravenous dexamethasone after volar plate surgery for distal radius fracture with brachial plexus block anaesthesia: a prospective, double-blind randomised clinical trial(). Anaesthesia. 2020;75(11):1448-60.
6. Murphy KJ, O'Donnell B. Rebound Pain-Management Strategies for Transitional Analgesia: A Narrative Review. J Clin Med. 2025;14(3).
7. Munoz-Leyva F, Cubillos J, Chin KJ. Managing rebound pain after regional anesthesia. Korean J Anesthesiol. 2020;73(5):372-83.
8. Sort R, Brorson S, Gogenur I, Nielsen JK, Moller AM. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study. Acta Anaesthesiol Scand. 2019;63(3):396-402.
9. Sunderland S, Yarnold CH, Head SJ, Osborn JA, Purssell A, Peel JK, et al. Regional Versus General Anesthesia and the Incidence of Unplanned Health Care Resource Utilization for Postoperative Pain After Wrist Fracture Surgery: Results From a Retrospective Quality Improvement Project. Reg Anesth Pain Med. 2016;41(1):22-7.
10. Galos DK, Taormina DP, Crespo A, Ding DY, Sapienza A, Jain S, et al. Does Brachial Plexus Blockade Result in Improved Pain Scores After Distal Radius Fracture Fixation? A Randomized Trial. Clin Orthop Relat Res. 2016;474(5):1247-54.
11. Barrio J, Madrid E, Gil E, Richart MT, Sanchez de Meras A. Influence of sensory block duration on rebound pain after outpatient orthopaedic foot surgery under popliteal sciatic nerve block: an observational study. Anaesthesia. 2025;80(5):582-3.
12. Williams BA, Bottegal MT, Kentor ML, Irrgang JJ, Williams JP. Rebound pain scores as a function of femoral nerve block duration after anterior cruciate ligament reconstruction: retrospective analysis of a prospective, randomized clinical trial. Reg Anesth Pain Med. 2007;32(3):186-92.
13. Luebbert E, Rosenblatt MA. Postoperative Rebound Pain: Our Current Understanding About the Role of Regional Anesthesia and Multimodal Approaches in Prevention and Treatment. Curr Pain Headache Rep. 2023;27(9):449-54.
14. Albrecht E, Chin KJ. Advances in regional anaesthesia and acute pain management: a narrative review. Anaesthesia. 2020;75 Suppl 1:e101-e10.
15. Jæger P, Grevstad U, Koscielniak-Nielsen ZJ, Sauter AR, Sørensen JK, Dahl JB. Does dexamethasone have a perineural mechanism of action? A paired, blinded, randomized controlled study in healthy volunteers. Br J Anaesth. 2016;117(5):635-41)
16. Baeriswyl M, Kirkham KR, Jacot-Guillarmod A, Albrecht E. Efficacy of perineural vs systemic dexamethasone to prolong analgesia after peripheral nerve block: a systematic review and meta-analysis. Br J Anaesth. 2017;119(2):183-91.
17. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth. 2013;111(3):445-52.
18. Touil N, Pavlopoulou A, Barbier O, Libouton X, Lavand'homme P. Evaluation of intraoperative ketamine on the prevention of severe rebound pain upon cessation of peripheral nerve block: a prospective randomised, double-blind, placebo-controlled study. Br J Anaesth. 2022;128(4):734-41.
19. Rosenfeld DM, Ivancic MG, Hattrup SJ, Renfree KJ, Watkins AR, Hentz JG, et al. Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia. 2016;71(4):380-8.
20. Maagaard M, Plambech MZ, Funder KS, Schou NK, Molgaard AK, Stormholt ER, et al. The effect of oral dexamethasone on duration of analgesia after upper limb surgery under infraclavicular brachial plexus block: a randomised controlled trial. Anaesthesia. 2023;78(12):1465-71.
21. Albrecht, E., Vorobeichik, L., Jacot-Guillarmod, A., Fournier, N. and Abdallah, F.W. Dexamethasone Is Superior to Dexmedetomidine as a Perineural Adjunct for Supraclavicular Brachial Plexus Block: Systematic Review and Indirect Meta-analysis Anesth Analg. 2019;128(3):543-554.
22. Li Q, Tian S, Zhang L, Chai D, Liu J, Sheng F, et al. S-Ketamine Reduces the Risk of Rebound Pain in Patients Following Total Knee Arthroplasty: A Randomized Controlled Trial. Drug Des Devel Ther. 2025;19:2315-27.
23. Soeding P, Morris A, Soeding A, Hoy G. Effect of intravenous magnesium on post-operative pain following Latarjet shoulder reconstruction. Shoulder Elbow. 2024;16(1):46-52.
24. Schnabel A, Reichl SU, Zahn PK, Pogatzki-Zahn EM, Meyer-
Frie.em CH. Efficacy and safety of buprenorphine in peripheral nerve
blocks: A meta-analysis of randomised controlled trials. Eur J Anaesthesiol)2017; 34: 576-586).
25. Poeran J, Hong G, Memtsoudis SG. Free academic discourse and the law: the case of liposomal bupivacaine. Reg Anesth Pain Med 2023; 48(10):526-529
26. Lahaye L, Coleman JR (February 4, 2025). Clinical use of local anesthetics in anesthesia. In: UpToDate, Maniker R (Ed), Wolters Kluwer. (Accessed: June 29, 2025).
27. Hardrick J et al. Orthopaedics and Traumatology: Surgery & research. https://doi.org/10.1016/j.otsr.2025.104190
Anne HOLMBERG (Oslo, Norway)
09:28 - 09:55
Q&A.
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B20
NETWORKING SESSION
Science for scientists
NETWORKING SESSION
Science for scientists
Chairperson:
Sam ELDABE (Consultant Pain Medicine) (Chairperson, Middlesbrough, United Kingdom)
08:00 - 08:00
Introduction.
08:00 - 08:22
Academic fraud.
Kariem EL BOGHDADLY (Consultant) (Keynote Speaker, London, United Kingdom)
08:22 - 08:44
Minimal clinically important difference.
Neel DESAI (Consultant in Anaesthetics) (Keynote Speaker, London, United Kingdom)
08:44 - 09:06
What should we be studying?
Alan MACFARLANE (Consultant Anaesthetist) (Keynote Speaker, Glasgow, United Kingdom)
09:06 - 09:28
PERMS ans PROMS as relevant endpoints.
Xavier CAPDEVILA (MD, PhD, Professor, Head of department) (Keynote Speaker, Médecin, Montpellier, France)
09:28 - 09:50
Q&A.
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C20
LIVE DEMONSTRATION
Invasive treatments for joint pain
LIVE DEMONSTRATION
Invasive treatments for joint pain
Demonstrators:
Vedran FRKOVIC (Senior Consultant in Anaesthesiology and pain medicine) (Demonstrator, Linkoping/ Sweden, Sweden), Andrzej KROL (Consultant in Anaesthesia and Pain Medicine) (Demonstrator, LONDON, United Kingdom)
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D20
NETWORKING SESSION
Goal based neuromodulation
NETWORKING SESSION
Goal based neuromodulation
Chairperson:
Athina VADALOUCA (Pain and palliative care medicine) (Chairperson, Athens, Greece)
08:00 - 08:00
Introduction.
08:00 - 08:22
#48625 - FT22 PATIENT SELECTION FROM CLINICAL DIAGNOSIS TO TESTING.
PATIENT SELECTION FROM CLINICAL DIAGNOSIS TO TESTING.
Pasquale De Negri MD,ESRA-DPM, FIPP*; Clara De Negri MD*
* Department of Anaesthesia, Intensive Care and Pain Medicine- Azienda Ospedaliera di Rilievo Nazionale S. Anna e S.Sebastiano - Caserta, Italy
Spinal Cord Stimulation (SCS) is an established technique for the treatment of refractory chronic pain, especially neuropathic pain. Careful patient selection is crucial to optimize outcomes and reduce therapeutic failures. SCS involves the implantation of epidural electrodes connected to a pulse generator, modulating pain transmission at the spinal cord level. It is mainly indicated for chronic neuropathic pain but is also used in other selected conditions. Main indications of SCS are: Refractory chronic neuropathic pain (e.g., Complex Regional Pain Syndrome, CRPS) , PSPS type I and II (Failed Back Surgery Syndrome - FBSS, Chronic non-operable radicular pain/ lumbar stenosis) , Painful diabetic neuropathy ,Critical limb ischemia (in selected cases)
Inclusion Criteria,
Clear and documented diagnosis. The ideal candidate has a definite diagnosis of chronic neuropathic pain, confirmed by clinical and instrumental tests (EMG, imaging, pain assessment scales such as DN4 or painDETECT).The SCS e-tool can be used to standardize and document these criteria efficiently, ensuring all key diagnostic steps are captured.
Duration and severity of pain: pain present for at least 6 months ; severe intensity (VAS/NRS > 6/10); proven failure of conventional treatments (pharmacological, physiotherapy, injections).The SCS e-tool helps to track and record pain duration, severity, and previous therapies, making the selection process more objective.
Response to previous treatments: the patient must have tried, without lasting benefit, at least two classes of medications (antiepileptics, antidepressants, opioids, etc.), plus physical and psychological therapies.This information can be systematically entered and monitored using the SCS e-tool.
Psychological and motivational status: it is essential to exclude uncontrolled severe psychiatric disorders (major depression, psychosis, substance abuse). A pre-implant psychological assessment is recommended to identify risk factors for failure or complications.The SCS e-tool can include checklists or templates to ensure psychological criteria are properly evaluated and documented.
Ability to manage the device:the patient must be able to understand and manage the device, with family support if needed.The SCS e-tool can help assess and record the patient’s ability to manage the device, as well as the availability of social support.
Exclusion Criteria: Pain of non-neuropathic origin (pure nociceptive), active systemic or local infections, uncorrectable coagulopathies, significant psychiatric instability, limited life expectancy (<1 year), non-adherence to therapies or lack of social support.The SCS e-tool provides a structured exclusion checklist, minimizing the risk of missing contraindications.
Multidisciplinary Evaluation: optimal selection requires a multidisciplinary approach, involving: Pain specialist, Neurosurgeon, Psychologist/Psychiatrist, Physiatrist.The SCS e-tool can be used collaboratively during team meetings to review, share, and document patient eligibility, ensuring all perspectives are considered and recorded.
Stimulation Trial: before permanent implantation, a trial period (whose length varies considerably across different healthcare systems and even within individual countries) may be performed. Success is defined by pain reduction ≥50%, significant functional improvement, and subjective patient satisfaction. Only those who pass the trial proceed to permanent implantation.
Prognostic Factors
Positive Factors: pure neuropathic pain (vs. mixed), pain duration <2 years, absence of major psychiatric comorbidities, good family/social support, low dose opioids.
Negative Factors: diffuse-poorly localized pain, high-dose opioid dependence, multiple surgical failures, poor motivation or compliance. The SCS e-tool can help to weigh these prognostic factors and track them over time for each candidate.
Ethical Aspects and Informed Consent. It is essential to provide clear, complete, and realistic information about expectations, risks (infections, lead displacement, device malfunction), and the limitations of SCS. Informed consent must be thoroughly documented.
Follow-up and long-term management. SCS requires regular follow-up to monitor clinical efficacy, manage complications or malfunctions, and optimize device programming. Multidisciplinary follow-up is recommended, especially in the first 12 months after implantation.
Evidence and Guidelines. Major scientific societies (International Neuromodulation Society, EFIC, NICE) emphasize the importance of rigorous selection. Success rates exceed 60-70% in well-selected cases, but drop significantly if criteria are not met.The SCS e-tool can help ensure that your practice aligns with current guidelines and evidence-based protocols.
Conclusion: Patient selection for SCS is a complex process requiring the adoption of rigorous selection criteria: a multidisciplinary evaluation, accuracy, and attention to both clinical and psychological aspects are key elements for the success of SCS in chronic neuropathic pain. Careful selection increases the chances of success and reduces the risk of complications or dissatisfaction.The integration of the SCS e-tool streamlines each step, providing structured support for patient selection and allows for maximization of clinical benefits, minimization of risks, and a more effective and sustainable management of patients eligible for SCS.
References
1)Deer T, Pope J, Hayek S, et al. Neurostimulation for the treatment of axial back pain: a review of mechanisms, techniques, outcomes, and future advances. Neuromodulation. 2014 Oct;17 Suppl 2:52-68. doi: 10.1111/j.1525-1403.2012.00530.x.
2)North RB, Calodney A, Bolash R, et al. Redefining Spinal Cord Stimulation "Trials": A Randomized Controlled Trial Using Single-Stage Wireless Permanent Implantable Devices. Neuromodulation. 2020 Jan;23(1):96-101. doi: 10.1111/ner.12970. Epub 2019 Jun 3.
3)Thomson S, Huygen F, Prangnell S,et al. Applicability and Validity of an e-Health Tool for the Appropriate Referral and Selection of Patients With Chronic Pain for Spinal Cord Stimulation: Results From a European Retrospective Study. Neuromodulation. 2023 Jan;26(1):164-171
4)Eldabe S, Duarte RV, Gulve A, et al. Does a screening trial for spinal cord stimulation in patients with chronic pain of neuropathic origin have clinical utility and cost-effectiveness (TRIAL-STIM)? A randomised controlled trial. Pain. 2020 Dec;161(12):2820-2829. doi: 10.1097/j.pain.0000000000001977.
5)De Negri P, Paz-Solis JF, Rigoard P, et al. Real-world outcomes of single-stage spinal cord stimulation in chronic pain patients: A multicentre, European case series. Interv Pain Med. 2023 Jun 24;2(3):100263. doi: 10.1016/j.inpm.2023.100263.
6)Thomson, S., Helsen, N., Prangnell, et al. Patient selection for spinal cord stimulation: The importance of an integrated assessment of clinical and psychosocial factors. European Journal of Pain 2022, 26(9), 1873-1881.doi.org/10.1002/ejp.2009
Pasquale DE NEGRI (Caserta, Italy), Clara DE NEGRI
08:22 - 08:44
Technology at the service: Machine learning to improve outcome.
Reda TOLBA (Department Chair and Professor) (Keynote Speaker, Abu Dhabi, United Arab Emirates)
08:44 - 09:06
#48663 - FT21 Validity of genomic expression and patient profiles to predict outcomes.
Validity of genomic expression and patient profiles to predict outcomes.
Introduction
The prediction of clinical outcomes in spinal cord stimulation (SCS) for chronic pain is crucial as it enables the optimization of patient selection, enhances therapeutic efficacy, reduces unnecessary interventions, and minimizes costs and risks associated with invasive procedures. Given that 30–40% of patients do not achieve sustained relief after neurostimulator implantation, identifying potential responders beforehand is key to avoiding explantations, patient dissatisfaction, and healthcare system burdens, as emphasized by the American Academy of Pain Medicine in its consensus guidelines (1).
The integration of patient profiles and biomarkers, including gene expression and clinical characteristics, has shown potential to improve response prediction. Gene expression plays an emerging role in personalized medicine for chronic pain, particularly in predicting clinical outcomes and optimizing patient selection for SCS. Gene expression analysis can identify underlying biological processes such as inflammation, neuroimmune modulation, and tissue repair mechanisms, which may influence SCS response (2-4).
However, current evidence indicates that while altered genes and biological pathways have been identified in chronic pain patients and SCS responders, no specific gene signatures reliably predict individual clinical responses to SCS to date. Changes in genes like proenkephalin (PENK) and inflammatory cytokines correlate with clinical progression, but their utility as standalone predictive biomarkers remains limited and requires further validation (2, 3).
The use of gene panels and next-generation sequencing has advanced understanding of pain’s genetic architecture and opened avenues for patient stratification, though routine clinical application is not yet established (5, 6).
Patient clinical profiles, such as age and comorbidities, are also relevant for outcome prediction and personalized SCS candidacy. Older age is associated with higher explantation risk and lower long-term success rates, while obesity increases complication risks and reduces therapy efficacy. Untreated psychiatric comorbidities, particularly depression, are linked to poorer outcomes and are considered relative contraindications (1).
Clinical profiles should assess sex, body mass index, pain duration, and neuropathic pain presence, as these influence treatment response. For example, neuropathic pain and female sex correlate with higher response likelihood, whereas advanced age and depression reduce functional improvement odds (7, 8).
While the integration of gene expression and personalized medicine is promising, validated genetic biomarkers for reliable SCS response prediction remain elusive. However, combining clinical, neurophysiological, and genetic data via machine learning models shows potential to enhance prediction and candidate selection, though routine clinical use is not yet established (9-11).
Comprehensive clinical profiling and personalized medicine tools are essential to optimize patient selection and maximize SCS benefits for chronic pain (7, 8).
The ability to predict clinical outcomes in spinal cord stimulation is important to maximize clinical benefit, reduce risks and costs, and move towards precision medicine in the treatment of chronic pain (9).
Principles of gene expression and their measurement
Fundamental gene expression principles involve DNA transcription to messenger RNA (mRNA) and subsequent translation into functional proteins, which determine cellular phenotype and pathophysiological responses, including chronic pain perception and modulation. In personalized medicine and SCS outcome prediction, precise gene expression quantification helps identify biomarkers, molecular pathways, and response profiles to guide candidate selection and therapeutic optimization (12, 13).
The main techniques for measuring gene expression include:
• Gene expression microarrays: Analyze thousands of known genes simultaneously via labeled mRNA hybridization to specific probes. Useful for cross-group expression comparisons but limited to annotated genes and less sensitive for low-abundance genes (12, 14).
• RNA Sequencing (RNA-Seq): Uses next-generation sequencing to globally quantify all sample transcripts, including unannotated genes, splice variants, and non-coding RNA. RNA-Seq offers higher sensitivity, dynamic range, and discovery potential than microarrays, making it the preferred method for transcriptomic studies in chronic pain and SCS (14, 15).
• Proteomic analysis: Directly assesses protein levels and modifications, the functional end-products of gene expression. Though complementary, proteomics is more complex and less routine for clinical prediction but can elucidate action mechanisms and therapeutic targets (16).
Gene Expression Applications in Personalized Medicine
Gene expression profiles are used in other diseases for prediction and personalized medicine, particularly in oncology. Clinically validated examples include:
• Breast cancer: The Oncotype DX test analyzes 21-gene expression in hormone receptor-positive, HER2-negative tumors, stratifying patients into low-, intermediate-, and high-recurrence risk groups. This personalizes chemotherapy decisions, sparing low-risk patients unnecessary toxicity while ensuring high-risk patients receive beneficial therapies. Oncotype DX and similar panels (MammaPrint, PAM50, EndoPredict) are supported by multiple studies and recommended by the Evaluation of Genomic Applications in Practice and Prevention Working Group for early breast cancer (17, 18).
• Colon cancer: The ColoPrint test (18-gene analysis) stratifies recurrence risk in stage II colon cancer, guiding adjuvant chemotherapy decisions (19).
• Acute myeloid leukemia (AML): Gene expression profiles subclassify AML and predict therapy response, though no universally adopted commercial panel exists (20).
• Lung cancer: Panels like VeriStrat predict EGFR inhibitor response in advanced non-small cell lung cancer, though use is less widespread than in breast cancer (21).
Integrating Clinical and Omics Data
Integrating clinical and omics data (genomics, transcriptomics, proteomics, etc.) in predictive models is essential for personalized medicine, as it captures biological complexity and interindividual heterogeneity. Clinical data provide consolidated phenotypic and prognostic information, while omics data reveal underlying molecular mechanisms, functional alterations, and therapeutic targets not detectable with clinical variables alone (22, 23).
This integration improves clinical outcome prediction accuracy, risk stratification, disease subclassification, and personalized treatment selection, outperforming models based solely on clinical or single-omics data. For example, in breast cancer, combining clinical and multi-omics profiles enhances survival and therapy response prediction (24, 25).
Multi-omics approaches also identify composite biomarkers and relevant biological pathways, enabling precision medicine where clinical data are insufficient or ambiguous (22, 26).
Limitations of Clinical-Omics Integration
Common limitations include:
• Sample heterogeneity: Variability in sample quality, origin, and processing introduces biases and reduces model reproducibility. Differences in data collection, technologies, and studied populations hinder generalizability (27-29).
• Overfitting: High omics variable counts versus limited patient samples ("curse of dimensionality") can cause models to overfit training data, impairing external cohort performance. Robust validation and variable selection strategies are critical (28, 29)
• Lack of external validation: Many integrative models lack validation in independent cohorts, limiting their clinical applicability and robustness. The absence of external validation is one of the main reasons why few models are ever implemented in clinical practice (30).
Other challenges include missing data, class imbalances (e.g., few events vs. many controls), data harmonization difficulties, and incomplete clinical integration, which may yield less parsimonious models (27, 31, 32).
Addressing these requires rigorous study design, quality control, appropriate statistical/machine learning methods, and multicenter validation (28, 30).
Genomic Expression as a Predictor in Neuromodulation
Examples of gene expression profiles for neuromodulation outcome prediction focus on identifying biomarkers and therapeutic targets to guide patient selection and therapy personalization.
Transcriptomic studies of dorsal root ganglia and spinal cord have identified gene signatures linked to neuropathic pain and SCS response. For instance, differential expression of genes related to immune signaling, neuronal plasticity, and endogenous opioid modulation has been associated with chronic pain development and maintenance, suggesting predictive potential for neuromodulation (33-35).
Validated blood-based gene combinations (e.g., SH3BGRL3, TMEM88, CASP9) distinguish neuropathic pain patients from controls and could stratify candidates for advanced therapies like neuromodulation (36, 37). Gene expression analysis has also identified potential pharmacological targets, such as the Syk tyrosine kinase pathway, preclinically validated as a pain modulator post-neuromodulation (33).
Though not yet standard clinical practice, integrating gene expression with clinical and neurophysiological data represents a promising path for personalized neuromodulation outcome prediction (36, 37).
In animal neuropathic pain models, SCS modulates inflammation-, glial activation-, and neurotransmission-related genes. Differential programming (e.g., DTMP) reverses microglial and neuronal gene expression toward healthy profiles, correlating with behavioral pain improvement. SCS waveform intensity and type differentially modulate key pain genes (e.g., cFos, GABAbr1, 5HT3ra, TNFα), with gene modulation-clinical improvement correlations observed (38-42).
Our research group conducted a genomic association study in humans with persistent spinal pain syndrome type 2 (PSPS 2) to explore SCS response predictors. High-density microarrays analyzed serum gene expression in PSPS 2 patients versus pain-free post-lumbar surgery controls. Multivariate discriminant analysis and gene ontology enrichment identified relevant biological processes.
The study found 11 genes significantly downregulated in PSPS 2 patients, linked to heightened inflammation, tissue repair, and proliferative responses. Post-SCS, two additional downregulated genes suggested therapy-modulated inflammatory/restorative processes. However, no genes discriminated SCS responders from non-responders, indicating that while molecular alterations are associated with pain and therapeutic response, current serum gene expression cannot reliably predict individual outcomes (2).
Our group also investigated SCS-induced serum proteomic changes in PSPS 2 patients. Mass spectrometry compared protein profiles pre-/post-SCS and between responders/non-responders and controls. Multivariate discriminant and bioinformatic analyses identified relevant biological processes.
Results showed PSPS 2 alterations in inflammation-, immunity-, iron metabolism-, and synaptic signaling-related proteins. SCS modulated these processes, reducing inflammatory proteins and increasing neuronal repair markers. Though molecular differences correlated with clinical response, serum protein expression could not reliably predict SCS response, highlighting biomarker potential and limitations for chronic pain personalization (43).
Clinical profiles (demographics, comorbidities) showed no significant responder/non-responder differences. Overall, integrating gene expression and clinical data does not yet enable robust SCS response prediction in PSPS 2 but elucidates underlying mechanisms, particularly neuroimmune modulation and tissue repair (2). Clinical application requires further validation (44).
Current Challenges and Future Directions
Challenges in using gene expression and clinical profiles for neuromodulation outcome prediction include sample heterogeneity, model overfitting, and lack of external validation. Variability in sample processing and phenotypic diversity limit reproducibility. Overfitting arises from high omics variable counts versus small sample sizes, often yielding non-replicable models. Most studies lack robust external validation, restricting clinical applicability (10, 11, 45-47).
Currently, no validated genomic biomarkers reliably predict individual SCS responses, though genes/pathways linked to inflammation, neuronal plasticity, and immune modulation may hold future predictive value (48, 49). Integrative models combining clinical, neurophysiological (e.g., intraoperative EEG), and self-report data show promising accuracy but require multicenter validation and standardization before clinical adoption (10, 11, 45, 47).
Future integration of clinical and omics data via AI/machine learning, composite biomarker development, and large prospective registries will advance personalized neuromodulation, optimizing patient selection and outcomes. However, method standardization, external validation, and multicenter collaboration are essential to overcome current limitations and translate advances into clinical practice (10, 11, 45, 47).
References
1. Shanthanna H, Eldabe S, Provenzano DA, Bouche B, Buchser E, Chadwick R, et al. Evidence-based consensus guidelines on patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain. Reg Anesth Pain Med. 2023; 48(6):273-87.
2. Fabregat-Cid G, Cedeno DL, De Andrés J, Harutyunyan A, Monsalve-Dolz V, Mínguez-Martí A, et al. Insights into the pathophysiology and response of persistent spinal pain syndrome type 2 to spinal cord stimulation: a human genome-wide association study. Reg Anesth Pain Med. 2024.
3. De Andrés J, Navarrete-Rueda F, Fabregat G, García-Gutiérrez MS, Monsalve-Dolz V, Harutyunyan A, et al. Differences in Gene Expression of Endogenous Opioid Peptide Precursor, Cannabinoid 1 and 2 Receptors and Interleukin Beta in Peripheral Blood Mononuclear Cells of Patients With Refractory Failed Back Surgery Syndrome Treated With Spinal Cord Stimulation: Markers of Therapeutic Outcomes? Neuromodulation. 2021; 24(1):49-60.
4. Johnston KJA, Cote AC, Hicks E, Johnson J, Huckins LM. Genetically Regulated Gene Expression in the Brain Associated With Chronic Pain: Relationships With Clinical Traits and Potential for Drug Repurposing. Biol Psychiatry. 2024; 95(8):745-61.
5. Kringel D, Lötsch J. Knowledge of the genetics of human pain gained over the last decade from next-generation sequencing. Pharmacol Res. 2025;214:107667.
6. Kringel D, Malkusch S, Kalso E, Lötsch J. Computational Functional Genomics-Based AmpliSeq™ Panel for Next-Generation Sequencing of Key Genes of Pain. Int J Mol Sci. 2021; 22(2).
7. Bastiaens F, van de Wijgert IH, Bronkhorst EM, van Roosendaal BWP, van Heteren EPZ, Gilligan C, et al. Factors Predicting Clinically Relevant Pain Relief After Spinal Cord Stimulation for Patients With Chronic Low Back and/or Leg Pain: A Systematic Review With Meta-Analysis and Meta-Regression. Neuromodulation. 2024; 27(1):70-82.
8. Kapural L, Wu C, Calodney A, Pilitsis J, Bendel M, Petersen E, et al. Demographics and PainDETECT as Predictors of 24-Month Outcomes for 10 kHz SCS in Nonsurgical Refractory Back Pain. Pain Physician. 2024; 27(3):129-39.
9. De Andres J. Neurostimulation in the patient with chronic pain: forecasting the future with data from the present - data-driven analysis or just dreams? Reg Anesth Pain Med. 2024; 49(3):155-62.
10. Gopal J, Bao J, Harland T, Pilitsis JG, Paniccioli S, Grey R, et al. Machine learning predicts spinal cord stimulation surgery outcomes and reveals novel neural markers for chronic pain. Sci Rep. 2025; 15(1):9279.
11. Hadanny A, Harland T, Khazen O, DiMarzio M, Marchese A, Telkes I, et al. Development of Machine Learning-Based Models to Predict Treatment Response to Spinal Cord Stimulation. Neurosurgery. 2022; 90(5):523-32.
12. Segundo-Val IS, Sanz-Lozano CS. Introduction to the Gene Expression Analysis. Methods Mol Biol. 2016;1434:29-43.
13. Wang D, Kim H, Wang XM, Dionne R. Genomic methods for clinical and translational pain research. Methods Mol Biol. 2012;851:9-46.
14. Perkins JR, Antunes-Martins A, Calvo M, Grist J, Rust W, Schmid R, et al. A comparison of RNA-seq and exon arrays for whole genome transcription profiling of the L5 spinal nerve transection model of neuropathic pain in the rat. Mol Pain. 2014;10:7.
15. Wang D, Karamyshev AL. Next Generation Sequencing (NGS) Application in Multiparameter Gene Expression Analysis. Methods Mol Biol. 2020;2102:17-34.
16. Zhang J, Qi L, Sun Y, Chen S, Liu J, Chen J, et al. Integrated bioinformatics analysis of the effects of chronic pain on patients with spinal cord injury. Front Cell Neurosci. 2025;19:1457740.
17. Recommendations from the EGAPP Working Group: does the use of Oncotype DX tumor gene expression profiling to guide treatment decisions improve outcomes in patients with breast cancer? Genet Med. 2016; 18(8):770-9.
18. Berton Giachetti PPM, Carnevale Schianca A, Trapani D, Marra A, Toss A, Marchiò C, et al. Current controversies in the use of Oncotype DX in early breast cancer. Cancer Treat Rev. 2025;135:102887.
19. Maak M, Simon I, Nitsche U, Roepman P, Snel M, Glas AM, et al. Independent validation of a prognostic genomic signature (ColoPrint) for patients with stage II colon cancer. Ann Surg. 2013; 257(6):1053-8.
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21. Molina-Pinelo S, Pastor MD, Paz-Ares L. VeriStrat: a prognostic and/or predictive biomarker for advanced lung cancer patients? Expert Rev Respir Med. 2014; 8(1):1-4.
22. Olivier M, Asmis R, Hawkins GA, Howard TD, Cox LA. The Need for Multi-Omics Biomarker Signatures in Precision Medicine. Int J Mol Sci. 2019; 20(19).
23. Karczewski KJ, Snyder MP. Integrative omics for health and disease. Nat Rev Genet. 2018; 19(5):299-310.
24. Chakraborty S, Sharma G, Karmakar S, Banerjee S. Multi-OMICS approaches in cancer biology: New era in cancer therapy. Biochim Biophys Acta Mol Basis Dis. 2024; 1870(5):167120.
25. Vazquez AI, Veturi Y, Behring M, Shrestha S, Kirst M, Resende MF, Jr., et al. Increased Proportion of Variance Explained and Prediction Accuracy of Survival of Breast Cancer Patients with Use of Whole-Genome Multiomic Profiles. Genetics. 2016; 203(3):1425-38.
26. Ahmed Z. Practicing precision medicine with intelligently integrative clinical and multi-omics data analysis. Hum Genomics. 2020; 14(1):35.
27. López de Maturana E, Alonso L, Alarcón P, Martín-Antoniano IA, Pineda S, Piorno L, et al. Challenges in the Integration of Omics and Non-Omics Data. Genes (Basel). 2019; 10(3).
28. Khan SR, Manialawy Y, Wheeler MB, Cox BJ. Unbiased data analytic strategies to improve biomarker discovery in precision medicine. Drug Discov Today. 2019; 24(9):1735-48.
29. Mayer G, Heinze G, Mischak H, Hellemons ME, Heerspink HJ, Bakker SJ, et al. Omics-bioinformatics in the context of clinical data. Methods Mol Biol. 2011;719:479-97.
30. Glaab E, Rauschenberger A, Banzi R, Gerardi C, Garcia P, Demotes J. Biomarker discovery studies for patient stratification using machine learning analysis of omics data: a scoping review. BMJ Open. 2021; 11(12):e053674.
31. Volkmann A, De Bin R, Sauerbrei W, Boulesteix AL. A plea for taking all available clinical information into account when assessing the predictive value of omics data. BMC Med Res Methodol. 2019; 19(1):162.
32. Zhao J, Feng Q, Wei WQ. Integration of Omics and Phenotypic Data for Precision Medicine. Methods Mol Biol. 2022;2486:19-35.
33. Ghazisaeidi S, Muley MM, Tu Y, Finn DP, Kolahdouzan M, Pitcher GM, et al. Conserved transcriptional programming across sex and species after peripheral nerve injury predicts treatments for neuropathic pain. Br J Pharmacol. 2023; 180(21):2822-36.
34. North RY, Li Y, Ray P, Rhines LD, Tatsui CE, Rao G, et al. Electrophysiological and transcriptomic correlates of neuropathic pain in human dorsal root ganglion neurons. Brain. 2019; 142(5):1215-26.
35. Pokhilko A, Nash A, Cader MZ. Common transcriptional signatures of neuropathic pain. Pain. 2020; 161(7):1542-54.
36. Niculescu AB, Le-Niculescu H, Levey DF, Roseberry K, Soe KC, Rogers J, et al. Towards precision medicine for pain: diagnostic biomarkers and repurposed drugs. Mol Psychiatry. 2019; 24(4):501-22.
37. Young B, Stephenson J, Islam B, Burke NN, Jennings EM, Finn DP, et al. The Identification of Human Translational Biomarkers of Neuropathic Pain and Cross-Species Validation Using an Animal Model. Mol Neurobiol. 2023; 60(3):1179-94.
38. Cedeño DL, Kelley CA, Vallejo R. Effect of stimulation intensity of a differential target multiplexed SCS program in an animal model of neuropathic pain. Pain Pract. 2023; 23(6):639-46.
39. Smith WJ, Cedeño DL, Thomas SM, Kelley CA, Vetri F, Vallejo R. Modulation of microglial activation states by spinal cord stimulation in an animal model of neuropathic pain: Comparing high rate, low rate, and differential target multiplexed programming. Mol Pain. 2021;17:1744806921999013.
40. Tilley DM, Cedeño DL, Kelley CA, Benyamin R, Vallejo R. Spinal Cord Stimulation Modulates Gene Expression in the Spinal Cord of an Animal Model of Peripheral Nerve Injury. Reg Anesth Pain Med. 2016; 41(6):750-6.
41. Vallejo R, Gupta A, Kelley CA, Vallejo A, Rink J, Williams JM, et al. Effects of Phase Polarity and Charge Balance Spinal Cord Stimulation on Behavior and Gene Expression in a Rat Model of Neuropathic Pain. Neuromodulation. 2020; 23(1):26-35.
42. Vallejo R, Tilley DM, Cedeño DL, Kelley CA, DeMaegd M, Benyamin R. Genomics of the Effect of Spinal Cord Stimulation on an Animal Model of Neuropathic Pain. Neuromodulation. 2016; 19(6):576-86.
43. Fabregat-Cid G, Cedeño DL, Harutyunyan A, Rodríguez-López R, Monsalve-Dolz V, Mínguez-Martí A, et al. Effect of Conventional Spinal Cord Stimulation on Serum Protein Profile in Patients With Persistent Spinal Pain Syndrome: A Case-Control Study. Neuromodulation. 2023; 26(7):1441-9.
44. de Geus TJ, Franken G, Joosten EAJ. Spinal Cord Stimulation Paradigms and Pain Relief: A Preclinical Systematic Review on Modulation of the Central Inflammatory Response in Neuropathic Pain. Neuromodulation. 2023; 26(1):25-34.
45. Harland T, Elliott T, Telkes I, Pilitsis JG. Machine Learning in Pain Neuromodulation. Adv Exp Med Biol. 2024;1462:499-512.
46. Kansal A, Copley S, Duarte RV, Warren FC, Taylor RS, Eldabe S. Systematic Review to Identify Patient-Level Predictors of Treatment Response to Spinal Cord Stimulation for Neuropathic Pain for Studies Published From 2012 to 2024. Neuromodulation. 2025.
47. Mackey S, Aghaeepour N, Gaudilliere B, Kao MC, Kaptan M, Lannon E, et al. Innovations in acute and chronic pain biomarkers: enhancing diagnosis and personalized therapy. Reg Anesth Pain Med. 2025; 50(2):110-20.
48. Dib-Hajj SD, Waxman SG. Translational pain research: Lessons from genetics and genomics. Sci Transl Med. 2014; 6(249):249sr4.
49. Nagel SJ, Hsieh J, Machado AG, Frizon LA, Howard MA, 3rd, Gillies GT, et al. Biomarker Optimization of Spinal Cord Stimulation Therapies. Neuromodulation. 2021; 24(1):3-12.
Gustavo FABREGAT (Valencia, Spain)
Video Recording
09:06 - 09:28
System programming and practice guidelines.
Jose DE ANDRES (Tenured Professor) (Keynote Speaker, Valencia (Spain), Spain)
09:28 - 09:50
Q&A.
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E20
ASK THE EXPERT
When pain remains
ASK THE EXPERT
When pain remains
Chairperson:
Samer NAROUZE (Professor and Chair) (Chairperson, Cleveland, USA)
08:00 - 08:00
Introduction.
08:00 - 08:12
How important is the neuropathic component of chronic pain after surgery.
Esther POGATZKI ZAHN (Full Professor) (Keynote Speaker, Muenster, Germany)
08:12 - 08:50
Q&A.
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F20
ASK THE EXPERT
My secret training recipe
ASK THE EXPERT
My secret training recipe
Chairperson:
Alexandros MAKRIS (Anaesthesiologist) (Chairperson, Athens, Greece)
08:00 - 08:00
Introduction.
08:00 - 08:30
How to teach pediatric RA blocks to residents.
Karen BORETSKY (Senior Associate in Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine) (Keynote Speaker, Boston, USA)
08:30 - 09:05
Q&A.
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H20
SIMULATION TRAININGS
SIMULATION TRAININGS
Demonstrators:
Josip AZMAN (Consultant) (Demonstrator, Linkoping, Sweden), Hana HARAZIM (Physician) (Demonstrator, Brno, Czech Republic), Clara LOBO (Medical director) (Demonstrator, Abu Dhabi, United Arab Emirates), Lara RIBEIRO (Anesthesiologist Consultant) (Demonstrator, Braga-Portugal, Portugal), Roman ZUERCHER (Senior Consultant) (Demonstrator, Basel, Switzerland)
This interactive, simulation-based learning experience allows you to explore the complications of regional anaesthesia in a fun and engaging way! Covering several challenging daily clinical situations and crisis management cases from the fields of trauma, orthopaedics and obstetrics, it combines all kinds of simulation to provide an excellent learning resource.
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C20.1
LIVE DEMONSTRATION
Hip
LIVE DEMONSTRATION
Hip
Demonstrators:
Bartosz FRĄCZEK (Head of department) (Demonstrator, Kraków, Poland), Philip PENG (Office) (Demonstrator, Toronto, Canada)
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09:05-09:50
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F20.1
ASK THE EXPERT
Facts and wisdom in obstetric anesthesia
ASK THE EXPERT
Facts and wisdom in obstetric anesthesia
Chairperson:
Thierry GIRARD (Deputy head of anaesthesiology) (Chairperson, Basel, Switzerland)
09:05 - 09:05
Introduction.
09:05 - 09:25
Hot topics in obstetric anesthesia - an update from the journals.
Nuala LUCAS (Speaker) (Keynote Speaker, London, United Kingdom)
09:25 - 09:50
Q&A.
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09:20-09:50
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E20.1
ASK THE EXPERT
Thoracic outlet syndrome
ASK THE EXPERT
Thoracic outlet syndrome
Chairperson:
Martina REKATSINA (Assistant Professor of Anaesthesiology) (Chairperson, Athens, Greece)
09:20 - 09:20
Introduction.
09:20 - 09:40
#48686 - FT32 Thoracic Outlet Syndrome - How can we help ?
Thoracic Outlet Syndrome - How can we help ?
THORACIC OUTLET SYNDROME
How can we help?
Pablo Rojas Zamora MD, MSc (ICM)
Andrzej Krol, MD, DEAA, FRCA. FFPMRCA, ESRA-DPM
Department of Anaesthesia and Chronic Pain Services, St Georges University Hospital, Blackshaw Road, SW170QT, Tooting, London, UK
Introduction
Thoracic Outlet Syndrome (TOS) consists of a group of disorders secondary to compression of neurovascular structures that traverse the thoracic outlet space, is divided into 3 distinct spaces: interscalene triangle, costoclavicular space and subcoracoid (retropectoralis minor space) 1.
Within them, we find neurovascular structures such as the brachial plexus, subclavian artery, and subclavian vein. Compression in this region is believed to be secondary to a genetic/anatomical predisposition– such as cervical ribs- combined with repeated stress and trauma, causing a narrowing around the neurovascular structures 2,3,4. This condition significantly impacts upper limb function and quality of life, more particularly in individuals performing repetitive or overhead arm movements 5,6. Diagnosis of TOS remains challenging due to its overlapping symptomatology with other conditions 2,7.
Classification
TOS is traditionally classified in three subtypes based on the affected structure: neurogenic (nTOS), venous (vTOS), and arterial (aTOS).
rj 90% of reported cases is nTOS 8. This subtype tends to appear either at the interscalene triangle or retropectoralis minor space.
vTOS usually presents either at the interscalene triangle or costoclavicular space, causing vascular microtrauma leading to potential thrombosis 4.
aTOS commonly is seen at the interscalene space leading to potential aneurysmal formation and distal embolization 4.
Epidemiology
Prevalence is not well known likely due to variations in diagnostic criteria and patient presentation. Recent studies estimate a prevalence of around 1% 7, particularly more frequent amongst those aged 20 to 50 years, nTOS being the most frequent 7,9.
Clinical Presentation
By subtype:
nTOS is associated with paresthesia, trapezius pain, and weakness in the neck, shoulder, and arm, often exacerbated by upper arm overhead activity. Symptoms radiate into the hand and fingers, with chronic cases presenting with muscle atrophy, although rare, particularly in abductor pollicis brevis, hypothenar muscles and interossei (Gilliat-Summer) 4,5,8,10. Classically, pressure in a painful area triggers neurological symptoms (Positive Tinel’s sign). Special test maneuvers are the One-Minute Elevated Arm Stress Test (EAST) or Upper Limb Tension Test 1.
vTOS typically presents with swelling, cyanosis, and a feeling of heaviness in the affected limb. Rarely, deep vein thrombosis may occur (Paget-Schroetter syndrome), particularly in younger, active individuals 8,11. On examination, patients may show features of swelling and plethora in the arm.
aTOS manifests classically with pallor, cold sensitivity, reduced pulses, and in severe cases, distal embolic phenomena due to turbulent blood flow or arterial damage 8,12. A combination of Adson’s test with EAST is advised for diagnosis as it holds a combined the specificity of 82%, as Adson’s test specificity alone has been reported as low 5.
Symptoms of TOS might be presented as one subtype or a mixture of them in different proportion , history and examination supported by imaging such as CXR, MRI, EMG and US is a key to diagnosis 5.
Differential diagnosis is broad and may include: distal entrapment neuropathies, complex regional pain syndrome, rotator cuff pathology or malignancies.
Treatment
Treatment options have been classified into surgical and conservative.
Surgical decompression has been the main treatment option, especially in vascular types of TOS. Aim of surgery is to reduce the tensile load on the region either through first or cervical rib resection, scalenectomy, release fibromuscular bands or pectoralis minor tenotomy, depending on site of pathology. Recently, local anaesthetic injections have been increasingly in use to predict a successful operative outcome 1,4.
Non-surgical options include education, changing the profile of physical activity and targeted physical therapy specially when symptoms are more subtle, mainly in different forms of nTOS. More recently, new options have surfaced due to the increasing role of intramuscular and perineural targeted injections with diagnostic and therapeutic function.
Physical therapy has shown promising results mainly in nTOS specially by focusing on scapular and glenohumeral stability, but due to wide anatomical and symptomatologic variation results might be limited. Treatment should be continued for at least 6 months before considering more invasive interventions 4.
Local anaesthetic injections can be considered as first line treatment for nTOS or after failed physical therapy. Specific targeting with US while injecting local anaesthetic relaxes tensed muscles providing temporal symptomatic relief. A successful injection is defined as a >50% improvement in symptoms 4 hours after with a provocative test 4.
Botulinum toxin A (Botox) injections have shown to be a prognostic factor for successful surgery. Botox acts as a chemodenervation agent in the muscle, therefore reducing contraction. Relief is expected to range from 1 to 6 months and reduction of around 50% 1,4.
Ultrasound-guided hydrodissection relieves pressure through injecting high volume in the surrounding tissues, opening the space, improving passing neurovascular structures’ ability to glide through the dire passage. Various mixes of fluid have been injected, without consensus so far. Typically, mixtures of dextrose with saline with adjuvants such as LA, steroids and hyaluronidase. While hydrodissection has been increasingly established in various nerve entrapments, it still lacks validation in TOS 4.
We present our experience with the management of TOS through a mix of ultrasound hydrodissection with a large volume which contained: 10-20 ml of low concentration LA, 6 mg dexamethasone, 1500 u hyaluronidase, targeted brachial plexus pulsed radiofrequency [set up of 42ºC for 5 min, 5 PPS (pulse per second) ,5 ms pulse width] and 25-100 u Botox injection to interscalene or subclavius muscle depending on individual patient symptomatology.
Methods
A retrospective observational study was conducted at St George’s Hospital, in London, including 14 patients diagnosed with TOS who had undergone a combination of ultrasound-guided hydrodissection, Botox injection, and local anesthetic administration at least one year prior to data collection.
Informed consent was obtained from all participants via telephone follow-up. Patient-reported outcomes were collected, including Visual Analog Scale (VAS) for pain, painDETECT questionnaire for neuropathic pain components, and EQ-5D-5L for quality-of-life assessment. Data on duration of symptomatic relief and percentage of symptom reduction were also recorded and analyzed.
Results
14 patients were contacted and 8 (57%) were consented to participate. Among these, 6 patients (75%) reported a significant symptom improvement defined as greater than 50% relief.
The duration of symptom relief varied broadly, ranging from 2 weeks up to 6 months, with a mean duration of 2.5 months. 4 patients had undergone surgical intervention; and out of these, 2 (50%) had injection therapy due to postoperative complications. This subgroup exhibited a trend towards shorter duration of symptom relief and reported poorer quality of life, as reflected in lower EQ-5D-5L scores, suggesting a more refractory disease course. Regarding treatment frequency, 60% of patients received only one course, whereas the remainder received multiple injections (two or more), with a noted decline in the magnitude and duration of symptomatic relief upon subsequent injections.
Conclusion
Our findings support that ultrasound-guided hydrodissection combined with pulsed radiofrequency and botulinum toxin injections offers a promising non-surgical therapeutic option for selected patients with TOS, particularly those with neurogenic symptoms refractory to conservative management. The observed symptom relief, averaging around 2.5 months, underscores the potential utility of these minimally invasive interventions as both diagnostic and therapeutic modalities, consistent with emerging evidence in the literature4. Patients with previous surgical intervention seemed to have a more challenging clinical course, evidenced by shorter and less robust responses to injection therapy. The results of our short survey highlights the need for individualized treatment planning and further investigation into optimizing the timing and combination of interventions. These initial results are encouraging, and further larger prospective studies are required to establish standardized protocols and to elucidate long-term efficacy.
References
1. Foley J, Finlayson H, Travlos A. A Review of Thoracic Outlet Syndrome and the Possible Role of Botulinum Toxin in the Treatment of This Syndrome. Toxins. 2012 Nov 7;4(11):1223–35.
2. Chang KZ, Likes K, Davis K, Demos J, Freischlag JA. The significance of cervical ribs in thoracic outlet syndrome. J Vasc Surg. 2013;57(3):771–5.
3. Rochkind S, Shemesh M, Graif M, et al. Thoracic outlet syndrome part 2: Consensus on the management of neurogenic thoracic outlet syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery. Neurosurgery. 2023;92(1):E1–E10.
4. Capodosal G, Holden D, Maloy W, Schroeder JD. Thoracic Outlet Syndrome. Current Sports Medicine Reports [Internet]. 2024 Sep 1;23(9):303–9.
5. Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D, et al. Thoracic Outlet Syndrome: A Narrative Review. J Clin Med. 2021;10(5):962.
6. Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics. 2006;26(6):1735–50.
7. Serra R, Grande R, Perri P. Epidemiology, diagnosis and treatment of thoracic outlet syndrome: A systematic review. Acta Phlebologica. 2015;16(2):53–63.
8. Dengler NF, Ferraresi S, Rochkind S, Denisova N, Garozzo D, Heinen C, et al. Thoracic Outlet Syndrome Part I: Systematic Review of the Literature and Consensus on Anatomy, Diagnosis, and Classification of Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies’ Section of Peripheral Nerve Surgery. Neurosurgery. 2022 Mar 25;90(6):653–67.
9. Panther EJ, et al. Thoracic outlet syndrome: A review. J Shoulder Elbow Surg. 2022;31(9):e353–e362.
10. Blondin M, et al. Considerations for surgical treatment of neurogenic thoracic outlet syndrome: A meta-analysis of patient-reported outcomes. J Hand Surg Am. 2023;48(7):e511–e520.
11. Winn HR, ed. Brachial plexus nerve entrapments and thoracic outlet syndromes. In: Youmans and Winn Neurological Surgery. 8th ed. Elsevier; 2023.
12. Ferri FF. Thoracic outlet syndrome. In: Ferri's Clinical Advisor 2024. Elsevier; 2024.
Pablo ROJAS, Andrzej KROL (LONDON, United Kingdom)
09:40 - 09:50
Q&A.
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COFFEE BREAK
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A21
ESRA INTERNATIONAL
ESRA INTERNATIONAL
Chairpersons:
Yavuz GURKAN (Faculty member) (Chairperson, Istanbul, Turkey), Patrick NARCHI (Anesthesia) (Chairperson, SOYAUX, France)
10:30 - 10:40
Introduction and testing the voting system.
Patrick NARCHI (Anesthesia) (Keynote Speaker, SOYAUX, France), Yavuz GURKAN (Faculty member) (Keynote Speaker, Istanbul, Turkey)
10:40 - 10:55
Sympathetic Blocks and the Regionalist.
Kamen VLASSAKOV (Chief,Division of Regional&Orthopedic Anesthesiology;Director,Regional Anesthesiology Fellowship) (Keynote Speaker, Boston, USA)
10:55 - 11:10
Ιntrathecal morphine strikes again!
Peñafrancia CANO (Associate Professor; Chief, Division of Regional Anesthesia, University of the Philippines) (Keynote Speaker, Manila, Philippines)
11:10 - 12:10
Interactive MCQ session.
Melody ANDERSON (Director of Regional Anesthesiology) (Keynote Speaker, Charlotte, USA), Anju GUPTA (Faculty) (Keynote Speaker, New Delhi, India), Hosim PRASAI THAPA (Consultant Anaesthetist) (Keynote Speaker, Melbourne, Australia, Australia)
12:10 - 12:25
Perspectives on safety in regional anaesthesia?
Francois RETIEF (Head Clinical Unit) (Keynote Speaker, Cape Town, South Africa)
12:25 - 12:30
Q&A.
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B21
ASK THE EXPERT
Plan A blocks
ASK THE EXPERT
Plan A blocks
Chairperson:
Per-Arne LONNQVIST (Professor) (Chairperson, Stockholm, Sweden)
10:30 - 10:30
Introduction.
10:30 - 10:43
Plan A blocks for children.
Karen BORETSKY (Senior Associate in Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine) (Keynote Speaker, Boston, USA)
10:43 - 11:20
Q&A.
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C21
LIVE DEMONSTRATION
Knee
LIVE DEMONSTRATION
Knee
Demonstrators:
Maksym BARSA (Anaesthesiologist) (Demonstrator, Rivne, Ukraine), Thomas HAAG (Consultant) (Demonstrator, Oswestry, United Kingdom), Matthias HERTELEER (Anesthesiologist) (Demonstrator, Lille, France), Peter VAN DE PUTTE (Consultant) (Demonstrator, Bonheiden, Belgium)
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10:30-11:20
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D21
ASK THE EXPERT
I love Anatomy
ASK THE EXPERT
I love Anatomy
Chairperson:
Sandeep MIGLANI (Consultant) (Chairperson, Dublin, Ireland)
10:30 - 10:30
Introduction.
10:30 - 11:00
Radiological anatomy for spinal interventions.
Dan Sebastian DIRZU (consultant, head of department) (Keynote Speaker, Cluj-Napoca, Romania)
11:00 - 11:20
Q&A.
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E21
NETWORKING SESSION
Gaps in acute pain treatments
NETWORKING SESSION
Gaps in acute pain treatments
Chairperson:
Andrea SAPORITO (Medical Director) (Chairperson, Bellinzona, Switzerland)
10:30 - 10:30
Introduction.
10:30 - 10:52
Adequate prediction of acute postoperative pain.
Audun STUBHAUG (Professor and consultant) (Keynote Speaker, Oslo, Norway)
10:52 - 11:14
Predicting persistent postsurgical pain.
Athmaja THOTTUNGAL (yes) (Keynote Speaker, Canterbury, United Kingdom)
11:14 - 11:36
Modifiable factors to avoid chronification.
Rafael BLANCO (Pain medicine) (Keynote Speaker, Abu Dhabi, United Arab Emirates)
11:36 - 11:58
Is neuromodulation key.
Xavier CAPDEVILA (MD, PhD, Professor, Head of department) (Keynote Speaker, Médecin, Montpellier, France)
11:58 - 12:10
Q&A.
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F21
NETWORKING SESSION
AI will make our lives better
NETWORKING SESSION
AI will make our lives better
Chairpersons:
James BOWNESS (Consultant Anaesthetist) (Chairperson, London, United Kingdom), Sandy KOPP (Professor of Anesthesiology and Perioperative Medicine) (Chairperson, Rochester, USA)
10:30 - 10:30
Introduction.
10:30 - 10:52
Improved trainings.
Ammar SALTI (Anesthesiologist and Pain Physician) (Keynote Speaker, abu Dhabi, United Arab Emirates)
10:52 - 11:14
#48490 - FT37 Improved presenatations.
Improved presenatations.
Artificial intelligence (AI) is one of the most disruptive innovations of the contemporary era, with a growing impact across numerous fields of knowledge, including medical education. Its integration into teaching and learning processes has brought about a paradigm shift, wherein intelligent digital tools complement and enhance the training of future healthcare professionals. From high-fidelity clinical simulation environments to adaptive learning platforms and predictive analytics systems, AI offers unprecedented opportunities to enrich education, personalize learning, and strengthen pedagogical decision-making. Here’s a clear and straightforward look of the current role of artificial intelligence in medical education, exploring its main applications, advantages, and the ethical and operational challenges it poses within academic and clinical contexts.
As artificial intelligence becomes increasingly embedded in daily life, public concern has grown in parallel. These fears (often fuelled by a lack of understanding or by dystopian narratives portrayed in the media) reflect legitimate anxieties that warrant critical examination.
While it is true that AI-driven automation is progressively replacing routine tasks in sectors such as manufacturing, logistics, and customer service, concerns about widespread job loss tend to be overstated. Rather than eliminating professions entirely, artificial intelligence often redefines job roles, shifting value toward cognitive, creative, and interpersonal skills. At the same time, new professional opportunities are emerging in fields related to the development, governance, and oversight of these technologies, such as data science, AI ethics, and the management of automated systems.
The notion of an artificial intelligence system operating autonomously and beyond human control belongs largely to the realm of theoretical speculation and science fiction. While the concept of a "superintelligence", a cognitive entity capable of vastly surpassing human intellectual capacities, has gained attention in media discourse and certain philosophical circles, it remains far removed from current technological realities. Some experts advocate for proactive reflection on such long-term risks, emphasizing the importance of establishing ethical and regulatory frameworks in advance. However, from a technical standpoint, today's AI systems possess neither independent agency nor consciousness. They function based on algorithms trained with human-provided data and are directed toward objectives defined by human designers. Moreover, their operation is subject to continuous human oversight, validation, and adjustment. In this context, the fear of an uncontrollable AI is better understood as a hypothetical concern rather than an immediate, evidence-based threat.
When it comes to privacy, the use of artificial intelligence technologies in surveillance systems, facial recognition, and large-scale personal data analysis presents tangible and legitimate risks. Intelligent platforms, with their ability to collect, process, and interpret vast amounts of sensitive information, have raised growing public concern about the potential erosion of individual rights and the misuse of data. Furthermore, various AI-based tools may be vulnerable to malicious or fraudulent use if not implemented with appropriate safeguards. Nevertheless, it is important to emphasize that not all AI applications are inherently intrusive. Evolving regulatory frameworks, such as the General Data Protection Regulation (GDPR) in the European Union, aim to ensure the responsible deployment of these technologies. In parallel, there is a growing movement toward the development of ethical, transparent, and human-centered AI systems that prioritize the protection of fundamental rights.
While it’s natural to have concerns about AI, it is essential to recognize that the potential for malicious use does not lie inherently within the technology itself, but rather in the ethical frameworks, regulatory structures, and intentions of the human agents who design, implement, and govern it. When applied ethically, transparently, and in service of the public good, artificial intelligence can serve as a powerful tool to optimize processes, reduce operational burdens, and redirect professional efforts toward irreplaceable functions that require human judgment, interpersonal sensitivity, and the cultivation of meaningful relationships.
AI is changing how regional anaesthesia concepts are taught, enabling the development of more interactive, clear, and effective presentations. Its application in education not only enhances the quality of teaching materials but also expands the possibilities for content personalization and adaptation to different student profiles (FIG 1).
One big advantage of AI is the generation of advanced visual content. With intelligent tools, it is possible to create customized anatomical illustrations, simulated ultrasound images, or three-dimensional animations that accurately depict needle trajectories and anaesthetic spread. In addition, clinical images can be enhanced or edited to highlight key anatomical structures, making complex areas easier to understand.
These tools enable the creation of original visual content, which is essential for avoiding legal issues related to copyright infringement. There are hundreds of applications that can be used for this purpose, each offering its own advantages and features. The choice among them typically depends on personal preference or the balance they provide between cost and functionality. The author relies on platforms such as Clipdrop (https://clipdrop.co), Leonardo AI (https://leonardo.ai/), and Sora (https://openai.com/es-ES/sora/) to achieve this purpose.
AI also plays a significant role in simplifying and clarifying language. It can rewrite technical texts in more accessible language for learners at various levels, from undergraduate students to specialists. High-quality automatic translation is also available, which supports multilingual teaching and provides access to materials in foreign languages, thereby broadening the range of available resources.
Among the available tools for translation and text enhancement in multiple languages, Deep-L (https://www.deepl.com/es/translator) stands out for its proven track record and the remarkable quality of its results. Text-to-speech technologies should also not be overlooked, as they enable natural-sounding reading of any content in various languages and even allow for voice cloning, adding a striking level of realism. In this field, I recommend Eleven Labs (https://elevenlabs.io), a platform that excels in voice quality and the versatility of its features.
Another big plus is the use of virtual presentation assistants. These tools can generate presentation slides from basic texts or outlines and automatically insert summaries, glossaries, and key points to reinforce learning during lectures. The most well-known application for this purpose is Gamma (https://gamma.app), a platform that stands out for its ability to automatically generate visually engaging presentations using artificial intelligence.
In terms of assessment, AI facilitates the automated creation of exams and interactive quizzes, including instant feedback. It can also analyze student performance, allowing instructors to tailor their content to individual needs and learning progress. This type of task can be easily carried out using well-known applications such as ChatGPT (https://chatgpt.com/) or Copilot (https://copilot.microsoft.com)
And last but not least, AI helps a lot in research support and continuous content updating. Through the automated analysis of recent scientific publications, it can summarize and highlight the most relevant evidence, as well as suggest emerging techniques that should be incorporated into the teaching of regional anesthesia. For this purpose, I would suggest leveraging two particularly useful platforms: Perplexity (https://www.perplexity.ai/) and Open Evidence (https://www.openevidence.com/)
Vicente ROQUES (Murcia. Spain, Spain)
11:14 - 11:36
Improved image quality.
Balavenkat SUBRAMANIAN (Faculty) (Keynote Speaker, Coimbatore, India)
11:36 - 11:58
#48667 - FT38 Artificial Intelligence and Communication in Regional Anesthesia: From Procedural Clarity to Educational Innovation.
Artificial Intelligence and Communication in Regional Anesthesia: From Procedural Clarity to Educational Innovation.
Artificial Intelligence and Communication in Regional Anesthesia: From Procedural Clarity to Educational Innovation
Margarita Borislavova MD1, Liesbeth Brullot MD2, Steve Coppens MD, PhD2,3
1 Centre Hospitalier Simone Veil, Department of Anesthesiology, France
2 University Hospitals of Leuven, Department of Anesthesiology, Herestraat 49, B-3000, Leuven, Belgium
3 University of Leuven, Biomedical Sciences Group, Department of Cardiovascular Sciences, KU Leuven, B-3000, Leuven, Belgium
Abstract
Background: Regional anesthesia (RA) demands effective, real-time communication between clinicians, assistants, and trainees to ensure procedural accuracy, patient safety, and high-quality education. Yet communication breakdowns remain a significant challenge, particularly in high-pressure clinical settings and during hands-on workshops. With the rapid evolution of artificial intelligence (AI), new tools are emerging that can support, augment, and streamline communication in RA.
Objectives: This narrative review explores how AI technologies—ranging from ultrasound-integrated anatomical labeling to natural language processing and AI-powered dashboards—can improve communication in regional anesthesia practice and education. The article emphasizes real-world use cases, with particular attention to ultrasound-guided procedures and RA workshops.
Key Content and Findings: AI-enhanced ultrasound platforms allow for automatic real-time labeling of nerves, fascial planes, and vascular structures, improving both procedural clarity and educational consistency. Speech recognition and AI-based checklists can transcribe procedural narration into structured documentation, reducing ambiguity and cognitive load. Smart dashboards and alert systems facilitate team coordination and communication across perioperative workflows. In workshop environments, AI reduces the need for physical pointing or repeated verbal correction by visually reinforcing key anatomical landmarks.
Conclusions: AI tools have the potential to transform communication in regional anesthesia by reducing verbal ambiguity, improving visualization, and enhancing procedural documentation and workflow coordination. While these systems cannot replace clinical judgment, they represent a powerful adjunct for promoting clarity, safety, and instructional effectiveness in both clinical and teaching contexts.
Keywords: Regional anesthesia; artificial intelligence; ultrasound guidance; medical education; communication.
Introduction
Regional anesthesia (RA) has evolved significantly in the last two decades, particularly with the widespread adoption of ultrasound guidance and the shift toward enhanced recovery after surgery (ERAS) protocols. Despite these advances, communication remains a critical—and often underappreciated—element of safe and effective RA practice. Whether in the block room, operating theatre, or educational setting, communication failures can contribute to adverse events, delays, inefficiencies, or suboptimal learning experiences.1
Artificial intelligence (AI) has recently emerged as a powerful tool in healthcare, with applications ranging from predictive analytics to clinical decision support. In the context of regional anesthesia, AI offers a particularly promising avenue for improving how information is conveyed—between clinicians, between humans and machines, and between educators and trainees. This article explores the ways in which AI can enhance communication in RA, with a particular focus on ultrasound-integrated platforms and workshop facilitation.
The Communication Gap in Regional Anesthesia
Regional anesthesia, unlike general anesthesia, is a highly interactive and stepwise process that depends on shared understanding between team members. Communication must occur at several levels: verifying the block type and laterality, confirming drug and dose, describing visual findings during ultrasound guidance, and handing over key information about catheter placement or local anesthetic infusion plans.
In practice, this communication is often hampered by competing noise in the clinical environment, lack of standardization in language and terminology, and overreliance on verbal instructions without visual reinforcement. In educational settings such as workshops or live demonstrations, these challenges are amplified. Instructors may describe anatomical relationships verbally while simultaneously pointing to structures on an ultrasound screen, often without confirmation that learners have correctly understood what was seen or said. Learner misinterpretation is common, especially in large groups or when instructors are operating remotely.
While checklists, time-outs, and standard procedural templates can help mitigate communication breakdowns, these interventions are often inconsistently applied. There remains a critical need for more integrated, real-time communication tools that support both safety and teaching.
AI-Enhanced Ultrasound: Visualizing What We Say
One of the most promising developments in AI is its ability to enhance visual communication during ultrasound-guided RA.2,3 Deep learning algorithms trained on thousands of labeled scans can now accurately identify and outline key anatomical structures—nerves, blood vessels, muscles, and fascial planes—directly on the ultrasound screen. This functionality is already being incorporated into commercial ultrasound platforms, offering significant benefits both clinically and educationally.
In the clinical setting, AI-generated overlays improve shared understanding between the proceduralist and the assistant. Instead of needing to explain anatomy verbally or rely on gesturing toward the screen, the operator can focus on the task while the AI labels structures in real time. This can reduce ambiguity, speed up block placement, and help onboard less experienced staff with clearer visual references.
In educational workshops, AI-supported ultrasound offers even greater value. It enables instructors to communicate anatomical relationships without needing to physically point, preserving sterility and reducing cognitive overload. Trainees benefit from seeing consistent, labeled imagery that reinforces the verbal explanation. This can be particularly helpful in cadaveric or phantom model courses, where real-time anatomic variability often complicates traditional instruction.
Some platforms are also exploring interactive features that allow the instructor to highlight or annotate directly on the ultrasound image, either via voice command or touch interface, further supporting precise communication.
Natural Language Processing and Procedural Documentation
Another emerging area is the use of AI for real-time, voice-driven procedural documentation. Natural Language Processing (NLP), a subset of AI, enables systems to interpret spoken language and convert it into structured, actionable text. In regional anesthesia, this means that an anesthesiologist could narrate a procedure while performing it—for example, "Performing a left-sided transversus abdominis plane block with 20 mL of 0.25% bupivacaine"—and have this transcribed and automatically inserted into the patient’s electronic anesthesia record.
This approach streamlines documentation, improves standardization, and reduces the risk of omitted details.4 It also frees the clinician from needing to manually record information during or after the procedure, enhancing workflow efficiency. Some experimental systems even use NLP to cross-check spoken data with clinical protocols or drug libraries, providing alerts if inconsistencies or safety risks are detected. From a communication standpoint, this technology formalizes and preserves what would otherwise be fleeting verbal statements, turning them into accessible, traceable data that can be reviewed by colleagues, supervisors, or researchers.
AI could also be used to identify regional anesthesia procedures in historical unstructured notes to update registries or do retrospective analysis. Although this is a promising area, it still faces significant implementation problems.5
AI-Guided Checklists and Safety Prompts
While checklists are already a part of good anesthetic practice, they are often static and reliant on manual input. AI systems offer the potential to deliver dynamic, context-sensitive checklists that evolve with the case. These systems can track the progress of a procedure through voice or data input and deliver prompts accordingly.
For instance, if the AI system detects that the proceduralist is preparing a local anesthetic, it may prompt for confirmation of drug type, concentration, and volume. It might also remind the user to aspirate before injection or warn of potential contraindications based on patient data.
Some prototypes respond to speech using a closed-loop communication model:
Proceduralist: “Injecting 20 mL of 0.5% ropivacaine.”
System: “Confirming: ropivacaine 0.5%, 20 mL. Proceed?”
Such systems not only enhance safety but also reinforce shared situational awareness between team members, reducing the chance of misheard or misunderstood instructions.
Communication Across the Block Room: Workflow and Coordination
In busy institutions where multiple RA procedures are performed daily, communication challenges extend beyond individual blocks. AI-powered dashboards that aggregate scheduling, patient status, consent completion, and block progress can help coordinate efforts between anesthesia teams, surgeons, and operating room staff.
These systems can, for example, flag delays in block completion, notify teams when a patient is ready for transfer, or alert anesthetists about potential allergy conflicts or missing documentation. By serving as a centralized communication hub, they reduce reliance on fragmented verbal updates or paper tracking sheets.
This type of AI-supported communication promotes better alignment across the perioperative team and allows the regional anesthesia service to function more efficiently and transparently.
AI in Regional Anesthesia Workshops and Education
Workshops remain essential to the dissemination of RA techniques, particularly for newer fascial plane blocks or advanced catheter techniques. However, teaching these skills—especially with large groups or remote instruction—can be challenging. Communication must be clear, concise, and anatomically precise, yet is often undermined by poor visibility, variable skill levels among learners, and time constraints.
AI-enhanced ultrasound systems improve workshop communication by standardizing anatomical labeling across all learner stations. This ensures that even novice participants can identify key structures without constant verbal correction. Instructors can focus on advanced teaching points without needing to repeatedly identify nerve bundles or fascial layers.
Some platforms also offer automated scanning guidance, suggesting probe adjustments in real time to optimize image quality. These features act as a “silent assistant,” reinforcing instruction while reducing the instructor’s cognitive burden.
Finally, AI systems that store and annotate scans allow trainees to revisit images post-workshop, extending the learning experience beyond the session itself. This is particularly valuable for remote learners or those in low-resource settings.
Limitations and Considerations
Despite these promising applications, AI systems for communication in regional anesthesia face important limitations. Integration into existing clinical infrastructure remains uneven, and many commercial ultrasound platforms have yet to adopt open AI interfaces. The cost of upgrading equipment may be prohibitive, especially for community hospitals or educational institutions in lower-income regions.
There is also a risk of overreliance. If clinicians begin to trust AI labeling or voice prompts too heavily, they may overlook unexpected anatomical variants or clinical nuances. AI should be viewed as an adjunct, not a replacement, for clinical judgment.
Furthermore, AI models are only as good as their training data. In patients with atypical anatomy—such as the obese, elderly, or those with prior surgery—AI overlays may be less accurate. Continuous validation and updating of AI systems are essential to maintaining safety and reliability.
Privacy and data security present another layer of complexity. AI tools that record voice, video, or scan data must comply with GDPR, HIPAA, or similar regulations, particularly in teaching environments where patient anonymity must be preserved.
Future Directions
As the field matures, AI-driven communication tools will likely become more integrated and multimodal. We may soon see systems that combine speech recognition, ultrasound image interpretation, eye tracking, and gesture recognition to create fully interactive and intelligent block room environments.
Remote collaboration platforms may also benefit. An expert anesthesiologist could supervise multiple procedures at satellite centers, providing real-time feedback with the support of AI-enhanced ultrasound streams and structured communication protocols. In education, AI may support procedural scoring, skill assessment, and feedback delivery, making RA workshops more objective and scalable.
Conclusion
Artificial intelligence offers a compelling opportunity to improve communication in regional anesthesia—whether between team members during clinical care or between instructors and learners in workshops. Through applications in ultrasound labeling, voice-driven documentation, dynamic checklists, and workflow dashboards, AI can make communication more efficient, precise, and resilient to distraction. However, these technologies must be integrated thoughtfully, with attention to clinical context, training, and human oversight.
By enhancing clarity without adding complexity, AI can help overcome long-standing communication barriers in regional anesthesia and support the next generation of safe, effective, and well-taught anesthetic practice.
References
1. Hashimoto, D. A., Witkowski, E., Gao, L., Meireles, O. & Rosman, G. Artificial Intelligence in Anesthesiology: Current Techniques, Clinical Applications, and Limitations. Anesthesiology 132, 379–394 (2020).
2. Bowness, J. S. et al. Artificial intelligence for ultrasound scanning in regional anaesthesia: a scoping review of the evidence from multiple disciplines. Br J Anaesth 132, 1049–1062 (2024).
3. Mika, S., Gola, W., Gil-Mika, M., Wilk, M. & Misiołek, H. Artificial Intelligence-Supported Ultrasonography in Anesthesiology: Evaluation of a Patient in the Operating Theatre. J Pers Med 14, (2024).
4. Huber, S. et al. Evaluating an AI Documentation Assistant for Anesthesiology Teams. in Proceedings of the Extended Abstracts of the CHI Conference on Human Factors in Computing Systems 1–8 (ACM, New York, NY, USA, 2025). doi:10.1145/3706599.3706658.
5. Graham, L. A., Illarmo, S. S., Wren, S. M., Odden, M. C. & Mudumbai, S. C. Use of natural language processing method to identify regional anesthesia from clinical notes. Reg Anesth Pain Med 50, 271–275 (2025).
Borislavova MARGARITA, Liesbeth BRULLOT, Steve COPPENS (Leuven, Belgium)
11:58 - 12:20
Q&A.
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10:30-11:25
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G21
FREE PAPER SESSION 6/8
POSTOPERATIVE PAIN MANAGEMENT
FREE PAPER SESSION 6/8
POSTOPERATIVE PAIN MANAGEMENT
Chairperson:
Denisa ANASTASE (Head of the Anesthesiology and Intensive Care Department, Senior Consultant Anesthesia and Intensive) (Chairperson, Bucharest, Romania)
10:30 - 10:37
#45268 - OP54 Analgesic efficacy of serratus intercostal block versus epidural analgesia in open abdominal eventration: a randomised study.
OP54 Analgesic efficacy of serratus intercostal block versus epidural analgesia in open abdominal eventration: a randomised study.
Abdominal wall repair, including eventroplasty, is a frequent surgery in our operating theatres. These surgeries are associated with severe postoperative pain. The aim of the study is to evaluate whether serratus-intercostal block (SIPB) is equal or superior to epidural analgesia in terms of pain control and quality of postoperative recovery.
Following the approval of the ethical committee (no. 22-EO132 in September 2022) and registration (Trial registration number: NCT06014749), this prospective low-level intervention study of non-inferiority was initiated. The calculated sample size was determined to be n = 70, ensuring that a two-sided test with α = 0.05 would have 95% power to detect no difference in the proportion of patients. The NRS 3 was considered to be the difference. The inclusion criteria were abdominal eventration repair, over 18 years of age, ASA I-III. The two groups consisted of: SIPB (patients who received serratus-intercostal plane block) and epidural analgesia, both techniques associated with general anaesthesia. In the postoperative period, pain was assessed with specific forms using the NRS numeric rating scale and the quality of recovery with the modified QoR-15 scale. The statistics results show a no intraoperative fentanyl consumption difference between cohorts SIPB/Epi (243 /214 µg) (p 0,37) and a postoperative morphine consumption of SIPB 0.36 mg + 0.88 and epidural 1.79 mg + 1.04 (p 0,01). In dynamic pain control NRS 6 (SIPB 0.7; epidural 3.2) (p 0,008), NRS12 (SIPB 2.2; epidural 4.4) (p 0,001), NRS24 (SIPB 2; epidural 4.3) (p < 0,001). The adverse effects showed were (epidural: 5 catheters moved, 4 urine retention). Figure 1. The quality of recovery was better in SIPB group. Figure 2. In summary, both techniques have shown adequate postoperative pain control, although SIPB has shown a superiority in the first 24h, presenting this block as an alternative to epidural analgesia in eventroplasty.
María Teresa FERNÁNDEZ (Valladolid, Spain), Judith ANDRES SAINZ, Jose Juan ZURRO, Maria Fe MUÑOZ, Ana Cristina RUBIO, Rocio RIOJA, Alejandra FADRIQUE
10:37 - 10:44
#45514 - OP55 Comparison of the Postoperative Analgesic Efficacy of Pericapsular Nerve Group Block and Anterior Quadratus Lumborum Block in Hip Fracture Surgery: A Prospective Randomized Study.
OP55 Comparison of the Postoperative Analgesic Efficacy of Pericapsular Nerve Group Block and Anterior Quadratus Lumborum Block in Hip Fracture Surgery: A Prospective Randomized Study.
The Pericapsular Nerve Group (PENG) block and Anterior Quadratus Lumborum Block (aQLB) are regional anesthesia techniques commonly used for pain control after hip surgery. This study compared their analgesic efficacy during the first 48 hours following surgery under spinal anesthesia.
In this prospective, randomized, single-blinded study, patients were assigned to either the PENG group (n = 43) or the aQLB group (n = 30). Pain intensity (resting and dynamic NRS), tramadol consumption, time to first rescue analgesia, and complications were assessed at 2, 12, 24, and 48 hours postoperatively. Compared to the aQLB group, the PENG group had significantly lower total tramadol use (p = 0.004) and a longer duration before requiring rescue analgesia (p = 0.048) within 48 hours after surgery. The PENG block provides effective postoperative analgesia without causing motor blockade, making it advantageous for early mobilization in patients undergoing hip surgery. It may be a preferable option in multimodal analgesia protocols.
Serpil SEHIRLIOGLU (istanbul, Turkey), Dondu GENC MORALAR
10:44 - 10:51
#45551 - OP56 The effect of direct vision deep serratus anterior plane block on post operative pain in breast surgeries: A randomized double blind placebo control trial (SEAN).
OP56 The effect of direct vision deep serratus anterior plane block on post operative pain in breast surgeries: A randomized double blind placebo control trial (SEAN).
Ultrasound-guided deep Serratus Anterior Plane Block (SAPB) has shown effective analgesia in breast surgeries. We hypothesized that a surgeon-administered SAPB under direct vision at end of surgery provides superior analgesia to placebo.
To assess the efficacy of SAPB under vision versus saline placebo in breast surgeries with respect to pain scores.
In this double-blind randomized controlled trial, patients undergoing simple or modified radical mastectomy with axillary clearance post-chemotherapy were randomized into two groups. The study arm received 20 mL of 0.25% Levobupivacaine, and the control arm received normal saline. Maximum pain score within 24 hours was the primary outcome. Pain, nausea, vomiting, and sedation scores were recorded at shifting, 1 hour, 2 hours, and the next morning. Tramadol 50 mg and Metoclopramide 10 mg were used as rescue analgesic and antiemetic. Moderate pain was observed in 46.5% of the control group and 33.3% of the study group (p = 0.434). Immediate post-op pain scores at rest (p = 0.049) and on movement (p = 0.029), and vomiting at 1 hour (p = 0.049), were significantly lower in the study arm. Fewer patients required rescue analgesics in the study arm, though not statistically significant. Sedation, nausea, total opioid use, and time to analgesic were similar between groups. Deep SAPB showed benefit in early pain relief and reduced vomiting at 1 hour. Though overall outcomes were statistically similar, SAPB shows promise in postoperative analgesia and warrants further study.
Sheetal SHEETAL, Shubham SHUBHAM (Mumbai, India), Sumitra SUMITRA, Ashwini ASHWINI, Rinto RINTO
10:51 - 10:58
#47167 - OP57 Comparison of External Oblique Intercostal Plan Block, Oblique Subcostal Transversus Abdominis Plan Block and Local Anesthetic Infiltration Methods in Laparoscopic Cholecystectomies.
OP57 Comparison of External Oblique Intercostal Plan Block, Oblique Subcostal Transversus Abdominis Plan Block and Local Anesthetic Infiltration Methods in Laparoscopic Cholecystectomies.
In the context of postoperative pain management following laparoscopic cholecystectomies, the utilisation of local anaesthetic infiltration into the port sites or the administration of intraperitoneal local anaesthetics is strongly recommended. Erector spinae planus and transversus abdominis plane blocks are recommended as second-line treatment options. The present study investigated the efficacy of the newly discovered External Oblique Intercostal Plan Block (EOIP) block.
The study was designed as a prospective randomised controlled, double-blind experiment. In this study, 100 patients undergoing LK surgery were divided into four groups: EOIP Block Group E, OSTAP Block Group O, Local Anesthetic Infiltration Group L and Control Group K. The following outcomes were recorded at 0h, 30 min, 2h, 4h, 12h and 24h in the postoperative period: resting and mobile VAS values, amount of total tramadol consumption at pca device, intraoperative remifentanil consumption, 24th hour QoR-15 scores, additional analgesic needs and complications. A statistical analysis of the demographic and hemodynamic data revealed no significant differences between the groups. At 12 hours, VAS-I, VAS-H, 24-hour QoR-15 scores and postoperative additional analgesic requirement were statistically significantly lower in Group E compared to all other groups. The requirement for supplementary analgesics was found to be statistically significantly lower in patients who underwent block compared to Groups L and K. Çömez et al. found no significant difference between the EOIP block and OSTAP block groups in terms of analgesic effect, postoperative pain scores and opioid use in a study of 70 patients undergoing laparoscopic cholecystectomy. The results of our study demonstrated that EOIP and OSTAP blocks provided more effective analgesia and reduced postoperative opioid consumption compared to trocar site local anesthetic infiltration. Consequently, we advocate the implementation of fascial plane blocks as a primary treatment modality within the framework of multimodal analgesia, contingent upon their execution by seasoned anesthesiologists.
Buğra KURTOĞLU (Ankara, Turkey), Sena SARICAOĞLU ÖKTEM, Ayça Tuba DUMANLI ÖZCAN
10:58 - 11:05
#48097 - OP58 Pharmacogenetics in Perioperative Pain Management: An Overview of Patient Characteristics, Test Results, and Outcomes.
OP58 Pharmacogenetics in Perioperative Pain Management: An Overview of Patient Characteristics, Test Results, and Outcomes.
Pharmacogenetic testing for patients with a history of uncontrolled pain or opioid intolerance can inform personalized treatment plans. The aim of this study is to examine characteristics of patients undergoing pharmacogenetic testing through the HSS Perioperative Pain Service (POPS) and highlight information that pain management physicians utilize to inform decision making.
After IRB-approval, electronic medical record data were extracted for patients who were seen by POPS and underwent perioperative pharmacogenetic testing between April 6, 2019 and July 29, 2024. Descriptive statistics were used to summarize patient and case characteristics, test results and related pain management recommendations, incidence of severe acute postoperative pain, and postoperative opioid consumption. Twenty-four patients met inclusion criteria. Patient and case characteristics are described in Table 1. Pharmacogenetic findings are summarized in Table 2. Patients with a history of uncontrolled pain had genetic findings that aligned with their clinical presentation and aided in postoperative opioid type recommendations (e.g., hydromorphone or tapentadol for high-activity CYP3A4/5). Patients in which certain opioids did not provide analgesia were found to be OPRM1 A/G, DRD2 C/DEL, and/or COMT Met/Met, and patients with opioid-related adverse effects were confirmed to have altered opioid pharmacokinetics (e.g., intermediate, rapid, ultra-rapid metabolizers) mediated by CYP genes and ABCB1. For admitted patients, the frequency of severe acute pain (30.3%-50.0%) and median morphine milligram equivalents of opioid consumption (22.5-96.0) are reported in Table 3. Most patients (66.7%) received opioid prescriptions at discharge that aligned with the preoperative pain consult recommendations, and were discharged primarily with hydromorphone (n=5, 20.8%) or tapentadol (n=6, 25.0%). Pharmacogenetic test results used for clinical decision making included pharmacokinetic genes of opioid metabolism and pharmacodynamic genes for sensitivity to medications. The cohort highlights sensitivity or tolerance of opioids based on genetic factors. Previous literature focuses on CYP2D6 metabolism; 12.5% of our cohort however were intermediate metabolizers.
Faye RIM (New York, USA), Dae KIM, Maya TAILOR, William CHAN, Dale LANGFORD, Alexandra SIDERIS
11:05 - 11:12
#48102 - OP59 Regional analgesia for elective knee replacement surgery: A survey of current practice in the United Kingdom (UK).
OP59 Regional analgesia for elective knee replacement surgery: A survey of current practice in the United Kingdom (UK).
Knee replacement (KR) surgery is associated with significant pain, with up to 60% of patients experiencing moderate to severe postoperative discomfort. Inadequate pain control may lead to chronic postsurgical pain (CPSP) in up to 44% of cases. Perioperative nerve blocks can improve acute pain and potentially reduce CPSP. This survey aimed to describe current UK practices in regional analgesia for KR.
An anonymous, self-administered online survey was distributed to anaesthetists involved in KR surgery across NHS hospitals in the UK. A total of 324 responses were received between 31st October 2023 and 28th November 2023 from 12 UK regions (92.6% from consultants). Nerve blocks were reported as “always” used by 137 respondents (42.3%), “most of the time” by 42 (13%), and “sometimes” by 43 (13.3%). The adductor canal block was the most common (209 responses, 64.5%), followed by iPACK (43, 13.3%).
Regarding local infiltration analgesia (LIA), 89.5% reported its use in over 75% of cases. Single-shot blocks were preferred over continuous infusions (73.8% vs. 0.6%). Barriers to nerve block use included the belief that LIA alone was sufficient (41%), time constraints (21.9%), and lack of skill (19.4%); 42.6% reported no deterrents. There is variability in regional analgesia practices for KR in the UK. The adductor canal block is most commonly used, and LIA is widely adopted. These findings may guide future research for the development of evidence-based guidelines on the use of regional analgesia in KR surgery.
Nada M. MOUSA (Birmingham, United Kingdom), Fang SMITH, Ciro MORGESE
11:12 - 11:19
#48110 - OP60 Effects of cannabidiol (CBD) oral solution in patients undergoing bilateral total knee arthroplasty: a randomized, controlled, parallel, triple blind, pilot study.
OP60 Effects of cannabidiol (CBD) oral solution in patients undergoing bilateral total knee arthroplasty: a randomized, controlled, parallel, triple blind, pilot study.
Cannabidiol (CBD) is a non-intoxicating phytocannabinoid with limited clinical evidence of its pain relieving and opioid sparing properties. In the US, an oral cannabidiol solution, Epidiolex®, is approved by the FDA for the treatment of intractable seizures. We conducted an off-label pilot study of Epidiolex® in patients undergoing bilateral total knee arthroplasty (BTKA) to assess effects on opioid requirements, pain, inflammation, tolerability, sleep, mood, and pharmacokinetics.
After IRB-approval and trial registration (NCT04749628), 36 patients undergoing BTKA were randomized to receive four perioperative doses of placebo (Ora-Sweet SF) (n=12), 400mg (n=12) or 800mg (n=12) CBD oral solution (Epidiolex®) (Figure 1) with standardized anesthesia and analgesia regimen including regional techniques. Descriptive statistics were used to summarize patient and case characteristics and outcomes; pairwise t-tests were used to compare cumulative first 72-hour opioid consumption (primary outcome) between the three groups. Patient and case characteristics are summarized in Table 1. Compared to placebo, patients who received 400mg CBD had 30% lower cumulative 72-hour opioid requirements (mean: 209 MMEs versus 144 MMEs; p=0.04), with no difference between placebo and 800mg CBD (p=0.9) or between 400mg and 800mg CBD (p=0.09). Patients randomized to the 400mg CBD also had lower pain scores, while patients in the 800mg CBD had more side-effects compared to placebo and 400 mg CBD. Additional outcomes are summarized in Table 2. Our pilot findings suggest promising efficacy for pain relief and opioid reduction with 400 mg CBD. Adequately powered randomized controlled trials are needed and will help elucidate potential biphasic effects.
William CHAN (New York City, USA), Jiabin LIU, Lila BAAKLINI, Meghan KIRKSEY, Alex ILLESCAS, Seth WALDMAN, Kethy JULES-ELYSEE, Alexandra SIDERIS
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11:30-12:20
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D22
WORLD SISTER SOCIETIES MEETING
WORLD SISTER SOCIETIES MEETING
Chairperson:
Eleni MOKA (faculty) (Chairperson, Thessaloniki, Greece, Greece)
11:30 - 12:20
Introduction.
11:30 - 12:20
AOSRA-PM.
Justin KO (Faculty) (Keynote Speaker, Milwaukee, USA)
11:30 - 12:20
AFSRA.
Ezzat SAMY AZIZ (Professor of Anesthesia) (Keynote Speaker, Cairo, Egypt)
11:30 - 12:20
LASRA.
Ana SCHWARTZMANN BRUNO (President) (Keynote Speaker, Montevideo, Uruguay)
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11:30-12:25
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G22
FREE PAPER SESSION 7/8
PERIPHERAL NERVE BLOCKS
FREE PAPER SESSION 7/8
PERIPHERAL NERVE BLOCKS
Chairperson:
Lara RIBEIRO (Anesthesiologist Consultant) (Chairperson, Braga-Portugal, Portugal)
11:30 - 11:37
#45321 - OP61 Outpatient Continuous Adductor Canal Block in Total Knee Arthroplasty: A Double Blinded Randomized Controlled Trial.
OP61 Outpatient Continuous Adductor Canal Block in Total Knee Arthroplasty: A Double Blinded Randomized Controlled Trial.
Pain recovery following total knee arthroplasty (TKA) remains a significant barrier to rehabilitation. The adductor canal block (ACB) is a key component of multimodal analgesia.1 A continuous technique (CACB) has shown limited results in inpatients.2 We aimed to identify whether single injection (SACB) or CACB offers the best analgesia as measured by opioid consumption and quality of recovery scores at the post-surgical 48-hour mark in outpatient or short-stay setting
A single center double-blind, randomized controlled trial conducted on primary TKA outpatient or short-stay setting. Ethics board approval was obtained (#23-0223-C). Patients received the same perioperative management:spinal anesthetic, preoperative ACB, and IPACK blocks, and multimodal analgesia.3 Following surgery, a CACB catheter was inserted using the tunneled Interspace between Sartorius muscle and Femoral artery (ISAFE) technique,4 and infused at a rate of 5 ml/hour for 60 hours with a solution mixture of Ropivacaine 0.2% for the intervention group versus placebo. The primary outcome was total opioid consumption for the first 48 postoperative hours. Secondary outcomes were Quality of Recovery (QoR-15) scores,5 numerical rating scale (NRS), hospital length-of-stay (LOS), and complications. The sample size calculated was 60. Twenty-nine in the CACB group and 30 in the control group were included. Baseline characteristics between the two groups were similar (table 1). The 48-hour opioid consumption, in morphine oral equivalent, was lower in the CACB group with median [IQR ] 5 [0-15] mg (control group median [IQR ] 20 [10-36] mg ; p < 0.01) (Figure 1). QoR-15 scores were significantly higher for the CACB group than the SACB, p<0.01 (table 2). Pain scores were significantly lower for the CACB group. No differences for LOS. For outpatient or short-stay primary TKA, CACB provides superior analgesia and better quality recovery rates over SACB.
Yehoshua GLEICHER, Hermann DOS SANTOS FERNANDES, Sharon PEACOCK, Javiera VARGAS, Carlson ASANGHANWA, Fernanda LANZA, Naveed SIDDIQUI, Divya MAHAJAN (Toronto, Canada)
11:37 - 11:44
#45381 - OP62 Impact of peripheral nerve block technique on incidence of phrenic nerve palsy in shoulder surgery: A review.
OP62 Impact of peripheral nerve block technique on incidence of phrenic nerve palsy in shoulder surgery: A review.
Peripheral nerve blocks are an increasingly common method of providing post-operative analgesia for shoulder surgery.
However, the standard technique, the interscalene block (ISB), inevitably causes hemidiaphragmatic paresis (HDP),
secondary to phrenic nerve palsy. This can cause morbidity in patients with pre-existing respiratory compromise, prompting
investigation into alternative “phrenic-sparing” nerve blocks. The aim of this review was to give an overview of these blocks
and to critically evaluate the current literature to determine if any are suitable alternatives to the ISB. Incidence of HDP and
analgesic efficacy were considered.
We queried four electronic databases and one register.
Our initial search of online databases and registers yielded a total of 515 original papers following removal of duplicates. The titles and abstracts of these remaining articles were subsequently screened and 467 were removed following application of the inclusion and exclusion criteria. A total of 28 articles were included in the review. The use of ultrasound-guidance, lower volumes of local anaesthetic (LA) and injection 4mm outside
the brachial plexus fascia reduced HDP incidence for ISB, however no single modification did so sufficiently. While the
superior trunk block (STB) showed comparable analgesic effect to ISB, HDP prevalence was also high. The posterior
suprascapular nerve block (SSNB) produced consistently low HDP incidences but also inferior analgesia, except when
combined with an infraclavicular brachial plexus block. The aSSNB provided equivalent analgesia to ISB while reducing
HDP incidence. Lower LA volumes consistently led to lower HDP incidence across all blocks. This review demonstrated that the extra fascial ISB, and combined posterior SSNB with infraclavicular block showed the greatest promise in providing an effective alternative to gold-standard ISB for those patients with significant pulmonary co-morbidities. Further investigation into the minimum effective volumes is warranted to determine if any of these blocks can successfully balance HDP prevention with analgesic efficacy.
Aaron CAMPBELL (BELAST, United Kingdom), Chris JOHNSON, Shaun O'CONNOR
11:44 - 11:51
#47440 - OP63 Finding the sweet spot: optimising parasternal block volume at 0.125 % bupivacaine for enhanced post cardiac surgery analgesia.
OP63 Finding the sweet spot: optimising parasternal block volume at 0.125 % bupivacaine for enhanced post cardiac surgery analgesia.
Intense post sternotomy pain delays mobilisation and increases peri operative opioid exposure. Ultrasound guided bilateral parasternal block provides targeted anterior chest wall analgesia; however, the dose–volume relationship of local anaesthetic for this block remains undefined. After establishing that 0.125 % bupivacaine is clinically effective, we conducted a randomised controlled trial to evaluate whether varying injectate volumes at this fixed concentration modulate analgesic efficacy and opioid consumption.
This prospective, randomised, single‑blind trial enrolled 44 adults for elective median sternotomy. After ethics approval (Pauls Stradiņš Clinical University Hospital, 281123‑11L), patients received a bilateral parasternal block with 0.125 % bupivacaine: 20 ml (n = 12), 40 ml (n = 20) or 60 ml (n = 12). Pain intensity (Numerical Rating Scale, NRS 0–10) was measured at 0, 4, 8, 12, 20 and 24 h. Secondary endpoints were 24‑h opioid use and time‑to‑rescue analgesia. Median NRS at 12 hours postoperatively was 1 (IQR 0–3) after 20 ml, 1 (IQR 0–3) after 40 ml and 1 (IQR 0–2) after 60 ml (p = 0.801); pain scores did not differ significantly at any measured time point (p >0.05). Time to rescue was markedly shorter with 20 ml – median 120 min (IQR 120–300)—versus 40 ml – 995 min (IQR 440–1275) and 60 ml – 420 min (IQR 218–450); Repeated rescue opioid was needed in 25 % of patients who received 20 ml, whereas none required it after 40 ml or 60 ml (p = 0.012). Injectate volume was decisive: ≥ 40 ml abolished rescue‑opioid use; 40 ml produced the longest opioid‑free period with no safety issues, whereas 60 ml offered no added benefit. Thus, a 40 ml bilateral parasternal block with 0.125 % bupivacaine is the volume–efficacy sweet spot for post‑sternotomy analgesia. Larger multicentre trials should validate these findings and refine practice.
Edgars PROZOROVSKIS, Edgars PROZOROVSKIS (Riga, Latvia), Davis POLINS, Eva STRĪĶE, Aleksejs MISCUKS
11:51 - 11:58
#48118 - OP64 A Comparative Study on the Anesthetic Effects of Dexmedetomidine and Dexamethasone as Adjuvants.
OP64 A Comparative Study on the Anesthetic Effects of Dexmedetomidine and Dexamethasone as Adjuvants.
This study aimed to evaluate the effects of dexmedetomidine and dexamethasone, used as adjuvants in ultrasound-guided infraclavicular blocks, on block onset time, block duration, analgesic requirement, and adverse events in patients undergoing upper extremity surgery.
This prospective observational study included 44 patients undergoing upper extremity surgery. They were divided into two equal groups: Group A (dexmedetomidine, n=22) and Group B (dexamethasone, n=22). Variables recorded included hospital stay duration, onset and duration of sensory and motor block, time to first analgesic requirements, 24-hour postoperative analgesic need, hemodynamic parameters (HR, MAP, SpO₂), Ramsay Sedation Score (RSS), VAS scores, and complications. Demographics were similar between groups. Hospital stay and block onset times were significantly shorter in the dexmedetomidine group (p<0.001). Although block durations were also shorter in this group (p=0.003, p=0.023), the time to first analgesic was earlier and all patients (100%) required analgesia postoperatively, compared to only 5 patients (22.7%) in the dexamethasone group (p<0.001).
VAS scores were comparable at T0–T2 but significantly higher in the dexmedetomidine group at T3 and T4. RSS scores were also significantly higher at later time points, indicating greater sedation. Bradycardia was observed in 5 patients in the dexmedetomidine group and 1 in the dexamethasone group. No nausea, vomiting, hypotension, or nerve injury was observed. The choice between these two adjuvants may depend on the clinical context: dexmedetomidine may be preferred for rapid onset and intra-operative sedative effects, whereas dexamethasone may be more suitable for prolonged post-operative analgesia. Further comprehensive studies are needed to guide adjuvant selection, optimise dosing strategies, and explore their use in other types of regional anaesthesia.
Ezgi BAL (Istanbul, Turkey)
11:58 - 12:05
#48202 - OP67 Analgesic effect of the Erector spinae plane block as а part of multimodal anesthesia during surgery of open fixation of the thoraco-lumbar spine.
OP67 Analgesic effect of the Erector spinae plane block as а part of multimodal anesthesia during surgery of open fixation of the thoraco-lumbar spine.
Surgical treatment of open spinal fixation is accompanied by severe pain during surgery and in the postoperative period. The most common used drugs for perioperative analgesia in these surgeries are opioids. Although opioids provide good analgesia, they are related to plenty side effects and complications from their use. New regional anesthetic techniques, such as ultrasound-guided blocks, as part of multimodal analgesia provide good perioperative analgesia, with significant reduce of use of opiates and their side effects.The primary objective of the study is to determine the effect of the Erector spinae plane block (ESB) as part of multimodal analgesia, and opioid anesthesia (OA) on intraoperative and postoperative analgesia in open spinal fixation operations. Secondary objectives: 1. To determine the total dose of opiates given in each of the groups during operation and postoperatively. 2. To examine the postoperative occurrence of dizziness, diplopia, nystagmus, hallucinations, nightmares in both groups. 3. To determine the incidence of postoperative nausea and vomiting in both groups.
The study was randomized, prospective, interventional clinical trial with a total of 70 patients, using two parallel groups of 35 patients each, scheduled for open spinal fixation. Group 1 (OG-opioid group): 35 patients who received intermittent opioid – fentanyl as analgesia,
Group 2 (ESPBMM): in 35 patients, erector spinae muscle sheath block (ESPB) was administered with multimodal anesthesia, and postoperative low dose ketamine infusion. The combination of ESP block and multimodal analgesia provided excellent intraoperative analgesia and good postoperative analgesia compared to opioid group. There was significantly decreased use of opiates in the perioperative period in the ESP block with multimodal analgesia group, as well as a lower incidence of postoperative nausea and vomiting. The use of the ESPB as part of multimodal analgesia in open spinal fixation operations is safe and provides good perioperative analgesia.
Aleksandar DIMITROVSKI (Skopje, North Macedonia), Biljana KUZMANOVSKA, Marija TOLESKA, Blagica PETROVSKA, Natasha TOLESKA, Simona NIKOLOVSKA, Marina TEMELKOVSKA
12:05 - 12:12
#48177 - OP66 Effect of erector spinae block with bupivacaine and ketamine versus bupivacaine alone on acute postoperative pain and opioid consumption in patient undergoing modified radical mastectomy.
OP66 Effect of erector spinae block with bupivacaine and ketamine versus bupivacaine alone on acute postoperative pain and opioid consumption in patient undergoing modified radical mastectomy.
A significant postoperative pain has been documented in numerous breast cancer cases following modified radical mastectomy (MRM). We evaluated the effect of ketamine as an adjuvant to local anesthetic in erector spinae plane block (ESPB) in MRM Surgery.
In this randomized controlled trial, 50 women with breast cancer aged 18 to 70 years and scheduled for MRM were included and randomized into two equal groups. Patients in group A received USG guided ESPB with 30 ml of 0.25% bupivacaine alone whereas patients in group B received the same along with 1mg/kg ketamine. In the postoperative period, Numerical Rating Scale(NRS) score, DN4 score by Douleur Neuropathique Questionnaire(DN4 Questionnaire), cumulative opioid consumption in 24 hours, time to rescue analgesia, PONV scores and sedation scores were noted in both the groups. No significant difference was seen in NRS at 1 hour (p= 0.697), at 2 hours (p=0.069), at 4 hours (p= 0.415), at 8 hours (p=0.217), at 12 hours (p= 0.054), at 24 hours (p= 0.452) between group A and B. Similarly, cumulative opioid consumption in 24 hours, DN4 scores, time to rescue analgesia, PONV scores and sedation scores were comparable in both the groups. Our study did not demonstrate any benefit of adding Ketamine to Bupivacaine in a single shot Erector Spinae block in patients undergoing modified radical mastectomy. However, this was a preliminary study with a small sample size. Thus, larger studies may provide more generalized results.
Vaithi VISWANATH K (New Delhi, India), Akhil Kant SINGH
12:12 - 12:19
#48131 - OP65 ANALGESIC EFFICACY OF SACRAL ERECTOR SPINAE PLANE BLOCK IN LUMBOSACRAL SPINE SURGERIES AS COMPARED TO CONVENTIONAL MANAGEMENT: A RANDOMIZED CONTROLLED TRIAL.
OP65 ANALGESIC EFFICACY OF SACRAL ERECTOR SPINAE PLANE BLOCK IN LUMBOSACRAL SPINE SURGERIES AS COMPARED TO CONVENTIONAL MANAGEMENT: A RANDOMIZED CONTROLLED TRIAL.
Sacral erector spinae plane(SESP) block is a variant of erector spinae plane block(ESPB) at the sacral level, which has been deemed effective for various perineal and pelvic procedures. It is less invasive and safer compared to the lumbar ESPB. In our experience, this block provides effective analgesia for lumbosacral spine surgeries.(1) Hence, we planned this RCT to establish the analgesic efficacy of SESP block in lumbosacral spine surgeries.
Adult patients undergoing elective TLIF surgeries at L5-S1 level were randomised into two groups, Group S (sacral ESPB, N=38) and Group C (Control, N=38). Ultrasound-guided sacral ESPB was performed using ultrasound with 20ml of 0.25% Ropivacaine with 4 mg dexamethasone on each side at the level of S2. Both groups received PCA fentanyl postoperatively. Total intra and postoperative fentanyl consumption in 24 h, hemodynamic parameters, time to first analgesia, NRS scores at rest and on movement, patient satisfaction, quality of sleep(QOS), and quality of recovery (QoR-15) scores were noted. Mean(SD) post-operative fentanyl consumption was significantly in Group S [276.32(148.29) vs.500(209.81) µg;p<0.001].(Figure 1) The mean difference (95% CI) was -223.68 µg (306.73 to -41.67). Group S had a significantly longer mean(SD) TTFA [259.21 (87.63) vs. 106.84 (75.21) min; P<0.001]. Pain scores were significantly lower in the Block group, both at rest and during movement. In SESP group, 52.6% of patients rated their satisfaction level as "Excellent" compared to 39.5% in the Control group(p=0.36). Postoperative mean (SD) QOS [6.42 (0.85) vs. 7.05 (0.84); P=0.002] and QOR-15 scores were significantly better in the group S. This study highlights the sacral ESP block as a simple, yet valuable addition to the analgesic armamentarium for lumbosacral spine surgeries. By providing superior pain relief, minimizing opioid consumption, and enhancing recovery quality, the sacral ESP block addresses key challenges in perioperative pain management in lumbosacral spine fusion surgeries.
Anju GUPTA (New Delhi, India), Anjali PANDAY, Dr Ganga PRASAD, Vivek SHANKAR, Parin LALWANI, Dr Bikash RANJAN
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B22
PRO CON DEBATE
Parasternal and fascial plane blocks in cardiac surgery
PRO CON DEBATE
Parasternal and fascial plane blocks in cardiac surgery
Chairperson:
Johan RAEDER (Evaluering tor,sdag, fredag+overall, GK1V24) (Chairperson, Oslo, Norway)
11:35 - 11:35
Introduction.
11:35 - 11:50
For the Cons: They are useless.
Sina GRAPE (Head of Department) (Keynote Speaker, Sion, Switzerland)
11:50 - 12:05
For the Pros: They are useful.
Fabrizio FATTORINI (anesthetist) (Keynote Speaker, Rome, Italy)
12:05 - 12:25
Q&A.
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12:00-12:30
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C22
LIVE DEMONSTRATION
The good old paravertebral
LIVE DEMONSTRATION
The good old paravertebral
Keynote Speaker:
David NYSTAD (Anaesthesiologist) (Keynote Speaker, Beisfjord, Norway)
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LUNCH BREAK
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12:30-13:00
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H21
INDUSTRY SESSION
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13:15-13:45
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H22
INDUSTRY SESSION
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14:00-14:50
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A23
PROBLEM BASED LEARNING DISCUSSION
Nerve injuries may happen
PROBLEM BASED LEARNING DISCUSSION
Nerve injuries may happen
Chairperson:
Alan MACFARLANE (Consultant Anaesthetist) (Chairperson, Glasgow, United Kingdom)
14:00 - 14:00
Introduction.
14:00 - 14:20
Neurological damage after a popliteal block, a step-by-step approach.
Vishal UPPAL (Professor) (Keynote Speaker, Halifax, Canada, Canada)
14:20 - 14:20
Q&A.
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14:00-14:50
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B23
ASK THE EXPERT
When pain will not decrease
ASK THE EXPERT
When pain will not decrease
Chairperson:
Denisa ANASTASE (Head of the Anesthesiology and Intensive Care Department, Senior Consultant Anesthesia and Intensive) (Chairperson, Bucharest, Romania)
14:00 - 14:00
Introduction.
14:00 - 14:15
Pain Ahead? Choose Wisely: Acute Pain Trajectories and Decision-Making in Regional Anesthesia.
Ki Jinn CHIN (Professor) (Keynote Speaker, Toronto, Canada)
14:15 - 14:30
#48618 - FT08 Can we prevent the transition from acute to chronic pain?
Can we prevent the transition from acute to chronic pain?
Introduction
Acute pain contributes to nearly 70% of visits to the Emergency Department (ED), and most individuals experience acute pain at some point in their lifetime. Recent studies indicate that point prevalence of pain ranges between 37.7% and 84%, while the period prevalence can be as high as 78.6% [1]. The transition from acute to chronic pain occurs in approximately 10–50% of cases, with significant implications for patients' quality of life, increased morbidity, and economic burden due to lost productivity [2].
Preventing this transition is crucial, and understanding the predisposing factors can inform effective interventions. These risk factors are broadly categorized into preoperative, intraoperative, and postoperative domains.
Preoperative Factors
These factors include patient demographics, comorbidities, psychological states, pain genetics, and sociocultural influences.
Key risk populations for chronic pain development include those with:
• Pre-existing pain (even if not related to the surgical site),
• Central sensitization syndromes like fibromyalgia, chronic migraine, or irritable bowel syndrome [3],
• Psychological traits such as catastrophizing, depression, neuroticism, and anxiety [4],
• Young age and female sex—females are more likely to experience chronic post-surgical pain (CPSP) due to differences in pain perception, hormonal influence, and immune responses [5].
Emerging evidence has also shown that genetic and epigenetic variations, though still being elucidated, modulate pain perception and the transition to chronic pain, especially in conditions like burning mouth syndrome and migraine [6].
Intraoperative Factors
Certain surgical procedures have a higher risk of leading to chronic pain. These include:
• Mastectomy,
• Thoracotomy, and
• Mesh hernioplasties [7].
For example, post-thoracotomy pain is associated with nerve injury severity, while chronic pain after inguinal hernia repair is linked to ilioinguinal or iliohypogastric nerve involvement [8]. Modern surgical techniques such as minimally invasive procedures and nerve-sparing approaches have shown promise in reducing these risks [9].
Postoperative Factors
The intensity and duration of acute postoperative pain are strongly correlated with the risk of chronicity. Poorly controlled acute pain enhances peripheral and central sensitization, thereby increasing the risk of chronic pain [10].
Continuous pain assessment, early aggressive multimodal pain management, and individualized analgesic plans are critical in the postoperative period [11].
Mechanisms behind chronic pain development
The pathophysiology of chronic pain involves both peripheral sensitization (increased excitability of nociceptors due to inflammatory mediators) and central sensitization (hyperexcitability of dorsal horn neurons and altered descending modulation).
Recent neuroimaging studies have identified alterations in brain structures and white matter connectivity, particularly in regions involved in pain processing such as the prefrontal cortex and insula [12].
Intervention Strategies
Prevention can be categorized into:
1. Primary Prevention
Aimed at mitigating risk factors before pain onset. Strategies include:
• Ergonomic corrections,
• Weight management,
• Mental health promotion, and
• Lifestyle changes (avoiding smoking/alcohol) [13].
Successful primary prevention must integrate biopsychosocial components to ensure comprehensive coverage [14].
2. Secondary Prevention
Focuses on preventing acute pain from becoming chronic. Key strategies:
• Early identification of vulnerable populations (e.g., elderly, racial minorities, those with disabilities) [15],
• Bridging research gaps between basic science and clinical pain management.
Pain trajectories can be modified by timely multimodal analgesia, physical therapy, and psychological interventions [16].
3. Tertiary Prevention
Applies when chronic pain is already established. Goals include:
• Reducing frequency and severity of pain,
• Enhancing functional and emotional well-being.
Effective interventions:
• Cognitive-behavioral therapy (CBT),
• Mind-body techniques (e.g., yoga, mindfulness),
• Interdisciplinary rehabilitation,
• Multimodal pharmacotherapy and physiotherapy [17].
Technology can support tertiary prevention through web-based apps and remote monitoring, improving adherence and enabling real-time feedback [18].
Follow-up and Adherence
Tracking patients’ responses to interventions is crucial. Regular pain intensity ratings, functional assessments, and quality-of-life scales help optimize treatment. However, many tertiary interventions require self-management, making patient adherence a key determinant of success.
Digital health tools such as mobile apps, telehealth platforms, and wearable devices are proving effective in promoting adherence and engagement in long-term pain management plans [19].
Conclusion
While acute pain is common, a subset of patients are vulnerable to chronicity. A multifactorial understanding—including preoperative, intraoperative, and postoperative factors—guides early intervention. Both peripheral and central mechanisms underlie chronic pain, providing multiple therapeutic targets. Prevention, particularly timely and individualized interventions, is key to reducing the burden of chronic pain and improving patient outcomes.
References
1. Mesaroli G, Amodeo LR, Edmonds JK, Kim Y, Curran JA. Pain prevalence and management in emergency departments: A systematic review and meta-analysis. Pain Res Manag. 2020;2020:9156734.
2. van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology and its clinical relevance. Br J Anaesth. 2018;120(1):e23–32.
3. Clauw DJ, Häuser W. Fibromyalgia and the role of central sensitization in chronic pain: A systematic review. Mayo Clin Proc. 2019;94(9):1830–41.
4. Burke SM, Woodrow C, Molnar DS. Psychological risk factors for chronic post-surgical pain: A meta-analysis. Pain. 2021;162(5):1170–80.
5. Fillingim RB, Loeser JD, Baron R, Edwards RR. Assessment of chronic pain: Domains, methods, and mechanisms. J Pain. 2020;21(3-4):332–48.
6. Denk F, McMahon SB. Chronic pain: Emerging evidence for the involvement of epigenetics. Neuron. 2019;102(5):931–43.
7. Althaus A, Hinrichs-Rocker A, Chapman R, et al. Risk factors for chronic post-surgical pain: A systematic review. Eur J Pain. 2018;22(4):727–41.
8. Poobalan AS, Bruce J, Smith WC, King PM, Chambers WA, Krukowski ZH. Post-herniorrhaphy chronic pain and its impact on patient outcomes: A systematic review. BMJ Open. 2021;11(8):e045887.
9. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2018;393(10180):1537–46.
10. Lavand’homme P. Transition from acute to chronic pain after surgery. Curr Opin Anaesthesiol. 2019;32(5):623–28.
11. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: a clinical practice guideline. J Pain. 2019;20(3):453–72.
12. Baliki MN, Apkarian AV. Nociception, pain, negative moods, and behavior selection. Neuron. 2021;109(1):142–65.
13. Darnall BD, Ziadni MS, Stieg RL, Mackey IG, Kao MC, Flood P, et al. Pain psychology: A global needs assessment and national call to action. Pain Med. 2020;21(8):1425–35.
14. Hruschak V, Cochran G. Psychosocial and environmental factors in the transition from acute to chronic pain: A narrative review. J Pain Res. 2018;11:967–77.
15. Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prevention of persistent opioid use after surgery: A review. Anesth Analg. 2019;129(3):566–76.
16. Kaye AD, Cornett EM, Helander EM, Eng MR, Mogali S, Mena G, et al. Multimodal analgesia and chronic pain: An update on clinical practice. Best Pract Res Clin Anaesthesiol. 2020;34(3):487–97.
17. Sharma M, Kaur G, Thomas P, et al. Interdisciplinary rehabilitation for chronic pain: A systematic review. PLoS One. 2019;14(8):e0221189.
18. Eccleston C, Fisher E, Craig L, Duggan GB, Rosser BA, Keogh E. Psychological therapies for the management of chronic pain in adults: Digital health interventions. J Med Internet Res. 2020;22(1):e14550.
19. Wu YL, Johnson MI, Makris UE. Mobile applications to support self-management in people with chronic pain: A meta-analysis. JMIR Mhealth Uhealth. 2021;9(4):e23400.
Samridhi NANDA (Jaipur, India)
14:30 - 14:50
Q&A.
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14:00-14:50
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C23
LIVE DEMONSTRATION
Buttock
LIVE DEMONSTRATION
Buttock
14:00 - 14:50
Gluteal pain syndrome.
Dan Sebastian DIRZU (consultant, head of department) (Demonstrator, Cluj-Napoca, Romania), Michal BUT (Consultant pain clinic) (Demonstrator, Koszalin, Poland)
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14:00-14:50
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D23
ESRA | ASRA SESSION
Current and future developments
ESRA | ASRA SESSION
Current and future developments
Chairperson:
David PROVENZANO (Faculty) (Chairperson, Bridgeville, USA)
14:00 - 14:00
Introduction.
14:00 - 14:22
ESRA.
Eleni MOKA (faculty) (Keynote Speaker, Thessaloniki, Greece, Greece)
14:22 - 14:44
ASRA.
Steven COHEN (Professor) (Keynote Speaker, Chicago, USA)
14:44 - 14:50
Q&A.
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14:00-14:50
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E23
PRO CON DEBATE
Continuous infusions are better than intermittent injections
PRO CON DEBATE
Continuous infusions are better than intermittent injections
Chairperson:
Peñafrancia CANO (Associate Professor; Chief, Division of Regional Anesthesia, University of the Philippines) (Chairperson, Manila, Philippines)
14:00 - 14:00
Introduction.
14:00 - 14:15
For the PROs: Continuous infusions.
Peter MERJAVY (Consultant Anaesthetist & Acute Pain Lead) (Keynote Speaker, Craigavon, United Kingdom)
14:15 - 14:30
For the CONs: Intermittent injections.
Kariem EL BOGHDADLY (Consultant) (Keynote Speaker, London, United Kingdom)
14:30 - 14:50
Q&A.
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14:00-14:50
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F23
FREE PAPER SESSION 8/8
OBSTETRICS
FREE PAPER SESSION 8/8
OBSTETRICS
Chairperson:
Malcolm BROOM (?) (Chairperson, Glasgow, United Kingdom)
14:00 - 14:07
#44952 - OP68 Placenta accreta spectrum (pas): data review of pas cases successfully managed by a trained multidisciplinary team in our tertiary referral hospital.
OP68 Placenta accreta spectrum (pas): data review of pas cases successfully managed by a trained multidisciplinary team in our tertiary referral hospital.
Placenta accreta spectrum (PAS), is frequently associated with severe obstetric haemorrhage, anaesthesia risks and high mortality. We present a data review of PAS cases successfully managed by a trained, comprehensive, multidisciplinary team in an Italian Tertiary referral hospital.
The analysis includes all PAS cases which have been managed between 2020 and 1st semester of 2024 at Casa Sollievo della Sofferenza (CSS), city of San Giovanni Rotondo, Italy During the study period, 19 women underwent Caesarean Section for PAS-related reasons. More than half women were preterm at time of delivery and almost 100% had almost one previous caesarean section (CS) in their obstetric history. Regarding Obstetric management during pregnancy, 66.7% were placenta praevia major cases. MRI was performed in 3 cases. Regarding Multidisciplinary management at time of delivery, almost half CS were performed in Hybrid Operating Room; more than half were conducted under Regional Anaesthesia and for all of them interventional radiologic procedures with preoperative placement of catheters were carried out; iliac arteries occlusion was necessary for half of them. Ureteral stents were placed in 2 cases. Peripartum Hysterectomy was performed in 4 cases and one third of them were admitted to the ICU. More than half newborns were admitted to the NICU. No maternal or neonatal deaths occurred. CSS has developed an internal protocol for managing PAS cases. We presented our cases successfully managed by a trained, comprehensive, multidisciplinary team, composed of Gynaecologists, Obstetricians, Sonographers, Anaesthesiologists, Urologists and Interventional Radiologists. A careful antepartum diagnosis by ultrasound imaging is critical to get ready for surgery; surgical and anaesthetic skills are significant to reduce risk of injury; interventional radiologic technique is fundamental to minimise high risk of intraoperative haemorrhage. These skilled facilities are fundamental for optimal management of these increasingly frequent cases.
Tiziana PALLADINO (SAN GIOVANNI ROTONDO, Italy), Pasquale VAIRA, Ricciardi PIERA, Maglione ANNAMARIA, Paola Sara MARIOTTI
14:07 - 14:14
#45682 - OP69 Associations of pain, analgesia technique, and psychological factors with central sensitization after childbirth.
OP69 Associations of pain, analgesia technique, and psychological factors with central sensitization after childbirth.
Central sensitization is a phenomenon whereby the central nervous system becomes hyperresponsive to nociceptive input, resulting in amplified pain signals and increased sensitivity to stimuli that would normally be less painful or non-painful. Central sensitization may underlie chronic postpartum pain, yet its risk factors remain poorly understood. We aimed to identify independent predictors of severe postpartum central sensitization at 6–10 weeks postpartum.
We performed a secondary analysis of data from a clinical trial investigating association between labor epidural analgesia and postpartum depression. After obtaining written informed consent, term pregnant participants completed validated pre-delivery questionnaires evaluating pain and psychological vulnerabilities. Data on labor pain intensity, obstetric interventions, and neonatal outcomes were systematically collected. An online survey was conducted at 6–10 weeks postpartum to assess severe central sensitization, defined as a Central Sensitization Inventory (CSI) score of ≥50. Of the 816 participants, 401 (49.1%) had severe central sensitization at 6–10 weeks postpartum. Multivariable analysis identified six independent predictors of severe central sensitization: Pre-delivery factors including higher Edinburgh Postnatal Depression Scale (EPDS) score (adjusted odds ratio (aOR) 1.09, 95% confidence interval (CI)1.03–1.14, p=0.0009); a higher pre-delivery CSI score (aOR 1.08, 95%CI 1.06–1.10, p<0.0001); a higher Angle Labor Pain Questionnaire (A-LPQ) Enormity of pain subscale score (aOR 1.01, 95%CI 1.00–1.03, p=0.011), and a higher Fear-Avoidance Components Scale (FACS) pain-related anxiety subscale score (aOR 1.03, 95%CI 1.01–1.05, p=0.015); and obstetric complications including manual removal of placenta (aOR 4.33, 95%CI 1.17–16.03, p=0.028) and intrauterine growth restriction (aOR 12.29, 95%CI 1.29–117.57, p=0.029) (Area under the curve (AUC): 0.79 (95%CI 0.76–0.82)). Greater pre-delivery pain and psychological vulnerabilities, and obstetric complications were independently associated with the development of severe central sensitization at 6–10 weeks postpartum. Recognition of these risk factors may help identify women at risk and inform targeted strategies to mitigate persistent postpartum pain.
Shaohong WANG (Singapore, Singapore), Rehena SULTANA, Chin Wen TAN, Farida ITHNIN, Tiong Heng Alex SIA, Ban Leong SNG
14:14 - 14:21
#46409 - OP40 Personal Pain Perception, Patient Empathy and Trust Attitudes in Physicians Actively Interested in Pain: A Questionnaire-Based Cross-Sectional Study.
Personal Pain Perception, Patient Empathy and Trust Attitudes in Physicians Actively Interested in Pain: A Questionnaire-Based Cross-Sectional Study.
Empathy is one of the main determinants of the patient-physician relationship, especially in the assessment of subjective clinical findings such as pain. Empathic physicians have been shown to provide more reliable and effective pain management in the literature. However, how physicians' personal pain perception, self-care behaviors and their approach to the patient's statement reflect on their empathy levels has not been sufficiently investigated. This study aims to evaluate the relationship between personal pain perception, empathy level and trust in patient statement in physicians who actively deal with pain and to reveal the factors affecting these constructs.
In a cross-sectional study conducted online with 192 physicians directly involved in pain management, the Pain Sensitivity Questionnaire (PSQ), Jefferson Empathy Scale and structured questions were administered. Participants' demographic data, attitudes towards pain, self-care approaches and levels of trust in patient statements were analyzed. Data were evaluated by correlation, group comparisons and multiple regression analyses. Empathy level showed a significant positive relationship with trust in patient statement (ρ = 0.47, p < 0.001). Female gender and interventional treatment were significant factors that increased the level of empathy. Professional experience showed a significant positive association with trust in patient statement (ρ = 0.39, p < 0.001). No significant relationship was found between pain threshold and empathy. Physicians who did not care about their own pain had lower levels of empathy (p = 0.024). This study shows that the level of empathy is more related to trust in patient statement, self-awareness and professional attitudes than to biological pain sensitivity. Lack of self-care may negatively affect empathic capacity. The findings point to the need to consider empathy not only as an individual trait but also as a clinical competence that needs to be developed educationally and structurally.
Ali Hüseyin DEMİR, Hüseyin Cevahir İNCİRCİ, İlke DOLĞUN (ISTANBUL, Turkey)
14:21 - 14:28
#47346 - OP71 PASSPORT: Placenta Accreta Spectrum Patient Outcomes of Resuscitation + anesthesia Technique: an analysis of practice patterns at two large tertiary referral centres in North America.
OP71 PASSPORT: Placenta Accreta Spectrum Patient Outcomes of Resuscitation + anesthesia Technique: an analysis of practice patterns at two large tertiary referral centres in North America.
Placenta accreta spectrum (PAS) denotes a range of conditions with pathologic infiltration of trophoblastic and villous tissue resulting in higher rates of adverse maternal outcomes (1).The primary aim of this study was to review the anesthetic management of PAS at our institution.
This review was performed in a large tertiary centre in North America with two major sites that facilitate 6,800 deliveries annually. We conducted a chart review of PAS cases at our institution from 2019-2024. Thirty-nine cases were included, and relevant perioperative information is included in Table 1. Thirty-five patients received epidurals with the level ranging from T7-L5 to allow for a midline incision, exteriorization of the uterus and fundal extrication of the fetus. The most common epidural level administered was T10-T11 (8), followed by L3-L4 (6) and L2-L3 (5). The highest pain scores experienced in recovery were recorded (0-10). For those with an epidural at T10-11, the mean pain score was 3.88, 4.6 for L3-4 and 2.25 for L2-L3.
The average time to breakthrough analgesia was 95 minutes, with 35% of patients not requiring breakthrough pain medications, and 56.76% of patients not requiring opioids in recovery. The most common complication intraoperatively was a bladder cystotomy (6), and post-operatively was an ileus (4). Nine patients returned to hospital within 90 days (23%), and five were re-admitted. PAS at our institution was primarily managed with a general anesthetic, and epidural anesthesia for post-operative pain control. We hope to use this data to perform subgroup analysis and compare to other centres.
Annie BERG (Ottawa, Canada), Sarah ROBERTS, Mohamed EISSA, Wesley EDWARDS, Sony SINGH, Christopher PYSYK, Wesley RAJALEELAN
14:28 - 14:35
#47486 - OP72 Visual Multidisciplinary Estimation and Measurement of Blood Loss in Elective Caesarean Delivery at Mater Dei Hospital.
OP72 Visual Multidisciplinary Estimation and Measurement of Blood Loss in Elective Caesarean Delivery at Mater Dei Hospital.
The obstetric population is one which may experience significant blood loss during elective Caesarean delivery. This is not routinely measured at Mater Dei Hospital (MDH), and may cause significant morbidity and mortality if not recognised. The aim was to compare measured blood loss with visual multidisciplinary estimation of blood loss during elective Caesarean section at MDH.
This study is a prospective observational research study, carried out in November and December 2023. Approval from the University of Malta Ethics Committee, the MDH Data Protection Office and the relevant clinical Chairpersons was obtained. Information sheets were given to, and written consent was obtained from, each participant. All pregnant patients 18 years of age or older undergoing elective Caesarean delivery under subarachnoid block, epidural anaesthesia, combined spinal-epidural anaesthesia, or general anaesthesia were included. Demographic data, pre-operative blood results, measured volume of fluid in surgical suction canister, measured net weight of swabs, and visual estimation of blood loss from the most senior anaesthetist, the most senior obstetrician and the scrub nurse in theatre were obtained. 88 participants were included (67 ASA1, 20 ASA2); median age: 34 years. Median measured blood loss: 607.5 ml; median anaesthetist blood loss visual estimation: 500ml, IQR 350ml; median scrub nurse blood loss visual estimation: 500ml, IQR 300ml; median obstetrician blood loss visual estimation: 500ml, IQR 280ml. Chi-square tests for total measured blood loss versus: 1. anaesthetist visual estimation: p<0.001; 2. scrub nurse visual estimation p=0.08; 3. obstetrician visual estimation p=0.002. The visual estimations of all three groups underestimated the actual total measured blood loss. The anaesthetists’ visual estimations were the most statistically significant, followed by the obstetricians’. The scrub nurse visual estimations were not statistically significant in this study. There was no statistically significant difference in the visual estimation of blood loss between different grades of anaesthetists and obstetricians.
Gianluca FAVA (Valletta, Malta), Martina GERADA, Lauren BORG XUEREB, Petramay ATTARD CORTIS
14:35 - 14:42
#47546 - OP73 Prophylatic Ondansetron for Prevention of Spinal Anesthesia Induced Hypotension in Patients Undergoing Cesarean Section: A Double Blinded Randomized Clinical Trial.
OP73 Prophylatic Ondansetron for Prevention of Spinal Anesthesia Induced Hypotension in Patients Undergoing Cesarean Section: A Double Blinded Randomized Clinical Trial.
Spinal anesthesia (SA) has become the standard anesthesia technique for cesarean section (CS). Major side effects of SA are hypotension, bradycardia, nausea and shivering. Ondansetron has been studied as a potential preventive drug of SAIH. Despite the promising effects in some studies, much literature recommends further study. The goal of our study was to determine whether the prophylactic administration of ondansetron can attenuate SAIH in patients undergoing CS.
A double-blinded randomized clinical trial was conducted on 41 full-term parturients from June to September 2023. Patients were randomly allocated into Group O (n=22), who received ondansetron 4 mg, and Group C (n=19), who received normal saline. All the patients were monitored for blood pressure, heart rate, vasopressor requirement and side effects. The data analysis was carried out with independent samples T-test and Chi-square test. Fourteen patients in group C (73,6%) and twelve patients in group O (54,5%) had intraoperative hypotension, but the difference was not statistically significant (P = 0,164). The total phenylephrine requirement in group C was significantly higher than in group O (P = 0,030). Also, the ephedrine dose required in group C was higher than in group O, but the difference was not statistically significant (P = 0,309). There was no statistical difference in mean HR, SBP, DBP and MAP values from minute 0 to minute 40 between the two groups. The incidence of nausea was significantly higher in group C than in group O (P=0,013). Incidence of vomiting was superior in group C, but the difference was not statistically significant (p=0,141). Shivering and pruritus were found in one patient in group C. Prophylactic ondansetron was not effective in reducing the incidence of hypotension in parturients undergoing cesarean section, but it did reduce significantly the amount of vasopressor used and the incidence of nausea. Further research is necessary.
Sancha COSTA SANTOS (Ponta Delgada, Portugal), Helena SILVA, Joaquim BORBA, Rui FREITAS DA SILVA, Ana Cristina CASTANHA, António PAIVA
14:42 - 14:49
#48163 - OP74 Impact of a structured training programme on technical challenges in epidural catheter placement by trainees in parturients.
OP74 Impact of a structured training programme on technical challenges in epidural catheter placement by trainees in parturients.
In teaching hospitals, epidural analgesia in parturients is commonly performed by anesthesiology trainees. Given that epidural catheter placement is a blind technique, adequate training is essential to reduce technical difficulties and improve outcomes. This study evaluates the impact of a structured training programme on the incidence of technical challenges during epidural catheter placement by trainees in parturients.
Obstetric epidural procedural reports between March 2024 and February 2025 were analyzed. Provided by the anesthesiology department, all trainees received theoretical and simulation training, followed by a mandatory exam. After passing the exam, trainees performed their first five epidural catheter placements under direct supervision. Procedural documentation included technical challenges, bone contact, the number of attempts, and patient characteristics. As per institutional protocol, patients were evaluated the day after the puncture by the acute pain team for procedural satisfaction and screened for complications, such as post-dural puncture headache. A total of 1,280 epidurals were performed by 85 trainees, with 156 cases (12%) reported as difficult. Deep bone contact was noted in 266 cases (21%), and 277 procedures (22%) required two or more attempts; of these 51 (4%) needed three or more attempts. Dural punctures occurred in 10 cases (0.8%). The median patient-reported procedural satisfaction score was 9 (8-10), while the maximum NRS pain score during epidural placement had a median of 1 (0-3). Technical challenges were not influenced by the trainees' experience level. Our data suggest that the trainee teaching model provides adequate safety, efficacy, and a comparable number of attempts regardless of the trainee's experience level, supporting its continued use in anesthesiology training.
Eline GHYSELS (Antwerp, Belgium), Eline SOORS, Florence POLFLIET, Sterre WARSON, Admir HADZIC, Imré VAN HERREWEGHE
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H23
SIMULATION TRAININGS
SIMULATION TRAININGS
Demonstrators:
Josip AZMAN (Consultant) (Demonstrator, Linkoping, Sweden), Hana HARAZIM (Physician) (Demonstrator, Brno, Czech Republic), Clara LOBO (Medical director) (Demonstrator, Abu Dhabi, United Arab Emirates), Lara RIBEIRO (Anesthesiologist Consultant) (Demonstrator, Braga-Portugal, Portugal), Roman ZUERCHER (Senior Consultant) (Demonstrator, Basel, Switzerland)
This interactive, simulation-based learning experience allows you to explore the complications of regional anaesthesia in a fun and engaging way! Covering several challenging daily clinical situations and crisis management cases from the fields of trauma, orthopaedics and obstetrics, it combines all kinds of simulation to provide an excellent learning resource.
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COFFEE BREAK
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15:00-15:30
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G23
PROSPECT Trainees Session
PROSPECT Trainees Session
Chairperson:
Marc VAN DE VELDE (Professor of Anesthesia) (Chairperson, Leuven, Belgium)
15:00 - 15:30
Getting involved in PROSPECT guideline development for trainees and new consultants.
Benjamin ATTERTON (Regional Anaesthesia Fellow) (Animator, Cork, Ireland), Gillian CROWE (Animator, Dublin, Ireland)
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15:30-16:20
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A25
SECOND OPINION BASED DISCUSSION
Confused about CRPS?
SECOND OPINION BASED DISCUSSION
Confused about CRPS?
Chairperson:
Martina REKATSINA (Assistant Professor of Anaesthesiology) (Chairperson, Athens, Greece)
15:30 - 15:30
Introduction.
15:30 - 15:45
CRPS is primary Chronic Pain Syndrome.
Matthieu CACHEMAILLE (Médecin chef) (Keynote Speaker, Geneva, Switzerland)
15:45 - 16:00
Early interventions are effective in CRPS t 1 and 2.
Teodor GOROSZENIUK (Consultant) (Keynote Speaker, London, United Kingdom)
16:00 - 16:15
Neuromodulation techniques for CRPS.
Ashish GULVE (Consultant in Pain Medicine) (Keynote Speaker, Middlesbrough, United Kingdom)
16:15 - 16:20
Q&A.
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15:30-17:20
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B25
TRAINEES SESSION
Mastering Regional Anaesthesia Skills: A Trainee’s Guide to Success
TRAINEES SESSION
Mastering Regional Anaesthesia Skills: A Trainee’s Guide to Success
Chairpersons:
Fani ALEVROGIANNI (Resident) (Chairperson, Athens, Greece), Patrick NARCHI (Anesthesia) (Chairperson, SOYAUX, France)
15:30 - 15:30
Introduction.
15:30 - 15:50
Ultrasound-Guided Nerve Blocks: Fundamentals and Overcoming Common Challenges.
Daniel WEBER (Physician) (Keynote Speaker, Vienna, Austria)
15:50 - 16:10
Optimising Patient Safety in Regional Anaesthesia: Best Practices and Case Reviews.
Marie-Camille VANDERHEEREN (Anaesthesiologist) (Keynote Speaker, Kortrijk, Belgium)
16:10 - 16:30
Navigating Complex Anatomies: Strategies for Success in Challenging Procedures.
Joseph MCGEARY (SpR) (Keynote Speaker, Dublin, Ireland)
16:30 - 16:50
Training the Next Generation: Effective Strategies for Teaching Regional Anaesthesia.
Mathias MAAGAARD (MD, PhD) (Keynote Speaker, Copenhagen, Denmark)
16:50 - 17:10
Q&A.
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15:30-16:20
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C25
LIVE DEMONSTRATION
Gastric
LIVE DEMONSTRATION
Gastric
Demonstrators:
Rosie HOGG (Consultant Anaesthetist) (Demonstrator, Belfast, United Kingdom), Peter VAN DE PUTTE (Consultant) (Demonstrator, Bonheiden, Belgium)
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D25
ESRA SESSION
Science Pearls
ESRA SESSION
Science Pearls
Chairperson:
Guy WEINBERG (Faculty) (Chairperson, Chicago, USA)
15:30 - 15:32
Introduction.
Guy WEINBERG (Faculty) (Keynote Speaker, Chicago, USA)
15:32 - 15:44
A platform trial is not about viewpoints.
Vishal UPPAL (Professor) (Keynote Speaker, Halifax, Canada, Canada)
15:44 - 15:56
How I read a metaanalysis.
eric ALBRECHT (Program director of regional anaesthesia) (Keynote Speaker, Lausanne, Switzerland)
15:56 - 16:08
NAP8.
Alan MACFARLANE (Consultant Anaesthetist) (Keynote Speaker, Glasgow, United Kingdom)
16:08 - 16:20
Critical appraisal of the PROSPECT methodology.
Michele CARELLA (Head of Clinic) (Keynote Speaker, Liège, Belgium)
16:20 - 16:25
Q&A.
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15:30-16:20
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E25
ASK THE EXPERT
Covid still not to forget
ASK THE EXPERT
Covid still not to forget
Chairperson:
Andre VAN ZUNDERT (Professor and Chair Anaesthesiology) (Chairperson, Brisbane Australia, Australia)
15:30 - 15:30
Introduction.
15:30 - 16:00
Chronic pain after Covid and other viral infections.
Aikaterini AMANITI (Professor) (Keynote Speaker, Thessaloniki, Greece)
16:00 - 16:20
Q&A.
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15:30-17:20
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F25
NETWORKING SESSION
New stuff on the scene
NETWORKING SESSION
New stuff on the scene
Chairperson:
Aleksejs MISCUKS (Professor) (Chairperson, Riga, Latvia, Latvia)
15:30 - 15:30
Introduction.
15:30 - 15:52
Peripheral nerve stimulation for surgical pain management.
Magdalena ANITESCU (Professor of Anesthesia and Pain Medicine) (Keynote Speaker, Chicago, USA)
15:52 - 16:14
#48639 - FT39 New stuff on the scene. Role of non-pharmacological treatments.
New stuff on the scene. Role of non-pharmacological treatments.
A recent analysis of a large registry data (10415 patients from 10 countries) [1] reported that, despite considerable efforts to improvement during the last decades, postoperative pain is still a common experience for many patients. According to the findings, 50% of the patients endured severe pain (NRS > 7/10) and 25% spent more than 50% of their time in pain during the first 24h. More, severe pain negatively interfered with functional and emotional recovery in at least 30% of the patients [1]. How to explain these findings. On one hand, current guidelines for postoperative pain management as well as those promoting enhanced recovery after surgery remain poorly applied. Even multimodal analgesia is not systematically administered to all the patients [1]. On the other hand, by definition, pain is an individual, complex,multifaceted experience, that is shaped by a lifetime of learning processes and influenced by sensory, affective, cognitive and sociocultural factors [2]. That may explain the considerable variability of patients to experience pain and to respond to analgesic treatments. Thereby, it is not surprising that currently recommended postoperative pain management may not fit all the patients.
Today, acute pain management, including postoperative pain, mostly relies on the administration of pharmacological treatments. As previously discussed, their effectiveness suffers limitations, particularly in some patients. In contrast, the use of non-pharmacological interventions remains unfrequent (average 28% utilization), distraction-based interventions proposed to 25% of the patients and physical modality i.e. cold pack proposed to 8% of the previously mentioned cohort of patients [1]. The failures of classical perioperative analgesic treatments and the opioid health-related crisis have underscored the importance to optimize various approached to pain management and to further question the role and benefits of intergrating complementary medicine in perioperative pain management [3].
Complementary Medicine and Integrative Health
Complementary medicine (CM) is a term used to describe non-pharmacological approaches to health, healing and rehabilitation [3]. CM interventions may be categorized in 5 subgroups: alternative medicines (e.g. homeopathy), natural product based therapy (e.g. dietary supplements), energy therapies (e.g. acupuncture), body-based interventions (e.g. massages) and mind-body interventions (e.g. hypnotherapy).
Integrative Health is the practice of incorporating both traditional and CM into a comprehensive treatment plan [3]. Practice of Integrative Health, also called holistic medicine, considers all the aspects of the patient when choosing the most appropriate treatment [3]. Despite the patient’s preferences and their growing desire for a more integrated approach in their cares, several barriers to a regular use of CM in perioperative pain management are still present (see Table). The lack of rigorous scientific evidence supporting the use of CM still stands as a major barrier for health care providers. However, as stated in an editorial [4] “a little better is still better” and the marginal gains provided by non-pharmacological interventions could be used to improve postoperative recovery as a global human experience, even without much impact on pain intensity or opioids consumption. Utilization of CM treatments may help to reduce excessive anxiety and may improve sleep quality, two factors which greatly affect the pain severity, the need of rescue analgesics and the speed of postoperative recovery.
Evidence of CM usefulness in perioperative cares
Some CM therapies have gained more popularity in the recent years, by examples acupuncture and psychological interventions.
Acupuncture could be considered as the “most invasive” of all CM therapies. Perioperative acupuncture may reduce the incidence of postoperative nausea and decrease the frequency of anti-emetic drugs use [3]. It may also modulate the body stress response to the surgical injury. Decrease of stress biomarkers like troponin levels after open cardiac surgery or S100β levels after craniotomy has been observed [5,6]. Always in relation with the modulation of the stress response, perioperative acupuncture has been associated with decreased vasopressor requirements and improved glucose control. Transcutaneous electrical acupoint stimulation (TEAS) is an emerging therapeutic approach that combines the effects of TENS (transcutaneous electrical nerve stimulation) with acupuncture points stimulation [7]. TEAS is a non-invasive technique by contrast with traditional acupuncture and needle-based electrostimulation. Despite multiple applications, the mechanisms of TEAS still remain poorly understood and a large heterogeneity exists among published studies in relation with stimulation frequencies and stimulation points used [8]. Two systematic reviews seem to conclude to some benefit of TEAS on the control of perioperative nausea-vomiting and pain, allowing to reduce some hospitalization costs [7,8].
Psychological interventions include an umbrella of different types of interventions and techniques, from psycho-education, relaxation and behavioral modification therapies [9]. Because emotions and cognition are strongly associated with the development of acute and chronic pain, psychological interventions are defined as strategie targeted towards reducing stress, anxiety, negative emotions and depression. By these mechanisms, these interventions help to reduce postoperative opioids use and pain scores in some patients. Whether these interventions have demonstrated their efficacy in chronic pain management e.g. in cancer patients [10], there is a clear need to show the perioperative benefits and more specifically to determine the optimal technique, the optimal timing of administration and the optimal patient [9]. Two recent systematic reviews and meta-analysis have questioned the role of perioperative psychological interventions on postsurgical pain, disability and psychologic well-being [11,12]. Psychological approaches considered included cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT) and mindfulness-based interventions (MBIs). The last meta-analysis [12] which extended the review published by Nadinda et al [11], included 27 RCTs (around 3000 patients). Compared with usual care or control treatment, moderate quality evidence exists that psychological interventions reduced pain intensity and anxiety after surgery [12] but did not influence pain catastrophizing or depression. According to the results, CBT seemed the most beneficial for surgical patients [12]. Both reviews underlined the fact that psychological interventions delivered by a psychologist were more effective than those delivered by other professionals (i.e. anesthesiologists, surgeons, nurses…). It is worth noting the limitations of these systematic reviews, related to the quality and heterogeneity of the RCTs results. Among relaxation techniques, hypnosis and virtual reality (VR) are now very popular and widely used in perioperative setting. While hypnosis requires a specific formation, the utilization of VR only necessitates a specific equipment [13]. It is worth noting that virtual reality includes a huge variety in the type of applied VR, from augmented reality to mixed reality, even including hypnotic suggestions. Clinical studies suggest that therapeutic effects of VR in reducing acute pain may be most evident when VR is administered at the same time of the painful stimulus [13]. Some authors consider that VR and analgesia achieved from hypnosis are similar in that the patient is detached from reality. However, for hypnosis, patient susceptibility to hypnotic suggestion is an important consideration. Low quality evidence suggests that VR alone can reduce pain independent of hypnotizability. Further, the effectiveness of combining VR and hypnosis remains unclear [13,14]. A study comparing perioperative hypnosis versus enhanced standard of care after total knee arthroplasty [15] pointed out the fact that hypnosis lessened postoperative pain intensity (35%) and opioid use (54%) only in the subgroup of patients who were taking opioids before surgery. Well- known difficult perioperative management of this patients population makes the results particularly interesting and deserving further confirmation. Actual benefits of psychological interventions in operative setting have been measured in populations where patients suffering chronic pain conditions, presenting with psychiatric illness or chronic opioids intake have been excluded [9]. Finally, among available psychological interventions, patient’s education plays an important role although its real benefits in terms of postoperative pain and analgesics use are far from evident [9]. A recent study in patients presenting with a significant preoperative anxiety level has found that a brief short-term individualized information and empathic conversation, paired with an educational video significantly reduced preoperative anxiety compared to a standard preanesthetic consultation [16]. Further studies should assess the postoperative benefit of such intervention on global recovery.
In conclusion, patient’s participation to their perioperative cares has a major impact on the overall benefit of the surgical procedure. The failures of classical analgesic treatments and the opioid health-related crisis point out the importance to optimize current perioperative management by promoting different approaches. Today, growing evidences support the utilization of CM as adjuvants to standard perioperative treatments, particularly to improve postoperative recovery as a global human experience. Future research should question the role, the indications and the benefits of integrating complementary medicine in perioperative pain management. Rigorous research protocols are mandatory and need to consider the patient’s global recovery experience, beyond postoperative pain scores and opioid consumption.
References
1. Jena PORG, Chinese POUTn, Dutch POUTn, Mexican POUTn, Serbian POUTn, Spanish POUTn, French POUTn, Italian POUTn, Swiss POUTn, Irish POUTn, et al.: Status quo of pain-related patient-reported outcomes and perioperative pain management in 10,415 patients from 10 countries: Analysis of registry data. Eur J Pain 2022, 26:2120-2140.
2. Haythornthwaite JA, Campbell CM, Edwards RR: When thinking about pain contributes to suffering: the example of pain catastrophizing. Pain 2024, 165:S68-S75.
3. Kelleher DC, Kirksey MA, Wu CL, Cheng SI: Integrating complementary medicine in the perioperative period: a simple, opioid-sparing addition to your multimodal analgesia strategy? Reg Anesth Pain Med 2020, 45:468-473.
4. Leng JC, Mariano ER: A little better is still better: using marginal gains to enhance 'enhanced recovery' after surgery. Reg Anesth Pain Med 2020, 45:173-175.
5. Asmussen S, Przkora R, Maybauer DM, Fraser JF, Sanfilippo F, Jennings K, Adamzik M, Maybauer MO: Meta-Analysis of Electroacupuncture in Cardiac Anesthesia and Intensive Care. J Intensive Care Med 2019, 34:652-661.
6. Asmussen S, Maybauer DM, Chen JD, Fraser JF, Toon MH, Przkora R, Jennings K, Maybauer MO: Effects of Acupuncture in Anesthesia for Craniotomy: A Meta-Analysis. J Neurosurg Anesthesiol 2017, 29:219-227.
7. Szmit M, Krajewski R, Rudnicki J, Agrawal S: Application and efficacy of transcutaneous electrical acupoint stimulation (TEAS) in clinical practice: A systematic review. Adv Clin Exp Med 2023, 32:1063-1074.
8. Liu Y, Fan J, Zhang X, Xu W, Shi Z, Cai J, Wang P: Transcutaneous electrical acupoint stimulation reduces postoperative patients' length of stay and hospitalization costs: a systematic review and meta-analysis. Int J Surg 2024, 110:5124-5135.
9. Gorsky K, Black ND, Niazi A, Saripella A, Englesakis M, Leroux T, Chung F, Niazi AU: Psychological interventions to reduce postoperative pain and opioid consumption: a narrative review of literature. Reg Anesth Pain Med 2021, 46:893-903.
10. Berliere M, Roelants F, Watremez C, Docquier MA, Piette N, Lamerant S, Megevand V, Van Maanen A, Piette P, Gerday A, et al.: The advantages of hypnosis intervention on breast cancer surgery and adjuvant therapy. Breast 2018, 37:114-118.
11. Nadinda PG, van Ryckeghem DML, Peters ML: Can perioperative psychological interventions decrease the risk of postsurgical pain and disability? A systematic review and meta-analysis of randomized controlled trials. Pain 2022, 163:1254-1273.
12. Castano-Asins JR, Barcelo-Soler A, Royuela-Colomer E, Sanabria-Mazo JP, Garcia V, Neblett R, Bulbena A, Perez-Sola V, Montes-Perez A, Urrutia G, et al.: Effectiveness of peri-operative psychological interventions for the reduction of postsurgical pain intensity, depression, anxiety and pain catastrophising: A systematic review and meta-analysis. Eur J Anaesthesiol 2025, 42:609-625.
13. Shanthanna H, D'Souza RS, Johnson RL, YaDeau JT: How Real Are the Effects of Virtual Reality in Decreasing Acute Pain? Anesth Analg 2024, 138:746-750.
14. Rousseaux F, Bicego A, Ledoux D, Massion P, Nyssen AS, Faymonville ME, Laureys S, Vanhaudenhuyse A: Hypnosis Associated with 3D Immersive Virtual Reality Technology in the Management of Pain: A Review of the Literature. J Pain Res 2020, 13:1129-1138.
15. Markovits J, Blaha O, Zhao E, Spiegel D: Effects of hypnosis versus enhanced standard of care on postoperative opioid use after total knee arthroplasty: the HYPNO-TKA randomized clinical trial. Reg Anesth Pain Med 2022.
16. Salzmann S, Kikker L, Tosberg E, Becker N, Spies M, Euteneuer F, Rusch D: Impact of a Personalized Intervention on Preoperative Anxiety and Determination of the Minimal Clinically Important Difference in Anxiety Levels: A Randomized Clinical Trial. Anesthesiology 2025, 142:680-691.
Patricia LAVAND'HOMME (Brussels, Belgium)
16:14 - 16:36
#48492 - FT41 PVI (periarticular vasoconstrictor infiltration).
PVI (periarticular vasoconstrictor infiltration).
ABSTRACT
Osteoarthritis is among the most prevalent degenerative musculoskeletal disorders worldwide, with its clinical and epidemiological patterns varying by anatomical location, diagnostic criteria, and population characteristics. Gonarthrosis, or knee osteoarthritis, has a global estimated prevalence of 23% in adults over the age of 40, according to a recent meta-analysis, equating to approximately 654 million individuals (1). The condition is more frequent in women and its prevalence increases with both age and body mass index. Similarly, hip osteoarthritis shows an overall prevalence of 8.6% in adults, though regional disparities are evident: prevalence is highest in Europe (12.6%) and lowest in Africa (1.2%). Among individuals aged 60 years and older, the prevalence of symptomatic hip osteoarthritis is approximately 6.2%. Like gonarthrosis, its incidence rises with age, although no significant sex differences have been observed at the global level (2).
Low back pain also represents a leading global cause of disability, with an estimated point prevalence of 12% among adults and a lifetime prevalence approaching 40%. Spinal osteoarthritis, often underlying chronic back pain, shows highly variable prevalence rates depending on the population studied, the diagnostic methods used, and the spinal segment evaluated. For example, U.S. Medicare data report a prevalence of diagnosed degenerative spinal disease of 27.3% in older adults; however, this figure is likely underestimated due to asymptomatic cases that remain undiagnosed (3).
In the advanced stages of osteoarthritis, surgical intervention often becomes necessary to restore function and relieve pain. Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are considered the gold standard treatments for end-stage joint degeneration, offering substantial improvements in joint mobility and quality of life. Likewise, in the context of spinal pathology, most of which arises as a consequence of aging and is initially addressed with conservative management, surgery may be indicated when symptoms persist or worsen. This is particularly true in cases involving radicular pain unresponsive to medical therapy. Spinal fusion (arthrodesis) is a commonly employed surgical technique in such scenarios, involving the permanent union of adjacent vertebrae through osteogenesis to eliminate pathological motion and stabilize the affected segment.
Effective postoperative pain management following major orthopedic surgery remains a significant clinical challenge, as it has a direct and measurable impact on surgical outcomes, functional recovery, and overall patient satisfaction. Despite advances in perioperative care, procedures such as total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal fusion (SF) are still commonly associated with intense postoperative pain and substantial perioperative blood loss. These factors can delay mobilization, prolong hospital stays, and increase the risk of complications, thus underscoring the need for refined, evidence-based strategies.
Estimates of intraoperative blood loss in these major orthopedic procedures vary widely, with reported volumes ranging from approximately 726 to 1,768 mL (4). This variability reflects not only differences in surgical technique and patient physiology but also the influence of modifiable perioperative factors. Although the surgeon’s expertise remains a critical determinant of intraoperative outcomes, additional risk factors—such as patient age, comorbidities, anticoagulant use, and procedural complexity—can significantly influence the magnitude of blood loss. Consequently, a variety of intraoperative strategies have been proposed to reduce bleeding, including optimized patient positioning, acute normovolemic hemodilution, and controlled hypotension. While effective, these techniques require careful application, particularly in patients with cardiovascular or systemic comorbidities, where physiological reserves may be limited and the margin for hemodynamic compromise is narrow.
In parallel, the approach to postoperative analgesia has evolved substantially over recent decades. Historically reliant on opioids as the mainstay of treatment, contemporary pain management strategies have shifted toward multimodal analgesia. This model integrates multiple pharmacological and regional techniques with the aim of enhancing analgesic efficacy while minimizing opioid-related adverse effects such as nausea, constipation, respiratory depression, and the potential for dependency. The multimodal approach typically includes agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 selective inhibitors, gabapentinoids, and corticosteroids. When combined with motor-sparing regional nerve blocks, tailored to the surgical site and the individual patient, these regimens offer improved pain control, facilitate early rehabilitation, and support enhanced recovery protocols.
Together, these evolving strategies in bleeding control and analgesia reflect a broader paradigm shift toward precision perioperative care, where individualized risk assessment and patient-centered planning form the foundation of improved surgical outcomes.
In 1987, Dr. Jeffrey Klein first described tumescent anesthesia as a technique involving the infiltration of large volumes of a diluted solution containing lidocaine and epinephrine (5). Its main advantages include effective anesthesia and a marked reduction in perioperative bleeding, thereby facilitating surgical dissection and improving the overall surgical field.
Building on this technique, in 2010, Dr. Donald Lalonde introduced the use of tumescent anesthesia in orthopedic hand surgery under the acronym WALANT (Wide Awake Local Anesthesia No Tourniquet). WALANT eliminates the need for a tourniquet, thereby avoiding the discomfort it causes during limb surgeries. Due to its advantages in outpatient settings and its cost-effectiveness, WALANT has gained increasing popularity (6). Importantly, the risks associated with systemic local anesthetic toxicity (LAST) and vasoconstrictor-induced ischemia have proven to be minimal.
Effective postoperative pain control is a key determinant of patient satisfaction in both joint replacement and spinal fusion procedures. Poorly managed postoperative pain may evolve into chronic pain, making its aggressive treatment essential. One widely adopted technique is local infiltration analgesia (LIA), which involves the periarticular injection, by the surgeon during the procedure, of a combination of local anesthetics, epinephrine, and anti-inflammatory analgesics. This simple yet effective approach significantly contributes to early pain relief and enhanced recovery.
To date, however, there is no definitive evidence favoring a specific infiltration method, drug combination, or dosage in the use of LIA.
Systematic reviews and meta-analysis support LIA for postoperative pain management in TKA (7). However, there is little evidence to support using this technique in hip replacement and spine fusion, either intraoperatively or with a postoperative wound infusion catheter technique, if multimodal oral non-opioid analgesia is given. The use of LIA has retrospectively been shown to be associated with decreased perioperative blood loss in TKA (8). Nonetheless, not many randomised controlled trials have examined the effect of preoperative LIA on blood loss. Preoperative LIA seems to decrease perioperative blood loss by 39% during TKA surgery compared to its administration at the end of the surgery, while providing non-inferior postoperative pain relief (8). This occurrence is likely a result of the limited exposure time of epinephrine to a surgical field that has already undergone dissection when the administration takes place towards the conclusion of the surgery. Such a scenario might potentially result in a weakened vasoconstrictor impact of epinephrine, leading to a reduction in its overall effectiveness. Consequently, initiating the procedure at the commencement of the surgery could enhance haemostatic outcomes. In the case of hip surgery, there are no studies to date that demonstrate changes in blood loss when LIA is employed.
In this context, the periarticular vasoconstrictor infiltration (PVI) technique has recently been defined (9,10). PVI involves an ultrasound injection of diluted local anaesthetic with epinephrine into deep periarticular planes at the vascular capsular entry. This aims to achieve a chemical tourniquet and reduce perioperative bleeding adding good quality postoperative analgesia.
The vascular supply to a joint typically runs in close anatomical association with the nerves responsible for its innervation. This relationship enables the concurrent achievement of two key therapeutic objectives when anesthetic and vasoconstrictive agents are administered in the periarticular region: regional analgesia and localized vasoconstriction. Analgesia results from the blockade of afferent nerve fibers, while vasoconstriction reduces intraoperative bleeding and enhances surgical field visibility.
PVI is an ultrasound-guided technique that should be performed after the primary anaesthesia procedure (spinal or general anaesthesia, as appropriate). The mixture solution consists of a preparation of 200 ml levobupivacaine 0.125% or ropivacaine 0,2% with 1 mg of epinephrine (1:200,000). For those patients with an unstable heart condition, solutions with up to 1:1,000,000 epinephrine have shown to provide effective haemostasis.
BIBLIOGRAPHY
1. Katz JN, Arant KR, Loeser RF. Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. Jama. 2021;325(6):568-578. Boi:10.1001/jama.2020.22171.
2. Fan Z, Yan L, Liu H, et al. The Prevalence of Hip Osteoarthritis: A Systematic Review and Meta-Analysis. Arthritis Research & Therapy. 2023;25(1):51. doi:10.1186/s13075-023-03033-7.
3. Silva-Díaz M, Blanco FJ, Quevedo Vila V, et al. Prevalence of Symptomatic Axial Osteoarthritis Phenotypes in Spain and Associated Socio-Demographic, Anthropometric, and Lifestyle Variables. Rheumatology International. 2022;42(6):1085-1096. doi:10.1007/s00296-021-05038-4.
4. Donovan RL, Lostis E, Jones I, Whitehouse MR. Estimation of blood volume and blood loss in primary total hip and knee replacement: An analysis of formulae for perioperative calculations and their ability to predict length of stay and blood transfusion requirements. J Orthop. 2021 Mar 12;24:227-232. doi: 10.1016/j.jor.2021.03.004. eCollection 2021 Mar-Apr.
5. Klein. The tumescent technique for liposuction surgery. Am J Cosmet Surg, 4 (1987), pp. 263-267. https://doi.org/10.1177/074880688700400403.
6. Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin 2014 Feb;30(1):1-6. doi: 10.1016/j.hcl.2013.08.015. Epub 2013 Nov 9.
7. Andersen LO, Kehlet H. Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth. 2014 Sep;113(3):360-74. doi: 10.1093/bja/aeu155. Epub 2014 Jun 17.
8. Lapidus O, Baekkevold M, Rotzius P, Lapidus LJ, Eriksson K. Preoperative administration of local infiltration anaesthesia decreases perioperative blood loss during total knee arthroplasty - a randomised controlled trial. J Exp Orthop. 2022 Dec 12;9(1):118. doi: 10.1186/s40634-022-00552-1.
9. Roqués Escolar V, Oliver-Forner P, Fajardo Pérez M. Periarticular vasoconstrictor infiltration: a novel technique for chemical vasoconstriction in major orthopaedic surgery. Br J Anaesth 2022 Oct;129(4):e97-e100. doi: 10.1016/j.bja.2022.07.003. Epub 2022 Aug 13.
10. Roqués-Escolar V, Molina-Garrigós P. The periarticular vasoconstrictor infiltration technique (PVI) for total knee and hip arthroplasty. A brief description of a new technique complemented by audiovisual presentations. J Clin Anesth. 2024 Feb:92:111284. doi: 10.1016/j.jclinane.2023.111284. Epub 2023 Oct 16.
Vicente ROQUES (Murcia. Spain, Spain)
16:36 - 16:58
#48557 - FT40 Role of Oxytocin.
Role of Oxytocin.
Oxytocin, often referred to as the love hormone, is a neuropeptide composed of nine amino acids produced in the hypothalamus and released into the bloodstream from the posterior pituitary gland. Its receptor, the oxytocin receptor, plays a crucial role in various physiological and psychological processes, including social bonding, reproductive behaviours, and pain modulation.(Arrowsmith and Wray, 2014) This report explores the effects of oxytocin receptor activation, presents the differences between the two available oxytocin receptor agonists (oxytocin and carbetocin), and focuses on pain modulation as one of several central nervous system (CNS) effects.
History
The discovery of oxytocin dates back to 1906 when Sir Henry Dale first isolated it from the posterior pituitary gland.(Dale, 1909) The American biochemist Vincent du Vigneaud was awarded the Nobel Prize for Chemistry in 1955 for the isolation and synthesis of the two, closely related hormones oxytocin and vasopressin.(du Vigneaud et al., 1953) The oxytocin receptor, a member of the G-protein-coupled receptor family, was identified in the 1990s.
Biology
Oxytocin’s functions are primarily facilitating childbirth by promoting uterine contractions and milk ejection during lactation.(Arrowsmith and Wray, 2014) However, its influence is not confined to obstetrics; it also significantly impacts the cardiovascular system and the CNS.(Froemke and Young, 2021; Rosseland et al., 2013) Endogenously produced oxytocin is released directly into the CNS and, in addition, acts as a blood-borne hormone. This means that oxytocin acts as both a neurotransmitter and a hormone. Theoretically, the two drugs available that have oxytocin receptor effects are expected to have no CNS effects as they cannot pass the blood-brain barrier. However, even if the drugs are not supposed to pass the blood-brain barrier, studies indicate some CNS effects after nasal spray and intravenous injection.(Fathabadipour et al., 2022) Intrathecal oxytocin has been studied in animal and human studies with documented effects on pain.(Eisenach et al., 2023a)
Stimulation of the oxytocin receptor leads to different effects depending on the cell type. Systemic vascular resistance is reduced due to a relaxation of smooth muscle cells in the vessels, but the uterine smooth muscle cells contract. Oxytocin also has some stimulating effect on the vasopressin receptors, leading to an anti-diuretic effect, which, combined with excessive water drinking or glucose infusion, probably has led to many cases of severe hyponatremia.(Moen et al., 2009; SINGHI et al., 1985) This is the reason why we stopped giving oxytocin together with glucose many years ago.
The effects of oxytocin in the CNS are multifaceted. Oxytocin has been shown to modulate various neurobiological processes, including anxiety, stress response, and social behaviour. The oxytocin system interacts with other neurotransmitter systems, including dopamine, serotonin, and norepinephrine, to regulate mood and emotional states. Furthermore, oxytocin's anxiolytic and antidepressant effects have been explored, suggesting its potential therapeutic applications in anxiety and mood disorders. Oxytocin receptor stimulation may affect autism spectrum disorder, and differences in the oxytocin receptor gene are associated with autism.(Jacob et al., 2007)
One of the more intriguing effects of oxytocin is its potential for pain relief. Research has shown that oxytocin receptor agonists can play an analgesic role by modulating pain pathways in the brain and spinal cord, reducing the perception of pain.(Gutierrez et al., 2013) This effect may be mediated through the inhibition of pain pathways and the modulation of excitatory and inhibitory signals in the spinal cord, suggesting new avenues for pain management.
Oxytocin Receptor Agonists (ORA)
There are two ORAs available: carbetocin and oxytocin. Carbetocin is a synthetic derivative of oxytocin, with a slight modification in its molecular structure intended to increase the duration of the drug's effect.(Jaffer et al., 2022) It produces long-acting uterine contractions post-delivery, thereby mitigating postpartum haemorrhage. Carbetocin efficacy is comparable to the combination of oxytocin and methergine, but it has fewer side effects,(Jaffer et al., 2022) and less crossover stimulation of vasopressin receptors.(Arrowsmith and Wray, 2014) Another interesting feature is that carbetocin, unlike oxytocin, is temperature stable. In many countries, keeping cool storage of drugs is difficult, making oxytocin inactive.(Widmer et al., 2018)
Pain Management
ORA may have promising potential as a non-opioid therapy in treating acute post-surgical pain, but also in chronic pain syndromes, especially those that are resistant to conventional analgesics.(Mekhael et al., 2023) The analgesic properties of ORA may have significant implications for pain management strategies. The postpartum period, more so than pregnancy, offers protection against chronic hypersensitivity following peripheral nerve injury in rats, and this protection may be attributed to oxytocin signaling in the CNS during the postpartum period.(Gutierrez et al., 2013) ORA may protect against persistent pain, which raises interesting perspectives for the prevention of chronic pain.(Sun and Pan, 2019) Recently, intrathecal oxytocin was tested for pain relief in hip replacement surgery. The oxytocin group did not experience a decrease in worst daily pain, but they did have faster recovery and reduced opioid use.(Eisenach et al., 2023b) Intravenously administered carbetocin showed antinociceptive effects on experimental pain in healthy male volunteers compared with placebo.(Biurrun Manresa et al., 2021) Reported postoperative pain severity was inversely correlated with plasma oxytocin levels measured 1 hour and 24 hours after cesarean delivery.(Ende et al., 2019) Furthermore, carbetocin has been shown to reduce post-caesarean pain compared with oxytocin.(Bekkenes et al., 2023) Still, clinical studies investigating the analgesic effects of ORAs are few.
Conclusion
Oxytocin and its receptor system play a multifaceted role within the CNS, influencing not only peripheral physiological processes but also exerting profound effects on social behaviour, emotional regulation, and pain. The exploration of ORA in neurobiology paves the way for novel therapeutic applications. Research has challenged our understanding of its molecular interactions and biological impacts, and ORAs may contribute to innovative and effective treatments of acute and chronic pain-related conditions.
References
Arrowsmith, S., Wray, S., 2014. Oxytocin: Its Mechanism of Action and Receptor Signalling in the Myometrium. Journal of Neuroendocrinology. 26, 356-369.
Bekkenes, M.E., et al., 2023. Effects of 2.5 IU oxytocin or 100 mu g carbetocin on pain intensity and opioid consumption after planned cesarean delivery; a randomized controlled trial. In: ACTA ANAESTHESIOLOGICA SCANDINAVICA. Vol. 67, ed.^eds. WILEY 111 RIVER ST, HOBOKEN 07030-5774, NJ USA, pp. 538-539.
Biurrun Manresa, J.A., et al., 2021. Anti-nociceptive effects of oxytocin receptor modulation in healthy volunteers-A randomized, double-blinded, placebo-controlled study. Eur J Pain. 25, 1723-1738.
Dale, H.H., 1909. The action of extracts of the pituitary body. Biochemical Journal. 4, 427.
du Vigneaud, V., Ressler, C., Trippett, S., 1953. The sequence of amino acids in oxytocin, with a proposal for the structure of oxytocin. Journal of biological chemistry. 205, 949-957.
Eisenach, J.C., Curry, R.S., Houle, T.T., 2023a. Preliminary results from a randomized, controlled, cross-over trial of intrathecal oxytocin for neuropathic pain. Pain Medicine. 24, 1058-1065.
Eisenach, J.C., et al., 2023b. Randomized controlled trial of intrathecal oxytocin on speed of recovery after hip arthroplasty. Pain. 164, 1138-1147.
Ende, H.B., et al., 2019. Association of Interindividual Variation in Plasma Oxytocin With Postcesarean Incisional Pain. Anesth Analg. 129, e118-e121.
Fathabadipour, S., et al., 2022. The neural effects of oxytocin administration in autism spectrum disorders studied by fMRI: A systematic review. Journal of Psychiatric Research. 154, 80-90.
Froemke, R.C., Young, L.J., 2021. Oxytocin, Neural Plasticity, and Social Behavior. Annual Review of Neuroscience. 44, 359-381.
Gutierrez, S., et al., 2013. Reversal of peripheral nerve injury-induced hypersensitivity in the postpartum period: role of spinal oxytocin. Anesthesiology. 118, 152-9.
Jacob, S., et al., 2007. Association of the oxytocin receptor gene (OXTR) in Caucasian children and adolescents with autism. Neuroscience letters. 417, 6-9.
Jaffer, D., et al., 2022. Preventing postpartum hemorrhage after cesarean delivery: a network meta-analysis of available pharmacologic agents. American journal of obstetrics and gynecology. 226, 347-365.
Mekhael, A.A., et al., 2023. Evaluating the efficacy of oxytocin for pain management: An updated systematic review and meta-analysis of randomized clinical trials and observational studies. Canadian Journal of Pain. 7, 2191114.
Moen, V., et al., 2009. Hyponatremia complicating labour—rare or unrecognised? A prospective observational study. BJOG: An International Journal of Obstetrics & Gynaecology. 116, 552-561.
Rosseland, L.A., et al., 2013. Changes in Blood Pressure and Cardiac Output during Cesarean Delivery: The Effects of Oxytocin and Carbetocin Compared with Placebo. Anesthesiology. 119, 541-551.
SINGHI, S., et al., 1985. Iatrogenic neonatal and maternal hyponatraemia following oxytocin and aqueous glucose infusion during labour. BJOG: An International Journal of Obstetrics & Gynaecology. 92, 356-363.
Sun, K.W., Pan, P.H., 2019. Persistent pain after cesarean delivery. Int J Obstet Anesth. 40, 78-90.
Widmer, M., et al., 2018. Heat-Stable Carbetocin versus Oxytocin to Prevent Hemorrhage after Vaginal Birth. N Engl J Med. 379, 743-752.
Leiv Arne ROSSELAND (Oslo, Norway)
16:58 - 17:20
Q&A.
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14:00-16:00
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H23
SIMULATION TRAININGS
SIMULATION TRAININGS
Demonstrators:
Josip AZMAN (Consultant) (Demonstrator, Linkoping, Sweden), Hana HARAZIM (Physician) (Demonstrator, Brno, Czech Republic), Clara LOBO (Medical director) (Demonstrator, Abu Dhabi, United Arab Emirates), Lara RIBEIRO (Anesthesiologist Consultant) (Demonstrator, Braga-Portugal, Portugal), Roman ZUERCHER (Senior Consultant) (Demonstrator, Basel, Switzerland)
This interactive, simulation-based learning experience allows you to explore the complications of regional anaesthesia in a fun and engaging way! Covering several challenging daily clinical situations and crisis management cases from the fields of trauma, orthopaedics and obstetrics, it combines all kinds of simulation to provide an excellent learning resource.
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16:10-17:50
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G25
BEST FREE PAPER SESSION (CHRONIC PAIN)
BEST FREE PAPER SESSION (CHRONIC PAIN)
Chairpersons:
Andrzej DASZKIEWICZ (anesthesiologist) (Chairperson, Cieszyn, Poland), Kiran KONETI (Consultant) (Chairperson, SUNDERLAND, United Kingdom)
Examiners:
Athina VADALOUCA (Pain and palliative care medicine) (Examiner, Athens, Greece), Jan VAN ZUNDERT (Chair) (Examiner, Genk, Belgium)
16:10 - 16:21
#44905 - OP10 Chemical Ablation of Pericapsular Nerve Group (PENG) with 95% Ethanol for Pain Relief and Quality of Life in Patients with Hip Osteoarthritis: A Prospective, Double-Blinded, Randomized, Controlled Trial.
OP10 Chemical Ablation of Pericapsular Nerve Group (PENG) with 95% Ethanol for Pain Relief and Quality of Life in Patients with Hip Osteoarthritis: A Prospective, Double-Blinded, Randomized, Controlled Trial.
Chronic hip pain due to osteoarthritis significantly impairs quality of life, and conventional treatments often provide inadequate relief. Ultrasound-guided pericapsular nerve group (PENG) neurolysis with ethanol is a minimally invasive technique that may offer prolonged analgesia. This study evaluated the efficacy and safety of ultrasound-guided 95% ethanol neurolysis of the PENG compared to a sham procedure in patients with chronic hip pain.
This double-blind, single-center, randomized controlled trial (NCT06087588) was approved by the Bioethics Committee of Poznan University of Medical Sciences on March 9, 2023 (protocol number 224/23) and registered at ClinicalTrials.gov on October 17, 2023, before recruitment. The study was conducted in accordance with the Declaration of Helsinki and followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines.
A total of 100 patients with chronic hip pain unresponsive to conservative treatments were randomly assigned to either ethanol neurolysis (n=50) or a sham procedure (n=50). The primary outcome was pain intensity, assessed using the Numeric Rating Scale (NRS) at 7 days, 30 days, 3 months, and 6 months. Secondary outcomes included opioid consumption (oral morphine equivalents), quality of life (EQ-5D-5L), and neurological deficits. Ethanol neurolysis significantly reduced NRS scores at all follow-ups (p < 0.0001). Opioid consumption was lower in the neurolysis group at 7 days (11.8 ± 5.1 mg vs. 1.6 ± 2.4 mg, p < 0.0001) and remained reduced through 6 months (p < 0.0001). Quality of life improved significantly (p < 0.0001), and no neurological deficits were observed. Ultrasound-guided ethanol neurolysis of the PENG is a safe and effective intervention for chronic hip pain, providing long-term relief and reducing opioid dependency. Further multicenter trials are needed to validate long-term outcomes.
Malgorzata REYSNER (Poznan, Poland), Tomasz REYSNER, Kowalski GRZEGORZ, Aleksander MULARSKI, Przemysław DAROSZEWSKI, Katarzyna WIECZOROWSKA-TOBIS
16:21 - 16:32
#44906 - OP11 Chemical Ablation of Genicular Nerves with 95% Ethanol for Pain Relief and Quality of Life in Patients with Knee Osteoarthritis: A Prospective, Double-Blinded, Randomized, Controlled Trial.
OP11 Chemical Ablation of Genicular Nerves with 95% Ethanol for Pain Relief and Quality of Life in Patients with Knee Osteoarthritis: A Prospective, Double-Blinded, Randomized, Controlled Trial.
Knee osteoarthritis (gonarthrosis) is a prevalent cause of chronic pain and functional impairment in elderly patients. Conventional pharmacological treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and co-analgesics, often fail to provide sufficient pain relief. Ultrasound-guided chemical ablation of genicular nerves using 95% ethanol has emerged as a potential non-surgical intervention for pain management in knee osteoarthritis. This study aimed to assess the efficacy and safety of ultrasound-guided chemical ablation of genicular nerves with 95% ethanol in elderly patients with severe knee osteoarthritis.
This double-blind, single-center, randomized controlled trial (NCT06087601) was registered at ClinicalTrials.gov on October 10, 2023, with ethics approval from the Bioethics Committee of Poznan University of Medical Sciences (223/23, March 9, 2023).
Conducted at the Pain Treatment Clinic, Transfiguration of Jesus Clinical Hospital, the trial enrolled 100 patients (aged 65–92) with Kellgren–Lawrence grade 3 or 4 knee osteoarthritis and inadequate pain control (NRS >3). Patients were randomized to ultrasound-guided genicular nerve neurolysis with 95% ethanol (n=50) or a sham procedure (n=50). Neurolysis used 4 × 0.5 ml of 95% ethanol.
The primary outcome was pain intensity (NRS) at 7, 30 days, and 3, 6 months. Secondary outcomes included quality of life (EQ-5D-5L), opioid consumption, and neurological complications. Pain scores (NRS) and total opioid consumption were significantly lower in the neurolysis group compared to the sham group at all time points (p<0.0001). Quality of life scores (EQ-5D-5L) improved significantly in the neurolysis group, with a lower total opioid consumption (p<0.0001). No neurological deficits were observed in either group throughout the study duration. Ultrasound-guided chemical ablation of genicular nerves with 95% ethanol is a safe and effective treatment for severe knee osteoarthritis pain. It significantly reduces pain scores and opioid consumption while improving patients' quality of life, without inducing neurological deficits.
Malgorzata REYSNER (Poznan, Poland), Tomasz REYSNER, Kowalski GRZEGORZ, Aleksander MULARSKI, Przemysław DAROSZEWSKI, Katarzyna WIECZOROWSKA-TOBIS
16:32 - 16:43
#45844 - OP12 Does Continuous Peripheral Nerve Blocks reduce Phantom Limb Pain post amputation?
OP12 Does Continuous Peripheral Nerve Blocks reduce Phantom Limb Pain post amputation?
Phantom limb pain (PLP) is an incapacitating condition affecting a large proportion of amputees, with limited effective therapies. Prevalence, at more than 2 years, varies widely in literature from 76 to 87%. While the use of continuous peripheral nerve block (CPNB) in the postoperative period has become standard management due to consistent evidence that it reduces pain, there is currently limited evidence for the reduction in PLP.
This audit aims to establish whether the use of CPNB postoperatively in below-knee amputation (BKA) patients reduces the incidence of PLP 2 years on.
A retrospective observational study was conducted at St George’s Hospital, London, involving 40 BKA patients who underwent amputation surgery approximately 2 years before. Data such as phantom limb sensation, pain, stump pain and duration of CPNB were collected through patient phone interviews and medical record reviews. A survey was created based on validated questionnaires such as PainDETECT and EQ-5D-5L. Out of 40 eligible patients, 11 had passed away (27%). From the 29 remaining patients eligible for recruitment, 16 consented to participate. Out of them, 4 reported phantom limb sensation, with 2 describing it as PLP (12.5%). 7 patients experienced stump pain, primarily related to prosthesis issues (43%). This audit confirms postoperative CPNB as a potential effective preventive measure for PLP. There was no control group due to a well-established CPNB pathway in our hospital, therefore rendering unethical to randomize to a no-catheter group. Further larger scale analysis is advised.
Pablo ROJAS ZAMORA (London, United Kingdom), Vijay KOLLI, Jonathan LOHN, Andrzej KROL
16:43 - 16:54
#47380 - OP13 Genetic variants associated with chronic post-surgical pain: evidence from the China Surgery and Anaesthesia Cohort study.
OP13 Genetic variants associated with chronic post-surgical pain: evidence from the China Surgery and Anaesthesia Cohort study.
Chronic post-surgical pain (CPSP) is one of the most common surgical-related complications that significantly impacts patients' quality of life, while studies exploring the underlying genetics remains limited and controversial.
In a total of 17,025 individuals from the Chinese Surgery and Anaesthesia cohort (CSAC), we used Brief Pain Inventory questionnaire to measure the longitudinal pain intensity after surgery and defined CPSP either as a dichotomous or continuous trait across various surgical sites (i.e., abdomen, thorax, head and neck, limbs and body surfaces), as well as in the context of a prolonged pain trajectory (i.e., persistent pain intensity across multiple post-surgery follow-up points). Genome-wide association (meta-) analyses were then conducted among 9,022 individuals with genotyping data. We identified 16 independent genome-wide significant loci associated with different assessments of CPSP, respectively. Multiple approaches including gene mapping, annotation, and multi-omics colocalization prioritized several potential risk genes, such as ASTN1, RSU1, and C1QL3 that are involved in neuronal migration, ERK/MAPK signaling, and synaptic function. The SNP-based narrow-sense heritability was estimated as 13.7% (5.1%-22.4%) for CPSP by numeric definition. Polygenic risk scores of post-traumatic stress disorder, pain all over the body, multisite chronic pain, and opioid dependence were positively associated with CPSP, either at specific surgical sites or in general, at a nominal significance level. This largest available GWAS advance our understanding of the genetic predisposition to and pathogenesis of CPSP, which could vary across different surgical sites. Focusing on homogenous subgroup may open new areas for therapeutic investigation.
Jie SONG, Yanan ZHANG (Chengdu, China), Huan SONG, Qian LI
16:54 - 17:05
#47528 - OP14 Effectiveness of Digital Health Interventions for Cancer Pain Management: A Systematic Review.
OP14 Effectiveness of Digital Health Interventions for Cancer Pain Management: A Systematic Review.
Background:
Cancer-related pain remains a significant clinical burden. Emerging digital health interventions, including mobile applications, virtual reality (VR), and web-based self-management platforms, offer novel approaches to support traditional pain control strategies.
Objective:
To systematically review the effectiveness of digital health interventions, excluding telemedicine-only strategies, in reducing cancer-related pain.
A systematic review was conducted of studies published between 2015 and 2025. Randomized controlled trials and quasi-experimental studies were included if they evaluated mobile apps, VR tools, or web-based interventions targeting pain outcomes. A narrative synthesis was performed due to intervention heterogeneity. Eight studies (N=~1100 patients) were included. Mobile apps such as ePAL and AI-based platforms improved pain monitoring, reduced emergency visits, and enhanced analgesic adherence. Pediatric-focused apps significantly reduced home pain scores. VR interventions consistently achieved immediate, meaningful reductions in procedural and chronic pain, with average pain decreases of 1–2 points on a 0–10 scale. Web-based self-management tools enhanced pain coping skills and reduced pain interference in daily activities. Risk of bias was moderate due to self-reporting and lack of blinding. Digital health interventions offer effective, scalable adjuncts to cancer pain management. Mobile apps can improve real-time symptom tracking and proactive clinician intervention. VR provides potent, drug-free procedural analgesia. Web-based platforms strengthen coping strategies and self-efficacy. However, long-term sustainability, impact on opioid use reduction, and pediatric applications require further investigation. Digital interventions should be integrated into multimodal cancer pain strategies, supported by rigorous future trials.
Collin HO, Si Hui YAP (Singapore, Singapore)
17:05 - 17:16
#48096 - OP15 Complex Regional Pain Syndrome Case Characteristics and Treatment Patterns: A Retrospective Institutional Registry Study.
OP15 Complex Regional Pain Syndrome Case Characteristics and Treatment Patterns: A Retrospective Institutional Registry Study.
Complex Regional Pain Syndrome (CRPS) is a rare, debilitating pain condition often attributed to distinct inciting events, long-term overuse, or no obvious cause. Variable presentation makes consistent assessment, diagnosis, and treatment of CRPS difficult. To understand how pain management providers diagnose and treat CRPS patients, we created an automated analytical electronic health record (Epic)-based registry to capture new patient encounters with qualifying diagnoses, including CRPS. A retrospective chart review was manually conducted to investigate demographics, clinical characteristics, and treatment regimens of CRPS patients.
After IRB approval, patients diagnosed with neuropathic pain or CRPS between January 20th, 2022, and November 28th, 2023 were identified using CRPS ICD-10 codes from an institutional Epic-based registry. Data elements were manually extracted from Epic and collected in REDCap. Descriptive statistics were used to summarize data that includes patient demographics, co-morbidities, diagnostic details, and subsequent treatments. 100 patients were reviewed at the time of abstract submission and their characteristics are summarized in Table 1. Commonly reported symptoms at diagnosis were hyperalgesia/allodynia (64%), skin color asymmetry (63%), and asymmetric edema (67%) (Table 2). Probable inciting events included lower extremity surgery (54%), fracture (12%), and trauma without fracture (33%) (Table 3). The most commonly prescribed medication was gabapentin (34%), while the most frequently performed procedure was the lumbar sympathetic block (44%). Contrary to existing literature, CRPS of the lower extremities was more common than that of the upper extremities in our registry patients. Pain was commonly managed using sympathetic blocks and anticonvulsant medications. Ongoing analyses include examination of CRPS subtype-specific treatments, trends in the use of off-label medications, and the effectiveness of various treatments.
Tina CHEN (New York, USA), Marlena KOMATZ, William CHAN, Victoria XU, Daniel RICHMAN, Anuj MALHOTRA, Semih GUNGOR, Alexandra SIDERIS
17:16 - 17:27
#48098 - OP16 Long-Term Follow-up of the Effect of Conventional Radiofrequency Thermocoagulation Application to the Articular Branches of the Femoral and Obturator Nerve on Pain and Functional Capacity in Patients with Chronic Hip Pain.
OP16 Long-Term Follow-up of the Effect of Conventional Radiofrequency Thermocoagulation Application to the Articular Branches of the Femoral and Obturator Nerve on Pain and Functional Capacity in Patients with Chronic Hip Pain.
The objective of this study was to assess the long-term efficacy of conventional radiofrequency thermocoagulation (RFT) applied to the articular branches of the femoral and obturator nerves in reducing pain and improving functional capacity in patients with chronic hip pain.
Following ethics committee approval and the study was registered at ClinicalTrials.gov. This retrospective analysis was conducted using long-term follow-up data from patients previously included in two prospective doctoral theses at the Department of Algology. A total of 68 patients underwent conventional RFT under fluoroscopic and ultrasonographic guidance. Pain levels were assessed using the Verbal Pain Scale (VPS), and functional status was evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 12-month follow-up. Thirty-five patients were included in the final analysis (10 underwent surgery, 6 were deceased, and others were lost to follow-up). Comparison of pre-procedural and 12-month post-procedural WOMAC and VPS scores revealed statistically significant reductions across all parameters (p < 0.001). Significant improvements were also observed in all WOMAC subdomains, including pain, stiffness, and physical function (p < 0.001). Conventional RFT applied to the articular branches of the femoral and obturator nerves appears to be an effective and durable treatment option for managing chronic hip pain. It may offer a valuable alternative for patients who are not suitable candidates for surgery or who prefer to postpone hip arthroplasty.
Sinem SARI, Bilgenur ERGÜN, Sevilay KARAOGLU, Ferdi GULASTI, Didem UMUTLU, Yusufcan EKIN, Osman Nuri AYDIN (Aydın, Turkey)
17:27 - 17:38
#48111 - OP17 Trends in Preoperative Self-Disclosure of Cannabis Use in Chronic Pain Patients undergoing Outpatient Interventional Procedures: An Institutional Retrospective Study.
OP17 Trends in Preoperative Self-Disclosure of Cannabis Use in Chronic Pain Patients undergoing Outpatient Interventional Procedures: An Institutional Retrospective Study.
In New York State, cannabis has been legalized for medical and adult recreational use, potentially increasing use among patients. Limited studies exist regarding prevalence of cannabis use in the outpatient chronic pain setting. Therefore, a retrospective institutional study was conducted on patients undergoing an interventional procedure at our high-volume outpatient pain clinic to determine prevalence of self-reported cannabis use over time.
Following IRB-approval, outpatient interventional procedures performed in the Special Procedures Unit at the HSS 75th Street Campus between January 1st, 2018, and December 31st, 2023, with patient-disclosed cannabis use were identified using the SlicerDicer tool in Epic (electronic health record). The search logic returned cases with cannabis use entered in the social history intake form in Epic. Descriptive statistics were used to summarize patient demographics, procedure types, and yearly trends. Prevalence of self-reported cannabis use in patients undergoing an outpatient interventional procedure increased between 2018 and 2023 from 3.8% to 6.1% (Figure 1). Patient characteristics are summarized in Table 1. The most common procedure performed was epidural steroid injections (47%, n=1153); 55.7% (n=1361) of patients were diagnosed with spondylosis, while 11.5% (n=282) suffered from CRPS. Overall, 8.4% (n=205) of patients using cannabis reported use of at least one additional illicit substance. Yearly trends at our institution indicate that self-disclosure of cannabis use is increasing in patients undergoing outpatient interventional procedures. The increase in cannabis use disclosure could be attributed to increased use and accessibility, increased patient comfort with disclosing use, or both; however, the prevalence is markedly lower than national averages.
William CHAN (New York City, USA), Tina CHEN, Victoria XU, Marlena KOMATZ, Anuj MALHOTRA, Jashvant POERAN, Seth WALDMAN, Alexandra SIDERIS
17:38 - 17:49
#48124 - OP18 ESP Block with Dexamethasone Mitigates Pain Chronification After Cardiac Surgery: A 90-Day Randomized Study with Functional Impact.
OP18 ESP Block with Dexamethasone Mitigates Pain Chronification After Cardiac Surgery: A 90-Day Randomized Study with Functional Impact.
Persistent post-sternotomy pain is a disabling outcome of cardiac surgery, often under-recognized. While ESP blocks are increasingly used perioperatively, their role in preventing chronic pain—especially when combined with dexamethasone—has never been rigorously tested.
Objective:
To determine whether perineural dexamethasone with ESP block reduces long-term pain and functional impairment after CABG, using a structured 90-day follow-up.
Adult patients undergoing CABG were randomized to receive ESP blocks with ropivacaine ± dexamethasone (8 mg total). Pain intensity and interference were evaluated via the Brief Pain Inventory (BPI) at 30, 60, and 90 days. Evaluations included rest and movement conditions to capture the full pain spectrum. The dexamethasone group (n=22) demonstrated significantly lower pain scores at day 30 (worst pain: 1.77 vs. 2.24; p = 0.002) and less interference in key functions like sleep, activity, and enjoyment of life (global interference: 0.47 vs. 1.26; p = 0.023). These differences, most pronounced during movement, faded by day 90, when both groups reported minimal pain. No adverse events related to dexamethasone were observed. This is the first randomized study to show that dexamethasone-enhanced ESP block reduces chronic post-sternotomy pain and its impact on daily life. By integrating movement-sensitive metrics and longitudinal follow-up, our findings underscore a novel, actionable strategy to prevent pain chronification in cardiac surgical patients. Future multicenter trials should build on this pioneering evidence.
Luis Alberto RODRIGUEZ LINARES (sao paulo, Brazil), Raquel CHACON RUIZ MARTINEZ, Filomena Regina BARBOSA GOMES GALAS
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A26
NETWORKING SESSION
RAPM
NETWORKING SESSION
RAPM
Chairperson:
Samer NAROUZE (Professor and Chair) (Chairperson, Cleveland, USA)
16:30 - 16:30
Introduction.
16:30 - 16:52
Best papers in 2025 on RA.
David PROVENZANO (Faculty) (Keynote Speaker, Bridgeville, USA)
16:52 - 17:14
Associate editor in chief.
Sam ELDABE (Consultant Pain Medicine) (Keynote Speaker, Middlesbrough, United Kingdom)
17:14 - 17:36
Best papers in 2025 on chronic pain.
Jose DE ANDRES (Tenured Professor) (Keynote Speaker, Valencia (Spain), Spain)
17:36 - 17:40
Q&A.
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C26
LIVE DEMONSTRATION
Spine
LIVE DEMONSTRATION
Spine
16:45 - 17:00
Clinical examination of the cervical spine.
Manfred GREHER (Medical Hospital Director and Head of Department) (Demonstrator, Vienna, Austria)
16:30 - 16:45
Clinical examination of the lumbar spine.
Paul KESSLER (Consultant) (Demonstrator, Frankfurt, Germany)
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D26
ESRA DIPLOMATA
ESRA DIPLOMATA
Chairperson:
Eleni MOKA (faculty) (Chairperson, Thessaloniki, Greece, Greece)
16:30 - 16:35
Introduction.
Eleni MOKA (faculty) (Keynote Speaker, Thessaloniki, Greece, Greece)
16:35 - 17:05
Becoming an ESRA-DPM diplomate.
Andrzej KROL (Consultant in Anaesthesia and Pain Medicine) (Keynote Speaker, LONDON, United Kingdom)
17:05 - 17:35
Becoming an ESRA-DRA diplomate.
Morne WOLMARANS (Consultant Anaesthesiologist) (Keynote Speaker, Norwich, United Kingdom)
17:35 - 17:50
Q&A.
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E26
PANEL DISCUSSION
Update in cancer pain management
PANEL DISCUSSION
Update in cancer pain management
Chairperson:
Dan Sebastian DIRZU (consultant, head of department) (Chairperson, Cluj-Napoca, Romania)
16:30 - 16:30
Introduction.
16:30 - 16:45
How does immuno-chemotherapy affect pain modalities.
Efrossini (Gina) VOTTA-VELIS (speaker) (Keynote Speaker, Chicago, USA)
16:45 - 17:00
Efficacy of interventional procedures.
Ammar SALTI (Anesthesiologist and Pain Physician) (Keynote Speaker, abu Dhabi, United Arab Emirates)
17:00 - 17:15
Neuromodulation for Cancer Pain.
Sarah LOVE-JONES (Anaesthesiology) (Keynote Speaker, Bristol, United Kingdom)
17:15 - 17:30
Intratecal drug delivery.
Denis DUPOIRON (Head of Department) (Keynote Speaker, Angers, France)
17:30 - 18:00
Q&A.
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B26
TIPS & TRICKS
Upper abdomen needs care
TIPS & TRICKS
Upper abdomen needs care
Chairperson:
Kris VERMEYLEN (Md, PhD) (Chairperson, ZAS ANTWERP, Belgium)
17:30 - 17:30
Introduction.
17:30 - 17:45
External oblique intercostal: What is it good for.
Melody ANDERSON (Director of Regional Anesthesiology) (Keynote Speaker, Charlotte, USA)
17:45 - 18:00
Q&A.
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F27
PROBLEM BASED LEARNING DISCUSSION
Back ache dissected
PROBLEM BASED LEARNING DISCUSSION
Back ache dissected
Chairperson:
Reda TOLBA (Department Chair and Professor) (Chairperson, Abu Dhabi, United Arab Emirates)
17:30 - 17:30
Introduction.
17:30 - 17:45
Effective treatment options for dicogenic pain.
Ovidiu PALEA (head of ICU and Pain Department) (Keynote Speaker, Bucharest, Romania)
17:45 - 18:00
Q&A.
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A27
HONOURS & DIPLOMATES CEREMONY
HONOURS & DIPLOMATES CEREMONY
18:00 - 18:05
Introduction.
Eleni MOKA (faculty) (ESRA President, Thessaloniki, Greece, Greece)
18:05 - 18:20
PART I of the CEREMONY / ESRA People.
18:20 - 18:35
PART II of the CEREMONY / ESRA European Diploma of Regional Anaesthesia.
Morne WOLMARANS (Consultant Anaesthesiologist) (Keynote Speaker, Norwich, United Kingdom)
18:35 - 18:50
PART III of the CEREMONY / ESRA European Diploma of Pain Medicine.
Andrzej KROL (Consultant in Anaesthesia and Pain Medicine) (Keynote Speaker, LONDON, United Kingdom)
18:50 - 19:00
Conclusion.
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A30
NETWORKING SESSION
Our future needs extra care
NETWORKING SESSION
Our future needs extra care
Chairperson:
Fatma SARICAOGLU (Chair and Prof) (Chairperson, Ankara, Turkey)
08:00 - 08:05
Introduction.
Fatma SARICAOGLU (Chair and Prof) (Keynote Speaker, Ankara, Turkey)
08:05 - 08:27
Guidelines for pediatric acute pain management.
Peter MARHOFER (Director of Paediatric Anaesthesia and Intensive Care Medicine) (Keynote Speaker, Vienna, Austria)
08:27 - 08:49
How to differ agitation, delirium and pain in pediatric patients.
Tom HANSEN (Professor and consultant paediatric anaesthetist) (Keynote Speaker, Oslo, Norway)
08:49 - 09:11
#48628 - FT05 Regional anaesthesia and multimodal analgesia in cleft palate repair.
Regional anaesthesia and multimodal analgesia in cleft palate repair.
Regional anaesthesia and multimodal analgesia in cleft palate repair
Axel R. Sauter
(*) Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo,
Norway and Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
Cleft palate is one of the most common congenital birth defects, with an incidence rate of between one and 25 cases per 10,000 live births.[1] Repair of cleft palate is essential for improving both food intake and speech development. Effective postoperative pain management is crucial for enhancing recovery. Inadequate pain control may lead to agitation and crying, resulting in complications such as wound dehiscence and fistula formation. Conversely, children who receive adequate pain relief are more likely to resume normal feeding and drinking behaviours earlier in the postoperative period.
To develop recommendations for the optimal management of postoperative pain following cleft palate repair, the PROcedure SPECific POSToperative Pain Management (PROSPECT) group reviewed the available literature and developed procedure specific recommendations.[2] The analgesic regimen for cleft palate surgery should include intra-operative paracetamol and cyclo-oxygenase-2 (COX-2) specific inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs). The recommended interventions for improving postoperative pain included a suprazygomatic maxillary nerve block or a palatal nerve block if a maxillary nerve block cannot be performed. The use of dexmedetomidine as an adjuvant to local anaesthetic for suprazygomatic maxillary nerve block or, alternatively, as an intravenous perioperative administration is also recommended.
Several studies have confirmed the efficacy of maxillary nerve blocks as part of a multimodal postoperative pain management regimen for children undergoing cleft palate surgery.[3,4] The most commonly used technique for performing maxillary nerve blocks is the suprazygomatic approach, using a landmark-guided technique. Ultrasound guidance offers the theoretical advantage of real-time visualisation of both needle placement and local anaesthetic spread, which could increase block accuracy and safety. However, clinical studies have not yet demonstrated that ultrasound guidance achieves better results than landmark-based block techniques. A recent MRI study aimed to compare the effect of the guidance technique on the spread of local anaesthetic to the maxillary nerve in the pterygopalatine fossa.[5] Similar results were found for both methods, with success rates ranging from 65% for landmark guidance to 70% for ultrasound guidance.
Conclusion: Effective postoperative pain treatment is crucial for recovery after cleft palate repair surgery. A maxillary nerve block using the suprazygomatic approach is an important component of a multimodal pain management regimen. Landmark-guided techniques for maxillary nerve blocks are a viable alternative to ultrasound-guided techniques.
References:
1. Tanaka SA, Mahabir RC, Jupiter DC, Menezes JM Updating the epidemiology of isolated cleft palate. Plast Reconstr Surg 2013; 131: 650e-2e.
2. Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Reg Anesth Pain Med 2024.
3. Chiono J, Raux O, Bringuier S, et al. Bilateral suprazygomatic maxillary nerve block for cleft palate repair in children: a prospective, randomized, double-blind study versus placebo. Anesthesiology 2014; 120: 1362-9.
4. Sola C, Raux O, Savath L, Macq C, Capdevila X, Dadure C Ultrasound guidance characteristics and efficiency of suprazygomatic maxillary nerve blocks in infants: a descriptive prospective study. Paediatr Anaesth 2012; 22: 841-6.
5. Suleiman NN, Lien I, Akhavi MS, et al. Ultrasound guidance does not improve local anesthetic distribution in suprazygomatic maxillary nerve blocks in pediatric patients: a clinical, randomized, controlled, observer-blinded, crossover MRI trial. Reg Anesth Pain Med 2025.
Axel SAUTER (Oslo, Norway)
09:11 - 09:33
#48626 - FT06 Methadone for perioperative pain management in paediatric patients.
Methadone for perioperative pain management in paediatric patients.
Pasquale De Negri MD,ESRA-DPM, FIPP*; Clara De Negri MD*,
* Department of Anaesthesia, Intensive Care and Pain Medicine- Azienda Ospedaliera di Rilievo Nazionale S. Anna e S.Sebastiano - Caserta, Italy
Background: Perioperative pain management in paediatric patients presents unique challenges due to differences in physiology, pain perception, and pharmacokinetics compared to adults. Inadequate pain control can have both immediate and long-term consequences, including delayed recovery, increased risk of chronic pain, and psychological distress. Traditional opioid analgesics, while effective, are associated with significant side effects and risks, such as respiratory depression, opioid-induced hyperalgesia, and the potential for tolerance and dependence. Methadone, a synthetic opioid with a distinctive pharmacological profile, offers a promising alternative or adjunct in this context. Its use in paediatric perioperative settings has been limited but is gaining traction as new evidence emerges.
Pharmacological properties of methadone: Methadone distinguishes itself from other opioids through its dual mechanism of action. As a potent μ-opioid receptor agonist, it provides robust analgesia. Simultaneously, its antagonism of the NMDA receptor contributes to reduced central sensitization, inhibition of opioid-induced hyperalgesia, and potential prevention of chronic post-surgical pain. Methadone’s long and variable half-life (ranging from 8 to 59 hours in children, depending on age and individual metabolism) supports sustained analgesic effects, which can be particularly beneficial for procedures associated with significant or prolonged pain.
Pharmacokinetically, methadone is highly lipophilic, resulting in extensive tissue distribution and a large volume of distribution. It is metabolized in the liver, primarily by CYP3A4, CYP2B6, and CYP2D6 enzymes, with considerable inter-individual variability. This variability underpins the need for individualized dosing and careful monitoring, especially in paediatric populations where developmental differences further complicate pharmacokinetics.
Rationale for perioperative use in children: The rationale for methadone use in paediatric perioperative care is grounded in its ability to provide prolonged analgesia from a single intraoperative dose, potentially reducing the need for repeated opioid administration and minimizing fluctuations in pain control. Methadone’s NMDA antagonism may also decrease the risk of developing opioid tolerance and opioid-induced hyperalgesia, both of which are significant concerns in children undergoing repeated or extensive surgical interventions.
Moreover, the efficacy of methadone in treating neuropathic pain makes it a valuable option for surgeries involving nerve injury or where neuropathic pain components are anticipated, such as spinal fusion, major orthopaedic procedures, or thoracotomies.
Clinical evidence: Although the paediatric literature on perioperative methadone is not as extensive as in adults, a growing body of studies supports its utility. Several prospective randomized controlled trials and retrospective cohort studies have evaluated the efficacy and safety of intraoperative methadone in children:
- In spinal fusion surgery, single intraoperative doses of methadone (0.2–0.3 mg/kg) have been associated with lower postoperative pain scores, reduced opioid consumption, and decreased need for rescue analgesia compared to morphine or fentanyl.
- Studies in paediatric cardiac and abdominal surgery have reported similar findings, with methadone providing prolonged analgesia and improved patient comfort, often with no increase in adverse events when appropriately monitored.
- Case series and smaller trials suggest that methadone’s benefits extend to patients with opioid tolerance, where it can help overcome tolerance-related challenges and provide effective pain control
Despite these positive findings, the evidence base remains limited by small sample sizes, heterogeneous dosing regimens, and variability in outcome measures. Larger, multicentre trials are needed to confirm these results and develop standardized protocols.
Safety profile and risk mitigation: The main safety concerns with methadone in paediatric perioperative care are:
- Respiratory depression: the long half-life of methadone increases the risk of delayed respiratory depression, necessitating extended monitoring postoperatively, especially in children with risk factors such as obesity, sleep-disordered breathing, or concurrent sedative use.
- QT Interval prolongation: methadone can prolong the QT interval, predisposing to torsades de pointes and other arrhythmias. Baseline and postoperative ECG monitoring are recommended in children with known cardiac disease, electrolyte imbalances, or those on other QT-prolonging drugs.
Drug accumulation and interactions: Owing to its hepatic metabolism, the clearance of methadone may be affected by drug interactions (e.g., CYP inhibitors/inducers) and liver dysfunction. Individualized dosing and awareness of potential interactions are critical.
Other side effects: Nausea, vomiting, constipation, and pruritus are common to all opioids, including methadone. These are generally managed with standard supportive measures.
Overall, when administered by experienced clinicians in a monitored setting, the safety profile of methadone 22is comparable to other opioids, with the added benefit of less frequent dosing.
Practical application and dosing strategies: methadone is typically administered as a single intravenous dose at induction of anaesthesia, with suggested doses ranging from 0.1 to 0.3 mg/kg (maximum doses vary by protocol and institutional practice). Lower doses are advisable in younger children or those with risk factors for adverse effects. The timing of administration is usually at induction or early in the procedure to allow for titration and observation of initial effects.
Postoperative pain management should continue to incorporate multimodal strategies, including acetaminophen, NSAIDs, and regional anaesthesia where appropriate. The prolonged action of methadone may reduce or eliminate the need for patient-controlled analgesia (PCA) or frequent nurse-administered opioid boluses, streamlining postoperative care and potentially facilitating earlier mobilization and discharge.
Patient selection and monitoring: Not all paediatric patients are ideal candidates for perioperative methadone. Careful preoperative assessment is essential, with particular attention to:
- Cardiac history and baseline ECG
- Respiratory comorbidities (e.g., sleep apnea)
- Hepatic and renal function
- Concomitant medications (especially those affecting QT interval or methadone metabolism)
- Continuous cardiorespiratory monitoring is recommended for at least 24 hours postoperatively in patients receiving methadone, with prompt recognition and management of any adverse effects.
Current guidelines and expert consensus: There are currently no universally accepted guidelines for perioperative methadone use in paediatric patients. However, expert panels and institutional protocols increasingly recognize its value in selected cases, particularly for:
- Major surgeries with expected severe or prolonged pain
- Patients with opioid tolerance or chronic pain syndromes
- Cases where conventional opioids have failed or produced unacceptable side effects
- Education of the entire perioperative team—including anaesthesiologists, surgeons, nurses, and pharmacists—is vital to ensure safe and effective use.
Future directions and research needs: Key areas for future research include:
- Large, multicentre randomized controlled trials to establish optimal dosing, efficacy, and safety across diverse paediatric populations and surgical procedures
- Pharmacogenomic studies to identify predictors of methadone metabolism and response, enabling personalized medicine approaches
- Long-term outcome studies to assess the impact of perioperative methadone on chronic pain development, opioid use patterns, and quality of life
- Comparative effectiveness research evaluating methadone against other long-acting opioids and multimodal analgesic strategies
Additionally, the development of standardized protocols and consensus guidelines will facilitate broader and safer adoption of methadone in paediatric perioperative care.
Conclusions: methadone is an underutilized but promising option for perioperative pain management in paediatric patients. Its unique pharmacological profile—combining potent opioid analgesia with NMDA antagonism—offers several potential advantages over conventional opioids, including prolonged pain relief, reduced opioid requirements, and mitigation of opioid-induced hyperalgesia and tolerance. While safety concerns exist, particularly regarding respiratory depression and QT prolongation, these can be managed with careful patient selection, individualized dosing, and vigilant postoperative monitoring.
As evidence continues to accumulate, methadone may assume a more prominent role in paediatric anaesthesia, particularly for children undergoing major surgery, those with opioid tolerance, or in cases refractory to standard analgesic regimens. Ongoing research and the development of clear guidelines will be essential to maximize the benefits and minimize the risks associated with its use.
References
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2) van den Anker, J. Is it time to replace morphine with methadone for the treatment of pain in the neonatal intensive care unit?. 2012, Pediatr Res 89, 1608–1609 . https://doi.org/10.1038/s41390-021-01472-z.
3) Kharasch, E.D. Current Concepts in Methadone Metabolism and Transport. 2017 Clinical Pharmacology in Drug Development, 6: 125-134. https://doi.org/10.1002/cpdd.326
4) RM Ward, DR Drover, GB Hammer,et al.The pharmacokinetics of methadone and its metabolites in neonates, infants, and children. 2014 Paediatr. Anaesth. 24, 591–601.
5) Robinson KM, Eum S, Desta Z, et al. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2B6 Genotype and Methadone Therapy. 2024 Clin Pharmacol Ther. Oct;116(4):932-938. doi: 10.1002/cpt.3338. Epub 2024 Jun 11.
6) Packiasabapathy S, Aruldhas BW, Zhang P, et al. Novel associations between CYP2B6 polymorphisms, perioperative methadone metabolism and clinical outcomes in children. Pharmacogenomics. 2021 Jul;22(10):591-602. doi: 10.2217/pgs-2021-0039. Epub 2021 Jun 8.
7) Sharma A, Tallchief D, Blood J, et al.. Perioperative pharmacokinetics of methadone in adolescents. Anesthesiology. 2011 Dec;115(6):1153-61. doi: 10.1097/ALN.0b013e318238fec5.
8) Murphy GS, Szokol JW, Avram MJ, et al. Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, Controlled Trial. Anesthesiology. 2017 May;126(5):822-833. doi: 10.1097/ALN.0000000000001609.
9) Murphy GS, Szokol JW. Intraoperative Methadone in Surgical Patients: A Review of Clinical Investigations. Anesthesiology. 2019 Sep;131(3):678-692. doi: 10.1097/ALN.0000000000002755.
10) Berde CB, Beyer JE, Bournaki MC, et al. Comparison of morphine and methadone for prevention of postoperative pain in 3- to 7-year-old children. J Pediatr. 1991 Jul;119(1 Pt 1):136-41. doi: 10.1016/s0022-3476(05)81054-6.
11) Murphy GS, Szokol JW, Avram MJ, et al. Intraoperative Methadone for the Prevention of Postoperative Pain: A Randomized, Double-blinded Clinical Trial in Cardiac Surgical Patients. Anesthesiology. 2015 May;122(5):1112-22. doi: 10.1097/ALN.0000000000000633.
12) Ward RM, Drover DR, Hammer GB, et al. The pharmacokinetics of methadone and its metabolites in neonates, infants, and children. Paediatr Anaesth. 2014 Jun;24(6):591-601. doi: 10.1111/pan.12385. Epub 2014 Mar 26..
13) Tobias JD. Methadone: applications in pediatric anesthesiology and critical care medicine. J Anesth. 2021 Feb;35(1):130-141. doi: 10.1007/s00540-020-02887-4. Epub 2021 Jan 12.
14) Zuppa AF, Hammer GB, Barrett JS, et al. Methadone in pediatric intensive care: Use, pharmacokinetics, and pharmacodynamics. Pediatric Anesthesia. 2011;21(6):593-601.doi:10.1111/j.1460-9592.2011.03582.
15) Uhrbrand CG, Gadegaard KH, Aliuskeviciene A, Ahlburg P, Nikolajsen L. The effect of intraoperative methadone on postoperative opioid requirements in children undergoing orchiopexy: A randomized clinical trial. Paediatr Anaesth. 2024 Dec;34(12):1250-1257. doi: 10.1111/pan.15009. Epub 2024 Sep 22.
16) Iguidbashian JP, Chang PH, Iguidbashian J, et al. Enhanced recovery and early extubation after pediatric cardiac surgery using single-dose intravenous methadone. Ann Card Anaesth. 2020 Jan-Mar;23(1):70-74. doi: 10.4103/aca.ACA_113_18.
17) Kharasch ED, Clark JD. Methadone and Ketamine: Boosting Benefits and Still More to Learn. Anesthesiology. 2021 May 1;134(5):676-679. doi: 10.1097/ALN.0000000000003752.
18) Habashy C, Springer E, Hall EA, Anghelescu DL. Methadone for Pain Management in Children with Cancer. Paediatr Drugs. 2018 Oct;20(5):409-416. doi: 10.1007/s40272-018-0304-2.
19) Anghelescu DL, Patel RM, Mahoney DP, et al. Methadone prolongs cardiac conduction in young patients with cancer-related pain. J Opioid Manag. 2016 May-Jun;12(2):131-8. doi: 10.5055/jom.2016.0325.
20) Horst J, Frei-Jones M, Deych E, et al.. Pharmacokinetics and analgesic effects of methadone in children and adults with sickle cell disease. Pediatr Blood Cancer. 2016 Dec;63(12):2123-2130. doi: 10.1002/pbc.26207. Epub 2016 Aug 30.
21) Habashy C, Springer E, Hall EA,et al. Methadone for Pain Management in Children with Cancer. Paediatr Drugs. 2018 Oct;20(5):409-416. doi: 10.1007/s40272-018-0304-2.
Pasquale DE NEGRI (Caserta, Italy), Clara DE NEGRI
09:33 - 09:50
Q&A.
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08:00-09:50
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B30
TARA SESSION
Interventional treatment of headache
TARA SESSION
Interventional treatment of headache
Chairperson:
Sam ELDABE (Consultant Pain Medicine) (Chairperson, Middlesbrough, United Kingdom)
08:00 - 08:00
Introduction.
08:00 - 08:22
Cervical facet joints as a contributor to headaches.
Samer NAROUZE (Professor and Chair) (Keynote Speaker, Cleveland, USA)
08:22 - 08:44
Occipital nerves anatomy.
Sam ELDABE (Consultant Pain Medicine) (Keynote Speaker, Middlesbrough, United Kingdom)
08:44 - 09:06
US guided occipital nerve blockade.
Kiran KONETI (Consultant) (Keynote Speaker, SUNDERLAND, United Kingdom)
09:06 - 09:28
Occipital nerve visualisation under US.
Nina D’HONDT (Keynote Speaker, Belgium)
09:28 - 09:50
AI-Ready Health Data: Transforming Migraine Research and Treatment.
Daria VOLKOVA (Product Manager) (Demonstrator, London, United Kingdom)
09:50 - 09:50
Q&A.
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08:00-09:15
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C30
PANEL DISCUSSION
LA toxicity under control
PANEL DISCUSSION
LA toxicity under control
Chairperson:
Vrushali PONDE (yes) (Chairperson, Mumbai, India)
08:00 - 08:00
Introduction.
08:00 - 08:20
Calcium dynamics in heart cells is key.
Jason MAYNES (Chief, Anesthesia and Pain Medicine) (Keynote Speaker, Toronto, Canada)
08:20 - 08:40
Lipidomics may explain lipid rescue.
Per-Arne LONNQVIST (Professor) (Keynote Speaker, Stockholm, Sweden)
08:40 - 09:00
LAST in children: lessons learned.
Karen BORETSKY (Senior Associate in Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine) (Keynote Speaker, Boston, USA)
09:00 - 09:10
Q&A.
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08:00-08:30
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D30
REFRESHING YOUR KNOWLEDGE
Goodies to add
REFRESHING YOUR KNOWLEDGE
Goodies to add
Chairperson:
Nat HASLAM (Consultant Anaesthetist) (Chairperson, Sunderland, United Kingdom)
08:00 - 08:00
Introduction.
08:00 - 08:30
#48659 - FT23 Goodies to add - safe and effective perineural adjuncts.
Goodies to add - safe and effective perineural adjuncts.
Mathias Maagaard
Department of Anaesthesiology, Copenhagen University Hospital – North-Zealand, Hillerød, Denmark
Postoperative pain is one of the main pre-operative concerns for surgical patients.1 2 Postoperative pain is a major problem, and most patients will experience moderate to severe pain within the first 24 hours postoperatively.3 The risks of poorly controlled postoperative pain are well established and include delayed recovery and discharge from hospital, reduced quality of life, prolongation of opioid use, and risk of developing chronic postoperative pain.4 Nerve blocks provide the ability to control postoperative pain by shutting down the transmission of signals from peripheral nerves. If a nerve block fully covers the surgical area, postoperative pain is eliminated for the duration of the nerve block. However, conventional long-acting local anaesthetics will only provide a duration of 8 to 14 hours. Therefore, many drugs utilised in anaesthesiologic care has been tested as means for providing increased postoperative analgesia when used in combination with a peripheral nerve block.5-7 Specifically, many of the drugs have been mixed with a local anaesthetic and injected perineurally, and have therefore been called ‘adjuncts’ to nerve blocks. The drugs can also be provided intravenously. Most drugs have not been able to increase block duration to a clinically meaningful degree, and others have been associated with an increased risk of adverse events, outweighing beneficial effects. The two most promising adjuncts to peripheral nerve blocks are dexamethasone and dexmedetomidine.
Dexamethasone
Dexamethasone is a glucocorticoid with potent anti-inflammatory properties. It is an old drug that is used for a wide range of indications with a very well-established safety profile. Importantly, a single perioperative dose of dexamethasone has not been found to increase the risk of important adverse events such as infections, impaired wound healing, or clinically important changes in plasma glucose levels.8-14 In the context of increasing block duration, dexamethasone has been administered perineurally, intravenously, and orally. Systematic reviews of randomised trials have consistently showed that dexamethasone can increase block duration by up to 7 hours.15-20
There is an on-going debate on whether dexamethasone should be administered perineurally or intravenously. Research has indicated that the perineural route of administration might increase block duration by 1 to 3 hours when compared with the intravenous route.16 17 21-25 However, the potential increase in block duration with perineural versus intravenous dexamethasone does not seem to be clinically important. A recent trial investigated the effects of combining intravenous and perineural dexamethasone and found the duration of the block to be similar to intravenous dexamethasone alone.26 Furthermore, a trial in healthy volunteers employing a design controlling for the systemic effects of perineural administration did not find convincing evidence of an important perineural mechanism of action in the absence of inflammation from trauma or surgery.27 The potential effects of perineural dexamethasone also needs to be considered in the light of dexamethasone potentially being pharmacologically incompatible with local anaesthetics,28 29 not being approved for perineural administration, and that a biological perineural mechanism of action has not been proven.
Rebound pain is severe pain usually defined as pain at or above 7 out of 10 on the Numerical Rating Scale and occurs at block cessation. Adjunct dexamethasone reduces the risk of rebound pain,30 but a recent systematic review with network meta-analysis indicated that intravenous dexamethasone is more efficient in reducing the risk of rebound pain than perineural dexamethasone.31
Only one trial has investigated oral dexamethasone (24mg vs 12mg vs placebo) as an adjunct to infraclavicular brachial plexus blocks and found oral dexamethasone to increase time to first pain by 7-hours when compared with placebo.32 This increase was similar to the magnitude of increase in block duration with perineural and intravenous administration in other trials.32 However, the oral route of administration is yet to be compared to intravenous and perineural administration in a clinical trial.
Dexmedetomidine
Dexmedetomidine has also been found to be effective in prolonging block duration.33 Contrary to dexamethasone, research has suggested that an important perineural mechanism of action exists for dexmedetomidine. A trial in healthy volunteers controlling for the systemic effects of perineurally administered dexmedetomidine showed perineural administration to be superior to systemic dexmedetomidine.34 Randomised trials have also showed perineural administration to be superior to perineural administration.33 Dexmedetomidine whether administered perineurally or intravenously is associated with hypotension, bradycardia, and sedation, potentially outweighing the beneficial effects on block duration and limiting its use in ambulatory surgery.33
Dexamethasone versus dexmedetomidine
Systematic reviews with meta-analysis of randomised trials comparing dexamethasone and dexmedetomidine found dexamethasone to be superior to dexmedetomidine in increasing block duration.22 Therefore, given that dexamethasone increases block duration more than dexmedetomidine and that a single dose of perioperative dexamethasone is not associated with adverse effects, dexamethasone is favoured over dexmedetomidine as an adjunct to peripheral nerve blocks.
Combining dexamethasone and dexmedetomidine
As the mechanisms of action are different, the combination of dexamethasone and dexmedetomidine has been hypothesized to have additive effects on block duration. Several trials have investigated the effects of combining dexamethasone and dexmedetomidine. Meta-analysis of recent trials showed that the combination of dexamethasone and dexmedetomidine is not superior to dexamethasone alone.7 35 Therefore, the current evidence supports the use of dexamethasone as the sole agent for increasing block duration.
Other adjuncts
Several other perineural adjuncts have been investigated, including midazolam, various opioids (morphine, hydromorphone, tramadol, fentanyl), neostigmine, and ketamine. However, they have all been associated with lack of effectiveness.36 Epinephrine is added to some local anaesthetics by the manufacturers, but does not increase block duration by more than 1 hour.37 Buprenorphine effectively increases block duration by up to 8 hours, but also significantly increases the risk of pruritus and post-operative nausea and vomiting.38 Clonidine is less effective than dexmedetomidine in increasing block duration and also results in adverse effects such as hypotension, bradycardia, and sedation.39 Magnesium only increases block duration by up to 2 hours.40
Conclusion
In summary, dexamethasone should be the primary agent of choice for increasing block duration. There is no additional benefit of combining dexamethasone and dexmedetomidine. Intravenous dexamethasone is currently to be preferred over perineural dexamethasone. Intravenous dexamethasone should be administered in doses of 0.1 to 0.2 mg/kg.36
References
1. Apfelbaum JL, Chen C, Mehta SS, et al. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia 2003;97(2):534-40.
2. Gan TJ, Habib AS, Miller TE, et al. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Current Medical Research and Opinion 2014;30(1):149-60. doi: 10.1185/03007995.2013.860019 [published Online First: 20131115]
3. Gerbershagen HJ, Aduckathil S, van Wijck AJM, et al. Pain intensity on the first day after surgery. A prospective cohort study comparing 179 surgical procedures. Anesthesiology 2013;118(4):934-44.
4. Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. Journal of Pain Research 2017;10:2287-98. doi: 10.2147/JPR.S144066 [published Online First: 20170925]
5. Desai N, Albrecht E, El-Boghdadly K. Perineural adjuncts for peripheral nerve block. BJA Education 2019;19(9):276-82. doi: 10.1016/j.bjae.2019.05.001 [published Online First: 20190706]
6. Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review. Anaesthesia 2021;76 Suppl 1:100-09. doi: 10.1111/anae.15245
7. Maagaard M, Albrecht E, Mathiesen O. Prolonging peripheral nerve block duration: Current techniques and future perspectives. Acta Anaesth Scand 2025
8. Waldron NH, Jones CA, Gan TJ, et al. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. British Journal of Anaesthesia 2013;110(2):191-200. doi: 10.1093/bja/aes431 [published Online First: 2012/12/12]
9. Dieleman JM, de Wit GA, Nierich AP, et al. Long-term outcomes and cost effectiveness of high-dose dexamethasone for cardiac surgery: a randomised trial. Anaesthesia 2017;72:704-13.
10. Dieleman JM, Nierich AP, Rosseel PM, et al. Intraoperative high-dose dexamethasone for cardiac surgery: a randomized controlled trial. JAMA 2012;308:1761-67.
11. Polderman JA, Farhang-Razi V, van Dieren S, et al. Adverse side-effects of dexamethasone in surgical patients. Cochrane Database of Systematic Reviews 2018;23(11):11.
12. Toner AJ, Ganeshanathan V, Chan MT, et al. Safety of perioperative glucocorticoids in elective noncardiac surgery: a systematic review and meta-analysis. Anesthesiology 2017;126:234-48.
13. Pasternak JJ, McGregor DG, Lanier WL. Effect of single-dose dexamethasone on blood glucose concentration in patients undergoing craniotomy. Journal of Neurosurgical Anesthesiology 2004;16:122-25.
14. Sauër AC, Slooter AJ, Veldhuijzen DS, et al. Intraoperative dexamethasone and delirium after cardiac surgery: a randomized clinical trial. Critical Care 2013;17 (supplement 2):396.
15. Albrecht E, Kern C, Kirkham KR. A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks. Anaesthesia 2015;70(1):71-83. doi: 10.1111/anae.12823 [published Online First: 2014/08/16]
16. Baeriswyl M, Kirkham KR, Jacot-Guillarmod A, et al. Efficacy of perineural vs systemic dexamethasone to prolong analgesia after peripheral nerve block: a systematic review and meta-analysis. British Journal of Anaesthesia 2017;119(2):183-91. doi: 10.1093/bja/aex191 [published Online First: 2017/09/01]
17. Chong MA, Berbenetz NM, Lin C, et al. Perineural Versus Intravenous Dexamethasone as an Adjuvant for Peripheral Nerve Blocks: A Systematic Review and Meta-Analysis. Regional Anesthesia and Pain Medicine 2017;42(3):319-26. doi: 10.1097/AAP.0000000000000571 [published Online First: 2017/03/03]
18. Heesen M, Klimek M, Imberger G, et al. Co-administration of dexamethasone with peripheral nerve block: intravenous vs perineural application: systematic review, meta-analysis, meta-regression and trial-sequential analysis. British Journal of Anaesthesia 2018;120(2):212-27. doi: 10.1016/j.bja.2017.11.062 [published Online First: 2018/02/07]
19. Kirkham KR, Jacot-Guillarmod A, Albrecht E. Optimal Dose of Perineural Dexamethasone to Prolong Analgesia After Brachial Plexus Blockade: A Systematic Review and Meta-analysis. Anesthesia & Analgesia 2018;126(1):270-79. doi: 10.1213/ANE.0000000000002488
20. Pehora C, Pearson AM, Kaushal A, et al. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database of Systematic Reviews 2017;11:CD011770. doi: 10.1002/14651858.CD011770.pub2 [published Online First: 2017/11/10]
21. Desai N, Pararajasingham S, Onwochei D, et al. Comparison of intravenous versus perineural dexamethasone as a local anaesthetic adjunct for peripheral nerve blocks in the lower limb: A meta-analysis and systematic review. Eur J Anaesthesiol 2024;41(10):749-59.
22. Sehmbi H, Brull R, Ceballos KR, et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus block. Anaesthesia 2021;76(7):974-90. doi: 10.1111/anae.15288 [published Online First: 20201028]
23. Tan ESJ, Tan YR, Liu CWY. Efficacy of perineural versus intravenous dexamethasone in prolonging the duration of analgesia when administered with peripheral nerve blocks: a systematic review and meta-analysis. Korean Journal of Anesthesiology 2021;75(3):255-65.
24. Zhao WL, Ou XF, Liu J, et al. Perineural versus intravenous dexamethasone as an adjuvant in regional anesthesia: a systematic review and meta-analysis. Journal of Pain Research 2017;10:1529-43. doi: 10.2147/JPR.S138212 [published Online First: 2017/07/26]
25. Albrecht E, Renard Y, Desai N. Intravenous versus perineural dexamethasone to prolong analgesia after interscalene brachial plexus block: a systematic review with meta-analysis and trial sequential analysis. Br J Anaesth 2024;133(1):135-45.
26. Hussain N, Speer J, D'Souza RS, et al. Exploring the Additive or Synergistic Effects of the Systemic and Perineural Routes of Dexamethasone as Adjuncts to Supraclavicular Block: A Randomized Controlled Trial. Anesthesiology 2025;142(6):1127-37.
27. Maagaard M, Stormholt ER, Nielsen LF, et al. Perineural and Systemic Dexamethasone and Ulnar Nerve Block Duration: A Randomized, Blinded, Placebo-controlled Trial in Healthy Volunteers. Anesthesiology 2023;138(6):625-33.
28. Hoerner E, Stundner O, Putz G, et al. Crystallization of ropivacaine and bupivacaine when mixed with different adjuvants: a semiquantitative light microscopy analysis. Regional Anesthesia and Pain Medicine 2022;47:625-29.
29. Hwang H, Park J, Lee WK, et al. Crystallization of Local Anesthetics When Mixed With Corticosteroid Solutions. Annals of Rehabilitation Medicine 2016;40(1):21-7. doi: 10.5535/arm.2016.40.1.21 [published Online First: 20160226]
30. Singh NP, Makkar JK, Chawla JK, et al. Prophylactic dexamethasone for rebound pain after peripheral nerve block in adult surgical patients: systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials. British Journal of Anaesthesia 2024;132(5):1112-21.
31. Makkar JK, Singh NP, Khurana BJ, et al. Efficacy of different routes of dexamethasone administration for preventing rebound pain following peripheral nerve blocks in adult surgical patients: a systematic review and network meta-analysis. Anaesthesia 2025;80(6):704-12.
32. Maagaard M, Plambech MZ, Funder KS, et al. The effect of oral dexamethasone on duration of analgesia after upper limb surgery under infraclavicular brachial plexus block: a randomised controlled trial. Anaesthesia 2023;78(12):1465-71. doi: 10.1111/anae.16149 [published Online First: 20231021]
33. Andersen JH, Karlsen A, Geisler A, et al. Alpha2-receptor agonists as adjuvants for brachial plexus nerve blocks - a systematic review with meta-analyses. Acta Anaesthesiologica Scandinavica 2021;66(2):186-206.
34. Andersen JH, Jaeger P, Grevstad U, et al. Systemic dexmedetomidine is not as efficient as perineural dexmedetomidine in prolonging an ulnar nerve block. Regional Anesthesia and Pain Medicine 2019;44(3):333-40. doi: 10.1136/rapm-2018-100089 [published Online First: 20190123]
35. Maagaard M, Andersen JH, Jaeger P, et al. Effects of combined dexamethasone and dexmedetomidine as adjuncts to peripheral nerve blocks: a systematic review with meta-analysis and trial sequential analysis. Regional Anesthesia and Pain Medicine 2024;Online ahead of print.
36. Desai N, Albrecht E. Local anaesthetic adjuncts for peripheral nerve blockade. Current Opinion in Anaesthesiology 2023;36(5):533-40.
37. Tschopp C, Tramèr MR, Schneider A, et al. Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses. Anesth Analg 2018;127(1):228-39.
38. Schnabel A, Reichl SU, Zahn PK, et al. Efficacy and safety of buprenorphine in peripheral nerve blocks. A meta-analysis of randomised controlled trials. European Journal of Anaesthesiology 2017;34(9):576-86.
39. Pöpping DM, Elia N, Marret E, et al. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology 2009;111(2):406-15.
40. Li M, Jin S, Zhao X, et al. Does Magnesium Sulfate as an Adjuvant of Local Anesthetics Facilitate Better Effect of Perineural Nerve Blocks? A Meta-analysis of Randomized Controlled Trials. Clin J Pain 2016;32(12):1053-61.
Mathias MAAGAARD (Copenhagen, Denmark)
08:30 - 08:30
Q&A.
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08:00-08:30
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E30
TIPS & TRICKS
Be precise for the upper limb
TIPS & TRICKS
Be precise for the upper limb
Chairperson:
Philippe GAUTIER (MD) (Chairperson, BRUSSELS, Belgium)
08:00 - 08:00
Introduction.
08:00 - 08:20
The Role of Cutaneous Nerve Injury in the Transition from Acute to Chronic Pain.
Thomas Fichtner BENDTSEN (Professor, consultant anaesthetist) (Keynote Speaker, Aarhus, Denmark)
08:20 - 08:30
Q&A.
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08:00-08:50
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F30
ASK THE EXPERT
Beware of dosing
ASK THE EXPERT
Beware of dosing
Chairperson:
Ivan KOSTADINOV (ESRA Council Representative) (Chairperson, Ljubljana, Slovenia)
08:00 - 08:00
Introduction.
08:00 - 08:30
Maximal tolerated doses in children not the same as in adults.
Luc TIELENS (pediatric anesthesiology staff member) (Keynote Speaker, Nijmegen, The Netherlands)
08:30 - 08:50
Q&A.
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08:00-09:50
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G30
NETWORKING SESSION
The safety dance
NETWORKING SESSION
The safety dance
Chairperson:
Marc VAN DE VELDE (Professor of Anesthesia) (Chairperson, Leuven, Belgium)
08:00 - 08:00
Introduction.
08:00 - 08:22
#48654 - FT44 Infomed consent first.
Infomed consent first.
Title: Informed Consent for Regional Anaesthesia: Ethical Foundations, Practical Challenges, and Current Guidance Across Europe and the UK/Ireland
Dr. Caroline Brogan, Specialist Anaesthesiology Registrar, SAT 3.5, Letterkenny University Hospital.
Dr. EML Moran, Consultant Anaesthesiology, Letterkenny, University Hospital.
Abstract:
Background
Informed consent is a cornerstone of modern clinical practice, ensuring respect for patient autonomy. In regional anaesthesia, where procedures vary in complexity and timing, delivering valid consent necessitates balancing legal, ethical, and practical considerations. This abstract outlines key principles, synthesises recent UK/European guidance, and explores future approaches to optimising consent.
Defining Informed Consent
Consent is a dynamic process of information exchange and mutual understanding. According to the AMA, it involves communication between the patient and clinician leading to an authorised procedure1. The RCoA affirms that “valid consent is a process, not a one-off event” 2.
Key elements include:
• Disclosure of relevant risks, benefits, and alternatives.
• Comprehension and opportunity for questions.
• Voluntariness without coercion.
• Capacity to make decisions.
• Documentation of discussions and decisions.
Current Guidelines
RCoA’s Chapter 8: Guidelines for Regional Anaesthesia Services 2025 (May 2024) mandates local policies covering consent. Discussions must outline risks, benefits, and alternatives, including procedural sedation or general anaesthesia. Consent may be obtained on the day of surgery, if done early and away from the anaesthetic room. When regional anaesthesia is a standalone intervention (e.g. for rib fractures), written consent is advised2.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI), in their 2017 guidelines, reaffirm that documentation of consent discussions is essential, including details of risks, benefits, alternatives, and the patient's questions and responses. However, they clarify that a separate, signed consent form is not required for anaesthetic procedures performed to facilitate surgery. In these instances, anaesthesia is considered part of an integrated treatment. Conversely, if regional anaesthesia is the primary intervention, such as in pain management, a signed consent form is recommended3. These guidelines align with legal principles established in Montgomery, ensuring material risks are communicated based on what a reasonable person in the patient’s position would want to know4.
ESAIC’s 2023 guidance promotes shared decision-making and context-specific disclosure. It moves beyond outdated paternalism to emphasise capacity, clarity, and autonomy. Despite these policies, implementation varies: an Australian audit reported just 28% compliance with documentation standards5.
Current Evidence and Practical Challenges
McCombe and Bogod offer a comprehensive review of regional anaesthesia risks and consent, citing the legal precedent Montgomery v Lanarkshire (2015), which shifted consent standards toward what a reasonable patient would wish to know6. They also outline GMC consent guidance and the Association of Anaesthetists’ view that anaesthesia may not always require standalone consent unless it is a primary intervention.
Building upon the GMC guidance and the recognition of evolving legal expectations, Cook and Ainsworth argue that growing litigation involving consent justifies a re-evaluation of anaesthesia consent practices7. Their editorial draws attention to the evolving medico-legal climate, where anaesthesia, traditionally seen as low-risk from a litigation standpoint, is increasingly implicated in claims involving inadequate consent. This shift forces the speciality to ask whether anaesthesia, like surgery, should involve a more formalised, standalone consent process. However, they also acknowledge the real-world tensions: elective surgical lists often run to tight schedules, making such thorough discussions challenging. They highlight the tension between thorough discussion and elective workflow pressures, a dilemma echoed by Chrimes and Marshall in their editorial 'The Illusion of Informed Consent' 8. They argue that the expectations set by courts for what constitutes valid consent may be incompatible with the practical realities of anaesthetic care. Chrimes contends that if legal standards were applied strictly, patients might be overwhelmed by the sheer volume of information, leading to decision fatigue rather than empowerment.
Zarnegar et al. demonstrated low patient recall of regional anaesthesia risks, a finding that underscores the ongoing challenge of delivering information in a manner that is both understandable and retainable for patients undergoing anaesthesia, reinforcing the need for clear, repeated communication9. Rampersad et al. showed that a separate anaesthesia consent form improved patient understanding, albeit in a small cohort10.
The Legal Debate
The evolution of informed consent law is exemplified by two landmark cases. In Rogers v Whitaker (1992), the High Court of Australia ruled in favour of a patient who became completely blind following eye surgery, emphasising that even rare risks must be disclosed if they are material to that particular patient11. The patient, already blind in one eye, was not warned of the risk of sympathetic ophthalmia—a complication in the good eye—and the court found that the clinician had a duty to warn based on what a reasonable patient would want to know.
In the UK, Montgomery v Lanarkshire Health Board (2015) reaffirmed this approach. The court ruled that doctors must take reasonable care to ensure patients are aware of material risks involved in any recommended treatment, as well as reasonable alternatives4. Montgomery involved a diabetic woman of small stature who was not informed of the increased risk of shoulder dystocia during vaginal delivery. The court ruled that her autonomy to make an informed choice had been undermined.
Together, these cases reshaped medical law to emphasise patient-centred consent. They pose critical questions for anaesthetists: What constitutes a material risk in regional anaesthesia? Should rare but serious risks—such as permanent nerve damage—be discussed routinely, and how should these be weighed against the patient's values and context?
Improving Consent Delivery: Tools and Future Directions
Evidence from systematic reviews supports multi-modal consent processes:
• Digital tools (e.g. videos, apps) improved comprehension in 70% of studies without increasing anxiety12.
• Teach-back methods and multimedia formats enhance retention, especially in vulnerable populations13.
• Most written forms exceed ideal readability, limiting effectiveness14.
• Procedure-specific consent forms improve documentation but show mixed results in patient satisfaction and litigation impact15.
These studies highlight the need for tailored, layered consent using accessible formats, a principle that echoes the legal shift toward recognising patient-specific material risks, as outlined in the Rogers and Montgomery cases. Furthermore, they reinforce the ethical obligation of anaesthetists to ensure that patients comprehend key risks in a way that supports meaningful decision-making, thereby aligning legal, ethical, and clinical expectations.
Conclusion
Regional anaesthesia consent must be deliberate, flexible, and patient-focused. While guidelines exist, practice remains inconsistent. Innovations in education, consent tools, and institutional policies are essential to close the gap between policy and reality.
References:
1. American Medical Association. Code of Medical Ethics: Opinion 2.1.1. 2024. Available at: https://code-medical-ethics.ama-assn.org/ethics-opinions/informed-consent. Accessed 20 Jun. 2025.
2. RCoA. Chapter 8: Guidelines for Regional Anaesthesia Services 2025. Royal College of Anaesthetists. Published 13 May 2024.
3. Yentis SM, Hartle AJ, Barker IR, et al. AAGBI: Consent for anaesthesia 2017. Anaesthesia. 2017;72(1):93–105. https://doi.org/10.1111/anae.13762. Accessed 20 Jun. 2025.
4. Montgomery v Lanarkshire Health Board (2015) UKSC 11 (UK Supreme Court). Available at: https://www.supremecourt.uk/cases/docs/uksc-2013-0136-judgment.pdf. Accessed 20 Jun. 2025.
5. De Silva YJ, Anderson L. Documentation of informed consent for anaesthesia: A single-site retrospective audit at a rural Australian hospital. Anaesth Intensive Care. 2024. https://doi.org/10.1177/0310057X2412813
6. McCombe K, Bogod D. Regional anaesthesia: risk, consent and complications. Anaesthesia. 2021. Available at: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15246. Accessed 20 Jun. 2025.
7. Ainsworth MJG, Cook TM. Pre-operative information, shared decision-making and consent for anaesthesia: time for a rethink. Anaesthesia. 2023;78(10):1300–1303.
8. Chrimes N, Marshall SD. The illusion of informed consent. Anaesthesia. 2017. Available at: https://doi.org/10.1111/anae.14002. Accessed 20 Jun. 2025.
9. Zarnegar R, Brown MRD, Henley M, Tidman V, Pathmanathan A. Patient perceptions and recall of consent for regional anaesthesia compared with consent for surgery. J R Soc Med. 2015;108(11):451–456. https://doi.org/10.1177/0141076815604494
10. Rampersad K, Chen D, Hariharan S. Efficacy of a separate informed consent for anesthesia services: A prospective study from the Caribbean. J Anaesthesiol Clin Pharmacol. 2016;32(1):18–24. https://doi.org/10.4103/0970-9185.173364
11. Rogers v Whitaker (1992) 175 CLR 479 (High Court of Australia).
12. Bollinger C, Saito H, Zhang K, et al. Digital technology in informed consent for surgery: a systematic review. BJS Open. 2023.
13. Lee Y, Grant S, Kumar R. Interventions to improve patient comprehension in informed consent: An updated systematic review. BMJ Qual Saf. 2023.
14. Martínez E, Gómez N, Ortega L. Readability of informed consent forms for medical and surgical procedures: A systematic review. Medicina. 2024.
15. Ahmed R, Davies J, Morgan P, Lewis T. Procedure-specific consent forms in clinical practice: A systematic review. Ann R Coll Surg Engl. 2024.
Caroline BROGAN, Louise MORAN (Letterkenny, Ireland)
08:22 - 08:44
#48666 - FT45 Medication Errors in Regional Anesthesia: A Persistent Challenge.
Medication Errors in Regional Anesthesia: A Persistent Challenge.
Medication Errors in Regional Anesthesia: A Persistent Challenge.
Margo Borislavova MD1, Liesbeth Brullot MD2, Steve Coppens MD, PhD2,3
1 Centre Hospitalier Simone Veil, Department of Anesthesiology, France
2 University Hospitals of Leuven, Department of Anesthesiology, Herestraat 49, B-3000, Leuven, Belgium
3 University of Leuven, Biomedical Sciences Group, Department of Cardiovascular Sciences, KU Leuven, B-3000, Leuven, Belgium
Abstract
Background and Objectives: Regional anesthesia (RA) plays a key role in modern perioperative care. However, medication errors remain an underrecognized source of harm. This narrative review explores the prevalence, types, contributing factors, and mitigation strategies related to medication errors in RA.
Methods: We conducted a comprehensive review of literature related to medication errors in regional anesthesia, drawing on audits, surveys, case reports, and patient safety guidelines. A thematic synthesis was used to group errors and prevention strategies.
Results: Medication errors in RA include preparation, labeling, dose, and route errors. High-risk settings include obstetric anesthesia, combined spinal-epidural techniques, and continuous catheter infusions. Contributing factors span human (cognitive overload, fatigue) and systemic domains (non-standardized drug trays, look-alike packaging). Effective mitigation includes standardized labeling, prefilled syringes, checklists, barcoding, and ISO-compliant spinal connectors.
Conclusions: Despite advances in safety practices, medication errors in RA remain prevalent. Multimodal prevention strategies, combined with a culture of openness and learning, are essential to reducing patient harm.
Keywords: medication error, regional anesthesia, drug safety, neuraxial, local anesthetic toxicity, safety checklist
Introduction
Anesthesia practice inherently involves the administration of multiple potent pharmacologic agents, often in time-critical, high-stress environments. While modern anesthetic drugs have transformed perioperative care, their narrow therapeutic windows, variable pharmacodynamics, and high-risk routes of administration make them particularly susceptible to medication errors.1,2
Regional anesthesia techniques are widely regarded as effective, safe, and essential components of multimodal analgesia. However, as the complexity of drug regimens and procedural logistics has increased, so too has the risk of preventable adverse events—particularly medication errors.3,4 These errors, defined by the Institute of Medicine as “any preventable event that may cause or lead to inappropriate medication use or harm,” can occur at various stages: drug preparation, labeling, administration, or documentation. In regional anesthesia, where multiple agents and precise techniques are used in time-sensitive environments, the consequences of such errors can be catastrophic.5,6
This review aims to synthesize current evidence on medication errors in RA, outline contributing factors and high-risk scenarios, and propose evidence-based strategies for prevention. With the expansion of RA in enhanced recovery protocols and opioid-sparing pathways, ensuring medication safety is not merely optional but foundational to quality anesthetic care.
Discussion
Medication errors in regional anesthesia are often multifactorial, involving both human factors and system-level deficiencies. Although the absolute incidence of these events remains low relative to the number of blocks performed globally, the severity of their consequences—ranging from failed analgesia to permanent neurological damage and death—demands careful scrutiny. These events are rarely caused by a single failure; instead, they typically result from the convergence of multiple latent hazards in the preparation, labeling, or administration phases.1,5
Preparation and labeling errors remain the most frequently reported. In environments where numerous drugs must be prepared under time constraints, such as labor and delivery units or orthopedic block rooms, cognitive overload and interruptions are common. Many of the most devastating cases reported in the literature, such as inadvertent intrathecal injection of tranexamic acid or chlorhexidine, were facilitated by look-alike ampoules, unclear labeling, and failure to implement verification protocols.7 For example, chlorhexidine has been mistaken for bupivacaine, leading to catastrophic outcomes. In one case, a physician inadvertently injected chlorhexidine intrathecally after confusing two unlabelled cups containing clear liquids—normal saline and chlorhexidine—resulting in temporary paraplegia.8 Other cases ended in more devastating circumstances.9
High-risk clinical contexts include obstetric anesthesia, where the pace of work and high turnover increase cognitive strain; combined spinal-epidural techniques, which require simultaneous handling of multiple drugs and equipment; and regional catheter infusions, where concentration, volume, and pump programming must be verified with precision.10 Particularly devastating cases have occurred due to sound-alike, look-alike medication errors involving bupivacaine and tranexamic acid, leading to inadvertent intrathecal administration with catastrophic neurological consequences.11,12
In addition, transition points in care—such as shift handovers or the involvement of trainees—have been linked to increased error likelihood due to lapses in communication or inadequate supervision.
Several root causes recur in published reports and audits:
• Non-standardized drug trays and ampoule layouts, often leading to misselection.
• Unlabeled or ambiguously labeled syringes in sterile fields.
• Use of similar-looking containers for dissimilar agents
• Delegation of preparation tasks to inexperienced or unsupervised personnel.
• Insufficient use of checklists or time-out protocols, even in high-risk blocks.
The expanded use of adjuvants in RA, including clonidine, dexamethasone, epinephrine, and dexmedetomidine, introduces further complexity. These drugs are typically drawn into separate syringes and mixed by the proceduralist or assistant, increasing the risk of concentration or dosing errors. Mixing local anesthetic drugs (short/long acting) is not only not necessary, it can also lead to additional errors.13 The use of preservative-containing or incompatible solutions in neuraxial spaces, often due to unfamiliarity or mislabeling, poses additional danger. Furthermore, the use of local anesthetics in varying concentrations (e.g., 0.25% vs. 0.5% bupivacaine) can lead to under- or overdosing, particularly when vials look identical but are stored together.
Although human error is an inevitable component of clinical practice, the presence of poorly designed systems amplifies its impact. From a systems perspective, institutions that rely on individual vigilance without embedding safety into workflow are more vulnerable to high-impact events. For example, the absence of color-coded, prefilled syringes forces clinicians to depend on manual drawing and labeling, increasing both time pressure and error risk. Likewise, the absence of double-checking procedures before block performance removes a critical layer of protection against catastrophic drug administration errors.14
Neuraxial-specific NRFit™ connectors, standardized under ISO 80369-6, were developed to reduce the risk of wrong-route medication errors by ensuring that syringes and catheters used for neuraxial or regional procedures are incompatible with standard Luer connectors. Simulation studies and clinical evaluations have demonstrated that NRFit connectors provide comparable performance to Luer systems in terms of flow characteristics, connection integrity, and usability, while significantly reducing the risk of inadvertent intrathecal, epidural, or nerve block administration of non-neuraxial drugs. In response to persistent reports of wrong-route incidents, several national health authorities, including NHS England, have issued safety alerts mandating the transition to NRFit connectors in regional anesthesia practice. However, important limitations remain. NRFit does not prevent the administration of the wrong medication via the correct route. Furthermore, early implementation studies have reported practical concerns, including connector fragility, supply variability, increased dead space, and compatibility issues with existing equipment. These limitations highlight that while NRFit represents an important advancement in medication safety, it must be integrated within a broader multimodal strategy—including proper drug labeling, double-checking protocols, and clinician education—to meaningfully reduce the incidence of neuraxial drug errors.15
A growing body of evidence supports the use of bundled safety interventions to reduce medication errors in anesthesia. In regional anesthesia specifically, practices that are increasingly recommended include:
• Prefilled, barcoded syringes for common local anesthetics.
• Color-coded ISO-standard syringe labels, used even in sterile environments.
• Mandatory time-outs before block performance, including verification of drug, dose, and route.
• Use of neuraxial-specific connectors (ISO 80369-6), to prevent wrong-route administration.
• Storage segregation of high-risk drugs away from regional anesthesia supplies.
Despite the availability of these safety measures, their uptake remains inconsistent, particularly outside academic centers or in resource-limited settings. The reluctance to report medication errors, driven by fear of blame or litigation, further hinders institutional learning. Cultivating a non-punitive culture of safety is essential. Organizations must prioritize the reporting of near misses, recognizing that they offer invaluable opportunities to identify system vulnerabilities before harm occurs.
Simulation training offers another avenue for improvement. Incorporating medication error scenarios into RA simulation allows teams to rehearse recognition and response, while reinforcing standard operating procedures. Competency-based curricula should include modules on drug safety, ampoule recognition, and label interpretation, particularly for trainees.
Finally, the growing interest in artificial intelligence and real-time clinical decision support systems may, in the future, help detect pattern deviations (e.g., unusual syringe labeling, incompatible combinations) and issue alerts. Until such systems become commonplace, however, the burden remains on providers and institutions to build layers of defense that make errors difficult to initiate and easy to intercept.16
Conclusion
Medication errors in regional anesthesia, though uncommon, can result in devastating patient outcomes. Their causes are multifactorial, involving human factors, systemic vulnerabilities, and process failures. Recognizing high-risk settings, standardizing practice, and embracing technological and cultural solutions are key to mitigation. As RA becomes increasingly central to modern surgical care, ensuring the safe and accurate administration of drugs must be prioritized as a core component of patient safety. Anesthesia teams must remain vigilant, proactive, and committed to continuous learning to eliminate preventable harm.
References
1. Wahr, J. A. et al. Medication safety in the operating room: literature and expert-based recommendations. Br J Anaesth 118, 32–43 (2017).
2. Kim, J. Y. et al. Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS. Anaesth Intensive Care 50, 204–219 (2022).
3. Cook, T. M., Counsell, D. & Wildsmith, J. A. W. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 102, 179–190 (2009).
4. Beckers, A., Verelst, P. & van Zundert, A. Inadvertent epidural injection of drugs for intravenous use. A review. Acta Anaesthesiol Belg 63, 75–9 (2012).
5. Viscusi, E. R., Hugo, V., Hoerauf, K. & Southwick, F. S. Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review. Reg Anesth Pain Med 46, 176–181 (2021).
6. Maltby, J. R., Hutter, C. D. & Clayton, K. C. The Woolley and Roe case. Br J Anaesth 84, 121–126 (2000).
7. Bryan, R., Aronson, J. K., Williams, A. & Jordan, S. The problem of look-alike, sound-alike name errors: Drivers and solutions. Br J Clin Pharmacol 87, 386–394 (2021).
8. Douqchi, B. et al. Neurotoxic Myelitis Following Accidental Epidural Injection of Chlorhexidine During Obstetric Epidural Anesthesia: A Case Report. Cureus 17, e84299 (2025).
9. Bogod, D. The sting in the tail: antiseptics and the neuraxis revisited. Anaesthesia 67, 1305–1309 (2012).
10. Patel, S. & Loveridge, R. Obstetric Neuraxial Drug Administration Errors. Anesth Analg 121, 1570–1577 (2015).
11. Kaabachi, O., Eddhif, M., Rais, K. & Zaabar, M. Inadvertent intrathecal injection of tranexamic acid. Saudi J Anaesth 5, 90 (2011).
12. Patel, S., Robertson, B. & McConachie, I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia 74, 904–914 (2019).
13. Gadsden, J. et al. The Effect of Mixing 1.5% Mepivacaine and 0.5% Bupivacaine on Duration of Analgesia and Latency of Block Onset in Ultrasound-Guided Interscalene Block. Anesth Analg 112, 471–476 (2011).
14. Hew, C. M., Cyna, A. M. & Simmons, S. W. Avoiding Inadvertent Epidural Injection of Drugs Intended for Non-epidural Use. Anaesth Intensive Care 31, 44–49 (2003).
15. Merry, A. F., Shipp, D. H. & Lowinger, J. S. The contribution of labelling to safe medication administration in anaesthetic practice. Best Pract Res Clin Anaesthesiol 25, 145–159 (2011).
16. Ye, J. Patient Safety of Perioperative Medication Through the Lens of Digital Health and Artificial Intelligence. JMIR Perioper Med 6, e34453 (2023).
Borislavova MARGARITA, Liesbeth BRULLOT, Steve COPPENS (Leuven, Belgium)
08:44 - 09:06
Monitoring, injection pressure and neural damage.
Graeme MCLEOD (Professor) (Keynote Speaker, Dundee, United Kingdom)
09:06 - 09:28
Litigation.
Amy PEARSON (Interventional Pain Physician) (Keynote Speaker, Milwaukee, WI, USA)
09:28 - 09:50
Q&A.
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08:00-08:55
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H30
ASK THE EXPERT
Sedation
ASK THE EXPERT
Sedation
Chairperson:
Julien RAFT (anesthésiste réanimateur) (Chairperson, Nancy, France)
08:00 - 08:00
Introduction.
08:00 - 08:30
PK/PD to optimize sedation for regional anesthesia.
Alain BORGEAT (Senior Research Consultant) (Keynote Speaker, Zurich, Switzerland)
08:30 - 08:55
Q&A.
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| 08:40 |
08:40-09:10
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D30.1
REFRESHING YOUR KNOWLEDGE
Pelvic surgery
REFRESHING YOUR KNOWLEDGE
Pelvic surgery
Chairperson:
Wojciech GOLA (Consultant) (Chairperson, Kielce, Poland)
08:40 - 08:40
Introduction.
08:40 - 08:55
Blocks for pelvic surgery.
Dave JOHNSTON (Speaker, Examiner) (Keynote Speaker, Belfast, United Kingdom)
08:55 - 09:10
Q&A.
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08:40-09:50
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E30.1
PANEL DISCUSSION
Parturients in difficult situations
PANEL DISCUSSION
Parturients in difficult situations
Chairperson:
Malcolm BROOM (?) (Chairperson, Glasgow, United Kingdom)
08:40 - 08:40
Introduction.
08:40 - 09:00
RA and postpartum haemorrhage.
Sarah DEVROE (Head of clinic) (Keynote Speaker, Leuven, Belgium)
09:00 - 09:20
#48684 - FT34 Regional anesthesia and cardiac disease.
Regional anesthesia and cardiac disease.
Introduction
Cardiac disease remains one of the leading causes of maternal morbidity and mortality worldwide, particularly in developed countries where maternal mortality from hemorrhage and infection has been significantly reduced. Pregnancy imposes profound physiological changes on the cardiovascular system, which may unmask or exacerbate pre-existing cardiac conditions. The management of labor and delivery in parturients with cardiac disease presents a unique challenge to anesthesiologists, requiring a delicate balance between maternal hemodynamic stability and adequate analgesia or anesthesia. Regional anesthesia, particularly neuraxial techniques such as epidural and spinal anesthesia, plays a central role in obstetric anesthesia. In women with cardiac disease, these techniques must be tailored to minimize cardiovascular stress and avoid exacerbation of the underlying pathology.
Cardiovascular Changes During Pregnancy
During pregnancy, the cardiovascular system undergoes significant changes to accommodate the increased metabolic demands of the mother and fetus. These changes include a 30-50% increase in blood volume and cardiac output, a decrease in systemic vascular resistance (SVR), increased heart rate by 10-20 beats per minute, enhanced venous return and increased stroke volume. In healthy parturients, these changes are well tolerated. However, in those with cardiac disease, particularly those with limited cardiac reserve, these adaptations can lead to decompensation. The increased blood volume and cardiac output can precipitate heart failure, while the decreased SVR may exacerbate outflow obstruction in conditions such as aortic stenosis.
Classification and Risk Stratification
Cardiac disease in pregnancy can be broadly classified into congenital heart disease (CHD) and acquired heart disease, such as valvular heart disease, cardiomyopathy, and ischemic heart disease. Risk stratification tools such as the modified World Health Organization (WHO) classification of maternal cardiovascular risk and the CARPREG II risk score help guide the management of these patients. Categories range from WHO class I (minimal risk) to WHO class IV (extremely high risk, pregnancy contraindicated).
Goals of Anesthetic Management
The primary goals in anesthetic management of parturients with cardiac disease include minimizing myocardial oxygen demand, maintaining stable hemodynamics (through avoidance of tachycardia, hypotension, and hypertension), ensuring adequate oxygen delivery to the mother and fetus, preventing volume overload and pulmonary edema and finally providing effective pain relief to avoid sympathetic stimulation
Advantages of Regional Anesthesia
Regional anesthesia, particularly neuraxial techniques, provides several advantages in managing parturients with cardiac disease such as provision of effective analgesia which reduces pain-induced sympathetic stimulation, tachycardia, and hypertension and avoidance of airway manipulation and associated risks of general anesthesia. Furthermore, gradual onset (especially with epidural) allows titration and control of hemodynamic responses. An additional advantage is the lower risk of thromboembolic events compared to general anesthesia, while the ability to use low-dose local anesthetics combined with opioids minimizes motor blockade and allows for better maintenance of venous return.
Concerns and Contraindications
Despite its benefits, regional anesthesia must be approached cautiously in cardiac patients. Potential concerns include sudden drops in SVR and preload due to sympathetic blockade, which may cause hypotension and decompensation in fixed cardiac output states (e.g., aortic stenosis). Additionally, there may be potentail risks associated with anticoagulation (e.g., epidural hematoma), incomplete analgesia leading to sympathetic overactivity and difficulty in positioning due to orthopnea in patients with heart failure. Absolute contraindications of regional anesthesia include uncorrected severe aortic stenosis, severe hypovolemia, and infection at the injection site. Relative contraindications include coagulopathy, thrombocytopenia, and anticoagulation therapy.
Epidural anesthesia
Epidural anesthesia is often preferred over spinal anesthesia in high-risk cardiac parturients due to its slower onset and ability to titrate dosing. Benefits include its gradual onset which reduces the risk of abrupt hypotension, the fact that epidural allows for continuous infusion or incremental boluses and finally the ability of the epidural technique to be maintained throughout labor and used for cesarean delivery if needed. Careful preload and positioning are essential to avoid aortocaval compression. Invasive hemodynamic monitoring (e.g., arterial line, central venous pressure) may be indicated depending on the severity of disease.
Spinal Anesthesia
Spinal anesthesia, although widely used for cesarean delivery in healthy parturients, is generally avoided or used with extreme caution in high-risk cardiac patients due to the potential for abrupt hemodynamic changes. If used, modifications include low-dose or combined spinal-epidural (CSE) techniques, the slow injection of anesthetic agents and the requirement for close hemodynamic monitoring and availability of vasopressors.
Combined Spinal-Epidural (CSE) Anesthesia
CSE anesthesia allows for rapid onset of spinal anesthesia with the flexibility of extending the block via the epidural catheter. This technique can be advantageous in cardiac parturients if low-dose spinal anesthesia is used, followed by epidural top-ups as needed. It combines the benefits of both techniques but requires meticulous planning and monitoring.
General Anesthesia
General anesthesia is reserved for situations where regional techniques are contraindicated or fail. It poses several risks to the cardiac patient such as the increased myocardial oxygen demand from intubation and extubation responses, the risk of aspiration and airway complications, the potential for negative inotropic effects of induction agents. Therefore, careful selection of induction agents, short-acting opioids, and vasopressors is crucial. Close hemodynamic monitoring and a multidisciplinary team are essential.
Monitoring and Hemodynamic Management
Monitoring strategies should be individualized based on disease severity. Basic monitoring includes non-invasive blood pressure, pulse oximetry and electrocardiography. On the other hand, advanced monitoring may include an arterial line for beat-to-beat blood pressure monitoring, central venous pressure monitoring, echocardiography (transesophageal or transthoracic) or in extreme case the requirement for pulmonary artery catheterization. Hemodynamic management often requires a careful balance of fluids and vasoactive drugs. Agents such as phenylephrine or norepinephrine may be used to maintain blood pressure, depending on the underlying cardiac pathology.
Postpartum Management
The immediate postpartum period is critical due to autotransfusion from the contracting uterus and mobilization of extravascular fluid, which can precipitate volume overload and heart failure. Key considerations include close monitoring in a high-dependency or intensive care unit, jJudicious fluid management, the requirement for diuresis if signs of pulmonary congestion occur and finally the continuation of anticoagulation or heart failure therapy as needed.
Multidisciplinary Approach
Optimal outcomes are achieved through a multidisciplinary team approach, including many specialties such as obstetricians, anesthesiologists, cardiologists, intensivists and neonatologists. Pre-delivery planning, early epidural placement, continuous monitoring, and preparedness for emergency interventions are vital components of care.
Conclusion
Regional anesthesia is a cornerstone in the management of parturients with cardiac disease, offering numerous benefits when carefully planned and executed. The choice and administration of anesthesia must be tailored to the individual’s cardiac pathology, functional status, and obstetric considerations. Through a multidisciplinary approach, vigilant monitoring, and judicious use of regional techniques, maternal and fetal outcomes can be optimized even in the context of significant cardiac disease.
Kassiani THEODORAKI (Athens, Greece)
09:20 - 09:40
#48657 - FT33 RA in preeclampsia.
RA in preeclampsia.
RA FOR PREECLAMPSIA
Authors
Tatjana Stopar Pintarič
Pia Vovk Racman
1. INTRODUCTION
Preeclampsia is a pregnancy complication characterized by the new onset of hypertension, defined as a blood pressure of ≥140/90 mmHg on at least two occasions separated by a minimum of four hours. It is often accompanied by proteinuria or organ dysfunction and typically develops after 20 weeks of gestation. The condition usually resolves within three months postpartum. Preeclampsia affects approximately 3-10% of pregnancies and is a leading cause of maternal mortality and morbidity, primarily due to haemorrhagic stroke, pulmonary oedema, respiratory insufficiency, and acute renal failure [1]. Additionally, preeclampsia is a significant contributor to preterm births, accounting for 15-20%, which can adversely impact neonatal health [2]. Therefore, the key management goals in preeclampsia are blood pressure control to prevent haemorrhagic stroke, fluid management to prevent pulmonary oedema and respiratory failure, and maintaining adequate uteroplacental perfusion, considering disease severity and gestational age [2]. Traditionally, preeclampsia was classified based on gestational age at onset: early-onset (before 34 weeks) or late-onset (after 34 weeks). However, current definitions now incorporate two categories: preeclampsia with or without severe features. Preeclampsia without severe features can progress to severe features, where organ dysfunction becomes more clinically significant than gestational age alone [1,2]. This transition to severe features is often when an anaesthesiologist first becomes involved in the management of the patient [3].
2. PREOPERATIVE ASSESSMENT AND ANAESTHETIC MANAGEMENT OF THE PARTURIENT WITH PREECLAMPSIA
Preeclampsia with severe features usually prompts an urgent or emergent delivery. The decision to deliver involves multidisciplinary collaboration and shared decision-making. The delivery type depends on the maternal and foetal conditions, dilation of the cervix, gestational age, and foetal presentation. [1-3]
For patients with preeclampsia with severe features who are planned for vaginal delivery, neuraxial analgesia is recommended. It offers better blood pressure control, provides superior analgesia compared to systemic analgesics, and reduces the risk of intrapartum caesarean section and complications related to general anaesthesia. Regional anaesthesia also mitigates pain-induced hypertensive responses during uterine contractions by decreasing circulatory catecholamines, thereby reducing stress for both mother and foetus. However, in cases of severe thrombocytopenia, coagulopathy, or uncontrolled haemorrhage, general anaesthesia may be necessary. [4]
In cases requiring caesarean section, clinicians must decide between regional and general anaesthesia based on factors such as the urgency of delivery, maternal and foetal status, and the severity of preeclampsia (including coagulation status). Preoperative assessment, often conducted under urgent or emergent circumstances, typically includes obtaining a detailed history, physical examination, platelet count, coagulation profile, haemoglobin level, and blood type and screen. In severely preeclamptic patients, spinal anaesthesia-induced hypotension is readily managed, the risk of spinal or epidural hematoma is low, and there is no evidence suggesting adverse neonatal outcomes. Conversely, the potential complications of general anaesthesia—such as hypertensive crises, stroke, and difficult airway management—are leading causes of maternal morbidity and mortality in severe preeclamptic patients. Therefore, in most severely preeclamptic patients who are not coagulopathic or thrombocytopenic, the risks associated with difficult airway management and delayed recognition of maternal stroke during general anaesthesia are considered to outweigh the risk of spinal or epidural hematoma. [2,5-10]
A study comparing general anaesthesia to spinal anaesthesia in women with severe preeclampsia undergoing caesarean due to nonreasoning foetal heart rate found no differences in umbilical blood gases with base excess (BE) < 10. [11] In a larger multicentre randomized controlled trial involving 100 parturient, spinal anaesthesia was associated with a higher incidence of hypotension (SBP < 100 mmHg) during the first 20 minutes after induction (51% vs. 23%, P < 0.001) and a greater need for vasopressor (ephedrine 12 mg vs. 6 mg, P < 0.025), compared to epidural analgesia. No significant differences in neonatal outcomes, as measured by Apgar scores and arterial pH, were observed between the groups. [8]
3. FLUID MANAGEMENT
Women with preeclampsia are at greater risk of developing pulmonary oedema, especially if too much fluid is given. Excessive fluid can cause serious complications and may lead to ICU admission in up to 10% of severe cases. [2] The 2010 guidelines from the Royal College of Obstetricians and Gynaecologists recommend a cautious, restrictive approach to fluid administration. [12] This helps prevent fluid overload, particularly in the early postpartum period when excess fluids are naturally mobilized, even if it means the patient produces less urine (oliguria). Some clinicians have suggested using invasive hemodynamic monitoring—like placing a pulmonary artery catheter—to guide fluid therapy more precisely, especially in patients with low urine output. However, a Cochrane review in 2012 found no strong evidence from clinical trials that this method is safe or effective for managing fluids in severe preeclampsia. [13] A focus has shifted to the use of non- or minimally invasive methods to guide fluid therapy, such as pulse wave analysis, TTE or lung ultrasound (US). [14,15] Lung, which detects B-lines or comet tails, provides a useful way to assess and quantify extravascular lung water caused by cardiac dysfunction, increased vascular permeability, and reduced colloid osmotic pressure—all common in preeclampsia. [16] Nevertheless, studies suggest that cardiac dysfunction is a primary driver of pulmonary oedema in severe cases. Combining lung ultrasound with focused echocardiography to evaluate LV filling pressures allows clinicians to identify women at higher risk of pulmonary oedema, enabling more precise and safer fluid management. [15,16]
A study that employed pulse wave analysis found considerable variability in SV responsiveness in patients with severe preeclampsia given a colloid bolus before spinal anaesthesia for caesarean section. [17] Such variability suggests that in the absence of monitoring of SV responsiveness; fluid restriction is safer. [12] Recent insights have shifted the view of preeclampsia from a single disease to a spectrum of cardiovascular and hemodynamic changes. It is now understood to have two main phenotypes, which have important implications for perioperative fluid management: [14,15]
1. Type 1 (Placental preeclampsia): Characterized by high peripheral vascular resistance (PVR), low cardiac output (CO), and decreased blood volume. This pattern is often linked to placental dysfunction, severe imbalance of angiogenic factors, and foetal growth restriction.
2. Type 2 (Maternal preeclampsia): Features low PVR, high CO, and volume overload, reflecting the maternal heart’s maladaptive response to pregnancy (usually associated with preexisting obesity and hypertension). This form tends to develop later and is less frequently associated with foetal growth issues.
Around 74% of women with preeclampsia exhibit high PVR, with most having either low (58%) or normal (36%) CO. Recognizing these different hemodynamic profiles is crucial for tailoring management strategies, including fluid therapy and anaesthesia, to better support both mother and baby. Using TTE has revealed that the maternal heart often undergoes structural changes in response to these pressures, especially in severe cases. This can involve left ventricular (LV) hypertrophy, impaired diastolic function, and subtle systolic abnormalities. In women with high PVR, low CO, and foetal growth restriction, echocardiography frequently shows increased LV filling pressures, which raise the risk of pulmonary oedema. Both diastolic and systolic dysfunction contribute to increased extravascular lung water, making management more complex. For women with preeclampsia showing high PVR, low CO, and lung congestion, myocardial impairment with elevated LV filling pressures is likely, and these women require strict blood pressure control and cautious fluid replacement, typically limited to about 60-80 ml/hour. Conversely, women with low CO but no signs of lung fluid overload may benefit from small fluid boluses, around 300 ml, followed by careful infusion, as they tend to tolerate fluids better. On the other hand, women with a high CO and low vascular resistance can usually handle additional fluids, but if signs of pulmonary congestion appear, diuretics may be helpful. [14-19]
Management and prevention of eclampsia
Eclampsia is associated with generalized tonic-clonic seizures, which are usually self-limited. It is a life-threatening complication of preeclampsia and one of the main causes of intracranial haemorrhage, long-term morbidity, and death in parturients, and it also leads to significant foetal morbidity and mortality. Eclampsia is associated with posterior reversible encephalopathy syndrome, with a prevalence of 100%. Clinical signs are hypertension with headache, altered mental status, vision loss, seizures, and radiographic vasogenic oedema, localized to the posterior cerebral white matter. Therapy includes prevention of secondary maternal injury with airway protection and oxygen administration, with left uterine displacement and administration of magnesium sulphate. The decision to deliver involves multidisciplinary collaboration and shared decision-making. Delivery type depends on the maternal and foetal conditions, dilation of the cervix, gestational age, and foetal presentation. Vaginal delivery is considered in a cooperative parturient without altered mental status. [3] According to Moodley, RA could be undertaken if GCS is greater than or equal to 14, not needing rapidly acting anti-hypertensive medications, platelet count greater than 100.000 μ/l, cooperative, normal foetal heart rate, and no additional maternal or foetal complications. [20]
3. COAGULOPATHY
In preeclampsia, endothelial dysfunction can stimulate excessive platelet activation and consumption, which may contribute to the increased incidence of thrombocytopenia. However, the incidence of spinal–epidural hematoma among preeclamptic patients undergoing neuraxial procedures is unknown. Large survey studies have found that the incidence of spinal–epidural hematoma after neuraxial anaesthesia is lower among parturients than the general population. [21-23] Nevertheless, evidence suggests that the incidence of spinal–epidural hematoma has increased since the 1990s. [24] In large retrospective reviews and case reports, laboratory evidence of deranged haemostasis was found in a large proportion of pregnant and nonpregnant patients who developed spinal–epidural hematomas after neuraxial procedures. [21,22,24] In 1 large retrospective study, the only 2 cases of obstetric spinal–epidural hematoma occurred in patients with the syndrome of haemolysis, elevated liver enzymes, and low platelets (HELLP). [21] Spinal anaesthesia may confer a lower risk of spinal/epidural hematoma than CSE or epidural anaesthesia, since smaller calibres needles are associated with a lower incidence of spinal hematoma and single-shot spinal anaesthesia avoids the risks of an indwelling catheter. [24]
The Society for Obstetric Anesthesia and Perinatology consensus statement for neuraxial procedures in obstetric patients with thrombocytopenia provides risk–benefit guidelines for patients with preeclampsia and thrombocytopenia. If the patient does not have bleeding
associated with thrombocytopenia, does not have an additional comorbidity of an underlying disorder of haemostasis, has normal coagulation, has no rapid rate of decline in platelet count, and has a platelet count of greater than or equal to 70,000 μ/l measured within 6 h, it may be
reasonable to proceed with neuraxial analgesia. [25] In patients with preeclampsia who are also on aspirin therapy, there is a paucity of evidence to guide clinical practice. Neuraxial procedures in the setting of a low but stable platelet count is likely to be safer than the same low but rapidly falling platelet count. In the setting of HELLP, siting an early epidural catheter may be indicated to prevent having to perform a neuraxial procedure once the platelet count has fallen. A thorough risk–benefit analysis should be undertaken and discussed with the patient before performing a neuraxial technique. [25] Platelet count should be re-evaluated before removal of an epidural catheter when thrombocytopenia is present. The same factors used to assess the safety of placement of an epidural catheter should be considered when determining a safe time to remove the catheter. Although the risk of spinal epidural hematoma is low in healthy patients, the risks in patients with preeclampsia and thrombocytopenia is poorly defined. [25] In all patients who have neuraxial techniques, monitoring for appropriate resolution of sensorimotor blockade and advising patients to report deviations from normal. Recovery is essential for early detection and management of complications indices should be considered. Clinical judgment is critical in selecting the anaesthetic approach for a preeclamptic patient with a marginal platelet count or coagulation profile.
In conclusion, management of preeclampsia requires a comprehensive and multidisciplinary approach, with key considerations including vigilant blood pressure control, careful fluid management, and maintenance of uteroplacental perfusion. For vaginal delivery, neuraxial analgesia is preferred to systemic methods due to its superior blood pressure control and analgesic efficacy while reducing the risk of complications associated with general anaesthesia. In cases requiring caesarean section, the choice between neuraxial and general anaesthesia depends on factors such as urgency, maternal and foetal status, and the patient's coagulation profile. While spinal anaesthesia can be safely administered in many severely preeclamptic patients, clinicians must remain vigilant for the increased risks of cardiorespiratory adverse events. Fluid management should therefore be tailored to the to the individual patient with the aid of clinical assessment and where available, especially in complicated cases, non-invasive modalities such as lung ultrasound, TTE or pulse-wave monitors. In the absence of these, a fluid restriction as proposed by RCOG seems justified.
4. LITERATURE
1. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin Summary, Number 222. Obstet Gynecol 2020; 135:1492–5. DOI: 10.1097/AOG.0000000000003892
2. Brown MA, Magee LA, Kenny LC, et al. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens. 2018; 13: 291–310. doi: 10.1016/j.preghy.2018.05.004.
3. Dennis AT, Xin A, Farber MK. Perioperative Management of Patients with Preeclampsia: A Comprehensive Review. Anesthesiology 2025;142(2):378-402. doi: 10.1097/ALN.0000000000005296.
4. Henke VG, Bateman BT, Leffert LR. Focused review: spinal anesthesia in severe preeclampsia. Anesth Analg 2013;117(3):686-693. doi: 10.1213/ANE.0b013e31829eeef5. Erratum in: Anesth Analg 2013;117(5):1263.
5. Aya AG, Vialles N, Tanoubi I, et al. Spinal anesthesia-induced hypotension: a risk comparison between patients with severe preeclampsia and healthy women undergoing preterm cesarean delivery. Anesth Analg 2005;101(3):869–75. doi: 10.1213/01.ANE.0000175229.98493.2B.
6. Aya AG, Mangin R, Vialles N, et al. Patients with severe preeclampsia experience less hypotension during spinal anesthesia for elective cesarean delivery than healthy parturients: a prospective cohort comparison. Anesth Analg 2003;97(3):867–72. doi: 10.1213/01.ANE.0000073610.23885.F2.
7. Clark VA, Sharwood-Smith GH, Stewart AV. Ephedrine requirements are reduced during spinal anaesthesia for caesarean section in preeclampsia. Int J Obstet Anesth 2005;14(1):9–13. doi: 10.1016/j.ijoa.2004.08.002.
8. Visalyaputra S, Rodanant O, Somboonviboon W, et al. Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study. Anesth Analg 2005;101(3):862–8. doi: 10.1213/01.ANE.0000160535.95678.34.
9. Sharwood-Smith G, Clark V, Watson E. Regional anesthesia for cesarean section in severe preeclampsia: spinal anesthesia is the preferred choice. Int J Obstet Anesth 1999;8(2):85–9. doi: 10.1016/s0959-289x(99)80003-x.
10. Chiu CL, Mansor M, Ng KP, et. al. Retrospective review of spinal versus epidural anaesthesia for caesarean section in preeclamptic patients. Int J Obstet Anesth 2003;12(1):23–7. doi: 10.1016/s0959-289x(02)00137-1.
11. Dyer RA, Els I, Farbas J, et al. Prospective, randomized trial comparing general with spinal anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. Anesthesiology 2003;99(3):561-9; discussion 5A-6A. doi: 10.1097/00000542-200309000-00010.
12. National Institute for Health and Care Excellence (NICE). Hypertension in pregnancy: diagnosis and management (NICE guideline NG133) online. 2019, last updated 2023. https://www.nice.org.uk/guidance/ng133
13. Li YH, Novikova N. Pulmonary artery flow catheters for directing management in pre-eclampsia. Cochrane Database Syst Rev 2012; 2012(6):CD008882. doi: 10.1002/14651858.CD008882.pub2.
14. Ambrozic J, Brzan Simenc G, Prokselj K, et al. Lung and cardiac ultrasound for hemodynamic monitoring of patients with severe pre-eclampsia. Ultrasound Obstet Gynecol 2017;49(1):104-9. doi: 10.1002/uog.17331.
15. Ambrožič J, Lučovnik M, Cvijić M. The role of lung and cardiac ultrasound for cardiovascular hemodynamic assessment of women with preeclampsia. Am J Obstet Gynecol MFM 2024;6(3):101306. doi: 10.1016/j.ajogmf.2024.101306.
16. Zieleskiewicz L, Contargyris C, Brun C, et al. Lung ultrasound predicts interstitial syndrome and hemodynamic profile in parturients with severe preeclampsia. Anesthesiology 2014;120(4):906-14. doi: 10.1097/ALN.0000000000000102.
17. Dyer RA, Daniels A, Vorster A, et al. Maternal cardiac output response to colloid preload and vasopressor therapy during spinal anaesthesia for caesarean section in patients with severe preeclampsia: a randomised controlled trial. Anaesthesia 2018;73(1):23–31. doi: 10.1111/anae.14040.
18. Korenc M, Zieleskiewicz L, Stopar Pintaric T, et al. The effect of vitamin C on pulmonary oedema in patients with severe preeclampsia: a single-centre, randomised, placebo-controlled, double-blind trial. Anaesth Crit Care Pain Med 2021;40(1):100800. doi: 10.1016/j.accpm.2021.100800.
19. Ambrožič J, Lučovnik M, Cvijić M. Evolution of cardiac geometry and function in women with severe preeclampsia from immediately post-delivery to 1 year postpartum. Int J Cardiovasc Imaging 2021;37(7):2217-25. doi: 10.1007/s10554-021-02210-6.
20. Moodley J, Jjuuko G, Rout C. Epidural compared with eneral anaesthesia for caesarean delivery in conscious women with eclampsia. BJOG 2001; 108(4):378–82. doi: 10.1111/j.1471-0528.2001.00097.x.
21. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology 2004;101(4):950-9. doi: 10.1097/00000542-200410000-00021.
22. Bateman BT, Mhyre JM, Ehrenfeld J, et al. The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium. Anesth Analg 2013;116(6):1380–5. doi: 10.1213/ANE.0b013e318251daed.
23. Cook TM, Counsell D, Wildsmith JA; Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009;102(2):179–90. doi: 10.1093/bja/aen360.
24. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010;35(1):64-101. doi: 10.1097/aap.0b013e3181c15c70.
25. Bauer ME, Arendt K, Beilin Y, et al. The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia. Anesth Analg 2021;132(6):1531-44. doi: 10.1213/ANE.0000000000005355.
Tatjana STOPAR PINTARIC (Ljubljana, Slovenia), Pia VOVK RACMAN
09:40 - 09:50
Q&A.
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F30.1
ASK THE EXPERT
A thin structure you will never forget
ASK THE EXPERT
A thin structure you will never forget
Chairperson:
Siska BJORN (Resident) (Chairperson, Aarhus, Denmark)
09:00 - 09:00
Introduction.
09:00 - 09:20
How I look at the diaphragm to see if it works well.
Hari KALAGARA (Assistant Professor) (Keynote Speaker, Florida, USA)
09:20 - 09:50
Q&A.
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C30.2
TIPS & TRICKS
No humbug: caudals for adults
TIPS & TRICKS
No humbug: caudals for adults
Chairperson:
Kausik DASGUPTA (Consultant Anaesthetist) (Chairperson, NUNEATON,UK, United Kingdom)
09:20 - 09:20
Introduction.
09:20 - 09:40
Routine caudal for adults.
Per-Arne LONNQVIST (Professor) (Keynote Speaker, Stockholm, Sweden)
09:40 - 09:50
Q&A.
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D30.2
TIPS & TRICKS
RA and the environment
TIPS & TRICKS
RA and the environment
Chairperson:
Ottokar STUNDNER (Attending) (Chairperson, Innsbruck, Austria)
09:20 - 09:50
Introduction.
09:20 - 09:50
#48379 - FT24 The greenest block.
The greenest block.
The Greenest Block
Vivian H. Y. Ip MBChB FRCA
Clinical Professor,
Department of Anesthesia, Perioperative, and Pain Medicine
South Health Campus
University of Calgary
Calgary
Alberta
Canada
Email: hip@ualberta.ca
Conflict of Interests:
Dr. Vivian Ip is the Chair of the Environmental Sustainability Section, the Chair of the Regional Anesthesia Section at the Canadian Anesthesiologists’ Society, and the Chair of the Green Anesthesia Special Interests Group at the American Society of Regional Anesthesia and Pain Medicine.
Word count = 1516
References = 24
Introduction
Healthcare contributes to 4.6% of the net global carbon dioxide emission1 and the statistics provided by the ‘United Nations Environment Program” where to limit the global temperature rise to
1.5˚ C (34.7˚ F), carbon emissions must decrease by 42% by 2030 and by 57% by 2035.2 Limiting global temperature risk is crucial to prevent adverse impact on our ecosystem and species.3 For example, the temperature of the beach sand that female sea turtles nest in influences the gender of their offspring during incubation, the warming climate may be driving sea turtles into extinction by creating a shortage of males.4 The extremes and frequency of the intense weather events, such as uncontrollable wildfire, drought, deadly heatwave, flooding will be 150 times less likely if the global warming is contained below the 1.5 degrees Celsius threshold.5
As healthcare providers, it is our professional duties to first do no harm and reflect on our clinical practice to be good steward in environmental sustainability, as there is a significant negative impact from climate change on the health and livelihood of humanity.6
The objective of this abstract is to recognize the potential for regional anesthesia to be environmentally sustainable, however, resource utilization is a key component to achieving a truly ‘green’ regional anesthesia technique. The goal is to balance the reduction of carbon footprint and waste generation while maintaining patient safety.
Key aspects of the ‘Greenest’ block
Reduction of waste, energy efficiency, environmentally responsible medication use, as well as waste segregation and proper waste disposal are the key components in practicing the ‘greenest’ block.
Reduction of waste
Reducing waste require a conscious effort to use only the necessary supplies and equipment during clinical practice to reduce waste, especially the requirement of aseptic techniques, sterility and equipment packaging. Using reusable attires and equipment is the first step towards disposable waste reduction. Many life cycle assessments have demonstrated the reduction in carbon dioxide emission despite the energy used for processing reusable attires and equipment such as drapes, caps.7-10 It was previously thought that premade pack would be more environmentally sustainable, however, it depends on the method used to produce the pre-made pack. The premade pack should contain minimal equipment common to the group of practitioners.11 Furthermore, the manufacturing process and transportation of the items within the pack can affect the carbon emission, e.g., the material is produced within the facilities where the premade packs are made which omits the packaging of each material versus the manufacturers obtained packaged material requiring transportation and packaging for the items within the pack.12 Guided by evidence, only use items that are necessary for performing the nerve block, and forego the practice that are not rooted in evidence, e.g., the requirement of gown. The evidence for gowning during regional procedure is not robust, even for indwelling catheters that are 4 days or less.13 Previous observation study showed the energy used to process reusable gowns increases the carbon footprint as one of the reasons to explain the carbon emission for spinal anesthesia is disproportionately higher than that for a general anesthetic.14 Therefore, clinical decision of the duration of indwelling catheter (epidural or peripheral nerve blocks), is part of the consideration for environmental sustainability practice.
Strategies for reducing waste also includes doing more with less. Hand hygiene is rooted in evidence to reduce infection.15 Alcohol-based hand rub for use in between patients will reduce resource use and waste generation when compared to hand wash with soap and water, with the need to dry them with towels, unless they are visibly soiled.15,16
The same principle applies with the use of aseptic non-touch technique which is a clinical guideline incorporated into many protocols within institutions globally. Table 1 shows the practice parameters that achieved strong consensus (>=75% agreement) in the Delphi consensus study11 for the environmentally responsible use of resources during regional anesthesia. (Table 1)
Energy efficiency
Ineffective energy used has been demonstrated by the Canadian Coalition for Green Healthcare of up to 80% energy consumption by imaging devices when not scanning.17 The observation study quantifying the savings on energy consumption by switching ultrasound machine between uses also demonstrated 80% savings, as well as 100 CAD annual savings per ultrasound machine. The cumulative savings for the province of Alberta in Canada with 400 ultrasound machines are approximately 40,000 CAD per year.18 Previous theoretical calculation of electricity use and associated carbon emission showed that failing to turn off the ultrasound machine between uses require additional ‘plug-in’ time to replenish lost charge, which leads to wasted electricity in real-time, and the inability of battery to hold a charge long term, further increasing required ‘plug-in’ time. This process subsequently results in premature disposal and replacement of battery for the ultrasound machine.19
Environment
Many institutions have a separate area (block room) where regional techniques are performed prior to the patients entering the operating room. If this is the case, the temperature of the block room can be set to a comfortable temperature. Other measures which require support from facility managers are to change the light to LED lighting, or sensors-activated lighting such that the light are not switched on during after hours. Switching the computers off, as well as the ultrasound machines as aforementioned will reduce unnecessary electricity and energy consumption.
Medication use, waste and disposal
Refrain from preparing excessive number of local anesthetic syringes which will be wasted at the end of the day, or work with pharmacy for pre-filled local anesthetic syringes. For oxygen and sedation, goal-directed therapy titrated to individual needs will prevent overuse of oxygen. A previous observation study found the carbon dioxide emission is similar for all types of anesthetic due to the overuse of oxygen at 10L/min.14 Clinically, if oxygen consumption is increasing, perhaps consider reducing the amount of sedation or use an alternative method for sedation, e.g., music.20 Despite oxygen being abundant in the atmosphere, electricity is required to compress oxygen into liquid oxygen for medical use via cryogenic distillation which produces global warming potential of 0.49kg carbon dioxide equivalent per bed day, assuming 2L/min use.21 When oxygen is supplied to hospital in a cylinder format, there will be a substantial increase in environmental impacts from additional container and transportation.21
Contaminants of emerging concern comprise different contaminants, including pharmaceuticals with potential threat to the environment and public health.22 Therefore, proper disposal of medication is important to prevent water contamination or accumulation in the soil. There are commercially available drug destruction bags or containers which will be incinerated, as well as disposal through the pharmacy department. When choosing between multi-dose and single-use medication vials, patient safety is paramount. Centers for disease control and prevention has warned against misuse of multi-dose vials with outbreaks of 56% bacterial infections and 44% viral hepatitis, despite the presence of antimicrobial preservative in multi-dose vials to help limit the growth of bacteria, which has no effect on blood borne viruses.23 Despite potential reduction in solid waste from using multi-vial medications as it can be used for more than 1 patient when aseptic technique is followed,23 very often, the amount of drug waste may be higher than a single-use vials although there is a lack of data in this area.
Waste Disposal
While proper waste segregation and recycling are important, recycling is low yield, especially in healthcare as most materials are assumed to be contaminated and would either be sent to the landfill, or incineration. Therefore, it is crucial to eliminate wasteful and redundant practice, and opt for reusable supplies whenever possible, while balancing patient safety. Furthermore, even when items are collected for recycling, they are expensive to recycle with a lack of facilities to process the items to reprocess them into valuable products for use.24
Framework of “Green-gional anesthesia”
The basic requirement is systematic reduction to minimize waste while maintaining patient safety. There needs to be a balance between practice standards while balancing realistic goals for infection prevention and patient safety. Measures should be evidence-based, rather than expert-opinion consensus. This is especially relevant given that rates of infection are very low. While infection prevention remains critical, there comes a point where excessive resource allocation no longer yields clinically significant benefits. In fact, unnecessary waste can ultimately harm society and the humanity. Therefore, healthcare practices should be evaluated through a sustainability lens, and guided by current evidence. Mindful stewardship means resource consciousness should incorporated as a routine practice with every procedure. This not only reduce environmental impact of our clinical practice and healthcare contribution to the carbon dioxide emissions, these initiatives also save costs. The top rung is to achieve the triple bottom line of optimizing planet, people and profit.
Conclusion
The Greenest block is also the safest for patients as patient safety always remain the absolute non-negotiable priority in all green initiative. The greenest block is to re-evaluate our practice through both the evidence-based, and environmental sustainability lens to only use resources that are necessary and based on evidence for infection prevention. This mindful stewardship should be embedded into routine practice and data collection is encouraged. The greenest block is precise, efficient, and effective for both patient and planet – which ultimate means the humanity.
References
1. The Lancet Digital Health. Curbing the carbon footprint of health care. Curbing the carbon footprint of health care (Accessed May 25, 2025)
2. United Nation Environment programme. Emissions gap report 2024. 2024 (Oct) Emissions Gap Report 2024 | UNEP - UN Environment Programme (Accessed Nov 6, 2025)
3. NASA Science Editorial Team. A Degree of Concern: Why global tempertures matter. A Degree of Concern: Why Global Temperatures Matter - NASA Science (Accessed May 29, 2025)
4. Camryn J, Camryn T, Camryn Michael, et al. Environmental Warming and Feminization of One of the Largest Sea Turtle Populations in the World. Current Biology. 2018;28:154-159.e4. 10.1016/j.cub.2017.11.057
5. Philip SY, Kew SF, van Oldenborgh GJ et al. Rapid attribution analysis of the extraordinary heatwave on the pacific coast of the US and Canada June 2021. Scientific report (Accessed May 29, 2025)
6. U.S. Centers for disease control and prevention. Effects of climate change on health. Effects of Climate Change on Health | Climate and Health | CDC (Accessed May 29, 2025)
7. Donahue LM, Petit HJ, Thiel CL, et al. A life cycle assessment of reusable and disposable surgical caps. J of surg research 2024;299:112-119.
8. McGain McAlister S, McGavin A et al. The financial and environmental costs of reusable and single-use plastic anaesthestic drug trays. Anaesth Intensive Care 2010;38:538-544.
9. Vozzola E, Overcash M, Griffing E. An environmental analysis of reusable and disposable surgical gowns. AORN Journal 2020;315-325 doi.org/10.1002/aorn 12885.
10. Eckelman M, Mosher M, Gonzalez A, et al. Comparative life cycle assessment of disposable and reusable laryngeal mask airways. Anesth Analg 2012;114(5):1067-1072.
11. Ip VHY, Shelton CL, McGain F, Eusuf D, Kelleher DC, Li G, Macfarlane AJR, Raft J, Schroeder KM, Volk T, Sondekoppam RV; and Collaborators. Environmental responsibility in resource utilization during the practice of regional anesthesia: a Canadian Anesthesiologists' Society Delphi consensus study. Can J Anaesth. 2025 Mar;72(3):436-447. English. doi: 10.1007/s12630-025-02918-2. Epub 2025 Mar 17. PMID: 40097901.
12. Fouts-Palmer E, Kelleher D, Sondekoppam R, et al. A life cycle inventory of a single injection peripheral nerve block with and without pre-made supply pack. Canadian Anesthesiologists’ Society 2025 Annual meeting abstract. Pending publication.
13. Provenzano DA, Hanes M, Hunt C, Benzon HT, Grider JS, Cawcutt K, Doshi TL, Hayek S, Hoelzer B, Johnson RL, Kalagara H, Kopp S, Loftus RW, Macfarlane AJR, Nagpal AS, Neuman SA, Pawa A, Pearson ACS, Pilitsis J, Sivanesan E, Sondekoppam RV, Van Zundert J, Narouze S. ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine. Reg Anesth Pain Med. 2025 Apr 1:rapm-2024-105651. doi: 10.1136/rapm-2024-105651. Epub ahead of print. PMID: 39837579.
14. McGain F, Sheridan N, Wickramarachchi K, Yates S, Chan B, McAlister S. Carbon Footprint of General, Regional, and Combined Anesthesia for Total Knee Replacements. Anesthesiology. 2021 Dec 1;135(6):976-991. doi: 10.1097/ALN.0000000000003967. PMID: 34529033.
15. Teare L, Cookson B, Stone S. Hand hygiene. BMJ 2001; 323: 411–2. https://doi.org/10.1136/bmj.323.7310.411
16. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002; 23: S3–40. https://doi.org/10.1086/503164
17. Knott JJ, Varangu L, Waddington K et al. Assessing opportunities to reduce energy consumption in the health care sector. Medical Imaging Equipment Study, 2017;1, p. 43. Medical Imageing Equipment Energy Use- CCGHC 2017 (Accessed May 31, 2025)
18. Serghi E, Deacon T, Salah T, Kelleher DC, Fouts-Palmer E, Ip VHY. Ultrasound machine power-down between scans: an energy and cost-saving measure in regional anesthesia. Reg Anesth Pain Med. 2025 Apr 1:rapm-2025-106491. doi: 10.1136/rapm-2025-106491. Epub ahead of print. PMID: 40169359.
19. Singrey C, Fouts-Plamer E, Ip V, et al. Environmental impact of medical ultrasound use. ASRA Pain Medicine Annual Meeting 2024. Abstract 5465.
20. Graff V, Cai L, Badiola I, Elkassabany NM. Music versus midazolam during preoperative nerve block placements: a prospective randomized controlled study. Reg Anesth Pain Med. 2019 Jul 18:rapm-2018-100251. doi: 10.1136/rapm-2018-100251. Epub ahead of print. PMID: 31320504.
21. Tariq M, Siddhantakar A, Sherman JD et al. Life cycle assessment of medical oxygen. Journal of Cleaner Production 2024, 444:141126.
22. Fernandes JP, Almeida CMR, Salgado MA et al. Pharmceutical compounds in aquatic environments – occurrence, fate and ioremediation prospective. Toxics 2021;9(10):257.
23. Centers for disease control and prevention. Single-dose or multi-dose? Single-Dose or Multi-Dose (Accessed June 1, 2025)
24. Sullivan L. Recycling plastic is practically impossible – and the problem is getting worse. Greenpeace report finds most plastic goes to landfills as production ramps up : NPR (Accessed June 1, 2025)
Vivian IP (Calgary, Canada)
09:20 - 09:50
Q&A.
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COFFEE BREAK
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10:30-12:20
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A31
NETWORKING SESSION
Pulsed Radiofrequency revisited
NETWORKING SESSION
Pulsed Radiofrequency revisited
Chairperson:
Jose DE ANDRES (Tenured Professor) (Chairperson, Valencia (Spain), Spain)
10:30 - 10:35
Introduction.
Jose DE ANDRES (Tenured Professor) (Keynote Speaker, Valencia (Spain), Spain)
10:35 - 10:57
Physics of impulse generation, mechanism of action and biological effects.
Ashish GULVE (Consultant in Pain Medicine) (Keynote Speaker, Middlesbrough, United Kingdom)
10:57 - 11:19
Efficacy and safety of pulsed radiofrequency as a method of stimulation of dorsal root ganglia.
Thomas HAAG (Consultant) (Keynote Speaker, Oswestry, United Kingdom)
11:19 - 11:41
Interventional treatment for the sympathetic nervous system: radiofrequencay alone or something else?
Vaishali WANKHEDE (consultant) (Keynote Speaker, Switzerland, Switzerland)
11:41 - 12:03
50 Years of Radiofrequency for Lumbar Facet Joint Pain.
Jan VAN ZUNDERT (Chair) (Keynote Speaker, Genk, Belgium)
12:03 - 12:20
Q&A.
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10:30-11:40
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B31
EXPERT OPINION DISCUSSION
Anatomy at its finest
EXPERT OPINION DISCUSSION
Anatomy at its finest
Chairperson:
Ki Jinn CHIN (Professor) (Chairperson, Toronto, Canada)
10:30 - 10:35
Introduction.
Ki Jinn CHIN (Professor) (Keynote Speaker, Toronto, Canada)
10:35 - 10:50
The structure of the fascia is complex.
Jens BORGLUM (Clinical Research Associate Professor) (Keynote Speaker, Copenhagen, Denmark)
10:50 - 11:05
So many mistakes.
Matthias HERTELEER (Anesthesiologist) (Keynote Speaker, Lille, France)
11:05 - 11:20
#48641 - FT09 Fascia as the origin of chronic pain.
Fascia as the origin of chronic pain.
Fascia is a continuous connective tissue network surrounding muscles, bones, nerves, and organs. Historically dismissed as packing material, fascia indeed acts as a dynamic structure playing an active role in coordinating movement and transmitting force. [1] To overcome difficulties in terminology, we will focus on the concept of the fascial system which includes superficial, deep (muscular), visceral and neural fascia. [2,3]
The superficial fascia, in the subcutaneous tissue, consists of two fibro-adipose layers: superficial and deep adipose tissue connected to the skin and deep fascia by cutaneous ligaments. Rich in fat, vessels, nerve endings and corpuscles, superficial fascia interacts with the external environment, and plays a role in lymphatic drainage, skin trophism, thermoregulation and allows sliding between the skin and muscular planes. [4] Deep fascia surrounds muscles and comprises epimysial and aponeurotic fascia. It works together with muscles to perform movements, to manage posture and proprioception. A sliding plane between superficial and deep fascia maintains functional autonomy between external stimuli and internal perception. For these planes to operate properly, their autonomy must be maintained. The visceral fascia creates the vital space that houses the organs and permits their physiological movement. Finally, there is the neural fascia, which comprises the connective tissue surrounding peripheral nerves as well as the meninges. All these structures work together to create a sophisticated network that is the fascial system.
The properties of the fascial system can be conceptually split into a microlevel (molecular and cellular responses) and a macrolevel (mechanical properties). At the microscopic level, fascia is composed of collagen-rich tissue and contains various cell types embedded in extracellular matrix (ECM). Fibroblasts, the main resident fascial cells, are responsive to mechanical stimuli, and can become contractile (myofibroblasts) or synthetic, increasing tension and ECM output. Following trauma, fibroblasts contribute to fibrosis through N-cadherin–mediated collective migration, especially in deep fascia. [5] Changes in fibroblast and macrophage subtypes have been observed during conditions like acute compartment syndrome and necrotizing fasciitis, highlighting their roles in inflammation. [6, 7] The ECM - composed of water, collagens, proteoglycans/glycosaminoglycans, elastin, laminins, and other glycoproteins - is a reservoir of extracellular and signaling molecules secreted locally. It provides structural support, elasticity, and adaptability. Collagen types I and III offer tensile strength and flexibility, while elastin allows tissue recoil. Hydrophilic glycosaminoglycans (in particular hyaluronic acid [HA]) maintain lubrication and regulate osmotic pressure. Healthy fascia requires specific levels of matrix components. For example, HA content varies regionally, with higher concentrations in the fascia lata or rectus sheath (43 μg/g) compared to the epimysium of the deltoid and trapezius muscles (6 μg/g). These variations correspond with different gliding functions of the fascia, depending on the anatomical site. The aponeurotic fascia, like the thigh’s fascia lata or the abdomen rectus sheath, should glide over the muscles. [8] Alterations in HA viscosity (affected by pH, temperature, pressure) contribute to fascial stiffness. Structural and biochemical properties of fascia are intimately linked to its innervation which is essential to its functions.
Superficial fascia is densely innervated, with Pacinian and Ruffini corpuscles (exteroception), enabling it to perceive mechanical stimuli linking with skin mechanoreceptors and thermoreceptors. Superficial fascia of the human hip was found to be the second most highly innervated tissue after the skin, with a density of 33 ± 2.5/cm2 and a mean nerve size of 19.1 ± 7.2 µm. Superficial fascia is highly sensitive, providing fine tactile discrimination and autonomic innervation is well represented, with sympathetic fibers that account for 30% of superficial fascia innervation, often associated with small arteries. [9]
The deep aponeurotic fascia contains free nerve endings while epimysial is rich in encapsulated receptors (Golgi corpuscles and muscle spindles) interconnected in a network (perimysium septa) for detecting multidirectional tension and it plays a role in dynamic proprioception and pain. [10] Muscle spindles’ capsule is structurally continuous with the perimysium and forms multiple connections in different orientations. Spindles are very sensitive to the tension of the epimysial fascia. Changes in muscle length and alterations in the (epimysial) fascia tension (for example with fibrosis and aging) influence muscle spindles and accordingly proprioception and posture. [11]
Electrical stimulation of deep fascia evokes dull and unpleasant pain, whereas stimulation of the hypodermis and superficial fascia produces a sharp, well-localized pain, confirming that the two fasciae have different roles. In healthy volunteers, stimulation of the thoracolumbar fascia with hypertonic saline generates pain, and this pain is more intense referring to a larger area compared to injection within the erector spinae muscles. [12]
The presence of substance P (presumably nociceptive) fibers in chronically inflamed thoracolumbar fascia suggests that fascia can undergo pathological changes leading to chronic pain. [13] Chronic irritation of the deep fascia can also induce central sensitization. In rats with chronic thoracolumbar fascia inflammation, Hoheisel et al. showed that the spinal segments involved in nociceptive afference expanded [14] while Taguchi et al. demonstrated that repeated mechanical (pinching) stimuli could induce c-Fos protein expression in the spinal segments receiving sensory input. [15]
Normal fascia is elastic and adaptable, supports muscles and regulates muscular function. Many factors can disrupt fascial architecture leading to fibrosis, HA densification, reduced gliding, with different impacts on stiffness. [16] Fibrotic fascia limits muscle mobility and induces dysfunction and pain also in distant regions. Some estimates suggest that bone receives 70% of the muscular force to perform movement, while peri-muscular fascia receives 30%. Subsequently, when the muscles contract, they create tension in the fascia. The myofascial connections may affect how the body works and explain pain and dysfunction in distant areas. [17] Thoracolumbar fascia shear strain is about 20% lower in human subjects with chronic low back pain. [18] In a recent systematic review and meta-analysis, including over 4000 patients, thoracolumbar fascia injury (TLFI) has 28% incidence rate after percutaneous vertebral augmentation. Additionally, uni- and multivariate analyses show that TLFI significantly increases the risk of residual chronic back pain. [19] Prolonged static posture or repetitive activities can cause degeneration and fibrosis, reducing elasticity and impairing fascial gliding. [20] Nordez et al. also hypothesized that fascial stiffness could limit the maximal range of motion of a joint. [21] Hip osteoarthritis is associated with a dysfunctional, stiffened fascia lata, with impaired sliding. Changes in composition of the collagen and significant decrease in the content of HA suggest that osteoarthritis may be considered as an extra-articular disease affecting the normal physiology of the fascia. [22] Interestingly, fascia also exhibits active mechanical behavior. Schleip et al. showed that active contraction of fascia could influence the coordination of motor neurons in the lumbar region, affecting the biomechanical behavior of the entire musculoskeletal system. Fascia contains myofibroblasts, which can actively regulate the tension of the fascia through a contraction mechanism similar to smooth muscle. When the fascia is biochemically stimulated (such as with transforming growth factor β1 or thromboxane A2), it can respond in ways that affect its biomechanical properties. [23, 24] Mechanical stress can degrade hyaluronan, triggering inflammatory cascades that impair fascia function and regeneration. [25] The biomechanical properties of the fascia change with muscle exercise, overuse, disuse or pathological loading, often leading to HA fascial densification, which results in greater resistance to fascial layers sliding and increased stiffness. [26, 27] Zhao et al. evaluated hyaluronan and collagen concentration in the gastrocnemius muscle and thoracolumbar fascia in unilateral lower limb peripheral nerve-injured rats to explore systemic ECM alterations following peripheral nerve injury and impacts on functional recovery. They highlighted systemic ECM alterations following sciatic nerve injury, focusing on HA and collagen changes in lower limb muscles and the thoracolumbar fascia. [28] Fascia may contribute to complex regional pain syndrome through neuro-inflammation, fibrosis and autonomic dysregulation. Fascia’s rich innervation facilitates peripheral and central sensitization, while inflammatory mediators drive fibrosis, and reduce elasticity. Autonomic dysfunction worsens hypoxia and oxidative stress, fueling chronic dysfunction. [29]
Ultrasound (US) and sonoelastography are increasingly used to assess fascial alterations [30]. In a 68-year-old man with chronic pain caused by thoracic zoster, Fusco et al. studied the affected regions through elastography. They highlighted high muscular rigidity and fascial densification. After erector spinae plane (ESP) block, sonoelastography showed reduction in densification of the deep fascia and less muscular stiffness. The mechanism of the ESP block is still debated and potentially related to the injectate spread toward thoracic intercostal nerve, paravertebral space and dorsal root ganglion. Nevertheless, considering the rich innervation of fascia, the authors postulated that the fascial block worked on the fascial nerve endings, and by reducing densification and muscular stiffness, as elastography demonstrated, revealing a possible clinical relationship between the fascial administration of local anesthetic and the reduction of stiffness and pain generation. Further, the duration of the pain relief after the block was much longer than the effect of the local anesthetic itself. [31] This may suggest that fascia may become a target itself for fascial blocks in pain management, [32] by administering not only local anesthetic, but also electric or mechanical stimulation, as dry needling. [33] Another confirmation of the potential role of the fascial system as pain generator was shown when Fusco and colleagues found that injecting hot saline (40°C) into the ESP caused immediate pain relief in chronic myofascial pain. Hot saline does not block the pain transmission as the local anesthetic does, but the fascial hydro-dissection with warm solution potentially stimulates the nerve endings and reduces HA aggregation (macromolecules and densification) with improvement in fascial gliding, muscle stiffness and pain. [34] In chronic pain, alterations in fascia can cause fibrosis (adhesions and connective septa) that may compromise sliding with an alteration of the synergistic contraction of the interconnected muscles. The injection of local anesthetic (fascial hydro-dissection or hydro-release) in the fascial planes may break the connective septa and optimizes the fascial sliding. [35, 36] An interesting report by Fusco et al. further advanced this approach. [37] Both ultrasound and micro-endoscopic guidance were used to perform a targeted ESP block in a patient who had refractory chronic post-surgical thoracic pain. This technique made it possible to dynamically hydro-dissect the planes and directly visualize adhesions. (Figure 1) After the block, significant tissue (fascial and muscular) elasticity improvement was confirmed by elastography, closely mirroring the patient's recovery. The authors argued how this imaging-guided intervention could disrupt fibrous septa, restore fascial gliding, and facilitate recovery.
In conclusion, nowadays, fascia is seen as a functional, innervated network essential to movement, force transmission, and pain modulation rather than as inert connective tissue. Novel approaches to diagnosing and treating chronic pain originating from fascial dysfunction are made possible by developments in imaging and interventional techniques, such as elastography and ultrasound-guided fascial plane blocks. [38] Gaining a better understanding of the biomechanical and neurophysiological functions of fascia offers encouraging prospects for functional rehabilitation and individualized pain management.
References
[1] Wilke J, Schleip R, Yucesoy CA, Banzer W. Not merely a protective packing organ? A review of fascia and its force transmission capacity. J Appl Physiol. 2018;124:234-44.
[2] Adstrum S, Hedley G, Schleip R, Stecco C, Yucesoy CA. Defining the fascial system. J Bodyw Mov Ther. 2017;21:173-7.
[3] Stecco C, Pratt R, Nemetz LD, Schleip R, Stecco A, Theise ND. Towards a comprehensive definition of the human fascial system. J of Anatomy. 2025;00:1-15.
[4] Fede C, Clair C, Pirri C, et al. The Human Superficial Fascia: A Narrative Review. Int J Mol Sci. 2025;26(3):1289
[5] Jiang D, Christ S, Correa-Gallegos D. et al. Injury triggers fascia fibroblast collective cell migration to drive scar formation through N-cadherin. Nat Commun 2020;11:5653.
[6] Wang T, Long Y, Ma L, et al. Single-cell RNA-seq reveals cellular heterogeneity from deep fascia in patients with acute compartment syndrome. Front Immunol. 2023;13:1062479.
[7] Wang T, Zhang L, Chen W, et al. Single-Cell RNA-Seq Uncovers Cellular Heterogeneity from Deep Fascia in Necrotizing Fasciitis Patients. J Inflamm Res. 2025;18:995-1012.
[8] Fede C, Angelini A, Stern R, Macchi V, Porzionato A, Ruggieri P, De Caro R, Stecco C. Quantification of hyaluronan in human fasciae: Variations with function and anatomical site. J Anat. 2018;233:552–6.
[9] Fede C, Petrelli L, Pirri C et al. Innervation of human superficial fascia. Front Neuroanat. 2022 Aug 29;16:981426
[10] Stecco C, Gagey O, Belloni A et al. Anatomy of the deep fascia of the upper limb. Second part: study of innervation. Morphologie. 2007;91:38-43.
[11] Sun Y, Petrelli L, Fede C, Biz C, Incendi D, Porzionato A, Pirri C, Zhao X, Stecco C. Novel fascial mapping of muscle spindles distribution: insights from a murine model study. Front Physiol. 2025;16:1571500.
[12] Schilder A, Hoheisel U, Magerl W, Benrath J, Klein S, Treede RD. Sensory findings after stimulation of the thoracolumbar fascia with hypertonic saline suggest its contribution to low back pain. Pain 2014;155;222-31.
[13] Hoheisel U, Rosner J, Mense S. Innervation changes induced by inflammation of the rat thoracolumbar fascia. Neuroscience. 2015;6:351-9.
[14] Hoheisel U, Taguchi T, Treede RD, Mense S. Nociceptive input from the rat thoracolumbar fascia to lumbar dorsal horn neurones. Eur J Pain. 2011;15:810-5.
[15] Taguchi T, Yasui M, Kubo A et al. Nociception originating from the crural fascia in rats. Pain. 2013;154:1103-14.
[16] Ganjaei KG, Ray JW, Waite B, Burnham KJ. The fascial system in musculoskeletal function and myofascial pain. Current Physical Medicine and Reabilitation Reports. 2020;8:364-72.
[17] Stecco C, Pirri C, Fede C, Fan C, Giordani F, Stecco L et al. Dermatome and fasciotome. Clin Anat. 2019;32:896-902.
[18] Langevin HM, Fox JR, Koptiuch C, et al. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskelet Disord. 2011;12:203.
[19] Ahmed Mohamed A, Xuyang X, Zhiqiang Z, Chen J. Association between thoracolumbar fascia injury and residual back pain following percutaneous vertebral augmentation: a systematic review and meta-analysis. Front Endocrinol (Lausanne). 2025;16:1532355.
[20] Warneke K, Rabitsch T, Dobert P, Wilke J. The effects of static and dynamic stretching on deep fascia stiffness: a randomized, controlled cross-over study. Eur J Appl Physiol. 2024;124(9):2809-18.
[21] Nordez A, Gross R, Andrade R, et al. Non-Muscular Structures Can Limit the Maximal Joint Range of Motion during Stretching. Sports Med. 2017;47(10):1925-9.
[22] Fantoni I, Biz C, Fan C, et al. Fascia Lata Alterations in Hip Osteoarthritis: An Observational Cross-Sectional Study. Life (Basel). 2021;11(11):1136.
[23] Schleip R, Klingler W, Lehmann-Horn F. Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Med Hypotheses. 2005;65(2):273-7.
[24] Schleip R, Gabbiani G, Wilke J, et al. Fascia Is Able to Actively Contract and May Thereby Influence Musculoskeletal Dynamics: A Histochemical and Mechanographic Investigation. Front Physiol. 2019;10:336.
[25] Stecco A, Bonaldi L, Fontanella CG, Stecco C, Pirri C. The Effect of Mechanical Stress on Hyaluronan Fragments' Inflammatory Cascade: Clinical Implications. Life (Basel). 2023;13(12):2277.
[26] Luomala T, Pihlman M, Heiskanen J, Stecco C. Case study: could ultrasound and elastography visualized densified areas inside the deep fascia?. J Bodyw Mov Ther. 2014;18(3):462-8.
[27] Pavan PG, Stecco A, Stern R, Stecco C. Painful connections: densification versus fibrosis of fascia. Curr Pain Headache Rep. 2014;18(8):441.
[28] Zhao X, Fede C, Petrelli L, et al. The Impact of Sciatic Nerve Injury on Extracellular Matrix of Lower Limb Muscle and Thoracolumbar Fascia: An Observational Study. Int J Mol Sci. 2024;25(16):8945.
[29] Pirri C, Pirri N, Petrelli L, Fede C, De Caro R and Stecco C. An emerging perspective on the role of fascia in complex regional pain syndrome: a narrative review. Mol. Sci. 2025;26:2826.
[30] Gatz M, Bejder L, Quack V, Schrading S, Dirrichs T, Tingart M, et al. Shear wave elastography (SWE) for the evaluation of patients with plantar fasciitis. Acad Radiol. 2020; 27:363-70.
[31] Fusco P, Stecco C, Petroni GM, Ciaschi W, Marinangeli F. ESP block and chronic pain: the dark side of the moon. Minerva Anestesiol 2022;88:528-9.
[32] Fusco P, Nazzarro E, De Sanctis F, Petroni GM. Can we consider the fascia as the target of our fascial block? Indian J Anaesth 2024;68:832-3.
[33] Fusco P, De Paolis V, De Sanctis F, Di Carlo S, Petrucci E, Marinangeli F. The association of erector spinae plane block and ultrasound guided dry needling could be a winning strategy for long-term relief of chronic musculoskeletal pain. Minerva Anestesiol 2019;85:1138-9.
[34] Fusco P, Stecco C, Maggiani C, Ciaschi W. Erector spinae plane block with warm saline solution for treating chronic myofascial pain. Minerva Anestesiol 2024;90:217-8.
[35] Shiwaku K, Otsubo H, Suzuki D, Pirri C, Kodesyo T, Kamiya T, Taniguchi K, Ohnishi H, Teramoto A, Stecco C. Biomechanical effects of fascial hydrorelease: a cadaveric study. BMC Musculoskelet Disord. 2025;26(1):306.
[36] Fusco P, Nazzarro E, Petroni G, Stecco C, Ciaschi W, Marinangeli F. Fascial plane blocks and chronic pain: Another step towards the future. J Clin Anesth. 2023;84:111010.
[37] Fusco P, Marrone F, Petroni GM, Pullano C, Stecco C. A targeted erector spinae plane block for treatment of chronic postsurgical myofascial pain: A case report. JCA Advances 2025;2:100128.
[38] Marrone F, Pullano C, De Cassai A, Fusco P. Ultrasound-guided fascial plane blocks in chronic pain: a narrative review. J Anesth Analg Crit Care 2024;4:71.
Francesco MARRONE (Rome, Italy)
11:20 - 11:35
The retrodural space.
Sandeep DIWAN (Consultant Anaesthesiologist) (Keynote Speaker, Pune, India)
11:35 - 11:40
Q&A.
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PRO CON DEBATE
Emergency caesarean section in a woman with labour epidural
PRO CON DEBATE
Emergency caesarean section in a woman with labour epidural
Chairperson:
Livija SAKIC (anaesthesiologist) (Chairperson, Zagreb, Croatia)
10:30 - 10:30
Introduction.
10:30 - 10:43
#48675 - FT12 For the PROs: Topping up epidural in the emergency CS.
For the PROs: Topping up epidural in the emergency CS.
Title
Emergency caesarean section: why topping up an epidural is better than taking it out and using a single shot spinal
Author
Petramay Attard Cortis MD (Melit.), DESAIC, MMEd (Dundee)
Consultant Anaesthetist and Lead Clinician – Obstetric Anaesthesia
Department of Anaesthesia, Intensive Care and Pain
Mater Dei Hospital, Msida, Malta, Europe
Petramay.cortis@gov.mt
Introduction
Emergency caesarean section is a decision taken by obstetricians when there is concern about the health of the mother or the foetus, or when a vaginal delivery is not deemed a suitable option. In this situation, anaesthesiologists need to provide anaesthesia in a timely manner, for the duration of the surgical procedure. In modern obstetric anaesthesia practice, neuraxial techniques are preferred over general anaesthesia in most scenarios, for improved maternal and foetal outcomes. When epidural analgesia is already established for labour pain, the possibility of converting this epidural analgesic to an epidural anaesthetic provides significant benefits over taking it out and using a single shot spinal. These include providing a safe, fast, and reliable anaesthetic; reducing the need for further neuraxial procedures and their potential complications; as well as additional considerations including financial implications, environmental impact, anaesthesiologist workload, and patient perspectives.
Providing safe, fast, and reliable epidural anaesthesia
Lumbar epidurals are regarded as the gold standard for labour analgesia1. Unless specifically contraindicated in individual parturients, labour epidural analgesia is suggested or recommended for high-risk obstetric patients, such as those living with modified WHO 3 and WHO 4 heart disease2, with maternal obesity3, in the presence of some ophthalmic pathologies4, and in laboring women with pre-eclampsia5. In these women, the recommendation for labour epidural analgesia is aims to achieve patient comfort; prevent deterioration of maternal medical conditions; reduce severe maternal morbidity6, and avoidance of further anaesthetic interventions including general anaesthesia, should an intra-partum surgical procedure be required.
The Obstetric Anaesthetists' Association (OAA) in the United Kingdom states that only 5% of labour epidurals will not work well enough for a Caesarean section7. In an Irish study, the rate of labour epidurals converted to spinal or general anaesthesia for Caesarean section was 9%8, the rate from an Indian study was approximately 4%9, a Maltese study identified a rate of epidural conversion to spinal or general anaesthesia for Caesarean section as 0.85% and 1.5% respectively10, a Chinese publication showed a conversion rate to general anaesthesia of 3%11, while a systematic review in 2022 by authors from the United Kingdom and the United States of America including over 3000 patients showed an overall prevalence of inadequate epidural anaesthesia of around 30%12. It is however worth noting that this systematic review relates to elective caesarean section, and not emergencies, with the possibility that epidural analgesia was not established for a sufficient period of time, prior to the procedure.
Most recently, the ESAIC focused guidelines for the management of the failing epidural during labour epidural analgesia published in 202513 quote a rate of failure to convert epidural analgesia to anaesthesia for intrapartum caesarean section requiring general anaesthesia between 3.5 – 38%. These rates were obtained from four publications, including two observational studies, one randomized controlled trial, and one systematic review. Despite this, the authors issued a clinical practice statement stating: “We recommend pro-active early management of a failing epidural as the preferred technique to facilitate successful conversion to anaesthesia for intrapartum caesarean delivery” implying that conversion to epidural anaesthesia for emergency caesarean section would still be their preferred approach compared to alternatives.
Therefore, it is essential to ensure that the labour epidural analgesia is working well to increase chances of success of epidural anaesthesia for emergency Caesarean section13,14. Several risk factors have been identified as being associated with a failure of conversion from epidural analgesia to anaesthesia including a greater number of unplanned epidural top ups needed to maintain effective analgesia in labour15-17, increased maternal reported pain in the two hours before caesarean section15, management by a non-obstetric anaesthetist15,18,19, and urgency of the caesarean section15.
In relation to speed of onset, the time required for an epidural top up to a level adequate for surgical anaesthesia compares favourably with that required for a spinal, and in some cases, even with that required for a general anaesthetic. A 2018 retrospective cohort study showed that unadjusted median operating room-to-incision intervals were 6 minutes for general anaesthesia, 11 minutes for epidural top-up, and 13 minutes for spinal anaesthesia20. It is important to point out that when relating to clinical significance, general anaesthesia was associated with worse short term neonatal outcomes in this study, and that longer time intervals to establishment of surgical anaesthesia for epidural were not associated with worse neonatal outcomes20. A 2007 retrospective audit from Australia showed mean decision-to-delivery times of 17 (±6) minutes for general anaesthesia, 19 (±9) minutes for epidural, and 26 (±9) minutes for spinal21. It has also been reported that established epidural analgesia may mitigate the increased anaesthesia and surgery time required in obese obstetric patients undergoing caesarean section22.
Finally, epidural anaesthesia for emergency caesarean section has the benefit of being topped up as often as required to prolong the duration of the anaesthetic block. It allows for manipulation of the time of onset of the anaesthetic, speeding it up by using lignocaine together with adjuvants such as opiates, bicarbonate, or adrenaline; or even providing a gentle onset of neuraxial anaesthetic blockade when required, for example, in patients with severe heart disease. Single shot spinal anaesthesia does not confer these benefits.
Therefore, it can be said that in over 60-90% of cases where functioning labour epidural analgesia is present, this can be satisfactorily used for emergency Caesarean section anaesthesia in a timely manner. This encourages the anaesthesiologist to utilize the labour epidural, instead of removing it and attempting an alternative technique. This position is supported by Guasch et al.23 in their 2020 experts’ consensus publication regarding European minimum standards for obstetric analgesia and anaesthesia departments where they “advise administration of an epidural top-up” in case of emergency caesarean section, especially if category 1.
Reducing the need for further neuraxial procedures and their potential complications
The decision to remove a labour epidural for an emergency caesarean section and opt for a spinal anaesthetic has disadvantages. Firstly, as described above, the anaesthesiologist is losing an anaesthetic option which has a high chance of success. Secondly, the patient is being exposed to the potential complications associated with a second procedure, which may not have been justifiably necessary. In this case, there is always the possibility that a spinal anaesthetic is not possible to site due to patient anatomy, difficulty with appropriate positioning in an emergency, and psychological stress due to the urgency felt by the multidisciplinary team, among others. This may result in the anaesthesiologist having to resort to general anaesthesia, which may further expose the patient to complications such as awareness, aspiration, and difficulty with airway manoeuvres.
Additionally, there is controversy in the literature regarding the safety of spinal anaesthesia following pre-established labour epidural analgesia in obstetric patients. Several authors express concerns regarding the risk of high spinal or total spinal with the injection of local anaesthetic and adjuvants into the cerebrospinal fluid once this is already compressed by the contents of the epidural space15,24. This seems to be more of an issue if a recent epidural bolus would have just been administered, as compared to an epidural infusion only24,25. Case reports of these complications have been published, even as early as 199426,27, and the 2025 ESAIC guidelines13 also comment about the possibility of high spinal block in these instances.
Additional considerations
When considering the choice between topping up a labour epidural or removing it and using a spinal for emergency caesarean section, one should also factor in financial issues, environmental impact, anaesthesiologist workload, and patient perspectives.
It can be argued that removing a labour epidural and performing spinal anaesthesia is more costly than topping up the already-present epidural. New sterile attire is used by the anaesthesiologist, together with the opening of a new sterile pack for spinal anaesthesia. This will include consumables, such as the spinal needle, the cleaning solution and swabs; as well as the cost of cleaning, decontamination, and sterilization of any reusable items, which involves the cost of additional staff. The repeated use of personal protective equipment, utilization of consumables, and processes associated with cleaning, decontamination, and sterilization also carries an environmental impact. In a world where cost-efficiency is key, and minimization of environmental impact is important, these considerations cannot be ignored.
Choosing to remove a labour epidural and use a spinal anaesthetic for an emergency caesarean section may also affect the anaesthesiologist in terms of stress and workload. Deciding to remove a satisfactory epidural analgesia catheter before even giving it a chance to work is eliminating a realistic anaesthetic option for an emergency procedure. This limits the tools available to the anaesthesiologist as it is not usually feasible for an epidural catheter to be re-inserted in an emergency. It also requires the anaesthesiologist to explain this additional procedure to the patient and gain informed consent in a challenging situation. This extra workload, i.e., explaining, gaining informed consent, and inserting a spinal anaesthetic, may be stressful for the anaesthesiologist. Also, the individual is now required to perform a procedure in a time-pressured and high-stakes environment. Performance anxiety may play a part if the anaesthesiologist is very keen to avoid a general anaesthetic, for example, if they feel the patient’s airway looks particularly difficult or the patient has pre-eclampsia and would therefore be at a higher risk of complications.
Patient perspectives should also be considered. The author has found no published literature specifically relating to patient preference regarding epidural or spinal anaesthesia for emergency Caesarean section. However, it is reasonable to think that a patient who has a working labour epidural already has confidence in the technique and as a result, may feel more reassured with epidural anaesthesia for emergency caesarean section as compared to alternatives.
Conclusion
In summary, labour epidurals providing satisfactory analgesia should be topped up to provide epidural anaesthesia for emergency caesarean sections. In fact, this is one of the main benefits of siting labour epidurals in patients who are at a higher risk for caesarean section. In addition, there are disadvantages to the alternative of removing the labour epidural and using a single shot spinal. Finally, there are financial, environmental, anaesthesiologist, and patient considerations that may further support the choice of epidural anaesthesia over single shot spinal.
References
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25. Dadarkar P, Philip J, Weidner C, Perez B, Slaymaker E, Tabaczewska L, Wiley J, Sharma S. Spinal anesthesia for cesarean section following inadequate labor epidural analgesia: a retrospective audit. International journal of obstetric anesthesia. 2004 Oct 1;13(4):239-43.
26. Siddik-Sayyid SM, Gellad PH, Aouad MT. Total spinal block after spinal anesthesia following ongoing epidural analgesia for cesarean delivery. Journal of anesthesia. 2012 Apr;26(2):312-3.
27. Gupta A, Enlund G, Bengtsson M, Sjöberg F. Spinal anaesthesia for caesarean section following epidural analgesia in labour: a relative contraindication. International journal of obstetric anesthesia. 1994 Jul 1;3(3):153-6.
Petramay CORTIS (MALTA, Malta)
10:43 - 10:56
For the CONs: Taking the epidural out and using a single shot spinal is optimal.
Tatiana SIDIROPOULOU (Professor and Chair) (Keynote Speaker, Athens, Greece)
10:56 - 11:20
Q&A.
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10:30-11:10
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D31
ASK THE EXPERT
My belly hurts
ASK THE EXPERT
My belly hurts
Chairperson:
Vishal UPPAL (Professor) (Chairperson, Halifax, Canada, Canada)
10:30 - 10:30
Introduction.
10:30 - 11:00
My standard procedure for the abdomen.
Rosie HOGG (Consultant Anaesthetist) (Keynote Speaker, Belfast, United Kingdom)
11:00 - 11:10
Q&A.
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10:30-11:20
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E31
ASK THE EXPERT
LAST and pediatrics
ASK THE EXPERT
LAST and pediatrics
Chairperson:
Valeria MOSSETTI (Anesthesiologist) (Chairperson, Torino, Italy)
10:30 - 10:30
Introduction.
10:30 - 10:50
Last time I saw LAST.
Guy WEINBERG (Faculty) (Keynote Speaker, Chicago, USA)
10:50 - 11:10
25 years of pediatric ultrasound guided regional anesthesia.
Peter MARHOFER (Director of Paediatric Anaesthesia and Intensive Care Medicine) (Keynote Speaker, Vienna, Austria)
11:10 - 11:15
Q&A.
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10:30-11:10
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F31
ESRA Infographics Competition
ESRA Infographics Competition
Chairperson:
Paolo GROSSI (Consultant) (Chairperson, milano, Italy)
Jurys:
Fani ALEVROGIANNI (Resident) (Jury, Athens, Greece), Oya Yalcin COK (EDRA Part I Vice Chair, EDRA Examiner, lecturer, instructor) (Jury, Türkiye, USA), Steve COPPENS (Head of Clinic) (Jury, Leuven, Belgium), Brian KINIRONS (Consultant Anaesthetist) (Jury, Galway, Ireland, Ireland), Clara LOBO (Medical director) (Jury, Abu Dhabi, United Arab Emirates), Athmaja THOTTUNGAL (yes) (Jury, Canterbury, United Kingdom)
10:30 - 10:34
#48914 - PAIN SAFE – A Pre-Procedural Checklist for Out-patient Interventional Pain Practice.
PAIN SAFE – A Pre-Procedural Checklist for Out-patient Interventional Pain Practice.
PAIN SAFE – A Pre-Procedural Checklist for Out-patient Interventional Pain Practice has been developed to promote a concise, easy-to-remember checklist acronym "PAIN SAFE" that standardizes the pre-procedural preparation of patients undergoing office-based, out-patient or ambulatory pain interventions.
The goal is to embed safety, efficiency, and clinical readiness into everyday practice without adding cognitive burden.
This addresses both chronic pain and regional block safety.
Abdullah NISAR, Ali Sarfraz SIDDIQUI (KARACHI, Pakistan), Shemila ABBASI
10:34 - 10:38
#48637 - Suprainguinal fascia iliaca block, a quick reference guide.
Suprainguinal fascia iliaca block, a quick reference guide.
Finding the ultrasound view when performing the suprainguinal fascia iliaca block can be difficult and off-putting to the non regionalist, yet is a block that is expected to be performed independently by Stage 1 anaesthetic residents in the United Kingdom. This guide was developed to assist in finding the view by breaking it down into four simple steps, using reliable landmarks and probe manipulation terminology, for both residents and occasional trauma anaesthetists.
Roisin HANSELL (Cardiff, United Kingdom), James LLOYD
10:38 - 10:42
#48690 - Infographic on the Updated Recommendations on Use of RA in Anticoagulated Patients 2025.
Infographic on the Updated Recommendations on Use of RA in Anticoagulated Patients 2025.
This infographic provides a concise updated recommendation regarding the use of regional anesthesia on patients undergoing antithrombotic therapy released this 2025. The chart above provides the time needed to stop antithrombotic medications before doing interventions (deep block) while the table below provides a schedule of when to restart the medications or when to pull out the catheter. This infographic will hopefully help clarify the timing and prevent confusion regarding times.
Roselle Aimee SY, Gracielle Mia BANARES (Manila, Philippines)
10:42 - 10:46
#48466 - Superblock: your new superhero in regional anaesthesia.
Superblock: your new superhero in regional anaesthesia.
The infographic illustrates contemporary approaches to the performance of regional anesthesia, based on principles of safety and efficacy. The SUPERBLOCK mnemonic serves as a structured algorithm that supports the standardization and optimization of nerve block techniques.
Ruslan SEDLETSKYI (Kyiv, Ukraine), Mokiia MOKIIA
10:46 - 10:50
#48385 - BiFeS Block: A Motor-Sparing Solution for Posterolateral Knee Pain.
BiFeS Block: A Motor-Sparing Solution for Posterolateral Knee Pain.
BiFeS Block: A Motor-Sparing Solution for Posterolateral Knee Pain
Why BiFeS Block?
Current techniques often require multiple injections, involve high technical complexity, and pose risks of nerve or vascular injury. Posterolateral knee pain—particularly after total knee arthroplasty (TKA)—remains a challenging area to manage. The BiFeS block offers a targeted and motor-sparing approach to effectively relieve pain in this region.
Alper KILICASLAN (KONYA, Turkey), Serkan TULGAR, Ali AHISKALIOGLU
10:50 - 10:54
#48844 - Clarity Above the Clavicle: Sequential Ultrasound Imaging Technique(SUIT), A 7 Steps Refined Approach to Brachial Plexus Blocks.
Clarity Above the Clavicle: Sequential Ultrasound Imaging Technique(SUIT), A 7 Steps Refined Approach to Brachial Plexus Blocks.
This infographic summarises recent advances in anatomical imaging and highlights the role of the Sequential Ultrasound Imaging Technique (SUIT), a seven-step, systematic approach that allows real-time identification of the C5 to T1 ventral rami, the three trunks, and the supra-scapular nerve. This technique enhances the accuracy of selective and intertruncal blocks.
Reference:
Karmakar MK, Pakpirom J, Songthamwat B, et al. Reg Anesth Pain Med 2020;45:344–350.
Debesh BHOI (NEW DELHI, India), Wasimul HODA
10:54 - 11:04
Results of voting - 3 winners annoucement.
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10:30-11:20
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G31
EXPERT OPINION DISCUSSION
What we forgot to ask
EXPERT OPINION DISCUSSION
What we forgot to ask
Chairperson:
Friedrich LERSCH (senior consultant) (Chairperson, Berne, Switzerland)
10:30 - 10:30
Introduction.
10:30 - 10:45
#48216 - FT46 Freakonomics: Optimize OR to have time for a coffee.
Freakonomics: Optimize OR to have time for a coffee.
In modern hospitals, the operating room (OR) represents one of the most cost-intensive areas, with an estimated average cost ranging between $30 to $100 per minute, depending on the local context and resource configuration. These costs are predominantly fixed: salaries of surgical and nursing staff, infrastructure maintenance, equipment depreciation, and general overheads do not vary with the number of procedures performed. In contrast, variable costs (such as drugs, surgical disposables, and anesthesia gases) are relatively marginal in this context. This cost structure implies that the true economic challenge in surgical services is not cost reduction per se, but optimization of time, the OR's most valuable and scarce asset.
From a microeconomic standpoint, improving the throughput of surgical programs —i.e., the number of surgeries performed in a fixed time window— is the key to maximizing value. One of the most effective levers is the reduction of changeover times between procedures. In this regard, the SMED (Single-Minute Exchange of Die) methodology, borrowed from industrial Lean Management, provides a structured approach to compress turnover times. SMED encourages the separation of internal (must be done when the OR is vacant) and external (can be done in parallel while the OR is in use) setup tasks, standardization of instrument trays, and enhanced role coordination among staff. When systematically applied, SMED can reduce changeover time by over 50%, enabling either more procedures per day or earlier finishes without compromising safety.
Another often underutilized strategy involves bypassing the Post-Anesthesia Care Unit (PACU). For selected patient populations (typically those undergoing short, low-risk procedures with fast-acting anesthetic agents or regional anesthesia) direct transfer to the ward postoperatively may be safe and appropriate. Although this does not necessarily generate large direct savings (PACU time per se is not a major cost driver), it prevents PACU bottlenecks, which are a common cause of OR delays. Since every minute of OR idle time carries a high fixed cost, avoiding PACU-induced disruptions yields significant indirect economic benefits. The saving is therefore calculated not by subtracting PACU costs, but by valuing OR time not wasted, typically quantified in terms of minutes preserved times cost per minute.
These strategies underscore a crucial paradigm: OR efficiency is less about reducing costs and more about enhancing value from fixed investments. The application of Lean principles, microeconomic logic, and patient-centered clinical criteria can together reshape surgical workflows.
Ultimately, optimizing OR time not only benefits institutional sustainability and patient access, it also releases pressure, carving out a little time for what every anesthesiologist deserves: a little time to enjoy a coffee.
Andrea SAPORITO (Bellinzona, Switzerland)
10:45 - 11:00
An Outpatient Nerve Injury Clinic Should Be Integral to Perioperative Medicine.
Thomas Fichtner BENDTSEN (Professor, consultant anaesthetist) (Keynote Speaker, Aarhus, Denmark)
11:00 - 11:20
Q&A.
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11:20-11:55
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D31.1
TIPS & TRICKS
Painfree Carotid endarterectomy
TIPS & TRICKS
Painfree Carotid endarterectomy
Chairperson:
Vivian IP (Hospital) (Chairperson, Calgary, Canada)
11:20 - 11:55
Introduction.
11:20 - 11:55
Painfree Carotid endarterectomy.
Wolf ARMBRUSTER (Head of Department, Clinical Director) (Keynote Speaker, Unna, Germany)
11:20 - 11:55
Q&A.
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11:30-11:55
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C31.1
TIPS & TRICKS
PNB for cardiac surgery
TIPS & TRICKS
PNB for cardiac surgery
Chairperson:
Danny HOOGMA (anesthesiologist) (Chairperson, Leuven, Belgium)
11:30 - 11:55
Introduction.
11:30 - 11:55
Peripheral nerve blocks for cardiac surgery.
Catalin-Iulian EFRIMESCU (Consultant) (Keynote Speaker, Dublin, Ireland)
11:30 - 11:55
Q&A.
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11:30-11:55
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E31.1
TIPS & TRICKS
Multimodals to avoid rebound pain
TIPS & TRICKS
Multimodals to avoid rebound pain
Chairperson:
Patricia LAVAND'HOMME (Clinical Head) (Chairperson, Brussels, Belgium)
11:30 - 11:55
Introduction.
11:30 - 11:55
#48677 - FT35 Multimodals to avoid rebound pain.
Multimodals to avoid rebound pain.
Rebound pain (RP) is a clinical entity first described in 2007 by Williams and colleagues[1] qualified as acute postoperative pain occurring in the immediate hours after complete resolution of a locoregional block, and measured with a score, the Rebound Pain Score, accurately characterized by the authors like: “the highest Numeric Rating Scale (NRS) score recorded within the first 12 hours after the block was not providing pain relief minus the NRS score that was reported at the time the patient reported that the nerve block was providing pain relief”.
Subsequently, different descriptions of this phenomenon have been given[2–9] without reaching unequivocal agreement on its precise definition.[10]
Due to the difficulty in providing an unambiguous definition of the RP phenomenon, it is also hard to establish its incidence. A recent retrospective cohort study found that nearly half of patients experienced severe RP. This was associated with younger age, female gender, bone surgery, and no perioperative dexamethasone. [7]
In a recently published prospective observational study, the frequency of RP in patients undergoing Peripheral Nerve Block (PNB) and treated with multimodal analgesia and intravenous dexamethasone was 27.7%.[11]
The currently available scientific literature agrees that, along with a proper definition and identification of risk factors and the pathophysiological understanding of the phenomenon of the RP, multimodal analgesia and the use of adjuvants represents one of the useful tools to counteract it.[6,12,13]
Among these, dexamethasone is the adjuvant that has been most studied as useful drug against RP. Widely adopted for the prevention of postoperative nausea and vomiting (PONV),[14] dexamethasone is considered a valuable adjuvant in multimodal analgesia because of its antinflammatory and immunomodulatory properties.[15]
A recent metanalysis on the use of dexamethasone compared with placebo concludes that its use reduces the incidence of RP.[16,17] In addition a network metanalysis of 14 randomized controlled trials (RCTs) with a sample size of about 1000 patients comparing intravenous dexamethasone, perineural dexamethasone, and placebo shows moderate certainty evidence that intravenous dexamethasone is superior in reducing the incidence of RP compared with placebo or perineural dexamethasone, and it was not associated with postoperative hyperglycemia or increased risk of infection.[18]
The main limitations of these studies are due to the low number of RCTs published on the topic, which often consider extremely wide dexamethasone dose ranges.
There is evidence that high doses of dexamethasone in the treatment of acute postoperative pain have an opioid sparing effect at 24 hours after surgery, however, there are still no adequate data testing their safety in terms of adverse effects such as hyperglycemia, prolongation of surgical wound healing time, infectious complications, and sleep disturbances.[19]
The role of ketamine in preventing RP has been evaluated in three RCTs,[20–22] of these, the study by Touil and colleagues[21] analyzing about 100 patients undergoing PNB of the upper extremity for day case surgery and treated with intravenous bolus of preoperative ketamine in comparison to placebo finds no difference in terms of incidence of RP. Ketamine, a non-selective inhibitor of N-methyl-D-aspartate receptors that displays analgesic, antihyperalgesic, and antinflammatory properties at dosages of 0.3 mg/kg intravenously does not appear to play a role in the incidence of RP suggesting that underlying the pathophysiological mechanisms of RP are no central sensitization mechanisms. In contrast, RP cases correlated significantly with higher pain catastrophizing scores. These results need to be confirmed by larger sample studies and they could also be explained by ketamine dosages which were kept extremely low in the intervention group.[22,23] However, this study highlights the possibility that beyond the appropriate multimodal analgesic treatments, catastrophizing or exaggerated negative mental attitude also plays a notable role in the incidence of RP suggesting that in addition to adherence to multimodal treatments, patient-centered therapeutic approaches are necessary to combat RP.
Little evidence still exists on the use of dexmedetomidine and perineural clonidine on the prevention of RP.[9,24]
Significantly the administration of hydromorphone at 6 hours after the performance of PNB had no effect on the incidence of RP, these results were explained by the finding that the timing of action of hydromorphone did not coincide with the complete resolution of the block still partially active, and considering that the population studied was not involved in bone surgery in which classically RP has higher incidence.[25]
In conclusion, the pathophysiological mechanisms underlying RP are complex, not fully known, and the variability in estimating its incidence is also due to the difficulty in establishing a common unambiguous definition. Within the chapter of multimodal analgesia, the most consistent data regarding the reduction of the incidence of RP are in favor of the use of intravenous dexamethasone, future treatment approaches should consider, in addition to risk factor limitation, specific patient-centered strategies not yet fully explored.
Bibliography
1 Williams B, Bottegal M, Kentor M, et al. Rebound Pain Scores as a Function of Femoral Nerve Block Duration After Anterior Cruciate Ligament Reconstruction: Retrospective Analysis of a Prospective, Randomized Clinical Trial. Regional Anesthesia and Pain Medicine. 2007;32:186–92. doi: 10.1016/j.rapm.2006.10.011
2 Dada O, Gonzalez Zacarias A, Ongaigui C, et al. Does Rebound Pain after Peripheral Nerve Block for Orthopedic Surgery Impact Postoperative Analgesia and Opioid Consumption? A Narrative Review. IJERPH. 2019;16:3257. doi: 10.3390/ijerph16183257
3 Muñoz-Leyva F, Cubillos J, Chin KJ. Managing rebound pain after regional anesthesia. Korean J Anesthesiol. 2020;73:372–83. doi: 10.4097/kja.20436
4 Kolarczyk LM, Williams BA. Transient Heat Hyperalgesia During Resolution of Ropivacaine Sciatic Nerve Block in the Rat: Regional Anesthesia and Pain Medicine. 2011;36:220–4. doi: 10.1097/AAP.0b013e3182176f5a
5 Galos DK, Taormina DP, Crespo A, et al. Does Brachial Plexus Blockade Result in Improved Pain Scores After Distal Radius Fracture Fixation? A Randomized Trial. Clinical Orthopaedics & Related Research. 2016;474:1247–54. doi: 10.1007/s11999-016-4735-1
6 Lavand’homme P. Rebound pain after regional anesthesia in the ambulatory patient. Current Opinion in Anaesthesiology. 2018;31:679–84. doi: 10.1097/ACO.0000000000000651
7 Barry GS, Bailey JG, Sardinha J, et al. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery. British Journal of Anaesthesia. 2021;126:862–71. doi: 10.1016/j.bja.2020.10.035
8 Williams BA. Forecast for Perineural Analgesia Procedures for Ambulatory Surgery of the Knee, Foot, and Ankle: Applying Patient-centered Paradigm Shifts. International Anesthesiology Clinics. 2012;50:126–42. doi: 10.1097/AIA.0b013e31821a00d0
9 Nobre LV, Cunha GP, Sousa PCCBD, et al. Bloqueio de nervos periféricos e dor rebote: revisão de literatura. Brazilian Journal of Anesthesiology. 2019;69:587–93. doi: 10.1016/j.bjan.2019.05.001
10 Hamilton DL. Rebound pain: distinct pain phenomenon or nonentity? British Journal of Anaesthesia. 2021;126:761–3. doi: 10.1016/j.bja.2020.12.034
11 Atar F, Özkan Sipahioğlu F, Karaca Akaslan F, et al. Frequency of rebound pain and related factors in a multimodal regimen including systemic dexamethasone and dexmedetomidine. Anaesthesiologie. 2025;74:148–55. doi: 10.1007/s00101-025-01502-z
12 Yin W, Luo D, Mi H, et al. Rebound Pain After Peripheral Nerve Block: A Review. Drugs. Published Online First: 22 May 2025. doi: 10.1007/s40265-025-02196-8
13 Uppal V. Rebound Pain After Peripheral Nerve Blocks: End of the Honeymoon Period. ASA Monitor. 2024;88:1–9. doi: 10.1097/01.ASM.0001016784.78910.8c
14 Weibel S, Rücker G, Eberhart LH, et al. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis. Cochrane Database of Systematic Reviews. 2020;2020. doi: 10.1002/14651858.CD012859.pub2
15 Myles PS, Corcoran T. Benefits and Risks of Dexamethasone in Noncardiac Surgery. Anesthesiology. 2021;135:895–903. doi: 10.1097/ALN.0000000000003898
16 Singh PM, Borle A, Panwar R, et al. Perioperative antiemetic efficacy of dexamethasone versus 5-HT3 receptor antagonists: a meta-analysis and trial sequential analysis of randomized controlled trials. Eur J Clin Pharmacol. 2018;74:1201–14. doi: 10.1007/s00228-018-2495-4
17 Yang Z-S, Lai H-C, Jhou H-J, et al. Rebound pain prevention after peripheral nerve block: A network meta-analysis comparing intravenous, perineural dexamethasone, and control. Journal of Clinical Anesthesia. 2024;99:111657. doi: 10.1016/j.jclinane.2024.111657
18 Makkar JK, Singh NP, Khurana BJK, et al. Efficacy of different routes of dexamethasone administration for preventing rebound pain following peripheral nerve blocks in adult surgical patients: a systematic review and network meta‐analysis. Anaesthesia. 2025;80:704–12. doi: 10.1111/anae.16566
19 Laconi G, Coppens S, Roofthooft E, et al. High dose glucocorticoids for treatment of postoperative pain: A systematic review of the literature and meta-analysis. Journal of Clinical Anesthesia. 2024;93:111352. doi: 10.1016/j.jclinane.2023.111352
20 Zhu T, Gao Y, Xu X, et al. Effect of Ketamine Added to Ropivacaine in Nerve Block for Postoperative Pain Management in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Randomized Trial. Clinical Therapeutics. 2020;42:882–91. doi: 10.1016/j.clinthera.2020.03.004
21 Touil N, Pavlopoulou A, Barbier O, et al. Evaluation of intraoperative ketamine on the prevention of severe rebound pain upon cessation of peripheral nerve block: a prospective randomised, double-blind, placebo-controlled study. British Journal of Anaesthesia. 2022;128:734–41. doi: 10.1016/j.bja.2021.11.043
22 Li Q, Tian S, Zhang L, et al. S-Ketamine Reduces the Risk of Rebound Pain in Patients Following Total Knee Arthroplasty: A Randomized Controlled Trial. DDDT. 2025;Volume 19:2315–27. doi: 10.2147/DDDT.S515741
23 Jen TTH, Victor AD, Ke JXC. Role of intraoperative ketamine in preventing severe rebound pain for patients undergoing ambulatory upper extremity surgery. Comment on Br J Anaesth 2022; 128: 734–41. British Journal of Anaesthesia. 2022;129:e32–3. doi: 10.1016/j.bja.2022.04.021
24 Hwang J-T, Jang JS, Lee JJ, et al. Dexmedetomidine combined with interscalene brachial plexus block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2020;28:2343–53. doi: 10.1007/s00167-019-05799-3
25 Uppal V, Barry G, Ke JXC, et al. Reducing rebound pain severity after arthroscopic shoulder surgery under general anesthesia and interscalene block: a two-centre randomized controlled trial of pre-emptive opioid treatment compared with placebo. Can J Anesth/J Can Anesth. 2024;71:773–83. doi: 10.1007/s12630-023-02594-0
Giulia LACONI (Ferrara, Italy)
11:30 - 11:55
Q&A.
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11:30-12:30
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F31.1
EXPERT OPINION DISCUSSION
Choices for lower abdomen surgery in children
EXPERT OPINION DISCUSSION
Choices for lower abdomen surgery in children
Chairperson:
Julien RAFT (anesthésiste réanimateur) (Chairperson, Nancy, France)
11:30 - 11:45
Caudal: spread and distribution.
Märit LUNDBLAD (MD, PhD Consultant) (Keynote Speaker, Stockholm, Sweden)
11:45 - 12:00
Caudals: Consider volume.
Paul CASTILLO (MD) (Keynote Speaker, Stockholm, Sweden)
12:00 - 12:15
ESP as an alternative.
Fatma SARICAOGLU (Chair and Prof) (Keynote Speaker, Ankara, Turkey)
12:15 - 12:30
Q&A.
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11:30-12:30
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G31.1
EXPERT OPINION DISCUSSION
Lower abdomen: Opinions from anterior and posterior
EXPERT OPINION DISCUSSION
Lower abdomen: Opinions from anterior and posterior
Chairperson:
Philippe GAUTIER (MD) (Chairperson, BRUSSELS, Belgium)
11:30 - 11:30
Introduction.
11:30 - 11:50
US guided intervention in sacroiliac dysfunction.
Siska BJORN (Resident) (Keynote Speaker, Aarhus, Denmark)
11:50 - 12:10
ESP or QLB? which one for what?
Justin KO (Faculty) (Keynote Speaker, Milwaukee, USA)
12:10 - 12:30
Q&A.
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11:50-12:20
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B32
TIPS & TRICKS
How to make catheters work
TIPS & TRICKS
How to make catheters work
Chairperson:
Admir HADZIC (Director) (Chairperson, New York, USA)
11:50 - 11:50
Introduction.
11:50 - 12:20
#48672 - FT10 How to make catheters work.
How to make catheters work.
Background
Peripheral regional anesthesia catheters offer the possibility of sufficient continuous pain therapy with reduction or avoidance of opioids and their side effects, such as drowsiness, nausea and vomiting. In addition, sleep quality, patient satisfaction, mobilization and rehabilitation can be improved. 1, 2 A major advantage is the gradual control of the blockade by flexible adjustment of the local anesthetic (LA) dose with the aim of differentiated analgesia while avoiding motor blocks. Most single-shot blocks on extremities or the trunk can be prolonged by catheters. Useful indications are expected severe pain that lasts longer than 24 hours postoperatively or due to injuries, as the effect of single-shot blocks rarely lasts longer. In particular, patients with a high risk of developing chronic pain or opioid dependence, or multimorbid and elderly patients for whom opioids should be avoided because of possible respiratory depression and vigilance reduction, can benefit. However, the technically complex implementation, the higher material and human resource consumption, block failures and possible complications due to infections, prolonged motor block or catheter malposition limit the utilization of catheters.
Some studies show a very limited or even no superiority of catheter procedures over systemic multimodal pain therapy in terms of analgesia quality and opioid consumption.3, 4 One cause may be primary or secondary failure of the catheter procedure. Beside technical problems (occlusion or disconnection of the catheters), a suboptimal dosage of LA and leakage, primary misplacement or secondary migration of the catheters play a significant role. The latter can also lead to serious complications with fatal patient outcomes due to intrapleural, epidural, intrathecal or intravascular misplacement 5, 6 or cause specific side effects such as Horner´s syndrome, hoarseness or dyspnea. 4, 7
Primary misplacement occurs when the usually blindly advanced catheter is not correctly positioned in the target area. Reliable data on the frequency are not available in the literature. In a cadaver study primary malposition was described in 80% of cases.8
Secondary dislocation is usually caused by catheter migration within the tissue (up to 70%) or, very rarely, by the catheter slipping out (< 3%) at the insertion site. 9 Unfortunately, primary and secondary malposition within the tissue cannot be detected from the outside, which presumably leads to reduced perception and underreporting of the problem. For the safe and effective application of the continuous catheter procedures, standardized processes are necessary, which include care by a 24/7 available pain service, the selection of suitable application techniques and catheter materials as well as proper local anesthetic delivery regimes.
Tips and tricks to make catheters work
Avoiding primary dislocations
The ultrasound-guided insertion of regional anesthesia catheters is associated with a higher success rate and fewer accidental vascular punctures compared to the landmark technique with peripheral nerve stimulation 10 and should therefore be standard.
The decisive factor is the verification of the correct catheter position in the target area. Despite echo-optimized catheter materials direct sonographic imaging of the catheter is challenging. In contrast to rigid cannulas, catheters are curling and less straight in the tissue. Therefore, catheters are less congruent with the ultrasound beam plane.2 Sonographic imaging of fluid spread, injected through the catheter, allows determination of optimal location of the catheter openings near the target structure.9 The application of 1-2ml saline bolus is usually sufficient. When using LA, possible side effects should be considered in case of malposition (e.g. intravascular in the vertebral artery, intrathecal or near the stellate ganglion in the case of interscalene blocks). The alternative injection of air or agitated liquid can deteriorate the image quality due to artifacts in the tissue. An additional application of color Doppler sonography can clarify the perception of the spread of the fluid bolus in the tissue.
In addition, primary catheter malposition depends largely on the application technique and the catheter material used. For example, the in-plane technique and rigid catheters promote dislocations, as the catheter is very often advanced past the target.11 However, so-called overshooting is not excluded even with the out-of-plane technique when using steep puncture angles. Flexible catheters or self-coiling catheters allow the catheter to roll up or curl in the target area as soon as the catheter exits the cannula tip. Thus, primary misplacements can be almost prevented. 12
In any case, the catheter position should be confirmed after placement by ultrasound imaging. In the case of a suboptimal position or malposition, the catheter must be corrected, usually by retracting the overshoot catheter. After withdrawal, however, the catheter is often only just 1-2cm within the target area. In these cases, there is a high risk of migration due to further slipping back of the catheter due to tissue movement when the patient is mobilized. In doubt of adequate catheter performance, verification of the catheter position by ultrasound can be repeated as often as necessary.
Avoiding secondary catheter migration
Only a few studies have examined the position of catheters over time. In volunteers, secondary catheter migration in the tissue occurred in femoral nerve blocks in 25% and interscalene blocks in 5% within 6 hours after catheter placement in out-of-plane technique. However, subjects with BMI > 30 kg/m2 were excluded. In clinical studies, a significantly higher secondary dislocation rate was found in various nerve blocks. 9, 13, 14
These dislocations usually occur on the day of surgery during repositioning in the PACU and rise up to 60% on the first postoperative day.9 The quality of pain therapy is significantly worse with dislocated catheters. 9
Also here, the out-of-plane technology and flexible as well as self-coiling catheters seem to offer advantages in terms of a significantly reduced rate of catheter migrations. The reason for this is that the catheter can be reliably placed adjacent to the target structure with a longer section and is therefore more robust against retraction by tissue movement.
Avoiding dislocation at insertion site
Dislocation at insertion site seems an overestimated problem. In the literature the rate is usually far below 3%. There is little evidence for better fixation of catheters with skin adhesives, tunneling and anchoring devices.15 However, further studies are needed comparing several fixation methods.
Avoiding leakage at insertion site
Regional anesthesia catheter techniques are often associated with leakage which may cause more frequent change of dressings and dislodgements at insertion site.
Catheter over the needle techniques decrease the rate of leakage.16, 17 However, this advantage never could be translated to a better catheter performance regarding dislocation rate or quality of pain management.
An alternative approach to diminish leakage is sealing the insertion site with skin glue.18
Optimal regime of LA infusion
In a meta-analysis from 2020 programmed intermittent bolus (PIB) regime showed moderate superiority in comparison to a continuous infusion whereas patient controlled bolus was not. Beyond that, also patient satisfaction improved and opioid consumption decreased. This result is mostly confined to lower limb and truncal blocks.19 The effect of improved pain management was greater between 24 and 48 hours postoperatively. Considering the high number of dislocated catheters postoperatively this result suggests PIB regime might compensate dislocations, since a LA bolus more likely approaches the targeted nerve over a particular distance within the tissue in contrast to a continuous infusion. All bolus regimes lowered LA consumption.
To maximize the utility of bolus application multi-orifice catheters are recommended.20 Flow from all orifices of multi-hole catheters depends on flow rate.21 Continuous infusion will deliver only a single hole, most likely the proximal one. Thus, for spread from all orifices a bolus application is required.
More recent studies showed conflicting results regarding better pain management by PIB. However, the majority of this studies did not use multi-orifice catheters. Nevertheless, most studies confirmed the decrease of LA dose using bolus application.
The heterogeneity of catheter types, applied block and catheter insertion techniques impede clear recommendations of optimal LA-dosage.
Prevention of Infections
Catheter associated infections occur up to 3% depending on the site of insertion. Risk factors are prolonged catheter duration > 48h, frequent change of dressing and absence of antibiotic prophylaxis 22 and patient related factors like obesity and diabetes.
Apart from respecting the hygiene guidelines for aseptic catheter placement tunneling of catheters, single shot antibiotic and removal of catheters as soon as practical are proper strategies to lower infections rate.23-25 Therefore, catheter dedicated to long duration should be tunneled.
Summery
Catheter techniques for continuous peripheral regional anesthesia provide excellent quality of pain management as long as we ensure correct catheter placement avoiding dislocations and infections. Utilization of ultrasound not only for placement but also for confirmation of proper catheter location adjacent to the target structure is a key element. There is little evidence to promote a universally applicable infusion regime. The combination of multi-orifice catheters with PIB seems to show moderate favors especially in terms of decreased LA consumption.
References
1 Richman JM, Liu SS, Courpas G et al., Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006; 102:248-57
2 Ilfeld BM. Continuous peripheral nerve blocks: an update of the published evidence and comparison with novel, alternative analgesic modalities. Anesthesia and Analgesia 2017; 124:308–335
3 Fisker AK, Iversen BN, Christensen S et al., Combined saphenous and sciatic catheters for analgesia after major ankle surgery: a double-blinded randomized controlled trial. Can J Anaesth 2015; 62(8):875-82
4 Rhyner P, Cachemaille M, Goetti P et al., Single-bolus injection of local anesthetic, with or without continuous infusion, for interscalene brachial plexus block in the setting of multimodal analgesia: a randomized controlled unblinded trial. Reg Anesth Pain Med 2024; 49:313-319
5 Gaus P, Kutz PH, Bachtler JA et al., cave: interscalene catheters. Anaesthesist 2017; 66:961-968
6 Souron V et al., Reiland Y, Traverse AD et al., Interpleural migration of an interscalene catheter. Anesth Analg 2003; 97(4):1200-1201
7 Fredrickson MJ, Leightley P, Wong A et al., An analysis of 1505 consecutive patients receiving continuous interscalene analgesia at home: a multicentre prospective safety study. Anaesthesia 2016; 71: 373–399
8 Luyet C, Herrmann G, Ross S et al., Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go? Br J Anaesth 2011; 106(2):246-54
9 Nickl R, Vicent O, Mueller T et al., Impact of self-coiling catheters for continuous popliteal sciatic block on postoperative pain level and dislocation rate: a randomized controlled trial. BMC Anesthesiol 2022; 22(1):159
10 Schnabel A et al., Meyer-Frießem CH, Zahn PK et al., Ultrasound compared with nerve stimulation guidance for peripheral nerve catheter placement: a meta-analysis of randomized controlled trials. British Journal of Anaesthesia 2013; 111(4):564-72
11 Ilfeld BM, Fredrickson MJ, Mariano ER, Ultrasound-guided perineural catheter insertion: three approaches but few illuminating data. Reg Anesth Pain Med 2010; 35:123-126
12 Luyet C, Seiler R, Herrmann G et al., Newly designed, self-coiling catheters for regional anesthesia-an imaging study. Reg Anesth Pain Med 2011; 36:171-176
13 Fujino T, Yoshida T, Kawagoe I et al., Migration rate of proximal adductor canal block catheters placed parallel versus perpendicular to the nerve after total knee arthroplasty: a randomized controlled study. Reg Anesth Pain Med 2023; 48:420-424
14 Hauritz RW, Pedersen EM, Linde FS et al., Displacement of popliteal sciatic nerve catheters after major foot and ankle surgery: a randomized controlled double-blinded magnetic resonance imaging study. Br J Anaesth 2016; 117:220-227
Oliver VICENT (Dresden, Germany)
12:20 - 12:20
Q&A.
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C32
REFRESHING YOUR KNOWLEDGE
Knobology
REFRESHING YOUR KNOWLEDGE
Knobology
Chairperson:
Kris VERMEYLEN (Md, PhD) (Chairperson, ZAS ANTWERP, Belgium)
12:00 - 12:30
Introduction.
12:00 - 12:30
Essential knobology to improve image quality.
Mireia RODRIGUEZ PRIETO (Anesthesiologist in Orthopaedics and Trauma surgery) (Keynote Speaker, Barcelona, Spain)
12:00 - 12:30
Q&A.
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D32
ASK THE EXPERT
Blocks for breast surgery
ASK THE EXPERT
Blocks for breast surgery
Chairperson:
Denisa ANASTASE (Head of the Anesthesiology and Intensive Care Department, Senior Consultant Anesthesia and Intensive) (Chairperson, Bucharest, Romania)
12:00 - 12:30
Introduction.
12:00 - 12:30
Best for breast.
Jens BORGLUM (Clinical Research Associate Professor) (Keynote Speaker, Copenhagen, Denmark)
12:00 - 12:30
Q&A.
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E32
TIPS & TRICKS
Communication
TIPS & TRICKS
Communication
Chairperson:
Andrzej DASZKIEWICZ (anesthesiologist) (Chairperson, Cieszyn, Poland)
12:00 - 12:30
Introduction.
12:00 - 12:30
Bodylanguage, what every doctor should know.
Margaretha (Barbara) BREEBAART (anaesthestist) (Keynote Speaker, Antwerp, Belgium)
12:00 - 12:30
Q&A.
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A33
EXPERT OPINION DISCUSSION
Thoracic Epidurals
EXPERT OPINION DISCUSSION
Thoracic Epidurals
Chairperson:
Efrossini (Gina) VOTTA-VELIS (speaker) (Chairperson, Chicago, USA)
14:00 - 14:00
Introduction.
14:00 - 14:15
Thoracic epidurals are not needed anymore.
Marc VAN DE VELDE (Professor of Anesthesia) (Keynote Speaker, Leuven, Belgium)
14:15 - 14:30
#49359 - FT49 But hold on….
But hold on….
D.F. Hoogma, MD, PhD1,2, Phillipe van Loon, MD1
1 University Hospitals Leuven, Department of Anesthesiology, UZ Leuven, Herestraat 49, B3000, Leuven, Belgium
2 University of Leuven, Biomedical Sciences Group, Department of Cardiovascular Sciences, KU Leuven,
Abstract:
Thoracic epidural analgesia (TEA) has been a cornerstone in perioperative pain management for many decades, particularly for thoracic and abdominal surgeries. With the evolving surgical practices and emergence of alternative analgesic techniques, including fascial plane blocks and, TEA has been considered by many as obsolete. This manuscript explores the current evidence supporting TEA's efficacy, addresses common criticisms, and delineates its role in contemporary anesthetic practice. In summary, TEA remains a valuable tool in the anesthesiologist's arsenal in selected patients.
Introduction:
The field of anesthesiology has witnessed remarkable changes over the past two decades, with the rise of enhanced recovery after surgery (ERAS) protocols, minimally invasive surgical techniques, and non-neuraxial regional anesthetic techniques such as fascial plane blocks.(1, 2) In this dynamic environment, thoracic epidural analgesia (TEA), once considered the gold standard for perioperative pain management in major thoracic and abdominal surgeries, has faced scrutiny. Critics have questioned its continued relevance, citing concerns about its invasiveness, potential complications, and the perceived equivalence of newer ultrasound guided techniques.(3-5) However, these assertions often lack context and fail to account the specific context in which TEA continues to offer unparalleled benefits. Rather than viewing TEA as a relic of the past, it is more appropriate to consider it a specialized and highly effective tool, one that, when used judiciously, can significantly enhance perioperative outcomes.
TEA offers robust segmental analgesia by blocking afferent nociceptive input and efferent sympathetic fibers at the thoracoabdominal level.(6) Especially the visceral component is unique and cannot be achieved by any of the proposed modern regional analgesic techniques.(6) As surgical invasiveness decreases, visceral pain often becomes the dominant source of postoperative discomfort, making TEA’s comprehensive analgesic profile even more valuable. Consequently, its efficacy in open abdominal or thoracic surgeries such as lobectomies, esophagectomies, and open aortic repairs is well-documented. Beyond excellent pain control, TEA has also been associated with improved pulmonary function and a reduced incidence of postoperative pulmonary complications (PPCs).(7) Recent meta-analyses continue to support these findings, demonstrating that TEA significantly reduces PPCs and improves pain scores compared to systemic opioids, particularly following esophagectomy.(8) This translated into relevant clinical benefits: reduced opioid requirements, enhanced patient satisfaction and earlier mobilization.
This manuscript aims to critically reexamine TEA's relevance by presenting current evidence, dispelling common myths, and highlighting clinical scenarios where TEA remains not only relevant but demonstrably superior to popular alternative techniques.
Benefits from TEA:
Opioids remain a cornerstone in perioperative anesthesia and analgesia.(9) Nevertheless, its liberal use is accompanied by multiple side effects, including postoperative nausea and vomiting, ileus, sedation, hyperalgesia, and respiratory depression. Strategies to mitigate these side-effects by reducing the amount of opioids are therefore essential to enhance recovery.(9) TEA produces an unparalleled potent opioid-sparing effect in patients undergoing major thoracic and abdominal surgeries. A meta-analysis concluded that TEA was associated with lower postoperative opioid use and superior pain control after open colorectal and upper GI surgeries.(10) This translates into fewer opioid-related adverse effects such as nausea, vomiting, ileus, and respiratory depression.(11, 12) Moreover, TEA contributes to earlier return of gastrointestinal function, improved pulmonary function and shorter hospital stays in major thoraco-abdominal surgeries.(10-12)
Role of TEA in ERAS protocols:
ERAS protocols aim to reduce surgical stress, maintain physiological function, and promote early mobilization using an evidence-based approach.(1) A central tenet of ERAS is the minimization of opioid use, as excessive reliance on opioids is a known contributor to ERAS failure doe to the aforementioned side effects.
Benefits of TEA aligns closely with these objectives.(11, 13, 14) By providing superior segmental analgesia, covering both somatic and visceral components, in addition to reducing to opioid consumption and mitigating opioid related side-effects, TEA also blunts the neuroendocrine stress response and facilitates early ambulation and recovery.(13, 15)
However, recent ERAS protocols increasingly emphasize incorporating non-neuraxial regional techniques, such as fascial plane blocks, as part of opioid-sparing strategies.(1-3) For many patients undergoing minimally invasive procedures, such as uniportal video-assisted thoracoscopic surgery or laparoscopic pancreaticoduodenectomy surgery, these alternative offer adequate analgesia.
Nevertheless, in patients at high-risk of severe pain or pulmonary complications or in those undergoing major thoraco-abdominal surgery, TEA remains the most effective technique. In this context, TEA has been associated with lower pain scores, reduced pulmonary complications, enhancing recovery and quality of life, and shorter length of intensive care and hospital stay.(16-19)
Dispelling common myths:
TEA causes persistent hypotension:
One of the most frequently cited drawbacks of TEA is the risk for persistent hypotension due, primarily due to sympathetic blockade.(15) This effect is particularly pronounced with thoracic epidurals, leading to vasodilation and reduced vascular resistance. While this is a legitimate concern, it is important to contextualize it within modern perioperative management strategies.
Moreover, this controlled sympathetic blockade created by TEA is not purely detrimental, as TEA has been shown to improve splanchnic perfusion, reduce myocardial oxygen demand, and reduce surgical stress hormone responses.(20) Contemporary strategies, including goal-directed fluid therapy, vasopressor titration and enhanced hemodynamic monitoring, have improved the ability to prevent and manage TEA-associated hypotension safely and effectively.(21)
TEA is technically difficult and unreliable:
A common argument against the use of TEA is its perceived technical difficulty and variability in success. However, as with any advanced technique, such variability should not justify its dismissal. Instead, institutions should prioritize structured training programs that include anatomical and simulation-based training, and the use of adjunctive or confirmatory technologies such as ultrasound, epidural wave form analysis or electrical epidural stimulation.(22) These efforts should be supported by continuous quality improvement initiatives to ensure procedural competence and consistency across providers.(21, 23)
Large cohort studies and expert consensus have consistently demonstrated that when performed by experienced practitioners within a well-supported system, TEA achieves high success rates with a low incidence of complications. Therefore, rather than abandoning TEA, it should be embraced as a valuable technique that can be safely and effectively be implemented in selected cases.(21, 22)
Fascial plane blocks are equally effective:
Recent popular fascial plane blocks, including transversus abdominis plane (TAP), paravertebral block (PVB), erector spinae plane (ESP) and serratus anterior plane (SAP) block. These techniques offer analgesia that is, in many cases, comparable to TEA for selected endpoints. In addition, they are generally considered technically easier to perform and are associated with more favorable safety profile. Among these, the PVB has reemerged as a preferred alternative in thoracic surgery. It provides effective unilateral analgesia with significantly fewer side effects compared to TEA. However, a meta-analysis comparing PVB and TEA in thoracotomy patients found that while both techniques were effective, TEA provided more consistent pain control and improved preservation of pulmonary function.(24)
The ESP and SAP block are often favored in by clinicians patients due to their superficial locations and perceived safety.(3, 15) However, their efficacy can be variable, even more in bilateral or extensive surgical fields.(25) Additionally, these blocks require higher volumes of local anesthetics, which may increase the risk of systemic toxicity.(26)
In summary, while fascial plane blocks appear attractive for low-risk patients undergoing minimally invasive procedures in, their role in high-risk surgeries and patients remains less well defined. TEA continues to be the most reliable technique in these settings, supported by robust evidence demonstrating superiority in enhancing recovery.(15) Therefore, TEA remains the primary choice for open thoraco-abdominal surgeries.(27, 28)
Conclusion
The assertion that thoracic epidurals are obsolete fails to account for the robust body of evidence supporting their continued use in carefully selected patient populations. TEA remains the gold standard for thoracic and abdominal procedures, particularly in high-risk patients and open surgeries. Its role in reducing postoperative complications, enhancing recovery, and minimizing opioid exposure cannot be overstated.
Rather than abandoning TEA, the focus should shift toward optimizing its use, through thoughtful patient selection, institutional support, and ongoing training. As anesthetic practice continues to evolve, TEA stands not as a relic, but as a precision instrument, highly effective when applied judiciously within the right clinical context.
References:
1. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019;55(1):91-115.
2. Hoogma DF, Brullot L, Coppens S. Get your 7-point golden medal for pain management in video-assisted thoracoscopic surgery. Curr Opin Anaesthesiol. 2024;37(1):64-8.
3. Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M, Anaesthesia PWGotESoR, et al. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2022;77(3):311-25.
4. Lin J, Liao Y, Gong C, Yu L, Gao F, Yu J, et al. Regional Analgesia in Video-Assisted Thoracic Surgery: A Bayesian Network Meta-Analysis. Front Med (Lausanne). 2022;9:842332.
5. Spaans LN, Dijkgraaf MGW, Susa D, de Loos ER, Mourisse JMJ, Bouwman RA, et al. Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery: A Randomized Noninferiority Trial. JAMA Surg. 2025.
6. Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management. Anesthesiology. 2011;115(1):181-8.
7. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321(7275):1493.
8. Macrosson D, Beebeejaun A, Odor PM. A systematic review and meta-analysis of thoracic epidural analgesia versus other analgesic techniques in patients post-oesophagectomy. Perioper Med (Lond). 2024;13(1):80.
9. Kharasch ED, Clark JD. Opioid-free Anesthesia: Time to Regain Our Balance. Anesthesiology. 2021;134(4):509-14.
10. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010;29(4):434-40.
11. Popping DM, Elia N, Marret E, Remy C, Tramer MR. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg. 2008;143(10):990-9; discussion 1000.
12. Guay J, Nishimori M, Kopp S. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery. Cochrane Database Syst Rev. 2016;7(7):CD001893.
13. Coppens S, Degroof P, Hoogma DF, Brullot L, Van Loon P. #36929 Thoracic epidurals for eras in thoracic and abdominal surgery- still relevant? Regional Anesthesia & Pain Medicine. 2023;48(Suppl 1):A362-A4.
14. Holte K, Kehlet H. Epidural anaesthesia and analgesia - effects on surgical stress responses and implications for postoperative nutrition. Clin Nutr. 2002;21(3):199-206.
15. Carver A, Wou F, Pawa A. Do Outcomes Differ Between Thoracic Epidurals and Continuous Fascial Plane Blocks in Adults Undergoing Major Abdominal Surgery? Current Anesthesiology Reports. 2023;14(1):25-41.
16. Pandraklakis A, Haidopoulos D, Lappas T, Stamatakis E, Valsamidis D, Oikonomou MD, et al. Thoracic epidural analgesia as part of an enhanced recovery program in gynecologic oncology: a prospective cohort study. Int J Gynecol Cancer. 2023;33(11):1794-9.
17. Feltracco P, Bortolato A, Barbieri S, Michieletto E, Serra E, Ruol A, et al. Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review. Dis Esophagus. 2018;31(5).
18. Chiew JK, Low CJW, Zeng K, Goh ZJ, Ling RR, Chen Y, et al. Thoracic Epidural Anesthesia in Cardiac Surgery: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials. Anesth Analg. 2023;137(3):587-600.
19. Semmelmann A, Baar W, Moneke I, Loop T. Criteria for continuous neuraxial analgesia associated with reduced mortality in patients undergoing thoracotomy. Reg Anesth Pain Med. 2024.
20. Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2016;2016(1):CD005059.
21. Coppens S, Dewinter G, Hoogma DF, Raudsepp M, Vogelaerts R, Brullot L, et al. Safety and efficacy of high thoracic epidural analgesia for chest wall surgery in young adolescents: A retrospective cohort analysis and a new standardised definition for success rate. Eur J Anaesthesiol. 2024;41(12):873-80.
22. Tran Q, Booysen K, Botha HJ. Primary failure of thoracic epidural analgesia: revisited. Reg Anesth Pain Med. 2024;49(4):298-303.
23. Dos Santos Fernandes H, Siddiqui N, Peacock S, Vidal E, Matelski J, Entezari B, et al. Effectiveness of preoperative thoracic epidural testing strategies: a retrospective comparison of three commonly used testing methods. Can J Anaesth. 2024;71(6):793-801.
24. Xu M, Hu J, Yan J, Yan H, Zhang C. Paravertebral Block versus Thoracic Epidural Analgesia for Postthoracotomy Pain Relief: A Meta-Analysis of Randomized Trials. Thorac Cardiovasc Surg. 2022;70(5):413-21.
25. Chin KJ, McDonnell JG, Carvalho B, Sharkey A, Pawa A, Gadsden J. Essentials of Our Current Understanding: Abdominal Wall Blocks. Reg Anesth Pain Med. 2017;42(2):133-83.
26. Coppens S, Hoogma DF, Dewinter G, Neyrinck A, Van Loon P, Stessel B, et al. Erector spinae plane block versus intercostal nerve blocks in uniportal videoscopic assisted thoracic surgery: a multicenter, double-blind, prospective randomized placebo controlled trial. Anesthesiology. 2025.
27. Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc. 2023;37(1):5-30.
28. Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, et al. Practice Advisory for Preoperative and Intraoperative Pain Management of Thoracic Surgical Patients: Part 1. Anesth Analg. 2023;137(1):2-25.
Danny HOOGMA (Leuven, Belgium)
14:30 - 14:45
Metrics and good indication might save it.
David HEWSON (Anaesthesia) (Keynote Speaker, Nottingham, United Kingdom)
14:45 - 14:50
Q&A.
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B33
ESRA Educational Video Competition
ESRA Educational Video Competition
Jurys:
Fani ALEVROGIANNI (Resident) (Jury, Athens, Greece), Oya Yalcin COK (EDRA Part I Vice Chair, EDRA Examiner, lecturer, instructor) (Jury, Türkiye, USA), Steve COPPENS (Head of Clinic) (Jury, Leuven, Belgium), Paolo GROSSI (Consultant) (Jury, milano, Italy), Brian KINIRONS (Consultant Anaesthetist) (Jury, Galway, Ireland, Ireland), Clara LOBO (Medical director) (Jury, Abu Dhabi, United Arab Emirates), Athmaja THOTTUNGAL (yes) (Jury, Canterbury, United Kingdom)
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C33
EXPERT OPINION DISCUSSION
On neuromodulation
EXPERT OPINION DISCUSSION
On neuromodulation
Chairperson:
Sarah LOVE-JONES (Anaesthesiology) (Chairperson, Bristol, United Kingdom)
14:00 - 14:00
Introduction.
14:00 - 14:15
Targets for peripheral neuromodulation in chronic pain.
Ashish GULVE (Consultant in Pain Medicine) (Keynote Speaker, Middlesbrough, United Kingdom)
14:15 - 14:30
Does peripheral neuromodulation have a role in postoperative pain and prevention of PPSP.
Sam ELDABE (Consultant Pain Medicine) (Keynote Speaker, Middlesbrough, United Kingdom)
14:30 - 14:45
No more implants! External neuromodulation high and low frequency.
Teodor GOROSZENIUK (Consultant) (Keynote Speaker, London, United Kingdom)
14:45 - 15:00
Q&A.
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D33
EXPERT OPINION DISCUSSION
Myth buster
EXPERT OPINION DISCUSSION
Myth buster
Chairperson:
Peter MERJAVY (Consultant Anaesthetist & Acute Pain Lead) (Chairperson, Craigavon, United Kingdom)
14:00 - 14:00
Introduction.
14:00 - 14:15
ESP: myths debunked.
John MCDONNELL (Professor of Anaesthesia and Intensive Care Medicine) (Keynote Speaker, Galway, Ireland)
14:15 - 14:30
#48243 - FT25 Midclavicle block: myth or reality.
Midclavicle block: myth or reality.
Clavicle fractures account for 2 to 3% of all fractures and approximately 35% of shoulder girdle injuries. Nearly 80% of these occur at the midshaft of the clavicle, with about 20% at the distal third, and only 2 to 3% at the proximal third.1 These fractures cause moderate to severe postoperative pain and given the brachial plexus’s proximity to the surgical field carry a perioperative nerve injury risk of 7 to 24%.2
In recent years, the incidence of surgical fixation for clavicle fractures has risen.1 At the same time, regional anesthesia has become more prominent because of its clear advantages over general anesthesia: superior analgesia, reduced postoperative opioid use, shorter hospital stays, and higher patient satisfaction.3 Traditionally, the interscalene brachial plexus block, alone or combined with a superficial cervical plexus block, has been considered the gold standard for clavicle anesthesia.4 However, unwanted side effects have been reported, such as ipsilateral diaphragmatic paralysis due to phrenic nerve block, dysphonia or hoarseness, and Horner’s syndrome.5
In 2019, Valdés-Vilches et al. described the clavipectoral fascia plane block (CPB), an innovative technique for anesthesia and analgesia midshaft clavicle fractures as an alternative to traditional brachial plexus approaches. It is simple to perform, uses clear superficial landmarks, and relies on the clavicle itself as a bony “stop” for needle placement. By targeting the peripheral nerve branches that innervate the clavicular periosteum, it provides effective anesthesia and analgesia without causing diaphragmatic, motor, or sensory block of the ipsilateral upper extremity. The technique’s name reflects a modern understanding of the clavipectoral fascia (CPF), which is thought to facilitate circumferential diffusion of anesthetic around the clavicular periosteum. Anatomically, this is based on a proposed fascial continuity between the cervical and thoracic fasciae, forming a CPF that completely envelops the clavicle and allows homogeneous, circumferential spread of anesthetic.6
Classically, CPF is described as a broad sheet of connective tissue in the anterior thorax, running along the coronal plane between and enclosing the pectoralis minor and subclavius muscles, and laterally fusing with Gerdy’s axillary suspensory ligament to form the roof of the axillary fossa.7 In contrast, in contemporary descriptions of the CPF, at least two distinct layers are proposed, each enveloping different anatomical structures in the region. The first, larger retropectoral (or interpectoral) layer inserts on the anterior border of the clavicle, lies in intimate continuity with the pectoral fascia, surrounds the pectoralis major muscle, and merges superiorly with the investing layer of the deep cervical fascia around the sternocleidomastoid and trapezius muscles. The second, smaller retropectoral layer inserts on the posterior border of the clavicle and is associated with the prevertebral layer of the deep cervical fascia also known as the omohyoid fascia. This deeper layer encases the axillary artery, axillary vein, and brachial plexus, fully isolating them from the anterior compartment. Inferiorly, it also envelops the coracoclavicular Caldani ligament.8 This complex fascial architecture underscores a key distinction between the classical and contemporary views of the CPF’s pattern of insertion and periosteal coverage. The modern hypothesis posits a continuous fascial plane between the cervical and thoracic fasciae, allowing the CPF to circumferentially envelop the clavicular periosteum in its entirety.8 In contrast, traditional anatomical texts locate the CPF’s origin on the posteroinferior aspect of the clavicle, from which it descends to encase only the subclavius and pectoralis minor muscles.7
In 2023, Labandeyra et al. performed the first cadaveric study of the CPB on specimens with intact clavicles. They found that while superficial dissection revealed methylene blue in supraclavicular nerve branches and the superficial muscular plane, neither the deep muscular plane nor the CPF showed any staining. On the periosteum, dye was predominantly anterosuperior (53.5%), with minimal posteroinferior spread (4%).9 Additionally, in another anatomical study that evaluated the CPB technique in midshaft clavicle fractures, diffusion remained largely anterosuperior (57.3%) with just 6.5% posteroinferior and there was no staining at the fracture site or in deeper structures such as pectoralis minor, subclavius, or CPF. These findings suggest that although both CPF layers anchor to the clavicle’s inferior margin around subclavius, they do not connect with cervical or thoracic fasciae, challenging the notion of complete circumferential diffusion via the CPF.10
Also, in 2023, Heredia-Carqués et al. conducted a cadaveric study comparing the distribution patterns of CPB versus direct subclavius injection. The CPB stained mainly the anterosuperior periosteum, whereas subclavius injections consistently stained the posteroinferior region. From this, they hypothesized that combining both approaches might achieve full periosteal coverage.11 Building on that, in 2024 Labandeyra et al. introduced the Midclavicle Block (MCB): CPB plus an additional injection through the subclavius targeting the posteroinferior periosteum. In their cadaveric study, methylene blue stained 37 ± 16% of the anterosuperior periosteum and 23 ± 13% of the posteroinferior, both focused at the midshaft without full circumferential coverage. Anterosuperior staining was centered on the midshaft with minimal lateral or medial (sternoclavicular-joint) involvement, while posteroinferior staining was confined to the subclavius insertion at the mid-to-lateral third junction. Although the stained regions did not align directly opposite each other, both surfaces showed significant uptake, indicating relevant coverage.12
These anatomical findings demonstrated a consistent anterosuperior periosteal staining pattern after CPB, with limited posteroinferior spread, even in the presence of fracture lines, suggesting that the CPF does not fully envelop the clavicle. In contrast, a separate cadaveric study using the SM approach showed consistent posteroinferior periosteal staining.9-11 These complementary results supported the hypothesis that combining both approaches could improve coverage. This ultimately led to the development of the MCB, a dual approach technique designed to enhance periosteal diffusion at the clavicle midshaft, challenging the contemporary fascial model and offering a more targeted anatomical solution.12
The clavicle functions as a transitional structure between the thorax and upper limb and is covered by multiple muscular and ligamentous insertions that influence both mobility and the organization of surrounding fascial planes. On its superior surface, muscles such as the sternocleidomastoid, trapezius, deltoid, and pectoralis major insert, while on its inferior aspect, the costoclavicular and coracoclavicular ligaments (trapezoid and conoid) and the SM are attached.13 These structures act as physical barriers that limit anesthetic spread, favoring its concentration around the midshaft region. The SM, originating from the first rib and inserting on the undersurface of the clavicle, courses within the CPF. Its anatomical position facilitates diffusion toward the posteroinferior periosteum and, given its proximity to the neurovascular structures of the brachial plexus, plays a critical role in balancing efficacy and safety in regional anesthesia.14
In this context, the MCB represents an anatomically grounded technique that takes advantage of natural muscular and ligamentous barriers to achieve a localized anesthetic diffusion pattern at the midshaft. Future clinical validation will be essential to determine its real world effectiveness and define its role among regional anesthesia techniques for clavicle surgery.
References
1. Ropars M, Thomazeau H, Huten D. Clavicle fractures. Orthopaedics and Traumatology: Surgery and Research. 2017;103(1):S53-S59. doi:10.1016/j.otsr.2016.11.007
2. Clitherow HDS, Bain GI. Major neurovascular complications of clavicle fracture surgery. Shoulder Elbow. 2015;7(1):3-12. doi:10.1177/1758573214546058
3. Hutton M, Brull R, Macfarlane AJR. Regional anaesthesia and outcomes. BJA Educ. 2018;18(2):52-56. doi:10.1016/j.bjae.2017.10.002
4. Olofsson M, Taffé P, Kirkham KR, Vauclair F, Morin B, Albrecht E. Interscalene brachial plexus block for surgical repair of clavicle fracture: A matched case-controlled study. BMC Anesthesiol. 2020;20(1):1-6. doi:10.1186/s12871-020-01005-x
5. Stundner O, Meissnitzer M, Brummett CM, et al. Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: A randomized, controlled trial. Br J Anaesth. 2016;116(3):405-412. doi:10.1093/bja/aev550
6. Ince I, Kilicaslan A, Roques V, Elsharkawy H, Valdes L. Ultrasound-guided clavipectoral fascial plane block in a patient undergoing clavicular surgery. J Clin Anesth. 2019;58:125-127. doi:10.1016/j.jclinane.2019.07.011
7. Gray H; Standring S. Section 6: Pectoral girdle and upper limb, Chapter 48: Shoulder girdle and arm. In: Standring S, ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. Elsevier; 2016:799.
8. Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, De Caro R. The pectoral fascia: anatomical and histological study. J Bodyw Mov Ther. 2009;13(3):255-261. doi:10.1016/j.jbmt.2008.04.036
9. Labandeyra H, Heredia-Carques C, Campoy JC, Váldes-Vilches LF, Prats-Galino A, Sala-Blanch X. Clavipectoral fascia plane block spread: an anatomical study. Reg Anesth Pain Med. 2024;49:368-372. doi:10.1136/rapm-2023-104785
10. Labandeyra H, Heredia C, Váldes-Vilches LF, Prats-Galino A, Sala-Blanch X. Clavipectoral fascia plane block in midshaft clavicle fractures: A cadaveric study. J Clin Anesth. 2024;96(February):0-4. doi:10.1016/j.jclinane.2024.111469
11. Heredia-Carqués C, Labandeyra H, Castellanos M, Váldes-Vilches LF, Tomás X, Sala-Blanch X. Clavipectoral Fascia and Clavipectoral Fascia Plane Block: To Be or Not to Be. Anesth Analg. Published online March 2024. doi:10.1213/ANE.0000000000006837
12. Labandeyra H, Váldes-Vilches LF, Prats-Galino A, Sala-Blanch X. Midclavicle block: An anatomical study. Eur J Anaesthesiol. Published online February 1, 2024. doi:10.1097/EJA.0000000000002079
13. Testut L; Latarjet A. Capítulo V: Miembros, Artículo Primero: Miembro superior o torácico. In: Tratado de Anatomía Humana. Tomo 1. 9th ed. Editorial Salvat; 1994:307-310.
14. Crepaz-Eger U, Lambert S, Hörmann R, Knierzinger D, Brenner E, Hengg C. The anatomy and variation of the coracoid attachment of the subclavius muscle in humans. J Anat 2022;240(2):376-84. doi:10.1111/joa.13548
Hipolito LABANDEYRA (Barcelona, Spain), Luis VÁLDES-VILCHES, Alberto PRATS-GALINO, Xavier SALA-BLANCH
14:30 - 14:50
Q&A.
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14:00-14:50
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E33
EXPERT OPINION DISCUSSION
Emergency blocks
EXPERT OPINION DISCUSSION
Emergency blocks
Chairpersons:
Fani ALEVROGIANNI (Resident) (Chairperson, Athens, Greece), Tatjana STOPAR PINTARIC (Head of Obstetric Anaesthesia Division) (Chairperson, Ljubljana, Slovenia)
14:00 - 14:00
Introduction.
14:00 - 14:15
Blocks in the emergency room.
Sandeep DIWAN (Consultant Anaesthesiologist) (Keynote Speaker, Pune, India)
14:15 - 14:30
#48695 - FT36 On-scene blocks for the trauma patient.
On-scene blocks for the trauma patient.
Regional anaesthesia (RA), particularly peripheral nerve blocks (PNBs), is gaining importance in prehospital trauma care. These techniques offer effective analgesia while reducing opioid use, thus improving patient comfort and limiting side effects.
Despite these advantages, only a few emergency medical services (EMS) currently include PNBs in routine prehospital analgesia. With the expected increase in elderly trauma - especially hip fractures - there is rising interest in using blocks such as the fascial iliaca compartment block (FICB) and femoral nerve block (FNB) before hospital arrival. These techniques are generally safe, easy to learn, and effective for lower limb pain.
However, implementation in the field remains complex. Key challenges include defining clear indications, developing simple and safe procedures, training EMS personnel (including paramedics and physicians), and managing potential complications such as local anesthetic systemic toxicity (LAST).
This session will explore practical approaches to expand the use of RA in prehospital care, address safety aspects, present training strategies, and highlight successful international examples.
Indications for Peripheral Nerve Blocks
PNBs can significantly improve prehospital pain control while limiting systemic opioid use. Common trauma patterns are amenable to specific blocks: FICB for proximal femoral fractures, interscalene block for shoulder dislocations or proximal humeral fractures, axillary plexus block for injuries to the distal upper limb, and FNB for patellar dislocations or isolated thigh trauma. These examples underline the clinical value of RA, especially in elderly or multimorbid patients.
Structural Heterogeneity in European EMS
EMS systems in Europe differ substantially in organisation, staffing, and procedural authority. In physician-led models - often staffed by anesthesiologists - RA techniques from hospital settings can be readily applied prehospitally. In contrast, systems relying on advanced paramedics often face legal or operational restrictions, and limited RA training may hinder broader adoption. Thus, system structure strongly influences RA feasibility.
Ultrasound Access in the Prehospital Setting
Nerve stimulation is often unsuitable in acute trauma due to patient discomfort and anatomical limitations. Ultrasound offers real-time imaging, lowers vascular puncture risk, and reduces the likelihood of LAST, making it the preferred guidance method. While portable ultrasound devices are increasingly available, access across EMS systems remains uneven and is a key factor in ensuring safe and effective RA delivery.
Safety Considerations
Safety concerns, especially regarding LAST, often limit RA use in EMS. Yet real-world data show that complications are rare and manageable, even in non-physician-led services. Ultrasound use further enhances block precision and safety. Although on-scene time is a valid concern, studies suggest that PNBs, including FICBs, do not significantly delay transport or affect outcomes. When standard hygiene measures are observed, infection risk is minimal. Access to lipid therapy for LAST management remains variable, but network-based solutions may help bridge this gap.
Training and Role Distribution
Structured training is crucial for safe PNB implementation in prehospital care. Hospital-based concepts can be adapted for emergency physicians. Moreover, growing evidence supports the safe use of PNBs by trained paramedics and nurses under clear protocols and supervision. In the long term, interdisciplinary models and emerging technologies such as AI-assisted ultrasound may support broader, scalable integration - even in physician-limited systems.
These key topics will be addressed in the upcoming lecture, which will focus on real-world applications, current evidence, and international experiences. Participants will gain insight into how to translate RA principles into safe, feasible practice for trauma patients in the prehospital setting.
Benjamin VOJNAR (Marburg, Germany)
14:30 - 14:45
ICU needs a regional anesthesia and pain specialist.
Wolf ARMBRUSTER (Head of Department, Clinical Director) (Keynote Speaker, Unna, Germany)
14:45 - 14:50
Q&A.
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14:00-14:50
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F33
EXPERT OPINION DISCUSSION
Dosing is also important for the adult
EXPERT OPINION DISCUSSION
Dosing is also important for the adult
Chairperson:
Steven PORTER (Anesthesiologist) (Chairperson, Jacksonville, USA)
14:00 - 14:00
Introduction.
14:00 - 14:15
#48685 - FT42 Optimal dose of dexamethasone to prolong a block.
Optimal dose of dexamethasone to prolong a block.
Dexamethasone (DXM) is frequently administered as an adjuvant of postoperative analgesia with widely varying dosing regimens. Based on the assumption that the optimal dosage of a drug should correspond to the amount needed to produce the desired effect with minimal adverse effects, when talking about the dosage of dexamethasone we should also refer to the route of administration, which for dexamethasone historically has been perineural and intravenous. [1] Recently a meta-analysis published by Albrecht et colleagues[2] comparing the intravenous versus perineural route of administration found low quality evidence that perineural administration of DXM increases duration of analgesia by an average of 2 hours compared with intravenous injection for interscalene brachial plexus block. This increase in the duration of analgesic block, from a clinical point of view was considered to be of little significance, even in the face of an administration, that of perineural, which remains off label, and which in any case should be considered only in cases where preservative free formulations are available, because of the otherwise known neurotoxic effects.[3]
These data also appear to be confirmed by a metanalysis by Sehmbi et colleagues[4] which showed that intravenous dexamethasone given at the time of regional anesthesia increases the duration of sensory block by 76 minutes, compared to local anesthetic alone, also recording a better performance respect to perineural route. In this regard, the authors of the paper pointed out that in addition to the route of administration of dexamethasone, reference must also be made to the type of locoregional blockade performed; peripheral blocks of the upper limb in fact, with greater vascularization than the lower limb, can certainly result in different systemic absorption, even with regard to perineural administration, creating a bias in the results of the studies.
In addition, intravenous dexamethasone administration might present better efficacy in reducing the incidence of rebound pain[5].
A meta-analysis published in 2011 by De Oliveira et al.[6] that considered the administration of DXM at low doses (less than 0.1 mg/kg), intermediate doses (0.11–0.2 mg/kg) and high doses (major or equal to 0.21 mg/kg) claimed that analgesic effects appeared at intermediate doses of DXM, and adverse effects typically related to the administration of DXM such as hyperglycemia, increased surgical wound healing times, surgical site infections remained negligible at these dosages. Recently, a study by Corcoran and colleagues[7] analyzing 8,880 adult patients undergoing non-urgent, non-cardiac surgery that received 8 mg of intravenous dexamethasone in comparison to placebo did not find a significant increase in surgical site infections within 30 days after surgery. A study by Porter and colleagues[8] investigated the impact of DXM on glycemic control and outcomes in patients with type 2 diabetes mellitus undergoing elective primary total joint arthroplasty showed an increased risk of elevated mean glucose on postoperative day (POD) 0-2 and hyperglycemia on POD 0, but this was not associated with an increase in total insulin dose administered or the occurrence of surgical site infections, hospital readmission, or mortality within 30 days after surgery.
A metanalysis by Laconi and collegues[9] about high doses of glucocorticoids (DXM major or equal to 0.2 mg/kg or major or equal to 15 mg intravenously) administered preoperatively 1 hours before surgery found an opioid-sparing effect at 24 hours after surgery of approximately 10 mg Oral Morphine Equivalents (OME), however, there are still inconsistent data on the adverse effects that high doses of DXM may cause.
Another study by Van Der Weegen and colleagues [10], a matched cohort study, found no difference in the proportion of patients needing rescue analgesics during hospitalization between the group of patients who received 20 mg of DXM preoperatively and the group of patients who received 8 mg.
Robust scientific evidence on the optimal dosage of DXM as adjunct to postoperative analgesia, especially with regard to the administration of high doses, has yet to be established. Administration of DXM should also take into account the type of peripheral nerve block that will need to be performed (sites with high or low vascularization). The most consistent data in the literature currently available concern intermediate doses (< 10 mg of DXM), which demonstrate an adequate safety profile, possibly even in high-risk populations such as diabetics. There are still no consistent data on high doses of DXM, particularly with regard to the possible assessment of adverse effects
Bibliography
Pehora C, Pearson AM, Kaushal A, et al. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database of Systematic Reviews. 2017;2017. doi: 10.1002/14651858.CD011770.pub2
2 Albrecht E, Renard Y, Desai N. Intravenous versus perineural dexamethasone to prolong analgesia after interscalene brachial plexus block: a systematic review with meta-analysis and trial sequential analysis. British Journal of Anaesthesia. 2024;133:135–45. doi: 10.1016/j.bja.2024.03.042
3 Knight JB, Schott NJ, Kentor ML, et al. Neurotoxicity of common peripheral nerve block adjuvants. Current Opinion in Anaesthesiology. 2015;28:598–604. doi: 10.1097/ACO.0000000000000222
4 Sehmbi H, Brull R, Ceballos KR, et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta‐analysis of adjunctive effects on supraclavicular brachial plexus block. Anaesthesia. 2021;76:974–90. doi: 10.1111/anae.15288
5 Makkar JK, Singh NP, Khurana BJK, et al. Efficacy of different routes of dexamethasone administration for preventing rebound pain following peripheral nerve blocks in adult surgical patients: a systematic review and network meta‐analysis. Anaesthesia. 2025;80:704–12. doi: 10.1111/anae.165666
6 De Oliveira GS, Almeida MD, Benzon HT, et al. Perioperative Single Dose Systemic Dexamethasone for Postoperative Pain: A Meta-analysis of Randomized Controlled Trials. Anesthesiology. 2011;115:575–88. doi: 10.1097/ALN.0b013e31822a24c2
7 Corcoran TB, Myles PS, Forbes AB, et al. Dexamethasone and Surgical-Site Infection. N Engl J Med. 2021;384:1731–41. doi: 10.1056/NEJMoa2028982
8 Porter SB, Wilson JR, Sherman CE, et al. Dexamethasone, Glycemic Control, and Outcomes in Patients With Type 2 Diabetes Mellitus Undergoing Elective, Primary Total Joint Arthroplasty. Arthroplasty Today. 2024;27:101391. doi: 10.1016/j.artd.2024.101391
9 Laconi G, Coppens S, Roofthooft E, et al. High dose glucocorticoids for treatment of postoperative pain: A systematic review of the literature and meta-analysis. Journal of Clinical Anesthesia. 2024;93:111352. doi: 10.1016/j.jclinane.2023.111352
10 Van Der Weegen W, Das D, Vrints K, et al. A 20 mg dose of dexamethasone does not reduce the proportion of joint replacement patients needing rescue analgesia: a matched cohort study. Ann Joint. 2023;8:4–4. doi: 10.21037/aoj-22-34
Giulia LACONI (Ferrara, Italy)
14:15 - 14:30
Dosing fascial plane blocks.
Thomas VOLK (Chair) (Keynote Speaker, Homburg, Germany)
14:30 - 14:50
Q&A.
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14:00-14:50
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G33
EXPERTS OPINION DISCUSSION
Gender Inclusion Diversity
EXPERTS OPINION DISCUSSION
Gender Inclusion Diversity
Chairperson:
Sandy KOPP (Professor of Anesthesiology and Perioperative Medicine) (Chairperson, Rochester, USA)
14:00 - 14:00
Introduction.
14:00 - 14:15
Men are from Mars, woman are from Venus.
Athmaja THOTTUNGAL (yes) (Keynote Speaker, Canterbury, United Kingdom)
14:15 - 14:30
#48692 - FT47 Gender differences in work performance in medicine and anesthesia.
Gender differences in work performance in medicine and anesthesia.
Gender differences in work performance in medicine and anesthesia
Introduction
Over the past two decades, the proportion of women in medicine has markedly increased, yet gender disparities persist in leadership, compensation, and academic advancement. While structural inequality is well-documented, less attention has been paid to how gender correlates with differences in clinical performance, communication styles, stress response, and team leadership—factors that are particularly relevant in high-acuity settings such as anesthesiology and perioperative care. Key findings related to gender and performance in medicine, with implications for the field of regional anesthesia and pain medicine are presented.
Quality of Care and Guideline Adherence
Several large-scale observational studies have demonstrated that female physicians are more likely to deliver guideline-concordant care. In a registry study of over 51,000 patients with type 2 diabetes, patients treated by female physicians achieved better control of their diabetes and prevention of complications.¹ A similar trend was observed in patients with chronic heart failure, where those under the care of female physicians were more likely to receive recommended pharmacotherapy at guideline-based dosages.² Notably, male physicians were less likely to prescribe optimal treatments to female patients, suggesting a potential interaction between physician and patient gender.
Physician–Patient Communication
Meta-analytic evidence indicates that female physicians engage in longer consultations and exhibit more patient-centered communication behaviors.³ These include increased use of empathy, psychosocial discussion, and participatory decision-making. In specialties where communication is a cornerstone of patient safety—such as preoperative assessment or acute pain management—these traits may enhance patient understanding, trust, and satisfaction. Although such communication requires more time and emotional labor, it may contribute to improved perioperative outcomes.
Gender and leadership in medicine.
Despite growing representation in the clinical workforce, women remain markedly underrepresented in leadership. In emergency medicine, fewer than 12% of department chairs are women, a figure stagnant for two decades.⁴ Qualitative analyses show that male chairs often describe leadership as a natural progression, supported by mentorship. Female leaders, by contrast, report heightened risk aversion, internalized scrutiny, and reliance on self-advancement.⁴ The result is a persistent gender gap in access to institutional power, particularly in surgical and anesthesiology departments.
Burnout and Workload Disparities
Physician burnout is a well-recognized phenomenon, but data consistently show that female physicians experience higher rates and more severe manifestations. In 2021, 56% of U.S. women physicians reported burnout symptoms compared to 41% of men.⁵ Contributing factors include; more time per patient and greater use of electronic health records, increased patient messaging and administrative burden, less autonomy and schedule flexibility, fewer leadership roles and less recognition, greater responsibilities at home (e.g., childcare, eldercare) Women also experience higher emotional exhaustion, while men more frequently report depersonalization.⁶ In anesthesiology, where unpredictable hours and clinical acuity are common, these gendered stressors may be amplified.
Personality traits and narcissism
Personality may influence both individual performance and team functioning. A recent large-scale study using the Narcissistic Admiration and Rivalry Questionnaire (NARQ) found that male surgeons score significantly higher on narcissistic rivalry—a construct associated with competitiveness, devaluation of others, and dominance.⁷ Female surgeons, by contrast, displayed lower narcissism levels and higher interpersonal sensitivity. In team-dependent specialties like anesthesiology, such traits may influence collaboration, communication, and conflict resolution.
Discussion
This review highlights that gender is not a neutral factor in medical performance. Female physicians, despite facing systemic barriers, often exhibit behaviors aligned with safer, more collaborative, and patient-centered care models. However, these strengths are counterbalanced by increased burnout and underrepresentation in leadership. In anesthesiology, where both cognitive and interpersonal performance are critical, ignoring gender dynamics risks undermining workforce well-being and patient safety.
Conclusions
Gender differences in medicine extend beyond representation. Female physicians tend to provide more guideline-based care, engage more deeply with patients, and foster collaborative environments—skills especially valuable in anesthesiology. Addressing the structural and cultural barriers that undermine these contributions is essential for both professional equity and optimal care delivery.
References
1. Berthold HK, Gouni-Berthold I, Bestehorn KP, et al. Physician gender is associated with the quality of type 2 diabetes care. J Intern Med. 2008;264(4):340-350.
2. Baumhäkel M, Müller U, Böhm M. Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure. Eur J Heart Fail. 2009;11(3):299–303.
3. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA. 2002;288(6):756–764.
4. Hobgood C, Draucker C. Gender differences in experiences of leadership emergence among emergency medicine department chairs. JAMA Netw Open. 2022;5(3):e221860.
5. Lyubarova R, Salman L, Rittenberg E. Gender differences in physician burnout: driving factors and potential solutions. Permanente J. 2023;27:23.023.
6. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population. Mayo Clin Proc. 2015;90(12):1600–1613.
7. Moellmann HL, Rana M, Daseking M, et al. Exploring grandiose narcissism among surgeons: a comparative analysis. Sci Rep. 2024;14:11665.
Geert-Jan VAN GEFFEN (NIjmegen, The Netherlands)
14:30 - 14:45
"Bias in Postoperative Pain Management” not “Failure to Rescue".
Girish JOSHI (Professor) (Keynote Speaker, Dallas, Texas, USA, USA)
14:45 - 14:50
Q&A.
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COFFEE BREAK
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15:30-16:20
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A35
EXPERT OPINION DISCUSSION
Peripheral nerve blocks are relevant for patient outcomes
EXPERT OPINION DISCUSSION
Peripheral nerve blocks are relevant for patient outcomes
Chairperson:
Admir HADZIC (Director) (Chairperson, New York, USA)
15:30 - 15:35
Introduction.
Admir HADZIC (Director) (Keynote Speaker, New York, USA)
15:35 - 15:55
Vascular surgery.
Alan MACFARLANE (Consultant Anaesthetist) (Keynote Speaker, Glasgow, United Kingdom)
15:55 - 16:15
OSAS patients.
Stavros MEMTSOUDIS (Chief) (Keynote Speaker, New York, USA)
16:15 - 16:20
Q&A.
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15:30-16:20
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B35
PRO CON DEBATE
What about fascial plane blocks in children?
PRO CON DEBATE
What about fascial plane blocks in children?
Chairperson:
Vrushali PONDE (yes) (Chairperson, Mumbai, India)
15:30 - 15:30
Introduction.
15:30 - 15:45
For the PROs: fascial plane blocks are evidently effective.
Fatma SARICAOGLU (Chair and Prof) (Keynote Speaker, Ankara, Turkey)
15:45 - 16:00
For the CONs: fascial plane blocks lack evidence in children.
Per-Arne LONNQVIST (Professor) (Keynote Speaker, Stockholm, Sweden)
16:00 - 16:20
Q&A.
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15:30-16:20
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C35
ASK THE EXPERT
Dyspnea
ASK THE EXPERT
Dyspnea
Chairperson:
Romualdo DEL BUONO (Member) (Chairperson, Milan, Italy)
15:30 - 15:30
Introduction.
15:30 - 16:00
Dyspnea in the recovery area: My POCUS protocol.
Hari KALAGARA (Assistant Professor) (Keynote Speaker, Florida, USA)
16:00 - 16:15
Q&A.
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15:30-16:20
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D34
ASK THE EXPERT
Difficult breathing
ASK THE EXPERT
Difficult breathing
Chairperson:
Ana SCHWARTZMANN BRUNO (President) (Chairperson, Montevideo, Uruguay)
15:30 - 15:30
Introduction.
15:30 - 15:45
How I treat patients with rib fractures.
Thomas WIESMANN (Head of the Dept.) (Keynote Speaker, Schwäbisch Hall, Germany)
15:45 - 16:20
Q&A.
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15:30-16:20
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E35
ASK THE EXPERT
Much better than a frost bite
ASK THE EXPERT
Much better than a frost bite
Chairperson:
Dmytro DMYTRIIEV (chief of pain medicine department) (Chairperson, Vinnitsa, Ukraine)
15:30 - 15:35
Introduction.
Dmytro DMYTRIIEV (chief of pain medicine department) (Keynote Speaker, Vinnitsa, Ukraine)
15:35 - 15:40
Trainees Chair.
Mathias MAAGAARD (MD, PhD) (Keynote Speaker, Copenhagen, Denmark)
15:40 - 16:00
Cryo neurolysis for acute pain.
Jacob HUTCHINS (Anesthesiologist) (Keynote Speaker, Minneapolis, USA)
16:00 - 16:20
Q&A.
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15:30-16:20
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F34
ASK THE EXPERT
Bone metastases
ASK THE EXPERT
Bone metastases
Chairperson:
Sarah LOVE-JONES (Anaesthesiology) (Chairperson, Bristol, United Kingdom)
15:30 - 15:30
Introduction.
15:30 - 15:50
#48627 - FT43 Bone metastasis - cryo and radiofrequency ablation.
Bone metastasis - cryo and radiofrequency ablation.
Pasquale De Negri MD,ESRA-DPM, FIPP*; Clara De Negri MD*
* Department of Anaesthesia, Intensive Care and Pain Medicine- Azienda Ospedaliera di Rilievo Nazionale S. Anna e S.Sebastiano - Caserta, Italy
Introduction:Bone metastases are a common and debilitating complication of advanced malignancies, particularly those arising from breast, prostate, lung, kidney, and thyroid cancers. The skeletal system is the third most common site of metastatic disease, after the lungs and liver. The clinical consequences of bone metastases include severe pain, pathological fractures, spinal cord compression, hypercalcemia, and significant impairment in quality of life. Traditional treatments—such as systemic therapies, external beam radiation therapy (EBRT), and surgery—are effective for many patients but have limitations, especially in cases of refractory pain or when local control is needed. In recent years, minimally invasive image-guided ablation techniques, notably cryoablation and radiofrequency ablation (RFA), have emerged as valuable options for the local treatment of bone metastases.This review will discuss the pathophysiology of bone metastases, the principles and techniques of cryoablation and RFA, clinical outcomes, safety profiles, patient selection, and future perspectives, with a focus on recent literature.
Pathophysiology of Bone Metastases: Bone metastases result from the dissemination of malignant cells from the primary tumor to the bone microenvironment. The process involves complex interactions between tumor cells, bone marrow stromal cells, osteoclasts, and osteoblasts. Metastatic lesions are classified as osteolytic, osteoblastic, or mixed, depending on whether bone resorption, bone formation, or both predominate. Osteolytic metastases are characterized by increased bone resorption mediated by osteoclast activation, while osteoblastic lesions involve excessive bone formation. The imbalance between bone destruction and formation leads to skeletal-related events (SREs), including pain, fractures, and neurological deficits.
Traditional Management of Bone Metastases: The main goals of therapy for bone metastases are pain relief, prevention of SREs, maintenance of function, and improvement of quality of life. Conventional treatments include:
- Systemic therapies: Chemotherapy, hormonal therapy, bisphosphonates, denosumab, and targeted agents.
- Radiation therapy: EBRT is the standard of care for localized painful bone metastases, with response rates up to 70-80%. Stereotactic body radiation therapy (SBRT) offers higher precision and ablative doses.
- Surgery: Reserved for patients with impending or established pathological fractures, spinal cord compression, or instability.
Despite these options, a significant proportion of patients experience inadequate pain relief, recurrent symptoms, or cannot tolerate certain interventions due to comorbidities or prior treatments. Image-guided ablation techniques have been developed to address these gaps.
Image-guided ablation involves the percutaneous insertion of probes into the tumor under imaging guidance (CT, MRI, or ultrasound) to deliver thermal or freezing energy, causing irreversible cellular injury and tumor destruction. The two most widely used modalities for bone metastases are cryoablation and RFA.
Cryoablation
Cryoablation uses the Joule-Thomson effect to create extremely cold temperatures (as low as -40°C to -100°C) at the probe tip, inducing rapid freezing of the surrounding tissue. The process involves:
- Ice crystal formation: Intracellular and extracellular ice formation disrupts cellular membranes and organelles.
- Vascular injury: Freezing damages blood vessels, causing ischemia and further cell death.
- Immunologic effects: Release of tumor antigens may stimulate an anti-tumor immune response.
Typically, two or more freeze-thaw cycles are performed to maximize cell death. The ablation zone is visualized as an “ice ball” on CT or MRI, allowing real-time monitoring of the ablation margin.
Technique: Under conscious sedation or general anesthesia, one or more cryoprobes are inserted percutaneously into the target lesion under CT or MRI guidance. The number and configuration of probes depend on tumor size and location. Adjunctive measures, such as hydrodissection or thermoprotection, may be used to protect adjacent structures (e.g., nerves, bowel).
Clinical Outcomes:Multiple studies have demonstrated the efficacy of cryoablation for pain relief and local tumor control in bone metastases
Pain Relief: Cryoablation provides rapid and durable pain relief in 70–90% of patients, often within days. Several prospective trials and retrospective analyses have reported significant reductions in pain scores and opioid consumption, with effects lasting several months or longer.
Local Control: Local tumor control rates range from 70% to 90%, depending on lesion size, location, and tumor histology. Cryoablation is particularly effective for small to moderate-sized lesions (<5 cm), but larger lesions may require multiple sessions or combination therapy.
Quality of Life: Improvements in mobility, function, and overall quality of life have been reported in most studies.
Safety Profile: Cryoablation is generally well-tolerated, with a low incidence of major complications. The most common adverse events include:transient post-procedural pain, bleeding or hematoma, nerve injury or neuropathy (rare, but a risk for lesions near neural structures), fracture (especially in weight-bearing bones or large ablation zones). Careful patient selection and procedural planning are essential to minimize risks.
Radiofrequency Ablation (RFA)
RFA uses alternating electrical current (typically 375–500 kHz) delivered via a needle electrode, causing ionic agitation and frictional heating in the surrounding tissue. Temperatures of 60–100°C are achieved, resulting in coagulative necrosis and tumor cell death. The ablation zone is typically smaller and less predictable than with cryoablation, but RFA is effective for small to medium-sized lesions.
Technique :The procedure is performed under CT or fluoroscopic guidance, with conscious sedation or general anesthesia. A radiofrequency electrode is advanced into the lesion, and energy is delivered for several minutes. Multiple ablations or repositioning may be required for larger tumors.
Clinical Outcomes: RFA has been extensively studied for the palliation of painful bone metastases:
Pain Relief: RFA achieves significant pain reduction in 60–80% of patients, with rapid onset (often within 1–2 weeks) and durable effect. The OsteoCool and STAR trials demonstrated sustained pain relief and improved function in large patient cohorts.
Local Control: Local control rates are generally high for lesions <3 cm, but decrease with larger or more aggressive tumors. RFA is less effective for lesions with extensive cortical destruction or in weight-bearing bones at risk for fracture.
Quality of Life: Patients report improved sleep, mobility, and reduced analgesic requirements.
Safety Profile: RFA is safe and minimally invasive, with potential complications including thermal injury to adjacent structures (nerves, skin, bowel), fracture, transient post-procedural pain. As with cryoablation, meticulous planning and imaging guidance are critical.
Comparative Effectiveness: Cryoablation vs. RFA
Both cryoablation and RFA are effective for the palliation of painful bone metastases and local tumor control. Several comparative studies and meta-analyses have examined their relative advantages:
Visualization: Cryoablation offers superior visualization of the ablation zone via the ice ball, allowing more precise targeting and margin assessment. RFA lacks this real-time feedback, increasing the risk of incomplete ablation or injury to adjacent structures.
Lesion Size and Location: Cryoablation is preferred for larger lesions, lesions near critical structures, or when precise margins are needed. RFA is effective for smaller, well-circumscribed lesions.
Pain Relief: Both modalities provide rapid and durable pain relief, with some studies suggesting slightly higher response rates with cryoablation.
Complications: Both techniques have low complication rates, but cryoablation may carry a higher risk of fracture in weight-bearing bones due to larger ablation zones.
Patient Selection and Indications
Ideal candidates for percutaneous ablation are those with painful bone metastases refractory to conventional therapies (radiation, analgesics), lesions not amenable to surgery or further radiation, oligometastatic disease requiring local control, impending or established pathological fractures (in combination with cementoplasty).Contraindications include uncorrectable coagulopathy, infection at the planned entry site, or proximity to critical structures that cannot be protected.
Combination Therapies
Ablation techniques are often combined with other interventions for enhanced efficacy:
Cementoplasty: Injection of polymethylmethacrylate (PMMA) cement after ablation stabilizes the bone, reduces fracture risk, and provides additional pain relief.
Radiation Therapy: Ablation can be used before or after EBRT for synergistic effect, particularly in radioresistant tumors.
Systemic Therapies: Ongoing systemic treatment is not a contraindication and may be continued as clinically indicated.
Future Directions and Emerging Technologies
Advances in ablation technology and imaging are expanding the role of minimally invasive treatments for bone metastases:
Microwave Ablation (MWA): Offers larger and more uniform ablation zones, with potential advantages over RFA and cryoablation.
Irreversible Electroporation (IRE): A non-thermal technique that preserves collagenous structures, potentially useful near nerves or joints.
High-Intensity Focused Ultrasound (HIFU): Non-invasive ablation using focused ultrasound waves, currently under investigation for bone metastases.
Immunomodulation: Ablation-induced release of tumor antigens may enhance systemic anti-tumor immunity, especially in combination with immunotherapies.
Ongoing clinical trials are assessing optimal patient selection, combination regimens, and long-term outcomes.
Recent Guidelines and Consensus Statements
Professional societies, including the Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), and National Comprehensive Cancer Network (NCCN), endorse percutaneous ablation as a standard option for selected patients with painful bone metastases refractory to conventional treatments.
Conclusion
Cryoablation and radiofrequency ablation are safe, effective, and minimally invasive options for the local treatment of bone metastases, offering rapid pain relief, durable local control, and improved quality of life for patients with advanced cancer. Careful patient selection, multidisciplinary collaboration, and advances in technology will continue to refine their role in the management of skeletal metastases.
References
1) Kurup AN, Callstrom MR. Image-guided percutaneous ablation of bone and soft tissue tumors. Semin Intervent Radiol. 2010 Sep;27(3):276-84. doi: 10.1055/s-0030-1261786.
2) Moynagh MR, Kurup AN, Callstrom MR. Thermal Ablation of Bone Metastases. Semin Intervent Radiol. 2018 Oct;35(4):299-308. doi: 10.1055/s-0038-1673422. Epub 2018 Nov 5.
3) Kurup AN, Callstrom MR. Ablation of skeletal metastases: current status. J Vasc Interv Radiol. 2010 Aug;21(8 Suppl):S242-50. doi: 10.1016/j.jvir.2010.05.001.
3) Kurup AN, Schmit GD, Morris JM, et al. Avoiding Complications in Bone and Soft Tissue Ablation. Cardiovasc Intervent Radiol. 2017 Feb;40(2):166-176. doi: 10.1007/s00270-016-1487-y. Epub 2016 Nov 8.
4) Kurup AN, Callstrom MR. Ablation of musculoskeletal metastases: pain palliation, fracture risk reduction, and oligometastatic disease. Tech Vasc Interv Radiol. 2013 Dec;16(4):253-61. doi: 10.1053/j.tvir.2013.08.007.
5) Callstrom MR, Kurup AN. Percutaneous ablation for bone and soft tissue metastases--why cryoablation? Skeletal Radiol. 2009 Sep;38(9):835-9. doi: 10.1007/s00256-009-0736-4.
6) Razakamanantsoa L, Kurup AN, Callstrom MR, et al. Bone ablations in peripheral skeleton: Rationale, techniques and evidence. Tech Vasc Interv Radiol. 2022 Mar;25(1):100804. doi: 10.1016/j.tvir.2022.100804. Epub 2022 Jan 16.
7) Hegg RM, Kurup AN, Schmit GD, et al Cryoablation of sternal metastases for pain palliation and local tumor control. J Vasc Interv Radiol. 2014 Nov;25(11):1665-70. doi: 10.1016/j.jvir.2014.08.011. Epub 2014 Sep 23.
8) Cazzato RL, de Rubeis G, de Marini P, et al. Percutaneous microwave ablation of bone tumors: a systematic review. Eur Radiol. 2021 May;31(5):3530-3541. doi: 10.1007/s00330-020-07382-8. Epub 2020 Nov 6.
9) Cazzato RL, Garnon J, Caudrelier J, et al. Percutaneous radiofrequency ablation of painful spinal metastasis: a systematic literature assessment of analgesia and safety. Int J Hyperthermia. 2018 Dec;34(8):1272-1281. doi: 10.1080/02656736.2018.1425918. Epub 2018 Jan 17.
10) Wallace AN, Robinson CG, Meyer J, et al. The Metastatic Spine Disease Multidisciplinary Working Group Algorithms. Oncologist. 2019 Mar;24(3):424. doi: 10.1634/theoncologist.2015-0085err. Erratum for: Oncologist. 2015 Oct;20(10):1205-15. doi: 10.1634/theoncologist.2015-0085.
11) Parvinian A, Welch BT, Callstrom MR, Kurup AN. Trends in Musculoskeletal Ablation: Emerging Indications and Techniques. Tech Vasc Interv Radiol. 2020 Jun;23(2):100678. doi: 10.1016/j.tvir.2020.100678. Epub 2020 May 25. PMID: 32591190.
12) Wallace AN, Tomasian A, Vaswani D, et al. Cryoablation and radiofrequency ablation for bone tumors. Semin Musculoskelet Radiol. 2021;25(3):335-347. doi:10.1055/s-0041-1729590
13) de Baere T, Tselikas L, Woodrum D, et al. Evaluating Cryoablation of Metastatic Lung Tumors in Patients--Safety and Efficacy: The ECLIPSE Trial--Interim Analysis at 1 Year. J Thorac Oncol. 2015 Oct;10(10):1468-74. doi: 10.1097/JTO.0000000000000632.
14) Pusceddu C, De Francesco D, Ballicu N, et al. Safety and Feasibility of Steerable Radiofrequency Ablation in Combination with Cementoplasty for the Treatment of Large Extraspinal Bone Metastases. Curr Oncol. 2022 Aug 20;29(8):5891-5900. doi: 10.3390/curroncol29080465.
Pasquale DE NEGRI (Caserta, Italy), Clara DE NEGRI
15:50 - 16:20
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G34
ASK THE EXPERT
Painomics - More than a buzz word
ASK THE EXPERT
Painomics - More than a buzz word
Chairperson:
Steven COHEN (Professor) (Chairperson, Chicago, USA)
15:30 - 16:20
Introduction.
15:30 - 16:20
Omics, Phenotyping and Patient Stratification: How do we choose the appropriate intervention?
Aikaterini AMANITI (Professor) (Keynote Speaker, Thessaloniki, Greece)
15:30 - 16:20
Q&A.
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A36
AWARDS CEREMONY
AWARDS CEREMONY
Chairperson:
Eleni MOKA (faculty) (Chairperson, Thessaloniki, Greece, Greece)
16:30 - 16:35
Introduction.
Eleni MOKA (faculty) (Keynote Speaker, Thessaloniki, Greece, Greece)
16:35 - 16:55
Carl Koller Award Lecture.
Andre VAN ZUNDERT (Professor and Chair Anaesthesiology) (Keynote Speaker, Brisbane Australia, Australia)
16:55 - 17:05
Summary of the Albert Van Steenbergue Award Article.
Rachel KEARNS (Consultant Anaesthetist) (Keynote Speaker, Glasgow, United Kingdom)
17:25 - 17:35
Announcement on the Best Chronic Pain Paper Award.
Piera LEVI-MONTALCINI (President) (Keynote Speaker, Torino, Italy)
17:05 - 17:15
Summary of the Chronic Pain Award Article.
Nina D’HONDT (Keynote Speaker, Belgium)
17:15 - 17:25
Announcement of the Best Free Paper and E-Poster Winners.
Luis Fernando VALDES VILCHES (Clinical head) (Keynote Speaker, Marbella, Spain)
17:35 - 17:40
Educational Grants.
Axel SAUTER (consultant anaesthesiologist) (Keynote Speaker, Oslo, Norway)
17:40 - 17:45
Research Grants.
Axel SAUTER (consultant anaesthesiologist) (Keynote Speaker, Oslo, Norway)
17:45 - 17:50
Winners of Infographics & Video Competition.
Paolo GROSSI (Consultant) (Keynote Speaker, milano, Italy)
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CONGRESS NETWORKING DINNER
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B40
EXPERT OPINION DISCUSSION
Awake surgery
EXPERT OPINION DISCUSSION
Awake surgery
Chairpersons:
Mathias MAAGAARD (MD, PhD) (Chairperson, Copenhagen, Denmark), Thomas VOLK (Chair) (Chairperson, Homburg, Germany)
09:30 - 09:30
Introduction.
09:30 - 09:45
Breast surgery.
Roman ZUERCHER (Senior Consultant) (Keynote Speaker, Basel, Switzerland)
09:45 - 10:00
Clavicle fracture surgery.
Luis Fernando VALDES VILCHES (Clinical head) (Keynote Speaker, Marbella, Spain)
10:00 - 10:15
Awake caudals for pediatric surgery.
Fatma SARICAOGLU (Chair and Prof) (Keynote Speaker, Ankara, Turkey)
10:15 - 10:30
Awake thoracic surgery.
Ismet TOPCU (Anesthesiologist) (Keynote Speaker, İzmir, Turkey)
10:30 - 10:40
Q&A.
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C40
PANEL DISCUSSION
Obstetric emergencies
PANEL DISCUSSION
Obstetric emergencies
Chairperson:
Nuala LUCAS (Speaker) (Chairperson, London, United Kingdom)
09:30 - 09:30
Introduction.
09:30 - 09:52
#48676 - FT13 Guideline driven management of obstetric haemorrhage.
Guideline driven management of obstetric haemorrhage.
Title
Guideline driven management of obstetric haemorrhage
Author
Petramay Attard Cortis MD (Melit.), DESAIC, MMEd (Dundee)
Consultant Anaesthetist and Lead Clinician – Obstetric Anaesthesia
Department of Anaesthesia, Intensive Care and Pain
Mater Dei Hospital, Msida, Malta, Europe
Petramay.cortis@gov.mt
Introduction
Obstetric haemorrhage is a significant worldwide concern. This year, quoting 2023 data, the WHO listed severe haemorrhage as a leading cause of maternal mortality, mainly in low and lower-middle income countries1. Haemorrhage is also an important cause of maternal deaths in high income countries. For example, the United Kingdom reports haemorrhage as the joint second commonest, direct cause of maternal mortality between 2020 – 2022, together with suicide and sepsis2, and it has also been identified as the single leading cause of peri-operative cardiac arrest in obstetric patients3. Therefore, it is essential that obstetric haemorrhage is prevented, recognized, and treated in a professional, multidisciplinary and efficient manner.
The Helsinki Declaration on Patient Safety in Anaesthesiology4 requires that institutions have protocols and facilities for managing massive haemorrhage. The World Health Organization has published recommendations for the prevention and treatment of postpartum haemorrhage (PPH)5 and defines this as blood loss of 500ml or more within 24 hours after birth, with severe PPH above 1000ml in the same period. Guideline-driven management of obstetric haemorrhage allows a planned and coordinated approach to this global problem, and many countries have developed such national guidelines5.
Prevention
Strong recommendations from the WHO include the use of uterotonics, specifically oxytocin as first line, for the active management of the third stage of labour for all deliveries including caesarean sections; delayed cord clamping for at least one minute after birth; and controlled cord traction for placenta removal during caesarean section6 for PPH prevention. In addition, the Irish Institute of Obstetricians and Gynaecologists, in their national clinical practice guideline, advise an antenatal or intrapartum risk assessment for all women, that includes haemoglobin and platelet levels, to identify at-risk women early7. The Royal College of Obstetricians and Gynaecologists also recommends that such high-risk women should only be delivered in a hospital which has an on-site blood bank8, and that any identified antenatal anaemia should be appropriately investigated and treated8. Oral iron is the suggested option for iron-deficiency anaemia9, with intravenous iron reserved for cases of intolerance, poor compliance, or a lack of time9. In contrast, there is limited evidence to support any interventions directed at the prevention of antepartum haemorrhage (APH)10, though modifiable risk factors such as smoking and drug misuse have been implicated10 and should be identified and addressed early.
Recognition
Obstetric haemorrhage, whether antepartum or postpartum, needs to be identified early for optimal management and outcomes. Visual estimation of blood loss during obstetric haemorrhage is often inaccurate8,11, and therefore, blood loss should be quantitatively and cumulatively measured5,7. A Welsh study demonstrated that this is possible in all hospitals and that measurement of blood loss is associated with a higher rate of identification of PPH12. Furthermore, the patient’s clinical signs and symptoms during blood loss are an essential part of the assessment7,8. Charting parameters on a modified obstetric early warning score chart gives a visual representation of the progression of the clinical situation and of its severity13,14. The cause of the obstetric haemorrhage should also be identified for example, placenta previa or abruption in APH, or uterine atony, retained tissue, trauma or coagulopathy in PPH, to allow targeted treatment.
Treatment
Managing obstetric haemorrhage requires treatment of the underlying cause concurrently with general haemodynamic and coagulation support, especially in the case of hypovolemic haemorrhagic shock, by well-trained multidisciplinary teams.
The commonest aetiology for PPH is uterine atony. In this case, first-line treatment includes intravenous oxytocin1,5,7,15 as an initial bolus, followed by an infusion. Carbetocin has been identified as a possible alternative to oxytocin16. Recommended second- and third-line uterotonics are the ergot alkaloids1,5,7,16 such as ergometrine and ergonovine, and prostaglandins1,5,7,16 including carboprost, sulprostone, and misoprostol. If these measures are unsuccessful, intrauterine balloon tamponade, uterine artery embolization, and even hysterectomy may be required8.
Haemodynamic support in obstetric haemorrhage includes isotonic crystalloids in preference to colloids for initial resuscitation1, and transfusion of blood products in line with local protocols9, which may be empirical ratio-based5, laboratory-result guided5, or dependent on point-of-care tests17. It is very important that administered fluids are warmed18, and cell salvage can be considered5,7,8. Vasopressors may be required to support the circulation in these circumstances but should not be seen as a substitute to appropriate intravascular volume replacement3.
Coagulopathy may be the cause, or occur as a result, of massive haemorrhage. Tranexamic acid is recommended for clot stabilization, with greatest mortality benefit observed when given within three hours of delivery19. Both viscoelastic testing, and laboratory levels, can guide replacement of platelets, fibrinogen, and coagulation factors. Platelet transfusion thresholds vary, but most guidelines would recommend administration of platelets to maintain a level above 50-75 x109/l5,7,8,9,15 although thrombocytopenia during PPH was found to be an uncommon occurrence20. Fibrinogen replacement is recommended to maintain a laboratory level >2g/l5,7,8,15,21, and viscoelastic testing can support early goal-directed fibrinogen replacement when FIBTEM A5 is less than 12mm (equivalent to Claus fibrinogen ≤2 g/l)20,21. Recombinant activated factor VII (rFVIIa) has also been considered in the context of obstetric haemorrhage, though most guidelines recommend its use only in life-threatening scenarios due to concerns about off-label use, cost, efficacy, and adverse effects5,22.
Should cardiac arrest occur in the context of massive PPH, the standard adult advanced life support algorithm is to be followed including attention to Hypovolemia as a reversible cause, as part of the 4Hs and 4Ts approach23. Some pregnancy-specific modifications include left lateral tilt or manual uterine displacement to avoid aortocaval compression; consideration of peri-mortem caesarean section; and early intubation23. The European Resuscitation Council will issue new guidelines in October 2025 and drafts available indicate an increased attention to pregnancy as a special circumstance in cardiac arrest24. This novel focus includes a new maternal cardiac arrest algorithm; an emphasis on intravascular and/or intraosseous access being achieved above the level of the diaphragm; and an introduction of the 4Ps as pregnancy-specific causes of cardiac arrest24.
Finally, many guidelines emphasize the importance of multidisciplinary patient care5,7,8,17, and advise simulation-based training1,5,7,8,17 to enhance preparedness in the guideline-driven management of obstetric haemorrhage.
Conclusion
Having a locally adapted, evidence based, and updated guideline to direct the management of obstetric haemorrhage allows for a planned, practiced, and coordinated response to this emergency, which will help to contribute to the reduction of patient morbidity and mortality from blood loss.
References
1. WHO. Maternal Mortality. Published 7th April 2025. Accessed at: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
2. MBRRACE-UK. Maternal Mortality 2020 – 2022, October 2024 Update. Last Updated January 2025 (v.11). Accessed at: https://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022#causes-of-maternal-deaths-uk-2020-2022
3. Lucas DN, Kursumovic E, Cook TM, Kane AD, Armstrong RA, Plaat F, Soar J. Cardiac arrest in obstetric patients receiving anaesthetic care: results from the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia. 2024 May;79(5):514-23.
4. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki declaration on patient safety in anaesthesiology. European Journal of Anaesthesiology| EJA. 2010 Jul 1;27(7):592-7.
5. de Vries PL, Deneux‐Tharaux C, Baud D, Chen KK, Donati S, Goffinet F, Knight M, D’Souzah R, Sueters M, van den Akker T. Postpartum haemorrhage in high‐resource settings: variations in clinical management and future research directions based on a comparative study of national guidelines. BJOG: An International Journal of Obstetrics & Gynaecology. 2023 Dec;130(13):1639-52.
6. WHO Guidelines Approved by the Guidelines Review Committee. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization. 2012.
7. Byrne B, Spring A, Barrett N, Power J, Mckernan J, Brophy D. National clinical practice guideline: prevention and management of primary postpartum haemorrhage. National Women and Infants Health Programme and The Institute of Obstetricians and Gynaecologists. 2022.
8. Mavrides E, Allard S, Chandraharan E, Collins P, Green L, Hunt BJ, Riris S, Thomson AJ on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG 2016 ; 124:e106–e149.
9. Green L, Connolly C, Cooper TK, Cho G, Allard S. Blood transfusion in obstetrics. Green-Top Guideline No. 47 Royal College of Obstetricians and Gynaecologists. 2007.
10. Thomson A, Ramsay J, Rich D. Antepartum Haemorrhage. Green Top Guideline No. 63. Royal College of Obstetricians and Gynaecologists. 2011.
11. Bose P, Regan F, Paterson‐Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG: An International Journal of Obstetrics & Gynaecology. 2006 Aug;113(8):919-24.
12. Bell SF, Watkins A, John M, Macgillivray E, Kitchen TL, James D, Scarr C, Bailey CM, Kelly KP, James K, Stevens JL. Incidence of postpartum haemorrhage defined by quantitative blood loss measurement: a national cohort. BMC pregnancy and childbirth. 2020 Dec;20:1-9.
13. Umar A, Ameh CA, Muriithi F, Mathai M. Early warning systems in obstetrics: A systematic literature review. PloS one. 2019 May 31;14(5):e0217864.
14. Pezdirc N, Pintarič TS, Lučovnik M. Obstetric-specific compared to general early warning system for predicting severe postpartum maternal morbidity. Biomolecules and Biomedicine. 2025.
15. Drew T, Carvalho JC. Major obstetric haemorrhage. BJA education. 2022 Jun 1;22(6):238-44.
16. Heesen M, Carvalho B, Carvalho JC, Duvekot JJ, Dyer RA, Lucas DN, McDonnell N, Orbach‐Zinger S, Kinsella SM. International consensus statement on the use of uterotonic agents during caesarean section. Anaesthesia. 2019 Oct;74(10):1305-19.
17. Hofer S, Blaha J, Collins PW, Ducloy-Bouthors AS, Guasch E, Labate F, Lança F, Nyfløt LT, Steiner K, Van de Velde M. Haemostatic support in postpartum haemorrhage: A review of the literature and expert opinion. European Journal of Anaesthesiology| EJA. 2023 Jan 1;40(1):29-38.
18. Bamber J, Lucas N, Knight M, on behalf of the MBRRACE-UK anaesthesia chapter writing group. Messages for anaesthetic care. In: M Knight, M Nair, D Tuffnell, J Shakespeare, S Kenyon, JJ Kurinczuk, on behalf of MBRRACE-UK, eds. Saving Lives, Improving Mothers' Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013–15. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2017: 67–73.
19. Shakur H, Roberts I, Fawole B, Chaudhri R, El-Sheikh M, Akintan A, Qureshi Z, Kidanto H, Vwalika B, Abdulkadir A, Etuk S. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017 May 27;389(10084):2105-16.
20. Collins PW, Bell SF, De Lloyd L, Collis RE. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the Cardiff experience. International journal of obstetric anesthesia. 2019 Feb 1;37:106-17.
21. de Lloyd LJ, Bell SF, Roberts T, Pereira JF, Bray M, Kitchen T, James D, Collins PW, Collis RE. Early viscoelastometric guided fibrinogen replacement combined with escalation of clinical care reduces progression in postpartum haemorrhage: a comparison of outcomes from two prospective observational studies. International Journal of Obstetric Anesthesia. 2024 Aug 1;59:104209.
22. Welsh A, McLINTOCK C, Gatt S, Somerset D, Popham P, Ogle R. Guidelines for the use of recombinant activated factor VII in massive obstetric haemorrhage. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2008 Feb;48(1):12-6.
23. Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J. European Resuscitation Council Guidelines 2021: cardiac arrest in special circumstances. Resuscitation. 2021 Apr 1;161:152-219.
24. Lott C, Karageorgos V, Abelairaz-Gomez C, Aird R, Alfonzo A, Bierens J, Cantellow S, Debaty G, Einav S, Fischer M, Gonzalez Salvado V, Grief R, Metelmann B, Metelmann C, Meyer T, Paal P, Peran D, Scapigliati A, Spartinou A, Thies K, Truhlar A, Deakins C, ERC Special Circumstances in Resuscitation Collaborator Group. Draft European Resuscitation Council Guidelines 2025: Special Circumstances in Resuscitation. Accessed in June 2025 at: https://cprguidelines.eu/assets/posters/ERC-Guidelines-2025-Special-Circumstances-final-for-public-comments.pdf
Petramay CORTIS (MALTA, Malta)
09:52 - 10:14
Optimising performance in the management of emergencies.
Tatiana SIDIROPOULOU (Professor and Chair) (Keynote Speaker, Athens, Greece)
10:14 - 10:36
Abnormal neurology after an epidural - what now?
Malcolm BROOM (?) (Keynote Speaker, Glasgow, United Kingdom)
10:36 - 10:40
Q&A.
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COFFEE BREAK
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B42
PRO CON DEBATE
Are fascial plane blocks a waste of time?
PRO CON DEBATE
Are fascial plane blocks a waste of time?
Chairperson:
Thomas VOLK (Chair) (Chairperson, Homburg, Germany)
11:10 - 11:10
Introduction.
11:10 - 11:25
For the PRO: Patients profit by a fascial block.
Girish JOSHI (Professor) (Keynote Speaker, Dallas, Texas, USA, USA)
11:25 - 11:40
#48655 - FT11 For the CON: Don´t waste your time for a fascial block.
For the CON: Don´t waste your time for a fascial block.
Don’t waste your time for a fascial block.
Nicky Van Der Leeden MD1, Liesbeth Brullot MD1, Steve Coppens MD, PhD1,2
1 University Hospitals of Leuven, Department of Anesthesiology, Herestraat 49, B-3000, Leuven, Belgium
2 University of Leuven, Biomedical Sciences Group, Department of Cardiovascular Sciences, KU Leuven, B-3000, Leuven, Belgium
Abstract
Background: Fascial plane blocks have emerged as an alternative to neuraxial techniques for postoperative analgesia in the context of laparoscopic and robotic surgeries, where reduced tissue trauma diminishes the need for deep regional interventions. These blocks aim to provide segmental analgesia by depositing local anesthetic in interfascial compartments under ultrasound guidance.
Discussion: This article critically examines the clinical evolution, anatomical rationale, and safety profile of these blocks. While initially celebrated for their simplicity and low invasiveness, the literature surrounding the fascial plane blocks is characterized by inconsistent terminology, poor methodological rigor, and limited comparative evidence. The blocks often fail to deliver reliable visceral analgesia, and their clinical efficacy is hampered by anatomical variability and unpredictable spread. Furthermore, systemic absorption of local anesthetics may contribute to analgesia more than previously understood, particularly in postoperative and obstetric populations where pharmacokinetics are altered. Although generally perceived as safe, they are not without risk—deep variants may endanger vascular structures, and high-volume injections raise concerns of local anesthetic systemic toxicity . Comparative trials with neuraxial or opioid-based analgesia remain scarce and underpowered, limiting their role in evidence-based enhanced recovery pathways. Clinically, the benefit of plane blocks appears transient and inconsistent, with the most appropriate use potentially limited to rescue scenarios in pain-sensitive patients or postoperative recovery units.
Conclusions: Fascial plane blocks are not a panacea for perioperative pain. Their utility lies in selective, patient-tailored rescue use rather than routine inclusion in enhanced recovery protocols. Future research must prioritize rigorous comparison with established techniques, improved anatomical understanding, and stratified approaches based on individual pain phenotypes.
Keywords: Fascial plane blocks; regional anesthesia; postoperative pain; local anesthetic systemic toxicity; enhanced recovery after surgery.
Introduction
The advent of laparoscopic and robotic surgery has fundamentally altered perioperative care, especially in the realm of postoperative analgesia. Precision-based dissections and smaller incisions have drastically reduced tissue trauma and inflammatory responses, challenging long-standing strategies built around more invasive pain management modalities. Techniques such as thoracic epidural analgesia and even paravertebral blocks once heralded for their ability to attenuate nociceptive transmission and the surgical stress response, now appear disproportionate in risk relative to the needs of many current surgical procedures.1
Despite its efficacy EA has been associated with a range of adverse events—spinal hematoma, epidural abscess, significant hypotension, and catheter malfunction among them. In parallel with the diminishing need for its use, a new category of regional blocks has emerged: fascial plane blocks (FPBs). These ultrasound-guided techniques aim to provide segmental analgesia by depositing local anesthetic (LA) solutions in anatomically defined fascial planes.2
Evolution of a Technique
FPBs initially gained attention as an elegant and intuitive solution to the gap between neuraxial and peripheral nerve blocks. By targeting tissue planes where nerves course within or between muscles, these blocks promised expansive dermatomal coverage with minimal invasiveness. Aided by advancements in ultrasonography, their clinical implementation grew rapidly.3,4
However, this growth was accompanied by an oversaturation of literature dominated by descriptive studies, case series, and low-powered trials.5–7 Novelty often took precedence over validation, and anatomical variations of existing approaches were frequently rebranded under new names. As a result, consistency in nomenclature and methodological rigor became casualties of the movement. The fact that a Delphi consensus process was required simply to clarify the names and anatomical logic behind these blocks reveals a deeper, systemic issue. Rather than addressing the clinical effectiveness of these techniques, the consensus process highlighted the extent of confusion—even within the expert panel itself, of which I was a member—regarding the fundamental anatomical identity of many of these blocks.8
Clinical Context and Shifting Utility
Initial applications of FPBs, such as the transversus abdominis plane (TAP) block, were met with optimism in gynecological, urological, and general surgery. Yet as operative techniques became increasingly refined, the significance of postoperative somatic pain began to wane. Smaller ports, reduced insufflation pressures, and more delicate instrument manipulation have made the contribution of abdominal wall pain less clinically relevant.
The PAROS trial, published in 2021, clearly demonstrated that lowering intra-abdominal insufflation pressure significantly reduces postoperative pain, highlighting the role of surgical technique in modulating pain outcomes.9 In contrast, no fascial plane block to date has convincingly demonstrated visceral analgesia.10 While theoretical models suggest that blocks like the erector spinae plane block (ESPB) or quadratus lumborum (QLB) might achieve paravertebral spread, this has not been consistently confirmed—even in cadaveric studies, which themselves carry significant methodological limitations.11
Moreover, growing evidence suggests that earlier studies on FPBs may have overestimated their benefits due to selective publication. Negative trials often faced delays or remained unpublished altogether. As contemporary investigations re-evaluated these techniques under newer surgical protocols, effect sizes appeared smaller, and reproducibility became an issue.
Biological Complexity of Fascial Compartments
The anatomical and histological understanding of fascia has evolved substantially in recent years. Contrary to early assumptions that fascial planes serve as open conduits for LA distribution, contemporary research has shown them to be dense, dynamic tissues filled with a matrix of collagen, elastin, and hyaluronan.7
These structures are neither uniform nor passive. Fasciacytes contribute to lubrication and movement, while architectural variations—such as septa, interconnections, and fusion zones—render LA distribution unpredictable. The variability in fascial thickness and nerve path trajectories between individuals further complicates the expected outcomes of FPBs.
Due to this anatomical variability and the presence of often-overlooked structural barriers, fascial plane blocks yield inconsistent and unpredictable analgesic outcomes. Given the clinical imperative to deliver reliable, effective, and low-risk perioperative pain management, their use should be approached with caution. At present, fascial plane blocks should not be considered a first-line analgesic strategy in surgical pathways where more established and reproducible techniques are available.
Actually the whole current nomenclature surrounding so-called fascial plane blocks is conceptually misleading. It encompasses a heterogeneous group of techniques—many of which are proxy blocks—without consistent interfascial injection. In reality, few of these blocks involve true deposition of local anesthetic between distinct fascial layers. For example, the rectus sheath block is anatomically a compartment block, targeting the space enclosed within the sheath rather than any fascial interface per se.
Although the ESPB is commonly classified among fascial plane blocks, its anatomical target does not conform to the classical definition of a true fascial plane. In standard technique, local anesthetic is deposited between the erector spinae muscle and the underlying transverse processes—a potential space that lacks a well-defined, named fascial boundary. Unlike established fascial plane blocks such as the TAP, which involves injection between distinct fascial layers, the ESPB relies on myofascial spread rather than interfascial confinement. Furthermore, the thoracolumbar fascia, often presumed to be involved, lies deeper and is not directly accessed by the block. 12As such, the ESPB may be more accurately described as a muscle–bone interface block or a volume-dependent myofascial injection rather than a true anatomical fascial plane block. This distinction is important, as it may explain the inconsistent spread and variable clinical efficacy observed across studies. It is not merely a semantic discussion.
Safety of Fascial plane blocks
Emerging research suggests that part of the analgesic effect attributed to FPBs may arise from systemic absorption of the local anesthetic (LA). Measurable plasma concentrations following high-volume interfascial injections indicate that non-specific, systemic effects on the central nervous system could play a role in pain modulation.
This may help explain why some FPBs appear more effective when administered after surgery. The altered physiology, increased vascularity, and active inflammatory milieu in the immediate postoperative period may enhance systemic absorption, amplifying analgesic effects that are not solely attributable to regional nerve blockade. In fact, our recent study published in Anesthesiology demonstrated that systemic absorption of local anesthetic following fascial plane block was approximately twice as high as that observed with surgical intercostal nerve blocks—a technique traditionally recognized for its high systemic uptake.13
FPBs are often characterized as low-risk interventions, especially when compared to neuraxial blocks. However Local anesthetic systemic toxicity (LAST) remains a relevant concern due to the large volumes often required.14 In combined techniques or continuous infusions, cumulative dosing may inadvertently exceed recommended thresholds. Postoperative anatomical disruption can further alter LA dynamics, creating unexpected complications. Physiological changes during pregnancy, such as decreased plasma albumin and α1-acid glycoprotein concentrations, can significantly influence the pharmacokinetics of local anesthetics. These proteins serve as primary binding sites for amide-type local anesthetics; when their levels decline, as commonly observed in pregnant patients, the unbound (free) fraction of the drug increases. This heightened free fraction enhances the potential for systemic toxicity, as only unbound drug is pharmacologically active and capable of crossing cellular membranes, including the blood-brain and placental barriers. Consequently, standard doses may produce exaggerated systemic effects in pregnant patients, underscoring the need for careful dose adjustment and vigilant monitoring.15,16
Their superficial location and ultrasound-guided nature support this perception, making them attractive options in patients with coagulation concerns or spinal abnormalities. Yet not all FPBs are inherently safe. Deep variations, such as anterior QLB, bring the needle in close proximity to major vascular structures like lumbar arteries. Other blocks, such as those involving the thoracic wall, risk encountering arteries like the thoracoacromial branches unless Doppler is employed.
Limitations in Comparative Research
Despite their widespread use, FPBs have not been adequately compared to more established techniques such as intrathecal morphine (ITM), paravertebral blocks (PVBs), or traditional neuraxial approaches. Many of the available studies are single-center, underpowered, and hampered by poor blinding and inconsistent outcome measures.5
Properly blinded studies might change the perception. 13,17–20Research priorities should shift toward multicenter trials with standardized definitions, validated pain endpoints, and longer-term follow-up. Without such data, the full therapeutic potential—and limitations—of FPBs will remain uncertain.
Clinical limitations
We can safely conclude that most fascial plane blocks lack any consistency in their clinical outcomes. However it is often omitted that even if they do add some analgesic benefit the duration of this effect rarely exceeds 6 hours.21 As a result, the duration of effective analgesia with single-injection fascial plane blocks is inherently limited. While continuous catheter techniques can extend their efficacy, they introduce additional challenges. Catheters may hinder early mobilization, require bilateral placement for adequate coverage, and involve complex local anesthetic dosing strategies. These logistical and pharmacological burdens often run counter to the core principles of Enhanced Recovery After Surgery (ERAS), undermining the very benefits these blocks were intended to support.
In our experience these blocks are most effective in a non-standardized way to alleviate pain in the rare cases of breakthrough pain in postoperative care units. Emerging approaches in pain phenotyping suggest that regional techniques, including fascial plane blocks, may find their most appropriate role as targeted interventions for individuals identified as pain-sensitive or pain-intolerant. These patients, often characterized by heightened nociceptive processing or poor coping mechanisms, may derive meaningful benefit from regional rescue strategies when standard multimodal analgesia proves insufficient. In contrast, pain-adaptive individuals—those with resilient neuropsychological and physiological profiles—tend to recover well without the need for additional regional interventions, underscoring the potential for a more individualized, phenotype-driven approach to perioperative pain management.22
Additionally, the patient experience in recovery—when pain is most pronounced—can amplify perceived benefits of any intervention, including those with limited anatomical efficacy. Placebo responses in this context should not be discounted.
Conclusion
Fascial plane blocks represent a notable advancement in regional anesthesia, especially within the context of modern, less invasive surgery. Their appeal lies in simplicity, adaptability, and a generally favorable safety profile. However, their widespread adoption must be accompanied by a balanced appraisal of their mechanistic limitations, clinical variability, and underexplored risks.
Future research must prioritize robust comparative data, better mechanistic insight, and clearly defined clinical endpoints. Enthusiasm alone cannot substitute for evidence. Used appropriately, FPBs can be adjuncts in perioperative pain management—but they should not be mistaken for comprehensive solutions. Don’t waste your valuable clinical time in adding these blocks in your normal standard enhanced recovery program. Use them as a rescue option in PACU, when surgery deviates from original plan, or you have patients who are more pain sensitive.
1. Rawal, N. Epidural technique for postoperative pain: Gold standard no more? Reg Anesth Pain Med 37, 310–317 (2012).
2. Rawal, N. Current issues in postoperative pain management. Eur J Anaesthesiol 33, 160–171 (2016).
3. Chin, K. J., Lirk, P., Hollmann, M. W. & Schwarz, S. K. W. Mechanisms of action of fascial plane blocks: a narrative review. Reg Anesth Pain Med 46, 618–628 (2021).
4. Kim, D. H., Kim, S. J., Liu, J., Beathe, J. & Memtsoudis, S. G. Fascial plane blocks: a narrative review of the literature. Reg Anesth Pain Med 46, 600–617 (2021).
5. Marhofer, P., Feigl, G. C. & Hopkins, P. M. Fascial plane blocks in regional anaesthesia: how problematic is simplification? Br J Anaesth 125, 649–651 (2020).
6. Tran, D. Q., Boezaart, A. P. & Neal, J. M. Fascial plane blocks: the next leap. Reg Anesth Pain Med 46, 568–569 (2021).
7. Black, N. D., Stecco, C. & Chan, V. W. S. Fascial Plane Blocks: More Questions Than Answers? Anesth Analg 132, 899–905 (2021).
8. El-Boghdadly, K. et al. Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks. Reg Anesth Pain Med 46, 571–580 (2021).
9. Celarier, S. et al. Low-pressure versus standard pressure laparoscopic colorectal surgery (PAROS trial): a phase III randomized controlled trial. British Journal of Surgery 108, 998–1005 (2021).
10. Boezaart, A. P. et al. Visceral versus somatic pain: an educational review of anatomy and clinical implications. Reg Anesth Pain Med 46, 629–636 (2021).
11. Luchsinger, M., Varela, V., Diwan, S., Prats-Galino, A. & Sala-Blanch, X. Erector spinae plane infiltration and anterior rami of spinal nerve: a cadaveric study. Reg Anesth Pain Med rapm-2024-105691 (2024) doi:10.1136/rapm-2024-105691.
12. Ivanusic, J., Konishi, Y. & Barrington, M. J. A Cadaveric Study Investigating the Mechanism of Action of Erector Spinae Blockade. Reg Anesth Pain Med 43, 567–571 (2018).
13. Coppens, S. et al. Erector spinae plane block versus intercostal nerve blocks in uniportal videoscopic assisted thoracic surgery: a multicenter, double-blind, prospective randomized placebo controlled trial. Anesthesiology (2025) doi:10.1097/ALN.0000000000005625.
14. Yawata, S., Imamachi, N., Sakura, S., Yamamoto, H. & Saito, Y. Local anesthetic systemic toxicity of levobupivacaine in erector spinae plane block. Korean J Anesthesiol 74, 271–272 (2021).
15. Salaria, O. N., Kannan, M., Kerner, B. & Goldman, H. A Rare Complication of a TAP Block Performed after Caesarean Delivery. Case Rep Anesthesiol 2017, 1–3 (2017).
16. Weiss, E. et al. Convulsions in 2 Patients After Bilateral Ultrasound-Guided Transversus Abdominis Plane Blocks for Cesarean Analgesia. Reg Anesth Pain Med 39, 248–251 (2014).
17. Dewinter, G. et al. Quadratus lumborum block versus perioperative intravenous lidocaine for postoperative pain control in patients undergoing laparoscopic colorectal surgery: A Prospective, Randomized, Double-blind Controlled Clinical Trial. Ann Surg 268, 769–775 (2018).
18. Hoogma, D. F. et al. Efficacy of erector spinae plane block for minimally invasive mitral valve surgery: Results of a double-blind, prospective randomized placebo-controlled trial. J Clin Anesth 86, 111072 (2023).
19. Hoogma, D. F. et al. Erector spinae plane block for postoperative analgesia in robotically-assisted coronary artery bypass surgery: Results of a randomized placebo-controlled trial. J Clin Anesth 87, 111088 (2023).
20. Coppens, S. et al. The effect of anterior quadratus lumborum block on morphine consumption in minimally invasive colorectal surgery: a multicentre, double‐blind, prospective randomised placebo‐controlled trial. Anaesthesia 79, 54–62 (2024).
21. White, P. F. The changing role of non-opioid analgesic techniques in the management of postoperative pain. Anesthesia and Analgesia vol. 101 S5 Preprint at https://doi.org/10.1213/01.ane.0000177099.28914.a7 (2005).
22. Schreiber, K. L., Wilson, J. M. & Chen, Y.-Y. K. Recognizing pain phenotypes: biopsychosocial sources of variability in the transition to chronic postsurgical pain. Reg Anesth Pain Med 50, 86–92 (2025).
Nicky VAN DER LEEDEN, Liesbeth BRULLOT, Steve COPPENS (Leuven, Belgium)
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Q&A.
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PANEL DISCUSSION
From rookie to rockstar: research fellowships
PANEL DISCUSSION
From rookie to rockstar: research fellowships
Chairperson:
Stavros MEMTSOUDIS (Chief) (Chairperson, New York, USA)
11:10 - 11:10
Introduction.
11:10 - 11:25
RAPM experience.
Crispiana COZOWICZ (Attending) (Keynote Speaker, Salzburg, Austria)
11:25 - 11:40
Salzburg-HSS experience.
Ottokar STUNDNER (Attending) (Keynote Speaker, Innsbruck, Austria)
11:40 - 12:00
Q&A.
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| 12:00 - 12:30 |
FAREWELL CONFERENCE
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