Pros and cons of USG-RA

1. Ultra Sound Guided
Regional Analgesia!
(USG-RA)
What is Good or bad about it???

2. Prof. Mridul M. Panditrao
Professor, Head & In-Charge of ICU
Department of Anaesthesiology & Intensive Care
Adesh Institute of Medical Sciences & Research
Dean Academic Affairs
Adesh University
Bathinda
Punjab

3. Why Use US:
Just like X-Rays, but without the obvious disadvantages of;
• Ultra sound can be considered as a ‘Beam’ & can be focused on the
desired object
Just Like Light:
• obey, the Laws of ‘Refraction’ & ‘ Reflection’
In contrast to both of these:
• Even minute structures like RBCs, can reflect US & can be imaged
• While being stationary or
• While in motion…… ‘Doppler effect’

4. Regional Analgesia: Modalities
• Conventional: Land Mark based, Blind, traditional
• X ray guided, C- arm Guided, Image Guided, fluoroscopy
• Peripheral Nerve Stimulator (PNS) Guided
• Ultra Sound Guided (USG)

5. Conventional: Landmark Based!!
• For almost more than a century
• Traditionally: Day to Day Teacher teaching, learner learning,
• Gaining experience, confidence
• Some failures, some successes,
• With age, experience, maturity, perfection
• Once effective; great confidence builder
• Simple, no equipment, no gadgets
• Economical, cost-effective
• Can be performed in field as well as in big institutes

6. Problems:
• Absolutely thorough knowledge of Anatomy : MUST
• In spite of this and as such, Failures/ Patchy/ incomplete blocks
• Especially in obese, un co-operative patients & distorted anatomy
• Supplementation in some form, generally imperative
• Larger dose is required, logically more chances of complications
• Biggest problem inadvertent vascular/ pleural punctures
• LAST ( Local Anaesthetic Systemic Toxicity)
• Undermining the confidence/reluctance to perform
• Had fallen in serious disrepute

7. Ultra Sound Guided (USG): Brachial Plexus block
• Anatomical structures can be easily identified,
• like nerves, blood vessels, the pleura,
• as can unexpected anatomical variations and abnormalities
• Unintentional penetration of these structures can be recognized and
avoided
• The insertion and placement of the block needle can be visualized in
real time
• positioning/if required, repositioning of the needle is performed
under direct vision and in real time as opposed to blind redirection
and repositioning of the needle with the PNS/conventional

8. Brachial Plexus block
• Penetration of a nerve/plexus sheath in most cases easily visualized
as indicated by initial indentation of the sheath followed by sudden
recoil of the sheath during needle penetration.
• Injection of the local anesthetic solution is easily visualized, in real
time as is the spread of the local anesthetic within the sheath and
around the nerves.
• The controversy regarding the presence or absence of septa within
the brachial plexus sheath becomes a nonissue
• As any nerve(s) that are not surrounded by local anesthetic during the
initial injection can be identified
• These nerves can then be blocked individually by simple repositioning
the block needle and injecting an additional bolus of local anesthetic

9. Brachial Plexus block
• Individual nerves can be identified and blocked anywhere along their
pathway from core to periphery
• Approaches that had fallen into disfavor due to potential complications
have regained their popularity, e.g. supraclavicular brachial plexus
block
• Peripheral nerve blocks can be safely performed in patients under
general anesthesia with the use of ultrasound, however this issue is
controversial

10. Net Result!
As a result of the benefits described above,
• The time to perform the block is decreased!
• As well as the onset time is decreased!
• The complication rate decreased!
• The success rate is increased!
• Overall patient satisfaction is improved

11. 3 in 1 block
• A study: whether ultrasound facilitates the approach for 3-in-1 blocks
• Forty patients undergoing hip surgery after trauma were randomly
assigned to either
• an ultrasound (US) or a nerve stimulator (NS) group
• They concluded that an US-guided approach for 3-in-1 block
• US:
• Reduces the onset time,
• improves the quality of the sensory block and
• minimizes the risks associated
• Overall patient satisfaction
Marhofer P, Schrogendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N. Ultrasonographic guidance improves sensory block and onset time of three-in-one
blocks. Anesth Analg 1997; 85:854-857.

12. Caudal Epidural
Using conventional blind technique:
• Failure rate of caudal epidural block in adults is high even in experienced
hands
• This could be attributed to anatomic variations that make locating sacral
hiatus difficult.
• With the advent of fluoroscopy and ultrasound in guiding needle placement,
the success rate has been markedly improved.
• Although fluoroscopy is still considered the gold standard
• US has been demonstrated to be highly effective in accurately guiding the
needle entering the caudal epidural space
• US could be as effective as fluoroscopy in preventing complications during
caudal epidural injection
Sheng-Chin Kao and Chia-Shiang Lin. Caudal Epidural Block: An Updated Review of Anatomy and Techniques. BioMed Research International
2017;https://doi.org/10.1155/2017/9217145

13. Disadvantages/problems of US
• Cost and availability of ultrasound machines
• USG-RA requires 2 individuals
• As the operator holds the probe in one hand and the needle in the other,
• Therefore a second person is required to inject the local anesthetic
• Failure to visualize the needle and unintentional probe movement are
the commonest drawbacks
• The errors that occur due to inexperienced use of the ultrasound
technique

14. Common/Inexperienced Operator Problems
• Failure to recognize local anesthetic maldistribution
• Intramuscular location of the needle tip,
• Failure to correlate the sidedness of the patient with that of the
machine image
• Poor choice of needle insertion site
• Fatigue

15. In conclusion
• The benefits of USG-RA far outweigh the few “disadvantages”
• The use of US definitely improves the accuracy of needle placement,
• Identifying specific nerves/plexuses, avoiding accidental ‘punctures’
• The final objective to provide safe, effective & efficient regional
anesthesia with minimal Patient discomfort is achieved with US!!

16. Thank you!