Ultra Sound Guided Regional Analgesia (USG-RA) provides several benefits over traditional landmark-based techniques: 1) Nerves, blood vessels, and other structures can be visualized in real-time to accurately place the needle and avoid unintended punctures. 2) Spread of local anesthetic can be seen as it surrounds the targeted nerves. 3) Individual nerves can be identified and blocked more precisely. 4) Procedures like supraclavicular blocks that were previously risky can be performed safely. While USG-RA requires an ultrasound machine and two providers, the advantages of improved accuracy, success rates, and safety outweigh the few disadvantages.

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!