do w e need ultrasound guidance for regional anesthesia ??

Director: Peripheral nerve AnalgesiaDirector: regional anesthesia Fellowship

Section Head: Orthopedic AnesthesiaCleveland Clinic

Do We Need Ultrasound Guidance for Regional Anesthesia??

Loran Mounir Soliman M.D

Goals and Objectives

Do we need Ultrasound for regional Anesthesia??

1Why to use Ultrasound

versus Not??

2Is there any evidence? 3Another

View

Advantage of UGRA……..

We talked about them before

1

Higher ResolutionPortable machinesBetter picture enhansment softwaresNeedle Guiding softwaresBetter sonographic needlesEasy to use interface

Safe TechnologyNon-invasive. Real- time picturesReproducible resultsSeeing is believing.

Advantages of UGRA

Why to change??

Need extra training Long h

istory

of

exper

ience

and sa

fety

of conv

entional

techniques

Nee

d to

redu

ce

cost

& e

xpen

ses

2 Is There Enough Evidence?

What type of outcomes are we looking at??

Did UGRA resulted in…….

Better Outcomes?

Quicker blocksFaster OnsetLesser attemptsBetter Success rateLonger durationPatient Satisfaction

Vascular puncturePneumothoraxDiaphragmatic paresisPost Operative Neurologic Symptoms (PONSs)Local Anesthetic Systemic Toxicity (LAST)

Types of outcomes

1. Kirvela O, Svedstrom E, Lundbom N. Ultrasonic guidance of lumbar sympathetic and celiac plexus block: a new technique. Reg Anesth. 1992;17:43Y46.

2. Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to landmark-guided approaches. Reg Anesth Pain Med. 2000;25:600Y604.

3. Kapral S, Krafft P, Eibenberger K, et al. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg. 1994;78:507Y513.

4. Ting PL, Sivagnanaratnam V. Ultrasonographic study of the spread of local anaesthetic during axillary brachial plexus block. Br J Anaesth. 1989;63:326Y329.

Has it been that long?

Plethora of Literature for UGRA

New techniques

No Advantage

Faster

New appro

ach

Less volume

complications

Met

a An

alys

is

Is one study is enough?

1999

Succesfull Block equals Surgical anesthesia (No GA, Spinal nor suplementation blocks)

Succesfull Block equals Surgical anesthesia(No GA, Spinal nor suplementation blocks)

No significant difference in success

rate of US guided blocks

US provided more successful blocks with risk ratio for block failure 0.41

Other benefits of Ultrasound included: faster onset, longer duration and higher patient

satisfaction.No single report suggesting that Ultrasound is inferior to other techniques or carry a higher

risk.

19 Studies

Performance time of the blockUS faster in 15 studies

US slower in One study

Same in 2 studies

US for upper extremity Blocks is found also to have :Faster Sensory onsetHigher Success RateLess Complication Rate

Only 7 Studies found

US faster onset and

higher success rate

Neuraxial

Ultrasound is superior than landmarks in determination of the midline, identification of the level and the depth from the skin

Ultrasound is better than Anatomical method but inferior to radiology imaging

Interventional Pain

Not Enough Data from the small studies in pediatrics.

Trend toward faster blocks and lower volumes

Conclusion

What About Safety?????

Nerve stimulation US

Onset

Volume

Success

Cost

Time

Complications of Regional Anesthesia

Ultrasound Has to be safer …..Seeing has to be better than blind techniques

Complications

• Less with Ultrasound

• Pneumothorax• Hemidiaphragmatic

paresis• Vascular Puncture

• No Difference

• LAST (local Anesthetic Systemic toxicity)

• Peripheral Nerve injuries

• 17,000 cases reviewed

There are no RCT data that unequivocally supportsuperior safety outcomes consequent to the use of UGRA

Case reports emphasize that absolute elimination of these seriouscomplications has not occurred.

Local Anesthetic toxicity

Seizure 0.8%(one case)Cardiac toxicity 0 cases

Could this one case had been avoided

Skills needed

Incidence of toxicity

5/3290Stimulatio

n

0/2146US

Nerve injuryThe Risk is not still eliminated

1.8% neurological symptoms lasting more than 5 days

0.9% lasting longer than 6 months

Nerve Injury is Multi Factorial

• Preexisting lesions• Surgical techniques• Position details• Volume of local

anesthetics• Needle trauma

• Regional Anesthesia & Pain Medicine.Sept 2012 p490

• Reported the incidence of perioperative nerve injury after total shoulder is 2.2% with no additional increase of risk with ISB

3 Another Vision for Ultrasound

Remote Blocks!!!!!!

3

Another Vision for Ultrasound

3

Another Vision for Ultrasound

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