Recommendations for anatomical structures to identify on ultrasound for the performance of intermediate and advanced blocks in ultrasound-guided regional anesthesia.

Recent recommendations describe a set of core anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia (UGRA). This project aimed to generate consensus recommendations for core structures to identify during the performance of intermediate and advanced blocks. An initial longlist of structures was refined by an international panel of key opinion leaders in UGRA over a three-round Delphi process. All rounds were conducted virtually and anonymously. Blocks were considered twice in each round: for "orientation scanning" (the dynamic process of acquiring the final view) and for "block view" (which visualizes the block site and is maintained for needle insertion/injection). A "strong recommendation" was made if ≥75% of participants rated any structure as "definitely include" in any round. A "weak recommendation" was made if >50% of participants rated it as "definitely include" or "probably include" for all rounds, but the criterion for strong recommendation was never met. Structures which did not meet either criterion were excluded. Forty-one participants were invited and 40 accepted; 38 completed all three rounds. Participants considered the ultrasound scanning for 19 peripheral nerve blocks across all three rounds. Two hundred and seventy-four structures were reviewed for both orientation scanning and block view; a "strong recommendation" was made for 60 structures on orientation scanning and 44 on the block view. A "weak recommendation" was made for 107 and 62 structures, respectively. These recommendations are intended to help standardize teaching and research in UGRA and support widespread and consistent practice.

International consensus on anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia.

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.

Arterial anatomy of the anterior abdominal wall: Ultrasound evaluation as a real-time guide to percutaneous instrumentation.

INTRODUCTION: Instrumenting the anterior abdominal wall carries a potential for vascular trauma. We previously assessed the presence, position, and size of the anterior abdominal wall superior and inferior (deep) epigastric arteries with computed tomography (CT). We now present a study using ultrasound (US) assessment of these arteries, to evaluate its use for real time guidance of percutaneous procedures involving the rectus sheath. MATERIALS AND METHODS: Twenty-four participants (mean age 67.9 ± 9 years, 15 M:9 F [62:38%]) were assessed with US at three axial planes on the anterior abdominal wall: transpyloric plane (TPP), umbilicus, and anterior superior iliac spine (ASIS). RESULTS: An artery was visible least frequently at the TPP (62.5 - 45.8%), compared with the umbilicus (95.8-100%) and ASIS (100%), on the left, χ2 (2) = 20.571; p < .001, and right, χ2 (2) = 27.842; p < .001, with a moderate strength association (Cramer's V = 0.535 [left] and 0.622 [right]). Arteries were most commonly observed within the rectus abdominis muscle at the level of the TPP and umbilicus, but posterior to the muscle at the level of the ASIS (95.8-100%). As with the CT study, the inferior epigastric artery was observed to be larger in diameter, start more laterally, and move medially as it coursed superiorly. CONCLUSIONS: These data corroborate our previous results and suggest that the safest level to instrument the rectus sheath (with respect to vascular anatomy) is at the TPP. Such information may be particularly relevant to anesthetists performing rectus sheath block and surgeons during laparoscopic port insertion.

Exploring patients' and clinicians' experiences of video consultations in primary care: a systematic scoping review.

BACKGROUND: Video consultation (VC) is an emerging consultation mode in general practice. The challenges and benefits of implementing it are not necessarily realised until it is in use, and being experienced by patients and clinicians. To date, there has been no review of the evidence about how patients and clinicians experience VC in general practice. AIM: The study aimed to explore both patients' and clinicians' experiences of VCs in primary care. DESIGN & SETTING: A systematic scoping review was carried out of empirical studies. METHOD: All major databases were searched for empirical studies of any design, published from 1 January 2010 to 11 October 2018 in the English language. Studies were included where synchronous VCs occurred between a patient and a clinician in a primary care setting. Outcomes of interest related to experience of use. The quality of included studies were assessed. Findings were analysed using narrative synthesis. RESULTS: Seven studies were included in the review. Patients reported being satisfied with VC, describing reduced waiting times and travel costs as a benefit. For patients and clinicians, VC was not deemed appropriate for all presentations and all situations, and a face-to-face consultation was seen as preferable where this was possible. CONCLUSION: The findings of this scoping review show that primary care patients and clinicians report both positive and negative experiences when using VCs, and these experiences are, to a certain extent, context dependent. VC is potentially more convenient for patients, but is not considered superior to a face-to-face consultation. Accounts of experience are useful in the planning and implementation of any VC service.

Arterial Anatomy of the Anterior Abdominal Wall: Evidence-Based Safe Sites for Instrumentation Based on Radiological Analysis of 100 Patients.

Multiple medical interventions require percutaneous instrumentation of the anterior abdominal wall, all of which carry a potential for vascular trauma. We assessed the presence, position, and size of the anterior abdominal wall superior and inferior (deep) epigastric arteries to determine the safest site with respect to vascular anatomy of the rectus sheath. In a review of 100 arterial phase, contrast-enhanced abdominal computed tomography scans, anterior abdominal wall arteries were assessed bilaterally at three axial planes: transpyloric, umbilicus, and anterior superior iliac spine (ASIS). The mean age of patients was 69.2 years (SD ± 15), with 62 male and 38 female. An artery was visible least frequently at the transpyloric plane (5%), compared with the umbilicus (72-79%) and ASIS (93-96%), on the left (χ2 (4) = 207.272; P < 0.001) and right (χ2 (4) = 198.553; P < 0.001), with a moderate strength association (Cramer's V = 0.588 (left) and 0.575 (right)). The arteries were most commonly observed within the rectus abdominis muscle at the level of the umbilicus and ASIS on both sides (62-68%). The inferior epigastric artery was observed to be larger in diameter, start more laterally, and move medially as it travelled superiorly. These data suggest that the safest site to instrument the rectus sheath, with respect to vascular anatomy, is at the transpyloric plane. This information on anatomical variation of the anterior abdominal wall vasculature may be of particular interest to anesthetists performing rectus sheath block and surgeons during laparoscopic port insertion. Clin. Anat. 33:350-354, 2020. © 2019 Wiley Periodicals, Inc.

Identifying the emergence of the superficial peroneal nerve through deep fascia on ultrasound and by dissection: Implications for regional anesthesia in foot and ankle surgery.

Regional anesthesia relies on a sound understanding of anatomy and the utility of ultrasound in identifying relevant structures. We assessed the ability to identify the point at which the superficial peroneal nerve (SPN) emerges through the deep fascia by ultrasound on 26 volunteers (mean age 27.85 years ± 13.186; equal male: female). This point was identified, characterized in relation to surrounding bony landmarks (lateral malleolus and head of the fibula), and compared to data from 16 formalin-fixed human cadavers (mean age 82.88 years ± 6.964; equal male: female). The SPN was identified bilaterally in all subjects. On ultrasound it was found to pierce the deep fascia of the leg at a point 0.31 (±0.066) of the way along a straight line from the lateral malleolus to the head of the fibula (LM-HF line). This occurred on or anterior to the line in all cases. Dissection of cadavers found this point to be 0.30 (±0.062) along the LM-HF line, with no statistically significant difference between the two groups (U = 764.000; exact two-tailed P = 0.534). It was always on or anterior to the LM-HF line, anterior by 0.74 cm (±0.624) on ultrasound and by 1.51 cm (±0.509) during dissection. This point was significantly further anterior to the LM-HF line in cadavers (U = 257.700, exact two-tailed P < 0.001). Dissection revealed the nerve to divide prior to emergence in 46.88% (n = 15) limbs, which was not identified on ultrasound (although not specifically assessed). Such information can guide clinicians when patient factors (e.g., obesity and peripheral edema) make ultrasound-guided nerve localization more technically challenging. Clin. Anat. 32:390-395, 2019. © 2019 Wiley Periodicals, Inc.

Systems and synthetic biology of the vessel wall.

Atherosclerosis is intimately coupled to blood flow by the presence of predilection sites. The coupling is through mechanotransduction of endothelial cells and approximately 2000 gene are associated with this process. This paper describes a new platform to study and identify new signalling pathways in endothelial cells covering an atherosclerotic plaque. The identified networks are synthesized in primary cells to study their reaction to flow. This synthetic approach might lead to new insights and drug targets.