Reva Ramlogan - Academia.edu (original) (raw)

Papers by Reva Ramlogan

BJA: British Journal of Anaesthesia, 2022

BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Des... more BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. METHODS After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. RESULTS Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). CONCLUSIONS Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Regional Anesthesia and Pain Medicine, Mar 28, 2019

Neuro-oncology, Nov 1, 2018

NEURO-ONCOLOGY • NOVEMBER 2018 els. RESULTS: Overall 30-day mortality was 5.2% and overall 2-year... more NEURO-ONCOLOGY • NOVEMBER 2018 els. RESULTS: Overall 30-day mortality was 5.2% and overall 2-year survival was 13.5%. Median overall survival varied between 4.8 and 14.9 months among hospitals, and biopsy percentages ranged between 16% and 73%. One hospital had lower than expected early mortality, and four hospitals had lower than expected late survival. Higher hospital volume was related with lower early mortality (P=0.031). A 10% increase in volume was associated with 3.9% relative decrease in early mortality, but not with overall survival. Patient-related risk factors (lower age; better performance; more recent years of treatment) were significantly associated with longer overall survival. Of the hospital characteristics, longer overall survival was associated with lower biopsy percentage (HR: 2.09, 1.34-3.26, P=0.001), and not with academic setting (HR: 0.951, 0.858-1.05), nor with hospital volume (HR: 0.954, 0.866-1.05). CONCLUSION: Hospitals vary more in late survival than early mortality after glioblastoma surgery. Widely varying biopsy percentages indicate treatment variation. Patient-related factors have a stronger association with overall survival than hospital-related factors.

Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Nov 2, 2017

Regional Anesthesia and Pain Medicine, Nov 1, 2009

Background and Objectives: Saphenous nerve (SN) block can be technically challenging because it i... more Background and Objectives: Saphenous nerve (SN) block can be technically challenging because it is a small and exclusively sensory nerve. Traditional techniques using surface landmarks and nerve stimulation are limited by inconsistent success rates. This descriptive prospective study assesses the feasibility of performing an ultrasound-guided SN block in the distal thigh. Methods: After the research ethics board's approval and written informed consent, 20 patients undergoing ankle or foot surgery underwent ultrasonography of the medial aspect of the thigh to identify the SN in the adductor canal, as it lies adjacent to the femoral artery (FA), deep to the sartorius muscle. An insulated needle was advanced in plane under real-time guidance toward the nerve. After attempting to elicit paresthesia with nerve stimulation, 2% lidocaine with 1:200,000 epinephrine (5 mL) and 0.5% bupivacaine (5 mL) were injected around the SN. Results: The SN was identified in all patients, most frequently in an anteromedial position relative to the FA, at a depth of 2.7 T 0.6 cm and 12.7 T 2.2 cm proximal to the knee joint. Complete anesthesia in the SN distribution developed in all patients by 25 mins after injection. Conclusions: In this small descriptive study, ultrasound-guided SN block in the adductor canal was technically simple and reliable, providing consistent nerve identification and block success.

Regional Anesthesia and Pain Medicine, May 1, 2010

I dentification of vascular structures during regional anesthesia procedures with ultrasound can ... more I dentification of vascular structures during regional anesthesia procedures with ultrasound can help to identify target nerves and plan for an appropriate needle approach to avoid puncture and intravascular injection. Arteries can be identified by their relative resistance to collapse from pressure exerted by the ultrasound probe along with the characteristic pulsatile flow demonstrated by color or pulse wave Doppler. Veins often go unidentified, leading to patient morbidity 1,2 and potential mortality. Because of their ease of collapse with minimal ultrasound probe pressure and their low-velocity-flow states that are not always well represented on ultrasound by color Doppler, veins can be difficult to recognize with ultrasound. We describe a novel technique to identify small or collapsed veins using any standard ultrasound with color Doppler. Once an area is identified that could contain venous structures, color Doppler is activated. During real-time ultrasound, any distal part of the patient's corresponding extremity is compressed or squeezed. This compression of the distal muscles and veins significantly increases venous blood flow that is then represented more reliably by color Doppler on ultrasound (Fig. 1). This technique may be repeated several times for complete evaluation of veins in an area and is well tolerated by patients. Other techniques can be used to visualize low-flow blood vessels such as probe tilt, adjustment of pulse repetition frequency, and increasing color gain, but none of these are effective in evaluating veins that are collapsed. Squeezing a distal extremity, as described here, results in the ability to evaluate both low-flow and completely collapsed venous structures. We have found this distal compression technique to be very useful in the identification of veins that are often closely associated with nerves. We routinely use this technique in the axillaq and the popliteal regions by squeezing the arm and calf, respectively.

Regional Anesthesia and Pain Medicine, May 1, 2010

BJA: British Journal of Anaesthesia, Aug 1, 2019

Anesthesiology, Sep 15, 2021

Background: There is need to identify perioperative interventions that decrease chronic opioid us... more Background: There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. Methods: This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase in opioid prescription fulfillment from postoperative day 90 to 365 relative to their baseline use before surgery. The authors' exposure was the receipt of a peripheral nerve block. results: The authors identified 48,523 people who underwent elective shoulder surgery from July 1, 2012, to December 31, 2017, at one of 118 Ontario hospitals. There were 8,229 (17%) patients who had persistent postoperative opioid prescription fulfillment. Of those who received a peripheral nerve block, 5,008 (16%) went on to persistent postoperative opioid prescription fulfillment compared to 3,221 (18%) patients who did not (adjusted odds ratio, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). This statistically significant observation was not reproduced in a coarsened exact matching sensitivity analysis (adjusted odds ratio, 0.85; 95% CI, 0.71 to 1.02; P = 0.087) or several other subgroup and sensitivity analyses. conclusions: This retrospective analysis found no association between receipt of a peripheral nerve block and a lower incidence of persistent postoperative opioid prescription fulfillment in ambulatory shoulder surgery patients.

Anaesthesia, 2021

The learning curve for novices developing regional anaesthesia skills, such as real‐time ultrasou... more The learning curve for novices developing regional anaesthesia skills, such as real‐time ultrasound‐guided needle manipulation, may be affected by innate visuospatial ability, as this influences spatial cognition and motor co‐ordination. We conducted a multinational randomised controlled trial to test if novices with low visuospatial ability would perform better at an ultrasound‐guided needling task with deliberate practice training than with discovery learning. Visuospatial ability was evaluated using the mental rotations test‐A. We recruited 140 medical students and randomly allocated them into low‐ability control (discovery learning), low‐ability intervention (received deliberate practice), high‐ability control, and high‐ability intervention groups. Primary outcome was the time taken to complete the needling task, and there was no significant difference between groups: median (IQR [range]) low‐ability control 125 s (69–237 [43–600 s]); low‐ability intervention 163 s (116–276 [44–600 s]); high‐ability control 130 s (80–210 [41–384 s]); and high‐ability intervention 177 s (113–285 [43–547 s]), p = 0.06. No difference was found using the global rating scale: mean (95%CI) low‐ability control 53% (95%CI 46–60%); low‐ability intervention 61% (95%CI 53–68%); high‐ability control 63% (95%CI 56–70%); and high‐ability intervention 66% (95%CI 60–72%), p = 0.05. For overall procedure pass/fail, the low‐ability control group pass rate of 42% (14/33) was significantly less than the other three groups: low‐ability intervention 69% (25/36); high‐ability control 68% (25/37); and high‐ability intervention 85% (29/34) p = 0.003. Further research is required to determine the role of visuospatial ability screening in training for ultrasound‐guided needle skills.

Anesthesiology, 2021

Background Peripheral nerve blocks are being used with increasing frequency for management of hip... more Background Peripheral nerve blocks are being used with increasing frequency for management of hip fracture–related pain. Despite converging evidence that nerve blocks may be beneficial, safety data are lacking. This study hypothesized that peripheral nerve block receipt would not be associated with adverse events potentially attributable to nerve blocks, as well as overall patient safety incidents while in hospital. Methods This was a preregistered, retrospective population-based cohort study using linked administrative data. This study identified all hip fracture admissions in people 50 yr of age or older and identified all nerve blocks (although we were unable to ascertain the specific anatomic location or type of block), potentially attributable adverse events (composite of seizures, fall-related injuries, cardiac arrest, nerve injury), and any patient safety events using validated codes. The study also estimated the unadjusted and adjusted association of nerve blocks with advers...

British Journal of Anaesthesia, 2021

BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Des... more BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. METHODS After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. RESULTS Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). CONCLUSIONS Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Regional Anesthesia & Pain Medicine, 2021

Background and objectivesWhile there are several published recommendations and guidelines for tra... more Background and objectivesWhile there are several published recommendations and guidelines for trainees undertaking subspecialty Fellowships in regional anesthesia, a similar document describing a core regional anesthesia curriculum for non-fellowship trainees is less well defined. We aimed to produce an international consensus for the training and teaching of regional anesthesia that is applicable for the majority of worldwide anesthesiologists.MethodsThis anonymous, electronic Delphi study was conducted over two rounds and distributed to current and immediate past (within 5 years) directors of regional anesthesia training worldwide. The steering committee formulated an initial list of items covering nerve block techniques, learning objectives and skills assessment and volume of practice, relevant to a non-fellowship regional anesthesia curriculum. Participants scored these items in order of importance using a 10-point Likert scale, with free-text feedback. Strong consensus items we...

Anaesthesia, 2021

SummaryOver the past two decades, regional anaesthesia and medical education as a whole have unde... more SummaryOver the past two decades, regional anaesthesia and medical education as a whole have undergone a renaissance. Significant changes in our teaching methods and clinical practice have been influenced by improvements in our theoretical understanding as well as by technological innovations. More recently, there has been a focus on using foundational education principles to teach regional anaesthesia, and the evidence on how to best teach and assess trainees is growing. This narrative review will discuss fundamentals and innovations in regional anaesthesia training. We present the fundamentals in regional anaesthesia training, specifically the current state of simulation‐based education, deliberate practice and curriculum design based on competency‐based progression. Moving into the future, we present the latest innovations in web‐based learning, emerging technologies for teaching and assessment and new developments in alternate reality learning systems.

Anesthesiology, 2021

Background There is need to identify perioperative interventions that decrease chronic opioid use... more Background There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. Methods This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase...

Anesthesiology, 2019

Editor’s PerspectiveWhat We Already Know about This TopicWhat This Article Tells Us That Is NewBa... more Editor’s PerspectiveWhat We Already Know about This TopicWhat This Article Tells Us That Is NewBackgroundNerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery.MethodsWe conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies...

BMJ Open, 2019

ObjectivesEducation in regional anaesthesia covers several complex and diverse areas, from theore... more ObjectivesEducation in regional anaesthesia covers several complex and diverse areas, from theoretical aspects to procedural skills, professional behaviours, simulation, curriculum design and assessment. The objectives of this study were to summarise these topics and to prioritise these topics in order of research importance.DesignElectronic structured Delphi questionnaire over three rounds.SettingInternational.Participants38 experts in regional anaesthesia education and training, identified through the American Society of Regional Anesthesia Education Special Interest Group research collaboration.Results82 topics were identified and ranked in order of prioritisation. Topics were categorised into themes of simulation, curriculum, knowledge translation, assessment of skills, research methodology, equipment and motor skills. Thirteen topics were ranked as essential research priority, with four topics each on simulation and curriculum, three topics on knowledge translation, and one top...

BJA: British Journal of Anaesthesia, 2022

BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Des... more BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. METHODS After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. RESULTS Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). CONCLUSIONS Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Regional Anesthesia and Pain Medicine, Mar 28, 2019

Neuro-oncology, Nov 1, 2018

NEURO-ONCOLOGY • NOVEMBER 2018 els. RESULTS: Overall 30-day mortality was 5.2% and overall 2-year... more NEURO-ONCOLOGY • NOVEMBER 2018 els. RESULTS: Overall 30-day mortality was 5.2% and overall 2-year survival was 13.5%. Median overall survival varied between 4.8 and 14.9 months among hospitals, and biopsy percentages ranged between 16% and 73%. One hospital had lower than expected early mortality, and four hospitals had lower than expected late survival. Higher hospital volume was related with lower early mortality (P=0.031). A 10% increase in volume was associated with 3.9% relative decrease in early mortality, but not with overall survival. Patient-related risk factors (lower age; better performance; more recent years of treatment) were significantly associated with longer overall survival. Of the hospital characteristics, longer overall survival was associated with lower biopsy percentage (HR: 2.09, 1.34-3.26, P=0.001), and not with academic setting (HR: 0.951, 0.858-1.05), nor with hospital volume (HR: 0.954, 0.866-1.05). CONCLUSION: Hospitals vary more in late survival than early mortality after glioblastoma surgery. Widely varying biopsy percentages indicate treatment variation. Patient-related factors have a stronger association with overall survival than hospital-related factors.

Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Nov 2, 2017

Regional Anesthesia and Pain Medicine, Nov 1, 2009

Background and Objectives: Saphenous nerve (SN) block can be technically challenging because it i... more Background and Objectives: Saphenous nerve (SN) block can be technically challenging because it is a small and exclusively sensory nerve. Traditional techniques using surface landmarks and nerve stimulation are limited by inconsistent success rates. This descriptive prospective study assesses the feasibility of performing an ultrasound-guided SN block in the distal thigh. Methods: After the research ethics board's approval and written informed consent, 20 patients undergoing ankle or foot surgery underwent ultrasonography of the medial aspect of the thigh to identify the SN in the adductor canal, as it lies adjacent to the femoral artery (FA), deep to the sartorius muscle. An insulated needle was advanced in plane under real-time guidance toward the nerve. After attempting to elicit paresthesia with nerve stimulation, 2% lidocaine with 1:200,000 epinephrine (5 mL) and 0.5% bupivacaine (5 mL) were injected around the SN. Results: The SN was identified in all patients, most frequently in an anteromedial position relative to the FA, at a depth of 2.7 T 0.6 cm and 12.7 T 2.2 cm proximal to the knee joint. Complete anesthesia in the SN distribution developed in all patients by 25 mins after injection. Conclusions: In this small descriptive study, ultrasound-guided SN block in the adductor canal was technically simple and reliable, providing consistent nerve identification and block success.

Regional Anesthesia and Pain Medicine, May 1, 2010

I dentification of vascular structures during regional anesthesia procedures with ultrasound can ... more I dentification of vascular structures during regional anesthesia procedures with ultrasound can help to identify target nerves and plan for an appropriate needle approach to avoid puncture and intravascular injection. Arteries can be identified by their relative resistance to collapse from pressure exerted by the ultrasound probe along with the characteristic pulsatile flow demonstrated by color or pulse wave Doppler. Veins often go unidentified, leading to patient morbidity 1,2 and potential mortality. Because of their ease of collapse with minimal ultrasound probe pressure and their low-velocity-flow states that are not always well represented on ultrasound by color Doppler, veins can be difficult to recognize with ultrasound. We describe a novel technique to identify small or collapsed veins using any standard ultrasound with color Doppler. Once an area is identified that could contain venous structures, color Doppler is activated. During real-time ultrasound, any distal part of the patient's corresponding extremity is compressed or squeezed. This compression of the distal muscles and veins significantly increases venous blood flow that is then represented more reliably by color Doppler on ultrasound (Fig. 1). This technique may be repeated several times for complete evaluation of veins in an area and is well tolerated by patients. Other techniques can be used to visualize low-flow blood vessels such as probe tilt, adjustment of pulse repetition frequency, and increasing color gain, but none of these are effective in evaluating veins that are collapsed. Squeezing a distal extremity, as described here, results in the ability to evaluate both low-flow and completely collapsed venous structures. We have found this distal compression technique to be very useful in the identification of veins that are often closely associated with nerves. We routinely use this technique in the axillaq and the popliteal regions by squeezing the arm and calf, respectively.

Regional Anesthesia and Pain Medicine, May 1, 2010

BJA: British Journal of Anaesthesia, Aug 1, 2019

Anesthesiology, Sep 15, 2021

Background: There is need to identify perioperative interventions that decrease chronic opioid us... more Background: There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. Methods: This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase in opioid prescription fulfillment from postoperative day 90 to 365 relative to their baseline use before surgery. The authors' exposure was the receipt of a peripheral nerve block. results: The authors identified 48,523 people who underwent elective shoulder surgery from July 1, 2012, to December 31, 2017, at one of 118 Ontario hospitals. There were 8,229 (17%) patients who had persistent postoperative opioid prescription fulfillment. Of those who received a peripheral nerve block, 5,008 (16%) went on to persistent postoperative opioid prescription fulfillment compared to 3,221 (18%) patients who did not (adjusted odds ratio, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). This statistically significant observation was not reproduced in a coarsened exact matching sensitivity analysis (adjusted odds ratio, 0.85; 95% CI, 0.71 to 1.02; P = 0.087) or several other subgroup and sensitivity analyses. conclusions: This retrospective analysis found no association between receipt of a peripheral nerve block and a lower incidence of persistent postoperative opioid prescription fulfillment in ambulatory shoulder surgery patients.

Anaesthesia, 2021

The learning curve for novices developing regional anaesthesia skills, such as real‐time ultrasou... more The learning curve for novices developing regional anaesthesia skills, such as real‐time ultrasound‐guided needle manipulation, may be affected by innate visuospatial ability, as this influences spatial cognition and motor co‐ordination. We conducted a multinational randomised controlled trial to test if novices with low visuospatial ability would perform better at an ultrasound‐guided needling task with deliberate practice training than with discovery learning. Visuospatial ability was evaluated using the mental rotations test‐A. We recruited 140 medical students and randomly allocated them into low‐ability control (discovery learning), low‐ability intervention (received deliberate practice), high‐ability control, and high‐ability intervention groups. Primary outcome was the time taken to complete the needling task, and there was no significant difference between groups: median (IQR [range]) low‐ability control 125 s (69–237 [43–600 s]); low‐ability intervention 163 s (116–276 [44–600 s]); high‐ability control 130 s (80–210 [41–384 s]); and high‐ability intervention 177 s (113–285 [43–547 s]), p = 0.06. No difference was found using the global rating scale: mean (95%CI) low‐ability control 53% (95%CI 46–60%); low‐ability intervention 61% (95%CI 53–68%); high‐ability control 63% (95%CI 56–70%); and high‐ability intervention 66% (95%CI 60–72%), p = 0.05. For overall procedure pass/fail, the low‐ability control group pass rate of 42% (14/33) was significantly less than the other three groups: low‐ability intervention 69% (25/36); high‐ability control 68% (25/37); and high‐ability intervention 85% (29/34) p = 0.003. Further research is required to determine the role of visuospatial ability screening in training for ultrasound‐guided needle skills.

Anesthesiology, 2021

Background Peripheral nerve blocks are being used with increasing frequency for management of hip... more Background Peripheral nerve blocks are being used with increasing frequency for management of hip fracture–related pain. Despite converging evidence that nerve blocks may be beneficial, safety data are lacking. This study hypothesized that peripheral nerve block receipt would not be associated with adverse events potentially attributable to nerve blocks, as well as overall patient safety incidents while in hospital. Methods This was a preregistered, retrospective population-based cohort study using linked administrative data. This study identified all hip fracture admissions in people 50 yr of age or older and identified all nerve blocks (although we were unable to ascertain the specific anatomic location or type of block), potentially attributable adverse events (composite of seizures, fall-related injuries, cardiac arrest, nerve injury), and any patient safety events using validated codes. The study also estimated the unadjusted and adjusted association of nerve blocks with advers...

British Journal of Anaesthesia, 2021

BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Des... more BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. METHODS After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. RESULTS Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). CONCLUSIONS Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Regional Anesthesia & Pain Medicine, 2021

Background and objectivesWhile there are several published recommendations and guidelines for tra... more Background and objectivesWhile there are several published recommendations and guidelines for trainees undertaking subspecialty Fellowships in regional anesthesia, a similar document describing a core regional anesthesia curriculum for non-fellowship trainees is less well defined. We aimed to produce an international consensus for the training and teaching of regional anesthesia that is applicable for the majority of worldwide anesthesiologists.MethodsThis anonymous, electronic Delphi study was conducted over two rounds and distributed to current and immediate past (within 5 years) directors of regional anesthesia training worldwide. The steering committee formulated an initial list of items covering nerve block techniques, learning objectives and skills assessment and volume of practice, relevant to a non-fellowship regional anesthesia curriculum. Participants scored these items in order of importance using a 10-point Likert scale, with free-text feedback. Strong consensus items we...

Anaesthesia, 2021

SummaryOver the past two decades, regional anaesthesia and medical education as a whole have unde... more SummaryOver the past two decades, regional anaesthesia and medical education as a whole have undergone a renaissance. Significant changes in our teaching methods and clinical practice have been influenced by improvements in our theoretical understanding as well as by technological innovations. More recently, there has been a focus on using foundational education principles to teach regional anaesthesia, and the evidence on how to best teach and assess trainees is growing. This narrative review will discuss fundamentals and innovations in regional anaesthesia training. We present the fundamentals in regional anaesthesia training, specifically the current state of simulation‐based education, deliberate practice and curriculum design based on competency‐based progression. Moving into the future, we present the latest innovations in web‐based learning, emerging technologies for teaching and assessment and new developments in alternate reality learning systems.

Anesthesiology, 2021

Background There is need to identify perioperative interventions that decrease chronic opioid use... more Background There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. Methods This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase...

Anesthesiology, 2019

Editor’s PerspectiveWhat We Already Know about This TopicWhat This Article Tells Us That Is NewBa... more Editor’s PerspectiveWhat We Already Know about This TopicWhat This Article Tells Us That Is NewBackgroundNerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery.MethodsWe conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies...

BMJ Open, 2019

ObjectivesEducation in regional anaesthesia covers several complex and diverse areas, from theore... more ObjectivesEducation in regional anaesthesia covers several complex and diverse areas, from theoretical aspects to procedural skills, professional behaviours, simulation, curriculum design and assessment. The objectives of this study were to summarise these topics and to prioritise these topics in order of research importance.DesignElectronic structured Delphi questionnaire over three rounds.SettingInternational.Participants38 experts in regional anaesthesia education and training, identified through the American Society of Regional Anesthesia Education Special Interest Group research collaboration.Results82 topics were identified and ranked in order of prioritisation. Topics were categorised into themes of simulation, curriculum, knowledge translation, assessment of skills, research methodology, equipment and motor skills. Thirteen topics were ranked as essential research priority, with four topics each on simulation and curriculum, three topics on knowledge translation, and one top...