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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