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To determine the preferences and attitudes of members of regional anesthesia societies during the COVID-19 pandemic.We distributed an electronic survey to members of the American Society of Regional Anesthesia and Pain Medicine, Regional Anaesthesia-UK, and the European Society of Regional AnaesthesiaPain Therapy. A questionnaire consisting of 19 questions was developed by a panel of experienced regional anesthesiologists and distributed by email to the participants. The survey covered the following domains: participant information, practice settings, preference for the type of anesthetic technique, the use of personal protective equipment, and oxygen therapy.The survey was completed by 729 participants from 73 different countries, with a response rate of 20.1% (729/3,630) for the number of emails opened and 8.5% (729/8,572) for the number of emails sent. Most respondents (87.7%) identified as anesthesia staff (faculty or consultant) and practiced obstetric and non-obstetric anesthesia (55.3%). The practice of regional anesthesia either expanded or remained the same, with only 2% of respondents decreasing their use compared with the pre-pandemic period. The top reasons for an increase in the use of regional anesthesia was to reduce the need for an aerosol-generating medical procedure and to reduce the risk of possible complications to patients. The most common reason for decreased use of regional anesthesia was the risk of urgent conversion to general anesthesia. Approximately 70% of the responders used airborne precautions when providing care to a patient under regional anesthesia. The most common oxygen delivery method was nasal prongs (cannula) with a surgical mask layered over it (61%).Given the perceived benefits of regional over general anesthesia, approximately half of the members of three regional anesthesia societies seem to have expanded their use of regional anesthesia techniques during the initial surge of the COVID-19 pandemic.RéSUMé: OBJECTIF: Déterminer les préférences et les attitudes des membres des sociétés d’anesthésie régionale pendant la pandémie de COVID-19. MéTHODE: Nous avons distribué un sondage électronique aux membres de l’American Society of Regional Anesthesia and Pain Medicine, de Regional Anesthesia-UK et de l’European Society of Regional AnaesthesiaPain Therapy. Un questionnaire composé de 19 questions a été élaboré par un panel d’anesthésiologistes régionaux d’expérience et distribué par courriel aux participants. Le sondage couvrait les domaines suivants : les renseignements sur les participants, les contextes de pratique, leur préférence quant au type de technique d’anesthésie, l’utilisation d’équipement de protection individuelle et l’oxygénothérapie RéSULTATS: Le sondage a été complété par 729 participants provenant de 73 pays différents, avec un taux de réponse de 20,1 % (729/3630) pour le nombre de courriels ouverts et de 8,5 % (729/8572) pour le nombre de courriels envoyés. La plupart des répondants (87,7 %) se sont identifiés comme anesthésiologistes (académique ou consultant) et pratiquaient l’anesthésie obstétricale et non obstétricale (55,3 %). Leur pratique de l’anesthésie régionale s’est étendue ou est demeurée inchangée, et seulement 2 % des répondants ont indiqué avoir diminué leur utilisation de cette pratique par rapport à la période pré-pandémique. Les principales raisons d’une augmentation de l’utilisation de l’anesthésie régionale étaient de réduire la nécessité d’une intervention médicale générant des aérosols et de réduire le risque de complications potentielles pour les patients. La raison la plus courante de diminution du recours à l’anesthésie régionale était le risque de conversion urgente à une anesthésie générale. Environ 70 % des intervenants ont utilisé des précautions en matière de propagation des aérosols lorsqu’ils procuraient des soins à un patient sous anesthésie régionale. La méthode d’administration d’oxygène la plus fréquemment utilisée était les canules nasales avec un masque chirurgical superposé (61 %). CONCLUSION: Compte tenu des avantages perçus de l’anesthésie régionale par rapport à l’anesthésie générale, environ la moitié des membres de trois sociétés d’anesthésie régionale semblent avoir élargi leur utilisation des techniques d’anesthésie régionale pendant la vague initiale de la pandémie de COVID-19.

BackgroundThere is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques.MethodsWe conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement.ResultsSixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified.ConclusionsHarmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Ultrasound-guided fascial plane blocks of the chest wall are increasingly popular alternatives to established techniques such as thoracic epidural or paravertebral blockade, as they are simple to perform and have an appealing safety profile. Many different techniques have been described, which can be broadly categorised into anteromedial, anterolateral and posterior chest wall blocks. Understanding the relevant clinical anatomy is critical not only for block performance, but also to match block techniques appropriately with surgical procedures. The sensory innervation of tissues deep to the skin (e.g. muscles, ligaments and bone) can be overlooked, but is often a significant source of pain. The primary mechanism of action for these blocks is a conduction blockade of sensory afferents travelling in the targeted fascial planes, as well as of peripheral nociceptors in the surrounding tissues. A systemic action of absorbed local anaesthetic is plausible but unlikely to be a major contributor. The current evidence for their clinical applications indicates that certain chest wall techniques provide significant benefit in breast and thoracic surgery, similar to that provided by thoracic paravertebral blockade. Their role in trauma and cardiac surgery is evolving and holds great potential. Further avenues of research into these versatile techniques include: optimal local anaesthetic dosing strategies; high-quality randomised controlled trials focusing on patient-centred outcomes beyond acute pain; and comparative studies to determine which of the myriad blocks currently on offer should be core competencies in anaesthetic practice.

This article aims to review the thoracic paravertebral block by discussing the relevant anatomy, and landmark and ultrasound-guided techniques. We will compare analgesic efficacy to established neuraxial techniques as well as discuss the complications. The quality of analgesia is comparable and non-inferior to epidural analgesia, especially for surgery involving a thoracotomy. The evidence regarding its use in abdominal surgery is not clear. There are long-term analgesic benefits for thoracic paravertebral blocks in breast surgery and it might potentially play a role in modulating cancer recurrence. Furthermore, latest research suggests an efficacious block can be achieved with a less invasive approach to the paravertebral space. The paravertebral block can achieve analgesia comparable to thoracic epidural, the use of ultrasound improves block success, and the complication rates are low. Novel techniques are emerging which might change the approach to the block in the future.

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.

Study objective Analysis of emergency cases performed during initial coronavirus disease 2019 (COVID-19) pandemic and the proportion completed under regional anesthesia (RA). Design Cohort study comparing surgical caseload during initial seven-week COVID-19 pandemic in 2020. Comparison was made with pre-COVID-19 caseload over the corresponding seven-week timeframe in 2019. Setting The setting of the study was emergency surgery theaters at Guy's and St Thomas' NHS Foundation Trust, London, UK. Patients All patients requiring emergency surgery over the defined study period were reviewed with the exception of obstetric and pediatric populations. Interventions Surgical caseload for 2020 and 2019 cohorts established using the Galaxy IT system used to log all operations. All relevant anesthetic charts for the 2020 cohort were subsequently reviewed to ascertain perioperative use of RA. Measurements The type of block, mode of approach, experience of the operator, personal protective equipment (PPE) worn, block complications, type of sedation and complications were entered into database. Main results A total of 338 emergency surgical cases were performed during the COVID-19 pandemic in 2020, compared to 603 cases over the corresponding period in 2019. This showed a 44% decrease in emergency surgical workload. There was a marked disparity in reduction of surgical caseload by surgical subspecialty. Trauma (137 vs 66 cases), a 52% decrease, and general surgery (193 vs 64 cases), a 66% decrease, were the most pronounced, and explanations for this are explored. RA was performed in 34% (26% as primary technique) of cases during the COVID-19 pandemic. The use of RA as the primary anesthesia technique was noticeably higher than previous UK data (11%), and was prominent in specialties such as general surgery, gynecology and urology, not traditionally completed under RA. Conclusions Surgical RA (and general anesthesia avoidance) has a significant role in the future to ensure high-quality perioperative care for patients whilst minimizing exposure to staff and utilization of scarce resources (PPE).

Local anesthetic systemic toxicity (LAST) is a life-threatening adverse event that may occur after the administration of local anesthetic drugs through a variety of routes. Increasing use of local anesthetic techniques in various healthcare settings makes contemporary understanding of LAST highly relevant. Recent data have demonstrated that the underlying mechanisms of LAST are multifactorial, with diverse cellular effects in the central nervous system and cardiovascular system. Although neurological presentation is most common, LAST often presents atypically, and one-fifth of the reported cases present with isolated cardiovascular disturbance. There are several risk factors that are associated with the drug used and the administration technique. LAST can be mitigated by targeting the modifiable risk factors, including the use of ultrasound for regional anesthetic techniques and restricting drug dosage. There have been significant developments in our understanding of LAST treatment. Key advances include early administration of lipid emulsion therapy, prompt seizure management, and careful selection of cardiovascular supportive pharmacotherapy. Cognizance of the mechanisms, risk factors, prevention, and therapy of LAST is vital to any practitioner using local anesthetic drugs in their clinical practice.

To the Editor, Since its original description in 2016,1 the ultrasound-guided erector spinae plane (ESP) block, a regional anaesthesia technique, has become increasingly popular and the potential clinical applications have been increasing.2 A popular indication is analgesia for rib fracture management. Although randomised controlled trial (RCT) -level evidence for the ESP block is lacking in rib fractures, a recent retrospective cohort study3 has shown increased incentive spirometry values and reduced pain scores in the first 24 hours after implementation of the ESP block compared with before block administration. Alternative techniques, such as thoracic epidurals and paravertebral blockade, have greater potential for complications and steeper learning curves. The serratus anterior plane block’s efficacy has been questioned in patients with posterior rib fractures, with potential technical challenges if surgical emphysema or chest drains are present.3 This makes the ESP block an attractive proposition in management of these challenging patients. At our institution, a survey of senior anaesthetic trainees highlighted the need for training in ESP blockade as a tool in their armamentarium for rib fracture analgesia when a thoracic epidural was not feasible or practical. …

Abdominal wall blocks rely on the spread of local anesthetic within musculofascial planes to anesthetize multiple small nerves or plexuses, rather than targeting specific nerve structures. Ultrasonography is primarily responsible for the widespread adoption of techniques including transversus abdominis plane and rectus sheath blocks, as well as the introduction of novel techniques such as quadratus lumborum and transversalis fascia blocks. These blocks are technically straightforward and relatively safe and reduce pain and opioid requirements in many clinical settings. The data supporting these outcomes, however, can be inconsistent because of heterogeneity of study design. The extent of sensory blockade is also somewhat variable, because it depends on the achieved spread of local anesthetic and the anatomical course of the nerves being targeted. The blocks mainly provide somatic analgesia and are best used as part of a multimodal analgesic regimen. This review summarizes the anatomical, sonographic, and technical aspects of the abdominal wall blocks in current use, examining the current evidence for the efficacy and safety of each.

In early-stage breast cancer, the primary treatment option for most women is breast-conserving surgery (BCS). There is a clear need for more accurate techniques to assess resection margins intraoperatively, because on average 20% of patients require further surgery to achieve clear margins. Cerenkov luminescence imaging (CLI) combines optical and molecular imaging by detecting light emitted by 18F-FDG. Its high-resolution and small size imaging equipment make CLI a promising technology for intraoperative margin assessment. A first-in-human study was conducted to evaluate the feasibility of 18F-FDG CLI for intraoperative assessment of tumor margins in BCS. Methods: Twenty-two patients with invasive breast cancer received 18F-FDG (5 MBq/kg) 45-60 min before surgery. Sentinel lymph node biopsy was performed using an increased 99mTc-nanocolloid activity of 150 MBq to facilitate nodal detection against the g-probe background signal (cross-talk) from 18F-FDG. The cross-talk and 99mTc dose required was evaluated in 2 lead-in studies. Immediately after excision, specimens were imaged intraoperatively in an investigational CLI system. The first 10 patients were used to optimize the imaging protocol; the remaining 12 patients were included in the analysis dataset. Cerenkov luminescence images from incised BCS specimens were analyzed postoperatively by 2 surgeons blinded to the histopathology results, and mean radiance and margin distance were measured. The agreement between margin distance on CLI and histopathology was assessed. Radiation doses to staff were measured. Results: Ten of the 12 patients had an elevated tumor radiance on CLI. Mean radiance and tumor-to-background ratio were 560 6 160 photons/s/cm2/sr and 2.41 6 0.54, respectively. All 15 assessable margins were clear on CLI and histopathology. The agreement in margin distance and interrater agreement was good (k 5 0.81 and 0.912, respectively). Sentinel lymph nodes were successfully detected in all patients. The radiation dose to staff was low; surgeons received a mean dose of 34 6 15 mSv per procedure. Conclusion: Intraoperative 18F-FDG CLI is a promising, low-risk technique for intraoperative assessment of tumor margins in BCS. A randomized controlled trial will evaluate the impact of this technique on reexcision rates.

Regional anaesthesia techniques are an important adjunct to perioperative care of breast surgery patients. This chapter focuses on the practical application, evidence base and advantages of peripheral nerve block regional anaesthesia in the anaesthetic management of patients undergoing breast surgery. Functional anatomy and fascial plane blocks are discussed alongside paravertebral and paraspinal techniques. Guidance on the performance the range of ultrasound-guided blocks is provided. The role that regional anaesthesia may have in reducing the risk of breast cancer recurrence following mastectomy surgery is explored.

To the editor, Interfascial plane blocks are emerging anesthetic and analgesic techniques for breast surgery and may be performed in various ways. These blocks are used as an alternative to paravertebral blockade (PVB) since they are considered simpler to perform, do not require repositioning of

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S S53 Introduction: Oncoplastic techniques are increasingly used in breast conserving surgery for better aesthetic outcome following breast cancer treatment without compromising oncological principles. This modified periareolar mammaplasty (MPM) gives excellent access for wide local excision, avoids scar on the breast mound and also gives a pleasing aesthetic outcome. We have critically evaluated our technique including oncological and aesthetic outcomes over a 14-month period. Methods: Details of patientswho underwentMPMbetweenOct 2013 and Dec 2014 were retrieved from our prospectively collected breast cancer operations database. Patient’s operative details including thedurationof operation, specimenweight, histopathology data, adjuvant therapy details and follow-up visits were updated. Medical photography was reviewed for all patients. Results: 25 women underwent MPM. The median age was 60 yrs (range 37e82). The median specimen weight was 34g (range 17e76). Along with breast cancer surgery, most of them had axillary staging according to standard practice. Two patients had re-excision of margins and one patient underwent completion skin sparing mastectomy for involved margins. Postoperative recovery and wound healing were uneventful except one patient had infection of axillary wound. 23 patients underwent radiotherapy to the breast remnant. Medical photography shows excellent aesthetic outcomes. Conclusion: MPM is a type of therapeutic mammaplasty which is easy to learn and reproduce, and a useful adjunct to oncoplastic breast conserving surgery. http://dx.doi.org/10.1016/j.ejso.2015.03.131 P094. Clinical feasibility of Cerenkov Luminescence Imaging (CLI) for intraoperative assessment of tumour excision margins and sentinel lymph node metastases in breast-conserving surgery Maarten Ruben Grootendorst, Ashutosh Kothari, Massimiliano Cariati, Hisham Hamed, Michael Douek, Tibor Kovacs, Gary Cook, Sarah Allen, Chris Sibley-Allen, Alan Britten, Amit Pawa, Fiona Nimmo, Kunal Vyas, David Tuch, Sarah Pinder, Arnie Purushotham, on behalf of the Cerenkov Luminescence Imaging Study Group 1 Department of Research Oncology, King’s College London, London, UK Department of Breast Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, UK 3 PET Imaging Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Department of Nuclear Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Medical Physics Department, St George’s Hospital, London, UK Anaesthetic Department, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Day Surgery Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK 8 Sagentia, Cambridge, UK Lightpoint Medical Ltd., Rickmansworth, UK Introduction: Cerenkov Luminescence Imaging (CLI) is a molecular imaging technique that detects light emitted by Positron Emission Tomography (PET) radiopharmaceuticals. This first-in-woman study evaluates F-FDG CLI for intraoperative assessment of tumour margins and sentinel lymph node (SLN) metastases with a view to reducing re-excision rates. Methods: To date 8 of 30 patients have been recruited (REC reference 14/WM/0050). Patients received 5 MBq/kg F-FDG 1e2 hours prior to surgery. Tc dose was increased to 150 MBq to facilitate SLN detection against the gamma-probe background signal (cross-talk) from F-FDG. The cross-talk was evaluated in a separate lead-in study of n 1⁄4 20 patients. Tumour specimens and SLNs were imaged with a CLI imager (Lightpoint Medical Ltd, UK) intraoperatively immediately after excision. Normalised decay-corrected radiance (ph/s/cm/str/MBq) was calculated for each ROI. Radiation doses to all staff were measured. Results: Elevated radiance was identified in the primary tumour (26.7 ROI SD 3.2), and the only metastatic (8mm) SLN (42.1 ROI SD 9.1) compared with negative SLNs (16.2 SD 12.5). The mean F-FDG cross-talk in the lead-in study was 348 cps and 357 cps in left and right axilla, respectively. SLN detection was successful in all patients undergoing CLI despite substantial F-FDG cross-talk. Table Staff radiation doses Staff Average dose per Maximum procedure (mSv) dose (mSv) Surgeon 28.6 64 Anaesthetist 8.6 15 Anaesthetist assistant 6.4 11 Scrub nurse 1.8 5 Recovery nurse 6.6 17 Conclusions: Intraoperative F-FDG CLI is a feasible and low risk procedure. Despite significant cross-talk, SLN biopsy can be performed successfully using 150 MBq Tc and blue dye. http://dx.doi.org/10.1016/j.ejso.2015.03.132 P095. Chemotherapy trends in early breast cancer in the under 55s in 2014 Caroline Strachan, Rajiv Dave, Sue Hartup, Nisha Sharma, Tom Hughes, Kieran Horgan The Leeds Breast Unit, St James University Hospital, Leeds, West Yorkshire, UK Neoadjuvant chemotherapy (NACT) is increasingly employed for early breast cancer in younger women with the potential benefit over adjuvant treatment (ACT) of conserving the breast and monitoring response. With wider ranging indications for NACT, is the use of ACT in the under 55s diminishing? Methodology: Clinico-pathological characteristics of patients under 55 undergoing chemotherapy in our unit over the last year were analysed, to review selection criteria for ACT in this age group. Results: 195 patients under 55 were diagnosed with breast cancers in 2014. 37 under 55 received NACT. 122 Patients under 55 consulted an oncologist for consideration of ACT and 54 patients (60%) received it. 68 patients did not receive ACT, due to personal choice or “adjuvantonline” / oncologist opinion not being persuasive. ACT in the 54 patients was preceded by breast conserving surgery (BCT) in 28 patients, and by mastectomies (Mx) in 26. Of the 26 who had Mx, 12 were considered obligate mastectomy candidates regardless of potential NACT response. 11 chose to have Mx, with 8 of those 11 being offered NACT. In 3 patients, Mx was performed for widespread DCIS and chemotherapy was not anticipated pre-operatively. Of the 28 patients who underwent BCT, NACT was not discussed as they were already conservable and MDT saw no benefit. Conclusions: The majority of younger women with early breast cancer treated with chemotherapy still receive it as an adjuvant treatment. 52% of women receiving adjuvant therapy do so as they are considered conservable without discussing primary systemic therapy, whereas 22%were deemed not conservable evenwithNACT.Adjuvant administration therefore remains the mainstay of systemic chemotherapy in this cohort of women. http://dx.doi.org/10.1016/j.ejso.2015.03.133