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.

Learning objectives By reading this article, you should be able to: Outline the risk of neuraxial and peripheral nerve blocks in a patient who is anticoagulated. Specify the classes of anticoagulant drugs, their key mechanisms of action and the available reversal agents. Explain which patient groups are at especially high risk of vertebral canal haematoma. Discuss principles guiding risk/benefit decisions before performing peripheral nerve blocks in patients who are anticoagulated. Regional anaesthesia is associated with a decreased rate of complications, reduced length of stay and decreased odds of ICU admission compared with GA alone in patients undergoing major truncal and lower limb surgery. 1 Central neuraxial block (CNB) may also improve perioperative outcomes after total hip and total knee arthroplasty. 2 Patients most likely to benefit from regional anaesthesia are often taking medications that increase the propensity for bleeding. Vertebral canal haematoma (VCH) is a potentially catastrophic complication of neuraxial anaesthesia. If not diagnosed and treated within 8e12 h, paraplegia is likely. 3 Whilst permanent neurological complications following peripheral nerve blocks (PNBs) are rare, seriously disabling consequences for a patient are still possible. 4 Estimates of the incidence of VCH vary substantially in the literature. Nevertheless, three large retrospective studies in Sweden (1.7 million CNB), the UK (700,000 CNB) and Finland (1.4 million CNB) indicate that this is a rare complication. 5e7 The Swedish study found that the incidence of VCH varied substantially by patient population: one in 200,000 in women undergoing obstetric epidural or combined spinaleepidural (CSE), but one in 3,600 females (and one in 9,000 males) undergoing knee arthroplasty under epidural or CSE. 5 The UK 3rd National Audit Project of the Royal College of Anaesthetists found an overall incidence of VCH of one in 117,000 for all CNBs (perioperative, obstetric, chronic pain and paediatric perioperative), but the incidence of VCH following perioperative epidural (excluding spinal anaesthesia and obstetric, paediatric and pain epidurals) was one in 16,321. 6 Similarly, the Finnish study found incidences of VCH haematoma of one in 775,000 following spinal anaesthesia, one in 26,400 for Toby Ashken FRCA is a specialty registrar at the Chelsea and Westminster Hospital, an honorary clinical teaching fellow at University College London and trainee representative for Regional Anaesthesia UK. Simeon West FRCA is a consultant anaesthetist at University College London Hospitals NHS Foundation Trust, honorary senior research associate in medical physics and bioengineering and a board member of Regional Anaesthesia UK.

Background/importanceThere is heterogeneity among the outcomes used in regional anesthesia research.ObjectiveWe aimed to produce a core outcome set for regional anesthesia research.MethodsWe conducted a systematic review and Delphi study to develop this core outcome set. A systematic review of the literature from January 2015 to December 2019 was undertaken to generate a long list of potential outcomes to be included in the core outcome set. For each outcome found, the parameters such as the measurement scale, timing and definitions, were compiled. Regional anesthesia experts were then recruited to participate in a three-round electronic modified Delphi process with incremental thresholds to generate a core outcome set. Once the core outcomes were decided, a final Delphi survey and video conference vote was used to reach a consensus on the outcome parameters.ResultsTwo hundred and six papers were generated following the systematic review, producing a long list of 224 unique outcomes. Twenty-one international regional anesthesia experts participated in the study. Ten core outcomes were selected after three Delphi survey rounds with 13 outcome parameters reaching consensus after a final Delphi survey and video conference.ConclusionsWe present the first core outcome set for regional anesthesia derived by international expert consensus. These are proposed not to limit the outcomes examined in future studies, but rather to serve as a minimum core set. If adopted, this may increase the relevance of outcomes being studied, reduce selective reporting bias and increase the availability and suitability of data for meta-analysis in this area.

We thank Turbitt et al. for their recent editorial on rationalising teaching of block diversity [1]. As regional anaesthesia fellows at a large London teaching hospital, we are both regional anaesthesia learners and, increasingly, regional anaesthesia teachers. We applaud the approach and, whilst the exact choice of blocks will doubtless generate debate, we believe the overall strategy of selecting a small number of blocks, and driving competence among as many consultants and trainees as possible, is compelling.

Rib fractures are associated with significant morbidity and mortality. Most of the morbidity stems from poorly controlled pain and therefore immobility and weak respiratory effort. Moreover, the number of injured ribs correlates with increasing risk of associated morbidity and mortality. We describe the analgesic management of an elderly co-morbid patient on oral anticoagulant therapy presenting with extensive multilevel rib fractures. According to the Western Trauma Association 2017 risk stratification, her mortality was as high as 20%. When a large number of ribs are involved, single level regional blocks may not provide sufficient local anesthetic spread to cover the extensive injury. Therefore, we employed erector spinae plane catheters at two levels. We believe that our therapeutic approach provided comprehensive, reliable and continuous analgesia, leading to a successful outcome in the case of our patient.