Technological and Pharmacological Advancements in Regional Anaesthesia and Acute Postoperative Pain

Vol 3 | Issue 1 | January-June 2022 | Page 03-07 | Abhijit S. Nair, Sandeep Diwan

DOI: 10.13107/ijra.2022.v03i01.046

Authors: Abhijit S. Nair [1], Sandeep Diwan [2]

[1] Department of Anaesthesia, Ibra Hospital, Ministry of Health-Oman, Ibra, Sultanate of Oman.
[2] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Abhijit S. Nair,
Department of Anaesthesia, Ibra Hospital, Ministry of Health-Oman, Ibra, Sultanate of Oman.

The last two decades have seen immense popularity and interest for using ultrasound (US) in the practice of regional anaesthesia (RA) for performing regional nerve blocks, fascial plane blocks, and even for central neuraxial blocks. [1-3] Use of US in RA not only increase the success rate; it also reduced the complications and also facilitated several new blocks especially the fascial plane blocks in recent years. Probably this was just a beginning because, in recent years, many technological advances have been made to popularize RA, to make it safe, and to provide long-lasting analgesia to the patient. [4,5] This editorial describes the technological and pharmacological advances made in the last decade related to RA and acute pain medicine.

Advanced Gadgets and Technology for RA:
Conventionally, the US machine used in routine RA practice is 2D or 2-dimensional, and the same is used in teaching institutes and workshops. The present US machines are light-weight, portable, have advanced features like touch-screen, high-resolution images, better needle visibility, taking snapshots or recording videos, and many more. Few papers have described the use of 3D US in RA. However, the issues with 3D-US in RA are a slow refresh rate than 2D and difficulty in real-time needle visualization and tracking. [6,7] Few RA enthusiasts have demonstrated successful use of 4D-US in RA. By using the 4D US, the performer can simultaneously visualize multiple planes like longitudinal, cross-sectional, and coronal adjusting the probe. 4D also provided a spatial relationship between anatomical structures of interest compared to standard imaging, which could prevent undesirable complications. With 4D US accurate volume measurements of LA can be made with visualization of the spread of LA at the site of interest. However, the issues are 4D US needs a different machine and probe which might not be feasible for someone who already has the 2D US. [8]
Portability has reached the next level with the introduction of the Lumify probe by Philips, USA. This probe can be connected to a smartphone or a tablet. [9] A Philips Lumify Ultrasound App is available for download on both Android and Apple phones for free. However, in India, the RA enthusiast needs to comply with the Pre-Conception and Pre-Natal Diagnostic Techniques (PC-PNDT) act before planning to buy and use it. [10]

Robotics in US-guided RA:
In the medical field, the principles of robotics have been applied successfully in robotic-assisted surgeries, rehabilitation, medical transportation, sanitation of hospitals, and drug dispensing. In 2002, Cleary et al used a robotic system developed by URobotics (Urology Robotics) Laboratory to perform nerve and facet blocks at the lumbar region of embalmed cadavers successfully thus opening a new avenue for performing RA techniques using advanced technology. [11] Later Tighe et al performed US-guided nerve blocks in phantom using the da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, CA). [12] This system is also used for robotic-assisted surgeries. The authors demonstrated successful single injections and perineural catheters using the robotic system. This led to the development of a task-specific robotic device for RA. Magellan system is a robotic system exclusively developed for US-guided regional anaesthesia. [13] The Magellan system comprises a joystick, a robotic arm, and a software control system.
Hemmerling et al described the first robotic US-guided nerve blocks in humans using the Magellan system which is a robotic system for US-guided RA. [14] The authors employed the sciatic nerve block in 13 patients all of which were successful and required 3-4 minutes to perform. Morse et al conducted a study in which they compared success rates, learning curves, and inter-subject performance variability of robot-assisted and manual US-guided nerve block needle guidance in simulation. [15] A Magellan robotic nerve block system was used for this study. The authors concluded that robot-assisted nerve blocks lead to faster learning of needle guidance over manual positioning and reduce inter-subject performance variability. Currently, the Magellan system is not FDA-approved, is costly, has not been validated by comparative, randomized studies.

Injection Pressure Monitoring:
In the current practice of RA, monitoring injecting pressure while injecting LA for a peripheral nerve block or a fascial plane block is considered the gold standard. A high injection pressure i.e., more than 20 pounds per square inch (PSI) has been associated with intraneural or intrafascicular injection leading to unwanted neurological consequences postoperatively. [16,17] At present there are three monitors available in the market with different pros and cons.
B-SmartTM (B. Braun Medical, Bethlehem, Pennsylvania, USA) was the first disposable, injection pressure monitor released in the market. It uses membrane sensing technology to monitor real-time injection pressure while injecting LA. [18] When the injection pressure crosses 15 psi, the piston-color changes from white to yellow, and after reaching a pressure of more than 20 psi, there is a change in piston color from yellow to orange. [19] NerveGuard® (Pajunk Medical Systems, Geisingen, Germany) is another gadget available for a similar purpose but with different technology. It detects high pressure while injecting (more than 20 psi) and automatically stops the injection of LA while performing a block. This is due to the presence of a Luer lock mechanism between the syringe and the extension tubing of the nerve block needle. [20,21] Recently, Medovate, a company in the United Kingdom introduced the SAFIRA (SAFer Injection in Regional Anaesthesia) pump which gives a combined benefit of injection pressure monitoring and controlled injection of LA. [22] The SAFIRA system consists of three components; a sterile single-use syringe, a driver, and a foot pedal. The foot pedal has two parts, a green and a yellow. On pressing the green part of the foot pedal, the syringe loaded with LA will infuse the LA at the site of interest. On pressing the yellow part of the foot pedal, the loaded LA is aspirated before injection. There are three driver indicator lights. When the green is on, it means LA is infusing. A yellow light indicated aspiration, and red light is suggestive of either a low battery or an empty syringe. The company mentions that the driver and foot pedal can be used for up to 200 peripheral nerve blocks comfortably. [23] The pump is currently available in the UK, USA, Australia, Israel, and a few European countries.

Needle Visualization on the US:
The SonixGPS® system (Ultrasonix Medical Corp, Richmond, BC, Canada) is an electromagnetic needle tracking system developed for US-guided needle interventions. This needs specially designated needles for planned interventions. Niazi et al used this system in 20 patients for performing spinal anaesthesia and concluded that with its use, the procedure is simplified especially with an out-of-plane approach. [24] The experience of Brinkmann et al with 20 patients in whom they performed spinal anaesthesia was similar. They concluded that US-guided subarachnoid block was easy to perform, with a low rate of failure and complications. [25]

Long-Acting, Sustained-Release Local Anaesthetics:
Liposomal bupivacaine, marketed as Exparel (Pacira Pharmaceuticals, Inc., Parsippany, NJ, USA) is an extended-release formulation of bupivacaine which was approved by US-FDA for a single-shot infiltration of the surgical site in 2011. [26] In a review article published by Hamilton et al in Cochrane Database Systematic Review, it was concluded that the use of Exparel did appear to reduce postoperative pain when compared to a placebo. [27]
Exparel consists of encapsulated multivesicular liposomes (DepoFoam formulation Multivesicular spherical lipid particles in a honeycomb formation). This unique liposomal-based structure confers stability and extended-release properties to the formulation. The median diameter of the liposome particles ranges from 24 to 31 μm. [28] Although Exparel was approved for use only for infiltration at the surgical site, researchers published their experiences of off-label use of Exparel in various peripheral nerve blocks of upper and lower extremities. To date, papers have been published with the use of Exparel in popliteal, ankle, femoral, intercostal, penile, pectoral nerve block, and transversus abdominis plane block with variable results. [29-32] With the introduction of liposome-based LA and analgesics and after the success depicted in case series and certain comparative studies, in the last few years there were several pharmacological agents which were launched in the market.

SABER Bupivacaine:
Durect Pharmaceuticals, California, USA developed an experimental drug with a working name: SABER bupivacaine (POSIMIR®). It is available as a thick, translucent solution and consists of bupivacaine, biodegradable depot composition (sucrose acetate isobutyrate), and benzyl alcohol thereby causing extended-release of bupivacaine after infiltration at the surgical site. In a 5 ml solution, there is 132 mg per ml of bupivacaine base which is equivalent to 743 mg of bupivacaine hydrochloride in the 5 ml solution. Studies have shown that the analgesic efficacy after infiltration peaks at 13-17 hours and fades by 72 hrs.
Hadj et al randomized patients undergoing open hernia repair to receive 2.5 ml (330 mg), 5 ml (660 mg) of SABER-bupivacaine with placebo. In both the groups which received the experimental drug, the analgesic efficacy was better than the placebo with no interference in wound healing and devoid of any adverse events. [33] BESST (Bupivacaine Effectiveness and Safety in SABER Trial) is registered with and has 3 cohorts: 1-laparotomy, 2- laparoscopic cholecystectomy, 3- laparoscopic-assisted colectomy. The results of this trial have not been published yet. [34] As of now, SABER-bupivacaine still awaits US-FDA approval.

HTX-011, now marketed as ZYNRELEF™ by Heron Therapeutics, Inc. is a novel formulation comprising extended-release, fixed-ratio of bupivacaine as the main drug with low-dose meloxicam to enhance the effectiveness of infiltrated bupivacaine. [35] This combination is integrated into a bioerodible polymer (Biochronomer®). On injection at the surgical site, there is controlled hydrolysis of the polymer which leads to sustained release of both bupivacaine and meloxicam for 3 days.
In the EPOCH-2 study, which is a phase 3, randomized, double-blind, active-controlled multicenter study; Viscusi et al enrolled 18 patients into 3 groups. In one group the patients received HTX-011, in second bupivacaine infiltration, and the third group received placebo. On analysis, the authors concluded that there was a significant improvement in postoperative pain control and a significant reduction in opioid consumption when compared to bupivacaine. [36] In another phase 2b, double-blind, placebo-controlled, and active-controlled trial by Lachiewicz et al, authors enrolled 232 patients undergoing unilateral total knee arthroplasty into 4 groups. [37] The first group received HTX-011 400 mg bupivacaine/12 mg meloxicam, applied without a needle into the surgical site. In the second group, patients received the same dose of HTX-011 with an additional 50 mg ropivacaine injection into the posterior capsule. The patients in the third and fourth group received bupivacaine 125 mg injection, and saline placebo injection respectively. On analysis, the authors concluded patients in the first two groups which received HTX-011 had better pain scores when compared to bupivacaine alone and placebo. ZYNRELEFTM is now US-FDA approved for treating acute postoperative pain by infiltration at the surgical site. [38]

Neosaxitoxin is a phycotoxin derived from the shellfish and has demonstrated a reversible block of voltage-gated sodium channels at the neuronal level. Neosaxitoxin shows more affinity to sodium channels in peripheral nerves when compared to that in the myocardium. This favorable property paved way for research in using it for prolonging the analgesic effect of LA.
Rodriguez-Navarro et al conducted a randomized, double-blind, placebo-controlled trial by recruiting 10 healthy volunteers who received subcutaneous injections in the middle posterior skin of the calf. One leg received 50 μg neosaxitoxin, and the contra-lateral leg received a placebo. The authors concluded that neosaxitoxin is an effective LA when injected into a subcutaneous plane. [39] In 2011, Rodriguez-Navarro et al conducted a randomized, double-blind trial comparing neosaxitoxin with bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy. [40] On analysis, the authors concluded that neosaxitoxin is safe, prolonged postoperative analgesia when compared to the control group. Later, Lobo et al investigated the safety and efficacy of neosaxitoxin alone and in combination with 0.2% bupivacaine with and without epinephrine in a double-blind, randomized, controlled trial involving 84 healthy male volunteers aged 18 to 35 years. [41] The authors concluded that neosaxitoxin combination did prolong LA and had a tolerable side effect profile. As of now, neosaxitoxin continues to be an experimental medication with no formal US-FDA approval and also lacks studies involving off-label use in clinical situations.

Percutaneous Peripheral Nerve Stimulation:
Percutaneous nerve stimulation (PNS) is a neuromodulation technique that has been used successfully in managing acute postoperative pain and chronic pain of varying causes.[42] The stimulating electrode of PNS is placed under US guidance in or around the muscle/nerve, usually 1–3 cm from the target. Initially, the electrodes are tested by placing them at the desired site using a Tuohy needle. Once convinced, the electrodes are connected to an external battery source (implanted) to generate current for stimulation. This modality is not only opioid-free but does not even need LA. It can be kept in situ for up to 60 days. [43] The product is US-FDA approved for chronic pain, post-traumatic, and postoperative pain. The stimulator is marketed by SPRINT® PNS System. [44]
In summary, the popularity of RA amongst all anaesthesiologists resulted in extensive research in developing newer and safer technologies that can be applied in RA. The newer pharmacological agents which are either approved or under investigation can be useful in providing cost-effective and opioid-sparing analgesia in the postoperative period. In other words, the future of RA and acute pain medicine looks bright.


1. Jeon YH. Easier and Safer Regional Anesthesia and Peripheral Nerve Block under Ultrasound Guidance. Korean J Pain. 2016; 29:1-2.
2. Gürkan Y, Kuş A. Fascial Plane Blocks in Regional Anaesthesia and New Approaches. Turk J Anaesthesiol Reanim. 2017; 45:85-86.
3. Gaur A, Dedhia J, Bouazza-Marouf K. Ultrasound and central neuraxial blocks. Saudi J Anaesth. 2018; 12:175-7.
4. Neal JM. Ultrasound-Guided Regional Anesthesia and Patient Safety: Update of an Evidence-Based Analysis. Reg Anesth Pain Med. 2016; 41:195-204.
5. Barrington MJ, Uda Y. Did ultrasound fulfill the promise of safety in regional anesthesia? Curr Opin Anaesthesiol. 2018; 31:649-55.
6. Clendenen SR, Robards CB, Clendenen NJ, Freidenstein JE, Greengrass RA. Real-time 3-dimensional ultrasound-assisted infraclavicular brachial plexus catheter placement: implications of a new technology. Anesthesiol Res Pract. 2010; 2010:208025.
7. Karmakar MK, Li X, Li J, Hadzic A. Volumetric three-dimensional ultrasound imaging of the anatomy relevant for thoracic paravertebral block. Anesth Analg 2012; 115:1246–50.
8. Clendenen NJ, Robards CB, Clendenen SR. A standardized method for 4D ultrasound-guided peripheral nerve blockade and catheter placement. Biomed Res Int. 2014; 2014:920538.
9. Available from:
Last accessed on: 9th January 2022.
10. Bhaktwani A. The PC-PNDT act in a nutshell. Indian J Radiol Imaging. 2012; 22:133-4.
11. Cleary K, Stoianovici D, Patriciu A, Mazilu D, Lindisch D, Watson V. Robotically assisted nerve and facet blocks: a cadaveric study. Acad Radiol. 2002; 9:821-5.
12. Tighe PJ, Badiyan SJ, Luria I, Boezaart AP, Parekattil S. Technical communication: robot-assisted regional anesthesia: a simulated demonstration. Anesth Analg. 2010; 111:813-6.
13. Morse J, Wehbe M, Taddei R, Cyr S, Hemmerling TM. Magellan: technical description of a new system for robot-assisted nerve blocks. J Comput 2013; 8: 1401–5.
14. Hemmerling TM, Taddei R, Wehbe M, Cyr S, Zaouter C, Morse J. Technical communication: First robotic ultrasound-guided nerve blocks in humans using the Magellan system. Anesth Analg. 2013; 116:491-4.
15. Morse J, Terrasini N, Wehbe M, Philippona C, Zaouter C, Cyr S, Hemmerling TM. Comparison of success rates, learning curves, and inter-subject performance variability of robot-assisted and manual ultrasound-guided nerve block needle guidance in simulation. Br J Anaesth. 2014; 112:1092-7.
16. Patil J, Ankireddy H, Wilkes A, et al. An improvised pressure gauge for regional nerve blockade/anesthesia injections: an initial study. J Clin Monit Comput 2015; 29:673e9.
17. Vassiliou T., Müller H. H., Limberg S., De Andres J., Steinfeldt T., Wiesmann T. Risk evaluation for needle-nerve contact related to electrical nerve stimulation in a porcine model, Acta Anaes-thesiol. Scand. 2016; 60:400–6.
18. Available from:
Last accessed on: 9th January 2022.
19. Weisman RS, Bhavsar NP, Schuster KA, Gebhard RE. Evaluation of the B-Smart manometer and the CompuFlo computerized injection pump technology for accurate needle-tip injection pressure measurement during peripheral nerve blockade. Reg Anesth Pain Med. 2019; 44:86-90.
20. (Available from:
Last accessed on 8th January 2022
21. Gadsden J. Current devices used for the monitoring of injection pressure during peripheral nerve blocks. Expert Rev Med Devices. 2018; 15:571-8.)
22. Available from:
Last accessed on 8th January 2022).
23. Bodhey A, Nair A, Seelam S. SAFIRA pump: A novel device for fixed injection pressure and to control local anaesthetic injection during peripheral nerve block. J Anaesthesiol Clin Pharmacol 2021; XX: XX-XX.- accepted manuscript.
24. Niazi AU, Chin KJ, Jin R, Chan VW. Real-time ultrasound-guided spinal anesthesia using the SonixGPS ultrasound guidance system: a feasibility study. Acta Anaesthesiol Scand. 2014; 58:875-81.
25. Brinkmann S, Tang R, Sawka A, Vaghadia H. Single-operator real-time ultrasound-guided spinal injection using SonixGPS™: a case series. Can J Anaesth. 2013; 60:896-901.
26. Available from:
Last accessed on 8th January 2022
27. Hamilton TW, Athanassoglou V, Mellon S, Strickland LH, Trivella M, Murray D, Pandit HG. Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb 1;2(2):CD011419.)
28. Chahar P, Cummings KC 3rd. Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012; 5:257-64.
29. Ilfeld BM, Viscusi ER, Hadzic A, Minkowitz HS, Morren MD, Lookabaugh J, Joshi GP. Safety and Side Effect Profile of Liposome Bupivacaine (Exparel) in Peripheral Nerve Blocks. Reg Anesth Pain Med. 2015; 40:572-82.
30. Discepola P, Bouhara M, Kwon M, et al. EXPAREL® (Long-Acting Liposomal Bupivacaine) Use for Popliteal Nerve Block in Postoperative Pain Control after Ankle Fracture Fixation. Pain Res Manag. 2020; 2020:5982567.
31. Hamilton TW, Athanassoglou V, Trivella M, et al. Liposomal bupivacaine peripheral nerve block for the management of postoperative pain. Cochrane Database Syst Rev. 2016;2016:CD011476.
32. Leiman D, Barlow M, Carpin K, Piña EM, Casso D. Medial and lateral pectoral nerve block with liposomal bupivacaine for the management of postsurgical pain after submuscular breast augmentation. Plast Reconstr Surg Glob Open. 2015;2:e282.
33. Hadj A, Hadj A, Hadj A, Rosenfeldt F, Nicholson D, Moodie J, et al. Safety and efficacy of extended-release bupivacaine local anaesthetic in open hernia repair: a randomized controlled trial. ANZ J Surg. 2012; 82:251-7.
34. Available from:
Last accessed on 8th January 2022.
35. Available from:
Last accessed on 9th January 2022.
36. Viscusi E, Minkowitz H, Winkle P, Ramamoorthy S, Hu J, Singla N. HTX-011 reduced pain intensity and opioid consumption versus bupivacaine HCl in herniorrhaphy: results from the phase 3 EPOCH 2 study [published correction appears in Hernia. 2020 Jun;24(3):679]. Hernia. 2019; 23:1071-80.
37. Lachiewicz PF, Lee GC, Pollak RA, Leiman DG, Hu J, Sah AP. HTX-011 Reduced Pain and Opioid Use After Primary Total Knee Arthroplasty: Results of a Randomized Phase 2b Trial. J Arthroplasty. 2020; 35:2843-51.
38. Available from:
Last accessed on: 8th January 2022).
39. Rodriguez-Navarro AJ, Lagos N, Lagos M, Braghetto I, Csendes A, Hamilton J, et al. Neosaxitoxin as a local anesthetic: preliminary observations from a first human trial. Anesthesiology. 2007; 106:339-45.
40. Rodríguez-Navarro AJ, Berde CB, Wiedmaier G, Mercado A, Garcia C, Iglesias V, et al. Comparison of neosaxitoxin versus bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy: a randomized, double-blind trial. Reg Anesth Pain Med. 2011; 36:103-9.
41. Lobo K, Donado C, Cornelissen L, Kim J, Ortiz R, Peake RW, et al. A Phase 1, Dose-escalation, Double-blind, Block-randomized, Controlled Trial of Safety and Efficacy of Neosaxitoxin Alone and in Combination with 0.2% Bupivacaine, with and without Epinephrine, for Cutaneous Anesthesia. Anesthesiology. 2015; 123:873-85.
42. Ilfeld BM, Grant SA, Gilmore CA, Chae J, Wilson RD, Wongsarnpigoon A, et al. Neurostimulation for postsurgical analgesia: A novel system enabling ultrasound-guided percutaneous peripheral nerve stimulation. Pain Pract. 2017; 17:892–901.
43. Sahoo R, Nair A. Implanted peripheral nerve stimulator – Another weapon for managing pain. Saudi J Anaesth. 2020; 14:267-9.
44. Available from:
Last accessed on: 8th January 2022.

How to Cite this Article: Nair AS, Diwan S | Technological and Pharmacological Advancements in Regional Anaesthesia and Acute Postoperative Pain | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 03-07.


(Abstract Text HTML)    (Download PDF)

Time to Standardize Regional Anesthesia Blocks: An International Effort for a Good Cause

Vol 3 | Issue 1 | January-June 2022 | Page 01-02 | Rafael Blanco

DOI: 10.13107/ijra.2022.v03i01.045

Authors: Rafael Blanco [1]

[1] Department of Anaesthesia, King’s College Hospital London, Dubai, UAE.

Address of Correspondence
Dr. Rafael Blanco,
Department of Anaesthesia, King’s College Hospital London, Dubai, UAE.

During the last 10 years, we have seen an explosion of novel nerve blocks based on different ways of describing either anatomical targets, fascial planes, or local anesthetic distributions. The introduction of ultrasound machines in regional anesthesia had a major impact factor in this. To put our readers in perspective more than 100 published blocks have been developed during this time. Very wisely, a group of sixty internationally recognized experts in the field of regional anesthesia embarked on a project to reach a consensus on this matter. These could be useful for educating or researching the new generation of interventional pain and regional anesthetists.

The project called the international Delphi consensus study on its first publication concentrated on abdominal, paraspinal and chest thoracic wall blocks. This is based on the popularity of these novel blocks when we look at publications in recent years.
The conclusion of the Delphi paper stated a strong consensus for the majority of block approaches. The following are some examples of this:
The posterior TAP and the lateral quadratus lumborum blocks were unified into the latter. For the paraspinal blocks there was a weak or no consensus so it will require more time for this.
The rhomboid intercostal plane block achieved strong consensus for the anatomical description only but this was not the case for the serratus plane block. Equally the PECS block did not achieve strong consensus into changing to inter pectoral plane block so will be discretionary for the time being. The same applies to the PECS II block into pecto-serratus block, which will be discretionary based on weak consensus.

Finally, there was a strong consensus that the superficial, deep, or muscle-related planes composed of connective tissue should be called fascial planes rather than interfascial planes applying only in reference to anatomical descriptions.

It is very important to address that this publication is the first of this kind and may be prone to bias and different answers, depending on the way the questions were formulated but it is a starting point. It aims to see the real impact over the coming years in the field. Simple, clear and descriptive approaches should be the three pillars to be used in regional anesthesia, the same as the three pillars that resume a good standard of care: education, research and clinical application. This year 2022 we will hopefully see published a second round on the matter, this time involving upper and lower limb blocks so we are optimistic in terms of a new era in regional anesthesia.

It is undeniable that we are living in a time of immense popularity of regional anesthesia specialty and we must not lose momentum to build recognition of the work well done. We have brought back the importance of basic medical subjects like anatomy, attracting interest within the anesthesiologist. We want our specialty to make sense and provide clear evidence of why we need to block and why the idea of “no patient without a block” or a “multimodal approach” is our goal. Regional anaesthesiologists are highly skilled doctors, with invaluable hands-on skills. Our colleagues know that and we should be proud of that. Other fields that are closely connected like chronic pain interventional medicine should be reviewed in the years to come and perhaps by them we could also address nomenclature and the technique effectiveness.

As part of this editorial, we would like to encourage our readers to work together in this direction, continue researching and sharing their expertise, their findings, for the benefit of our global community. Reevaluation will also be needed as some of the names in previously published article has gained popularity and most probably will be difficult to revert.


El-Boghdadly K, Wolmarans M, Stengel AD, et al. Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks Reg Anesth Pain Med 2021;46:571–580.

How to Cite this Article: Blanco R | Time to Standardize Regional Anesthesia Blocks: An International Effort for a Good Cause | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 01-02.


(Abstract Text HTML)    (Download PDF)

Lateral Femoral Cutaneous Nerve Block

Vol 3 | Issue 1 | January-June 2022 | Page 19-22 | Trishul Muniraju, Murali Thondebhavi

DOI: 10.13107/ijra.2022.v03i01.049

Authors: Trishul Muniraju [1], Murali Thondebhavi [1]

[1] Department of Anaesthesia and Pain Management, Apollo Hospitals, Bangalore, Karnataka, India.

Address of Correspondence
Dr. Trishul Muniraju,
Senior Registrar, Department of Anaesthesia and Pain Management, Apollo Hospitals, Bangalore, Karnataka, India.


The Lateral Femoral Cutaneous Nerve is a sensory nerve with a lot of anatomical variations. This article reviews the
latest updates in defining the anatomy of the lateral femoral cutaneous nerve. By understanding the anatomical
variations and the presence of a lateral femoral cutaneous nerve canal it is easier to locate the nerve under sonography and improve the accuracy of blocks. This nerve block is important in both acute post-operative pain and chronic pain condition, also known as Meralgia paresthetica.
Keywords: Meralgia paresthetica, LFCN canal, LFCN Anatomy


1. Hanna A. The lateral femoral cutaneous nerve canal. J Neurosurg. 2017; 126:972-978.
2. Williams A. 2005. Pelvic girdle and lower limb. In: Standring S, editor.Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 39th Ed. Philadelphia, PA: Churchill Livingstone. p 1399–1547
3. Tomaszewski KA, Popieluszko P, Henry BM, Roy J, Sanna B, Kijek MR, et al. The surgical anatomy of the lateral femoral cutaneous nerve in the inguinal region: A meta-analysis. Hernia 2016; 20:649-657.
4. Shannon J, Lang SA, Yip RW. Lateral femoral cutaneous nerve block revisited: a nerve stimulator technique. Reg Anesth. 1995; 20:100-104.
5. Ng I, Vaghadia H, Choi PT, Helmy N. Ultrasound imaging accurately identifies the lateral femoral cutaneous nerve. Anesth Analg. 2008; 107:1070-1074.

How to Cite this Article: Muniraju T, Thondebhavi M | Lateral Femoral Cutaneous Nerve Block | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 19-22.


(Abstract Text HTML)    (Download PDF)

Role of TAP block blue phantom in assessment and quality improvement of the anaesthesia department – A Prospective Study

Vol 3 | Issue 1 | January-June 2022 | Page 13-18 | Vaibhavi Upadhye, Amit Dikshit, Jaya Thakkar, Amrita Prayag

DOI: 10.13107/ijra.2022.v03i01.48

Authors: Vaibhavi Upadhye [1], Amit Dikshit [2], Jaya Thakkar [2], Amrita Prayag [1]

[1] Department of Anaesthesia, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India.
[2] Department of Anaesthesia, Ruby Hall Clinic, Pune, Maharashtra, India.

Address of Correspondence:
Dr. Vaibhavi Upadhye,
Department of Anaesthesia, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India.


Introduction: Ultrasound guided regional anaesthesia is a growing area of interest from the clinical as well as research point of view. Availability of Blue Phantom Mannequin to practice ultrasound guided regional anaesthesia offers a great advantage to trainees in achieving success. It contributes significantly towards the medical training and education of individuals. We considered the use of this technology to facilitate the performance of regional anaesthesia by practicing anaesthesiologists.
Methods: Prospective, comparative study conducted among working anaesthesia consultants and trainees. A pre-teaching assessment was obtained from the participants which was followed by training and practice. At the end of this, a post-training assessment was carried out.
Results: Of the 25 participants, 13 (52.0%) had less than 24 months of experience and 12 (48.0%) had an experience of more than 24 months. Probe stability and needle visualization differed significantly in the pre and post training sessions (p=0.001). Distribution of target reached and obtaining image optimization also differed significantly in the pre and post teaching sessions (p= 0.014 and 0.001 respectively). Identification of structures differed significantly at pre teaching and post teaching sessions (p=0.001).
Conclusion: Study concludes that TAP Block blue phantom is beneficial in improving the skill set of all the participants. Inexperienced candidates with less than 24 months experience rapidly mastered basic ultrasound skills, allowing them to successfully perform an interventional procedure. We recommend simulation training for quality improvement of anaesthesia department. Further educational efforts may be directed at validating the efficacy of TAP block blue phantom simulation training to enhance technical skills and reduce performance times.
Keywords: TAP block, Blue Phantom, Simulation


1.Rafi A. N. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia. 2001;56(10):1024–1026.
2.Rozen W. M., Tran T. M. N., Ashton M. W., Barrington M. J., Ivanusic J. J., Taylor G. I. Refining the course of the thoracolumbar nerves: A new understanding of the innervation of the anterior abdominal wall. Clinical Anatomy. 2008;21(4):325–333. doi: 10.1002/ca.20621.
3. Chapman GA, Johnson D, Bodenham AR. Visualisation of needle
position using ultrasonography. Anaesthesia. 2006;61:148Y158.
4.Oxford University Press. Available at:
5. Gordon JA, Wilkerson WM, Shaffer DW, Armstrong EG. “Practicing” medicine without risk: student’s and educators responses to high-fidelity patient simulation. Acad Med 2001; 76: 469-472.]
6. Issenberg SB, Scalesa RJ. Best evidence on high-fidelity simulation: what clinical teachers need to know. Clin Teach 2007; 4: 73-77.]
7. S Barry Issenberg ,William C McGaghie, Emil R Petrusa, David Lee Gordon, Ross J Scalese. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. 2005 Jan;27(1): 10-28.doi: 10.1080/01421590500046924.
8. Sites BD, Chan VW, Neal JM, et al. The American Society of Regional Anaesthesia and Pain Medicine and the European Society of Regional Anaesthesia and Pain Therapy Joint Committee recommendations for education and training in ultrasound-guided regional anaesthesia. Reg Anesth Pain Med 2009; 34: 40-46.
9. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ.Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10–28.
10. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med 2008;15: 988-994.
11. Syed Farjad Sultan, George Shorten, Gabriella Iohom et all Med Ultrason 2013, Vol. 15, no. 2, 125-131 DOI: 10.11152/mu.2013.2066.152.sfs1gs2
12. Blue Phantom TM Select Series Nerve Block Ultrasound Phantom. Kirkland, Washington: Advanced Medical Technologies LLC.
13. Fitts PI, Posner MI. Learning and skilled performance. In: Fitts PI, Posner MI, eds. Human Performance. London: Prentice/Hall, Inc; 1973:8–25.
14. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2003;79:S70–S81.
15. Sullivan ME, Ortega A, Wasserberg N, Kaufman H, Nyquist J, Clark R. Assessing the teaching of procedural skills: can cognitive task analysis add to our traditional teaching methods? Am J Surg. 2008;195:20–23.
16. Velmahos GC, Toutouzas KG, Sillin LF, et al. Cognitive task analysis for teaching technical skills in an inanimate surgical skills laboratory. Am J Surg. 2004;187:114–119.
17. Bernard Rosner. Fundamentals of Biostatistics, 2000, 5 th Edition, Duxbury, page 80-240.
18. Robert H Riffenburg. Statistics in Medicine 2005, 2 nd Edition, Academic press. 85-125.
19. Sunder Rao P, Richard J, An Introduction to Biostatistics, A manual for students in health sciences, New Delhi: Prentice hall of India. 2006; 4 th Edition, 86-160.
20. Graham Hocking, Simon Hebard, Christopher H. Mitchell. A review of the benefits and pitfalls of Phantoms in Ultrasound-Guided Regional Anaesthesia. Reg Anesth Pain Med 2011;36:162-170

How to Cite this Article: Upadhye V, Dikshit A, Thakkar J, Prayag A | Role of TAP block blue phantom in assessment and quality improvement of the anaesthesia department – A Prospective Study | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 13-18.


(Abstract Text HTML)    (Download PDF)

Phantom Limb Pain- Mechanism and Evidence Based Management

Vol 3 | Issue 1 | January-June 2022 | Page 08-12 | Rajendra Sahoo

DOI: 10.13107/ijra.2022.v03i01.47

Authors: Rajendra Sahoo [1]

[1] Department of Pain & Palliative Medicine, Kalinga Institute of Medical Sciences, KIIT Deemed University, Bhubaneswar, Odisha, India.

Address of Correspondence:
Dr. Rajendra Sahoo,
Senior Consultant, Department of Pain & Palliative Medicine, Kalinga Institute of Medical Sciences, KIIT Deemed University, Bhubaneswar, Odisha, India.


Phantom limb pain (PLP) is a complex condition resulting in manifestation of pain in the missing body part. PLP is very common in post-amputated individuals and the prevalence rate of as high as 80% has been reported in amputees. PLP leads to a poor quality of life and has a tremendous impact on socioeconomic status of individuals. The mechanism of pain in PLP is still poorly understood despite significant research involving the molecular and neurobiology of the pain. Similarly, various pharmacological and non-pharmacological therapies are described in the literature. This article aims at briefly reviewing the existing literature pertaining to the PLP mechanism and evidence based treatment.


1. Ephraim PL, Wegener ST, MacKenzie EJ, et al. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil 2005;86(10): 1910–1919.
2. Nikolajsen L and Jensen TS. Phantom limb pain. Br J Anesth 2001; 87(1): 107–16.
3. Whyte AS and Carroll LJ. A preliminary examination of the relationship between employment, pain and disability in an amputee population. Disabil Rehabil 2002;24(9): 462–470.
4. Barbin J, Seetha V, Casillas J-M, Paysant J, Perennou D. The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review. Ann Phys Rehabil Med. 2016;59(4):270–275.
5. Privitera R, Birch R, Sinisi M, Mihaylov IR, Leech R, Anand P. Capsaicin 8% patch treatment for amputation stump and phantom limb pain: a clinical and functional MRI study. J Pain Res. 2017;10:1623.
6. Bosmans JC, Geertzen JHB, Post WJ, et al. Factors associated with phantom limb pain: a 31/2-year prospective study. Clinical Rehabilitation 2010; 24(5): 444–453.
7. Davidson JH, Khor KE and Jones LE. A cross-sectional study of post-amputation pain in upper and lower limb amputees, experience of a tertiary referral amputee clinic. Disabil Rehabil 2010; 32(22): 1855–1862.
8. Dickinson BD, Head CA, Gitlow S, et al. Maldynia: pathophysiology and management of neuropathic and maladaptive pain – a report of the AMA council on science and public health. Pain Med 2010; 11(11): 1635–1653.
9. Baron R. Mechanisms of disease: neuropathic pain – a clinical perspective. Nat Clin Pract Neurol 2006; 2(2):95–106.
10. Ramachandran VS, Brang D and McGeoch PD. Dynamic reorganization of referred sensations by movements of phantom limbs. NeuroReport 2010; 21(10):727–730.
11. Chapman C. Neuromatrix theory. J Pain 1996; 5(2):139–142.
12. Robinson L, Czerniecki J, Ehde D, et al. Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study. Arch Phys Med Rehabil 2004;85(1): 1–6.
13. Spiegel DR, Lappinen E, Gottlieb M. A presumed case of phantom limb pain treated successfully with duloxetine and pregabalin. Gen Hosp Psychiatry. 2010;32(2):228.e5-7.
14. Bone M, Critchley P, Buggy DJ. Gabapentin in postamputation phantom limb pain: a randomized, double-blind, placebo-controlled, cross-over study. Reg Anesth Pain Med. 2002;27(5):481–486.
15. Smith DG, Ehde DM, Hanley MA, et al. Efficacy of gabapentin in treating chronic phantom limb and residual limb pain. J Rehabil Res Dev. 2005;42(5):645–654.
16. Nikolajsen L, Finnerup NB, Kramp S, et al. A randomized study of the effects of gabapentin on postamputation pain. Anesthesiology 2006; 105(5): 1008–1015
17. Abbass K. Efficacy of gabapentin for treatment of adults with phantom limb pain. Ann Pharmacother. 2012;46(12):1707–1711.
18. Harden RN, Houle TT, Remble TA, et al. Topiramate for phantom limb pain: a time-series analysis. Pain Med 2005; 6(5): 375–378.
19. Jaeger H and Maier C. Calcitonin in phantom limb pain: a double-blind study. Pain 1992; 48: 21–27.
20. Eichenberger U, Neff F, Sveticic G, et al. Chronic phantom limb pain: the effects of calcitonin, ketamine, and their combination on pain and sensory thresholds. Anesth Analg 2008; 106(4): 1265–1273.
21. Nikolajsen L, Hansen CL, Nielsen J, et al. The effect of ketamine on phantom pain: a central neuropathic disorder maintained by peripheral input. Pain 1996; 67(1): 69–77.
22. Ben Abraham R, Marouani N, Kollender Y, et al. Dextromethorphan for phantom pain attenuation in cancer amputees: a double-blind crossover trial involving three patients. Clin J Pain 2002; 18(5): 282–285.
23. Wiech K, Kiefer RT, Töpfner S, et al. A placebo-controlled randomized crossover trial
of the N-methyl-D-aspartic acid receptor antagonist, memantine, in patients with
chronic phantom limb pain. Anesth Analg 2004; 98(2): 408–413.
24. Schley M, Topfner S, Wiech K, et al. Continuous brachial plexus blockade in combination with the NMDA receptor antagonist memantine prevents phantom pain in acute traumatic upper limb amputees. Eur J Pain 2007; 11(3): 299–308.
25. Huse E, Larbig W, Flor H, et al. The effect of opioids on phantom limb pain and cortical reorganization. Pain 2001; 90(1–2): 47–55.
26. Wu C, Tella P, Staats P, et al. Analgesic effects of intravenous lidocaine and morphine on postamputation pain: a randomized double-blind, active placebocontrolled, crossover trial. Anesthesiology 2002; 96(2):841–848.
27. Wu C, Agarwal S, Tella P, et al. Morphine versus mexiletine for treatment of postamputation pain: a randomized, placebo-controlled, crossover trial. Anesthesiology 2008; 109(2): 289–296.
28. Barbin J, Seetha V, Casillas JM, Paysant J, Pérennou D. The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review. Ann Phys Rehabil Med. 2016 Sep;59(4):270-5.
29. Richardson C, Kulkarni J. A review of the management of phantom limb pain: challenges and solutions. J Pain Res. 2017;10:1861-1870.
30. Alviar MJ, Hale T, Dungca M. Pharmacologic interventions for treating phantom limb pain. Cochrane Database Syst Rev. 2016;10(10):CD006380.

How to Cite this Article: Sahoo R | Phantom Limb Pain- Mechanism and Evidence Based Management | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 08-12.


(Abstract Text HTML)    (Download PDF)

Management of Patient with Limb Girdle Muscular Dystrophy for ERCP and Regional Anaesthesia for Laparoscopic Cholecystectomy: Case Report

Vol 3 | Issue 1 | January-June 2022 | Page 27-30 | Shalini Saksena , Arnab Paul

DOI: 10.13107/ijra.2022.v03i01.051

Authors: Shalini Saksena [1], Arnab Paul [1]

[1] Department of Anaesthesia, PD Hinduja National Hospital & MRC, Mahim, Mumbai, Maharashtra, India.

Address of Correspondence:
Dr. Arnab Paul,
Department of Anaesthesia, PD Hinduja National Hospital & MRC, Mahim, Mumbai, Maharashtra, India.


Limb-Girdle muscular dystrophies (LGMDs) are a clinically and genetically heterogeneous group of disorders characterized in general by predominantly limb-girdle weakness. It manifests as proximal muscle weakness involving the pelvic girdle and scapular girdle. We report the anaesthetic management of a patient who is a known case of limb-girdle muscular dystrophy, presented with cholecystitis to our institution. Patient underwent endoscopic retrograde cholangio pancreatography (ERCP) under total intravenous anaesthesia followed by laparoscopic cholecystectomy under spinal anaesthesia which were managed successfully.
Keywords: Muscular Dystrophies, Limb-Girdle, Malignant Hyperthermia, Anaesthesia


1. Jayadev S. Muscular Dystrophies. Brenner’s Encyclopedia of Genetics 2013; 2: 522-4.
2. Allen T, Maguire S. Anaesthetic management of a woman with autosomal recessive limb-girdle muscular dystrophy for emergency caesarean section. Int J Obstet Anesth 2007; 16:370–374.
3. Iyadurai SJ, Kissel JT. The Limb-Girdle Muscular Dystrophies and the Dystrophinopathies. Continuum (Minneap Minn). 2016;22(6, Muscle and Neuromuscular Junction Disorders):1954–77
4. Chu ML, Moran E. The limb-girdle muscular dystrophies: is treatment on the horizon? Neurotherapeutics. 2018; 15:849–62.
5. Richa FC. Anaesthetic management of a patient with limb-girdle muscular dystrophy for laparoscopic cholecystectomy. Eur J Anaesthesiol 2011; 28:72–73.
6. Segura LG, Lorenz JD, Weingarten TN, et al. Anaesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures. Paediatr Anaesth 2013; 23:855–864.
7. Kim TW, Nemergut ME. Preparation of modern Anaesthesia workstations for malignant hyperthermia-susceptible patients: a review of past and present practice. Anesthesiology. 2011;114(1):205–12.
8. Wappler F. Anaesthesia for patients with a history of malignant hyperthermia. Curr Opin Anaesthesiol. 2010;23(3):417–22.
9. Bajwa SJ, Kulshrestha A. Anaesthesia for laparoscopic surgery: General vs regional anaesthesia. J Min Access Surg 2016; 12:4-9.
10. Catani M, Guerricchio R, De Milito R, et al. ‘Low-pressure’ laparoscopic cholecystectomy in high-risk patients (ASA III and IV): our experience. Chir Ital 2004; 56:71–80.
11. Van Obbergh LJ, Corteel J, Papadopoulos J, et al. Anaesthesia for a child suffering from a deletion in the Xp21 loci resulting in Duchenne disease, glycerol kinase deficiency and congenital adrenal hypoplasia. Paediatr Anaesth 2011; 21:1085–87.

How to Cite this Article: Saksena S, Paul A | Management of Patient With Limb Girdle Muscular Dystrophy for ERCP and Regional Anaesthesia for Laparoscopic Cholecystectomy: Case Report | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 27-30.


(Abstract Text HTML)    (Download PDF)

Dual Guidance in the Era of Ultrasound: An Overlooked Necessity or a Luxury!

Vol 3 | Issue 1 | January-June 2022 | Page 35-36 | Vedhika Shanker, Tuhin Mistry, Gurumoorthi Palanichamy, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i01.53

Authors: Vedhika Shanker [1], Tuhin Mistry [1], Gurumoorthi Palanichamy [1], Jagannathan Balavenkatasubramanian [1]

[1] Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.

Address of Correspondence
Dr. Tuhin Mistry,
Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.

Short Communication

Real-time ultrasonography (USG) guidance has revolutionized the practice of regional anesthesia (RA). As an adjunct to USG, nerve stimulation has been advocated for accurate and safe delivery of local anesthetic (LA) while performing peripheral nerve blocks [1]. This letter highlights the importance of dual guidance infraclavicular brachial plexus block (BPB) in a polytrauma patient for forearm surgery.
A 54-year-old male was brought to the emergency with an alleged history of a road traffic accident and multiple injuries, including left middle third clavicle fracture, bilateral multiple rib fractures, closed distal third both bones fracture of right forearm, scalp hematoma of the left parietal area, and left-sided pneumothorax. On arrival at the resuscitation bay, the overall pain score was 9/10 on a numeric rating scale. An intercostal drain was inserted, and he had been placed on noninvasive ventilation (NIV). A multimodal analgesia regimen was started, including continuous thoracic epidural, intravenous paracetamol 15 mg/kg, tramadol 2 mg/kg, and transdermal 10 mg buprenorphine patch. The patient has been on regular treatment for type 2 diabetes mellitus and hypertension for 15 years. He had suffered two episodes of myocardial infarction 8 years ago, for which he had undergone percutaneous transluminal coronary angioplasty and was on dual antiplatelet therapy. The transthoracic echocardiography revealed mild left ventricular hypertrophy, hypokinetic posterior, lateral, and inferior walls with a left ventricular ejection fraction of 40%. He also suffered an ischemic cerebrovascular accident involving the left middle cerebral artery 6 years ago. The patient had residual weakness of the right-sided hemiparesis, dysphagia, and slurring of speech. He was scheduled for open reduction and internal fixation with plating both right forearm bones 3 days after admission. The plan was to provide surgical anesthesia with a right-sided diaphragm sparing BPB. The anesthesia plan was explained to the patient and relatives, and informed written consent was obtained.
The patient was positioned supine with head-end elevation at 30° in the operation theater, and the ipsilateral arm was abducted. Standard monitors were attached, and a scout scan was performed with a high-frequency linear array transducer (Sonosite HFL 38xp/13–6 MHz; Fujifilm SonoSite Inc., Bothell, WA, USA) to assess the viability of the anesthetic plan (Fig. 1a). The right infraclavicular BPB was performed under dual guidance (USG and electrostimulatilation) with a 100 mm nerve block needle and 15 ml 0.75% ropivacaine and 4 mg dexamethasone was administered (Fig. 1b). Each cord of the brachial plexus was simulated separately, and 5 ml of LA was deposited after obtaining desired responses at <0.5 mA current, 0.1 ms impulse duration, and a frequency of 2 Hz. The lateral, posterior, and medial cords were identified by elbow flexion, wrist extension, and wrist flexion, respectively. The block was successful, and the procedure went off without any complications.
BPB above the clavicle is widely practiced for various upper limb surgeries. We ruled out this option to avoid inadvertent phrenic nerve palsy. Our patient was on intermittent NIV, and the procedure was undertaken once the patient could tolerate NIV-free periods without any respiratory distress. However, the challenge of the patient’s inability to lie supine remained. The costoclavicular approach could not be instituted as the patient had a right-sided subclavian central venous catheter. Hence, correct transducer placement and proper visualization of the brachial plexus were not possible (Fig. 1c). We also excluded the possibility of axillary BPB due to the presence of fungal skin infection. We opted for USG guided infraclavicular BPB, but discrimination of individual cords was not feasible. Hence, we used a combination of ultrasound and nerve stimulation for a sure-fire successful RA technique.
A successful infraclavicular BPB can be achieved either with electrostimulation or ultrasound guidance in experienced hands. However, USG shortens performance time compared to the dual-motor endpoint stimulation [2]. Although the LA deposition at a single point, cranioposterior to the axillary artery, could result in successful infraclavicular BPB, the success rate was reported to be higher with multiple-injection (53–100%) [4]. Gurkan et al. reported a similar success rate between dual guidance (95%) and single motor endpoint stimulation (93%) [5]. Hence, the use of ultrasound without neurostimulation may be sufficient to achieve a successful infraclavicular BPB. However, in particular cases, electrostimulation as an adjunct may help in the identification of individual cords based on the motor response as well as act as a safety monitor to prevent intraneural injection [1].
To conclude, Dual guidance was necessary for our patient to perform the infraclavicular BPB. Ultrasound helped in real-time visualization of spread and reduced the LA volume, while peripheral nerve stimulation aided in accurate localization of cords with evoked motor responses.


1. Gadsden JC. The role of peripheral nerve stimulation in the era of ultrasound-guided regional anaesthesia. Anaesthesia 2021;76 Suppl 1:65-73.
2. Brull R, Lupu M, Perlas A, Chan VW, McCartney CJ. Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance. Can J Anaesth 2009;56:812-8.
3. Dingemans E, Williams SR, Arcand G, Chouinard P, Harris P, Ruel M, et al. Neurostimulation in ultrasound-guided infraclavicular block: A prospective randomized trial. Anesth Analg 2007;104:1275-80.
4. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad Ø. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: A randomized, controlled, observer-blinded, comparative study. Anesth Analg 2008;106:1910-5.
5. Gurkan Y, Acar S, Solak M, Toker K. Comparison of nerve stimulation vs. ultrasound-guided lateral sagittal infraclavicular block. Acta Anaesthesiol Scand 2008;52:851-5.

How to Cite this Article: Shanker V, Mistry M, Palanichamy G, Balavenkatasubramanian J | Dual Guidance in the Era of Ultrasound: An Overlooked Necessity or a Luxury! | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 35-36.


(Abstract Text HTML)    (Download PDF)