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International consensus on anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia
  1. James Simeon Bowness1,2,
  2. Amit Pawa3,
  3. Lloyd Turbitt4,
  4. Boyne Bellew5,6,
  5. Nigel Bedforth7,
  6. David Burckett-St Laurent8,
  7. Alain Delbos9,
  8. Nabil Elkassabany10,
  9. Jenny Ferry2,
  10. Ben Fox11,
  11. James L H French7,
  12. Calum Grant12,
  13. Ashwani Gupta13,
  14. William Harrop-Griffiths5,
  15. Nat Haslam14,
  16. Helen Higham1,15,
  17. Rosemary Hogg4,
  18. David F Johnston4,
  19. Rachel Joyce Kearns16,17,
  20. Sandra Kopp18,
  21. Clara Lobo19,
  22. Sonya McKinlay16,17,
  23. Stavros Memtsoudis20,21,
  24. Peter Merjavy22,
  25. Eleni Moka23,
  26. Madan Narayanan24,
  27. Samer Narouze25,
  28. J Alison Noble26,
  29. David Phillips2,
  30. Meg Rosenblatt27,
  31. Amy Sadler12,
  32. Maria Paz Sebastian28,
  33. Alasdair Taylor12,
  34. Athmaja Thottungal29,
  35. Luis Fernando Valdés-Vilches30,
  36. Thomas Volk31,
  37. Simeon West32,
  38. Morné Wolmarans33,
  39. Jonathan Womack34 and
  40. Alan James Robert Macfarlane16,35
  1. 1OxSTaR, Oxford University, Oxford, UK
  2. 2Department of Anaesthesia, Aneurin Bevan Health Board, Newport, UK
  3. 3Department of Anaesthesia, Guy's and St Thomas' Hospitals NHS Trust, London, UK
  4. 4Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
  5. 5Department of Surgery & Cancer, Imperial College London, London, UK
  6. 6Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
  7. 7Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
  8. 8Department of Anaesthesia, Royal Cornwall Hospitals NHS Trust, Truro, UK
  9. 9Department of Anesthesia, Clinique Médipole Garonne, Toulouse, France
  10. 10Department of Anesthesiology & Intensive Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
  11. 11Department of Anaesthesia, Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, Norfolk, UK
  12. 12Department of Anaesthesia, NHS Tayside, Dundee, UK
  13. 13Department of Anaesthesia, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK
  14. 14Department of Anaesthesia, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
  15. 15Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  16. 16School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
  17. 17Department of Anaesthesia, NHS Greater Glasgow and Clyde, Glasgow, UK
  18. 18Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Graduate School for Biomedical Sciences, Rochester, Minnesota, USA
  19. 19Anestesiologista, Hospital das Forças Armadas Polo do Porto, Porto, Portugal
  20. 20Department of Anesthesiology, Critical Care & Pain Management, Hospital for Specialist Surgery, New York, New York, USA
  21. 21Weill Cornell Medical College, New York, New York, USA
  22. 22Department of Anaesthesia, Craigavon Area Hospital, Portadown, UK
  23. 23Department of Anaesthesiology, Hellenic Healthcare Group (HHG), Heraklion Crete, Greece
  24. 24Department of Anaesthesia, Frimley Park Hospital, Frimley, UK
  25. 25Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
  26. 26IBME, University of Oxford, Oxford, UK
  27. 27Mount Sinai Health System, New York, New York, USA
  28. 28Department of Anaesthetics, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
  29. 29Department of Anaesthesia & Pain Management, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
  30. 30Anesthesia Department, Hospital Costa del Sol, Marbella, Spain
  31. 31Department of Anaesthesiology, Critical Care & Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
  32. 32Department of Anaesthetics, University College London, London, UK
  33. 33Anaesthesiology, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
  34. 34Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK
  35. 35Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
  1. Correspondence to Dr James Simeon Bowness, OxSTaR, Oxford University, Oxford OX1 2JD, UK; james.bowness{at}jesus.ox.ac.uk

Abstract

There is no universally agreed set of anatomical structures that must be identified on ultrasound for the performance of ultrasound-guided regional anesthesia (UGRA) techniques. This study aimed to produce standardized recommendations for core (minimum) structures to identify during seven basic blocks. An international consensus was sought through a modified Delphi process. A long-list of anatomical structures was refined through serial review by key opinion leaders in UGRA. All rounds were conducted remotely and anonymously to facilitate equal contribution of each participant. Blocks were considered twice in each round: for “orientation scanning” (the dynamic process of acquiring the final view) and for the “block view” (which visualizes the block site and is maintained for needle insertion/injection). Strong recommendations for inclusion were made if ≥75% of participants rated a structure as “definitely include” in any round. Weak recommendations were made if >50% of participants rated a structure as “definitely include” or “probably include” for all rounds (but the criterion for “strong recommendation” was never met). Thirty-six participants (94.7%) completed all rounds. 128 structures were reviewed; a “strong recommendation” is made for 35 structures on orientation scanning and 28 for the block view. A “weak recommendation” is made for 36 and 20 structures, respectively. This study provides recommendations on the core (minimum) set of anatomical structures to identify during ultrasound scanning for seven basic blocks in UGRA. They are intended to support consistent practice, empower non-experts using basic UGRA techniques, and standardize teaching and research.

  • regional anesthesia
  • ultrasonography
  • pain management
  • lower extremity
  • upper extremity

https://doi.org/10.1136/rapm-2021-103004

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    Footnotes

    • Twitter @bowness_james, @amit_pawa, @LloydTurbitt, @boynebellew, @nigeb444, @alaindelbos, @nelkassabany, @Jennythatcanbl1, @benjaminLukeFox, @frenchjamesdoc, @ashwani_doc, @wharropg, @nathaslam, @HelenEHigham, @rosie_hogg, @davejohnston24, @rjharrison79, @claralexlobo, @GPeriop, @sgmemtsoudis, @PeterMerjavy, @mokaeleni, @madannarayanan, @NarouzeMD, @AlisonNoble_OU, @megrosenblatt, @mariapsebastian, @athmathottungal, @uclhregional, @docmorne, @womackjonathan, @ajrmacfarlane

    • Contributors Study concept, design, and conduct: BB, JSB, AJRM, AP, LT. Data collection: all authors. Manuscript preparation: JSB. Manuscript editing: BB, JSB, AJRM, AP, LT. Manuscript review and approval: all authors.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests AD, CL, EM, LFV-V, TV, and MW are members of the Executive Board of the European Society of Regional Anaesthesia & Pain Therapy (ESRA). NE, SK, SM, SN, and MAR are members of the Board of Directors of the American Society of Regional Anesthesia & Pain Medicine (ASRA). AG, NH, DFJ, RJK, AJRM, AP, MPS, AT, LT, SW, JW are members of the Board of Regional Anaesthesia UK (RAUK). WH-G is the Vice-President of the Royal College of Anaesthetists. JSB, DBSL, AJRM, DP & AT declare honoraria and/or research funding from Intelligent Ultrasound. JAN is a Senior Scientific Advisor for Intelligent Ultrasound Limited. AP declares consultancy fees for B Braun Medical UK and honoraria from GE Healthcare, Butterfly Net Inc, Sintetica UK Ltd, and Pacira.

    • Provenance and peer review Not commissioned; externally peer reviewed.