ESRA-DRA: Regional Anaesthesia and Acute Pain Preparation Guide Study Guide

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During an axillary scan, three rounded structures surround the artery, but one cannot be confidently identified. Follow it proximally or distally and correlate its course before choosing where additional local anaesthetic would provide useful coverage.

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A patient has good median, ulnar and radial sensory changes but retains lateral forearm sensation. Map the incision, locate the musculocutaneous nerve and review cumulative exposure before considering targeted supplementation.

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Explain why unexpected cerebrospinal fluid from a needle intended for epidural placement changes both the anatomical diagnosis and the dosing plan.

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While scanning a shoulder patient, locate both scalene muscles before labelling rounded structures as plexus roots. Trace the group toward the supraclavicular region to strengthen identification and distinguish it from an isolated structure within muscle.

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A neck scan shows a transverse process with a dominant posterior tubercle and little visible anterior tubercle. Use this as a C7 clue, then compare adjacent levels before explaining which neural structures are displayed.

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For a shoulder patient with substantial pulmonary disease, compare the desired analgesia with the consequences of ipsilateral diaphragmatic impairment and discuss suitable alternatives.

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An ultrasound image shows fluid spreading superficial to fascia iliaca while the femoral nerve remains beneath it. Recognise that proximity to the artery has not established appropriate spread toward the neural target.

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During a medial thigh demonstration, identify sartorius and the artery beneath it, then describe the adjacent muscles. Move the probe along the thigh to show how the relationships change.

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When landmarks are difficult, identify the sacrum and count interspaces rather than assigning a level from one palpated line. Ultrasound level counting assists localisation; it does not establish the conus position in every adult.

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Only the tibial component is obvious in the initial image. Scan proximally and laterally to locate the common fibular component, then demonstrate their convergence before explaining the intended spread.

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Show an interlaminar window and distinguish the posterior complex from the deeper anterior complex before estimating the depth to the neuraxial target.

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At a supraumbilical level above the arcuate line, identify rectus, posterior sheath, epigastric vessels and deeper peritoneum before selecting the plane.

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A small vascular signal crosses the proposed route to the posterior rectus plane. Change the planned path while preserving clear identification of the deeper boundary, rather than assuming a superficial approach cannot encounter important vessels.

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Demonstrate erector spinae muscle above a transverse process and identify the pleura relative to neighbouring ribs. Explain how separation beneath the muscle differs from an intramuscular deposit.

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Trace the plexus from the interscalene region into the supraclavicular fossa, then demonstrate where the first rib ends and pleura becomes the deeper boundary.

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If 20 of 100 patients need rescue analgesia, the risk is 0.20 and the odds are 20/80, or 0.25. Use the appropriate measure before comparing groups.

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Rescue opioid use falls from 40% to 25% during the first postoperative day. The absolute reduction is 0.15 and the reciprocal is 6.67, conventionally rounded up to an NNT of 7.

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A knee arthroplasty patient receives regional analgesia but has no planned non-opioid medication despite no relevant contraindication. Review the complete procedure-specific regimen and arrange rescue analgesia.

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After lower-limb surgery, a patient reports little resting pain but cannot tolerate a transfer to a chair. Assess pain location and movement-related symptoms, then relate them to coverage and motor function.

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A patient with an effective abdominal wall block reports deep diffuse discomfort rather than incisional tenderness. Provide appropriate systemic rescue while reassessing the pain source.

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A misplaced injection produces no sensory change despite an adequate planned drug mass. Reassess anatomical delivery and expected onset rather than assuming that progressively increasing concentration will establish the required conduction block.

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For 20 mL of 0.5% solution, convert 0.5% to 5 mg/mL and calculate 100 mg. Include that mass in the entire exposure assessment.

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Before rescuing a patchy block, reconstruct the drugs, concentrations, volumes and administration times for both the block and surgical infiltration. Include any infusion and patient-controlled boluses.

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For prolonged postoperative analgesia, compare a long-acting agent or catheter strategy with repeated lidocaine supplementation, including the resulting duration of weakness and cumulative exposure.

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A sedated patient receiving oxygen becomes less responsive while saturation remains high. Assess ventilation directly and inspect the exhaled carbon dioxide trace rather than concluding that breathing remains adequate.

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Distinguish anxiety from sharp focal surgical pain before increasing sedation. For bradycardia or limited haemodynamic reserve, include the sedative's cardiovascular effects in selection and titration.

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A deep target is poorly visible despite adequate coupling. Consider a lower-frequency setting or probe, then reassess whether the image distinguishes the nerve, vessels and planned needle path.

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If an unexpectedly low-current response occurs, stop and reassess the tip before injection. When no response occurs, check connections, electrode contact and actual delivered current rather than advancing solely to obtain a twitch.

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Pressure falls soon after spinal anaesthesia, before significant surgical blood loss. Consider sympathetic vasomotor blockade and its interaction with venous return rather than automatically attributing the change to haemorrhage.

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A term patient becomes hypotensive while supine after spinal anaesthesia. Explain why displacement may improve venous return while vasopressor treatment addresses reduced vascular tone, then reassess the response to both interventions.

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A patient with significant liver disease has received infiltration and is being considered for repeated supplementation. Review cumulative exposure and reduced elimination capacity before treating each injection as an isolated event.

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When discussing toxicity susceptibility, a trainee cites only the administered mass. Explain how altered binding and elimination can change exposure at excitable tissues without changing that administered mass.

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Two injections contain the same lidocaine mass. Explain how differing sites or vascular entry can change absorption, peak exposure and interpretation of subsequent symptoms.

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A knee patient reports improved pain but has difficulty activating quadriceps after proximal blockade. Relate motor function to the mixed neural supply before assuming poor mobilisation proves inadequate analgesia.

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Map both lateral and medial ankle incisions before selecting complementary sciatic and saphenous targets.

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For poorly palpable landmarks, demonstrate sacral identification, interspace counting and a transverse interlaminar window before explaining the proposed needle trajectory.

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A spinal produces unilateral sensory changes while the opposite incision territory remains sensitive. Reassess distribution and readiness rather than using one weak leg as proof of sufficient anaesthesia.

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After an epidural top-up, rapidly ascending numbness and arm weakness develop. Stop dosing and manage possible high neuraxial blockade rather than completing the planned volume.

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Explain the regional combination within the full arthroplasty pathway, then assess quadriceps function before assisted mobilisation.

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Plan bilateral injections for a midline incision and calculate their combined mass before adding the surgeon's infiltration or catheter doses.

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Fluid expands within erector spinae instead of lifting it from the transverse process. Explain the discrepancy and reassess needle position before further injection.

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Pain returns the next day after initially good popliteal analgesia. Check delivery, external catheter changes and sensory distribution before concluding that concentration is too low and increasing exposure.

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Most of an operative area is insensitive but one defined territory remains painful. Record the pattern and identify its nerve before selecting targeted supplementation, systemic treatment or another anaesthetic strategy.

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Fingers are numb after an axillary block, but the incision extends into the lateral forearm. Test that territory before allowing hand findings to stand in for the whole surgical field.

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The shaft remains bright but the tip disappears near a vessel. Pause and adjust alignment to recover the tip before any further progression or injection.

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During a femoral approach, fluid lifts superficial tissue while fascia iliaca remains between it and the nerve. Pause and reassess the compartment rather than adding volume to force an effect.

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After enoxaparin 40 mg at Monday 20:00 with creatinine clearance 60 mL/min, Tuesday 08:00 reaches the 12-hour pre-removal boundary. If removal occurs then, Tuesday 12:00 reaches the Clexane four-hour post-removal boundary. Administration still requires haemostasis, an appropriate prescription and assessment of bleeding and thrombosis risk.

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For a lateral abdominal wall incision, identify the three muscle layers and explain why a TAP target may fit better than deposition confined behind rectus.

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A patient develops a seizure shortly after a regional injection. Stop delivery, call for assistance and initiate supportive management while preparing the LAST response rather than waiting for an arrhythmia.

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For 50 kg, the initial bolus is approximately 75 mL and infusion 12.5 mL/min. If instability persists, repeat the bolus and increase infusion to 25 mL/min while tracking the 600 mL cumulative ceiling.

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Progressive weakness and urinary dysfunction after stopping an epidural trigger simultaneous imaging and specialist escalation, with onset and serial examination documented.

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Arm weakness and apnoea shortly after an epidural top-up require treatment of the airway and circulatory emergency while considering unintended intrathecal delivery.

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Compare reduced ipsilateral diaphragmatic excursion in an alert patient with pleuritic pain, unilateral respiratory findings and haemodynamic deterioration. Breathlessness alone does not identify one treatment.

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A patient with an epidural develops fever and increasing lumbar pain but retains normal leg strength. Stop using the catheter, examine and document neurological function, arrange urgent MRI and seek urgent neurosurgical and infectious-disease assessment for suspected epidural abscess. Normal strength does not justify observation until weakness appears. Review anticoagulant exposure and renal function to coordinate safe catheter removal while investigation and treatment proceed.

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A patient has weakness before analgesia. Document its distribution, then use serial findings after treatment to distinguish expected blockade from new deterioration or a changing injury-related problem.

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An older patient of average weight has impaired liver function and needs supplementary analgesia. Explain why a healthy adult's calculated allowance does not settle this patient's exposure decision.

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With baseline systolic pressure 120 mmHg, target at least 108 mmHg and avoid pressure below 96 mmHg. Significant maternal cardiac disease requires lesion-specific goals, vasopressor choice and consideration of a titratable neuraxial technique because abrupt sympathectomy may be poorly tolerated.

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For a 20 kg child, a teaching example containing 40 mg of lidocaine equals 2 mg/kg. Verify formulation and add other exposure before evaluating suitability.

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If the target occupies a small part of an excessively deep image, reduce unnecessary depth and move the focus toward it. Reassess probe choice and needle geometry if visibility remains poor.

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Hold and coordinate subsequent dosing. If removal occurs Tuesday at 20:00, Wednesday at 00:00 is the earliest boundary of the manufacturer's four-hour delay. Administration remains conditional on haemostasis, bleeding and thrombosis assessment, postoperative requirements and an appropriate renal-adjusted prescription.