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Current Concepts in Postoperative Pain Management Surgeries of Hip Joint: A Narrative Review

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Vol 3 | Issue 2 | July-December 2022 | Page 49-55 | Anju Gupta, Mallika Kaushal, Amit Malviya, Shalender Kumar, Sandeep Diwan

DOI: 10.13107/ijra.2022.v03i02.056

Authors: Anju Gupta [1], Mallika Kaushal [1], Amit Malviya [1], Shalender Kumar [1], Sandeep Diwan [2]

[1] Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.
[2] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Anju Gupta,
Assistant Professor, Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.
E-mail: drajugupta09@gmail.com

Abstract

Hip surgery is a common surgical procedure in the elderly and leads to significant pain postoperatively. The hip joint has a complex innervation which is unlikely to be covered with any single modality of pain relief. Multimodal analgesia has been critical in facilitating early recovery and rehabilitation in these patients. Regional analgesia is an important component of multimodal analgesia regimens and is instrumental in achieving optimal patient outcomes. Single shot or continuous central or peripheral nerve blocks provide effective and safe postoperative analgesia, lower opioid consumption, faster rehabilitation, and a high level of patient satisfaction. An ideal regional anaesthesia technique for hip surgery should be motor sparing while providing effective perioperative pain relief. Regional anaesthesia has seen enormous growth in the recent past due to advances in technology and research. These blocks have shown analgesic efficacy, have an opioid-sparing effect, and enable better patient positioning for central neuraxial blocks. Some of the novel interfascial plane blocks like Pericapsular Nerve Group (PENG) block are now being explored for hip analgesia. Within a few years of being described, these novel nerve blocks have seen tremendous favour in the literature and are being extensively used in the current practice of analgesia for hip surgery. In the present review, we aim to discuss the various modalities of analgesia which have been utilised in the past and would discuss few of the newer blocks for hip surgery.
Keywords: Nerve blocks, Ultrasonography, Analgesics, Total hip arthroplasty, Fascia illiaca block,
Multimodal analgesia, Transmuscular, Quadratus lumborum block

References

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16. Singelyn FJ, Ferrant T, Malisse MF, Joris D. Effects of patient controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total hip arthroplasty. Reg Anesth Pain Med. 2005;30:452-7
17. Nishio S, Fukunishi S, Fukui T, Fujihara Y, Okahisa S, Takeda Y et al. Comparison of continuous femoral nerve block with and without combined sciatic nerve block after total hip arthroplasty: a prospective randomized study. Orthop Rev (Pavia). 2017;9(2):7063
18. Kuchálik J, Granath B, Ljunggren A, Magnuson A, Lundin A, Gupta A. Postoperative pain relief after total hip arthroplasty: a randomized, double-blind comparison between intrathecal morphine and local infiltration analgesia. Br J Anaesth. 2013;111(5):793-9
19. Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. The efficacy of intraoperative periarticular injection in total hip arthroplasty: a systematic review and meta-analysis. BioMed Central Musculoskeletal Disorders. 2019;20:269
20. Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg. 1989;69:705-13
21. O’Reilly N, Desmet M, Kearns R. Fascia iliaca compartment block. BJA education. 2019;19(6):191-7
22. Zhang X, Ma J. The efficacy of fascia iliaca compartment block for pain control after total hip arthroplasty: a meta-analysis. Journal of orthopaedic surgery and research. 2019;14:33
23. Hong H, Ma Y. The efficacy of fascia iliaca compartment block for pain control after hip fracture: a meta-analysis. Medicine. 2019;98:28(e16157)
24. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-7
25. Tulgar S, Senturk O. Ultrasound guided erector spinae plane block at L-4 transverse process level provides effective postoperative analgesia for total hip arthroplasty. Journal of clinical anaesthesia. 2018;44:68
26. Azevedo AS, Fernandes HS, Júnior WC, Hamaji A, Ashmawi A. Lumbar erector spinae plane block for total hip arthroplasty analgesia. Case report. BrJP. São Paulo. 2021;4(1):91-3
27. Mujahid OM, Dey S, Nagalikar S, Arora P, Dey CK. Ultrasound-guided lumbar ESP block for post-operative analgesia as an alternative mode of analgesia in hip arthroplasty with multiple systemic issues: a case report. Ain-Shams Journal of Anesthesiology. 2021;13:47
28. Singh S, Ranjan R, Lalin D. A new indication of erector spinae plane block for perioperative analgesia is total replacement surgery – A case report. Indian J Anaesth. 2019;63(4):310-1
29. Kinjo S, Schultz A. Continuous lumbar erector spinae plane block for postoperative pain management in revision hip surgery: a case report. Rev Bras Anestesiol. 2019;69(4):420-2
30. Ahiskalioglu A, Tulgar S, Celik M, Ozer Z, Alici HA, Aydin ME. Lumbar erector spinae plane block as a main anesthetic method for hip surgery in high risk elderly patients: initial experience with a magnetic resonance imaging. Eurasian J Med. 2020;52(1):16-20
31. Xu L, Leng JC, Elsharkawy H, Hunter OO, Harrison TK, Vokach-Brodsky L et al. Replacement of fascia iliaca catheters with continuous erector spinae plane blocks within a clinical pathway facilitates early ambulation after total hip arthroplasty. Pain Medicine. 2020;21(10):2423-9
32. Blanco R. TAP block under ultrasound guidance: the description of a ‘non pops technique’. Reg Anesth Pain Med. 2007;32:130
33. Gupta A, Sondekoppam R, Kalagara H. Quadratus Lumborum Block: A technical review. Curr Anesthesiol Rep. 2019;9:257-62
34. Tiwari P, Bhatia R, Asthana V, Maheshwari R. Role of ultrasound-guided lumbar “Erector spinae plane block” and ultrasound-guided transmuscular “Quadratus lumborum block” for postoperative analgesia after hip surgeries: A randomized, controlled study. Indian Anaesth Forum. 2021;22:60-6
35. Li J, Wei C, Huang J, Li Y, Liu H, Liu J et al. Efficacy of quadratus lumborum block for pain control in patients undergoing hip surgeries: a systematic review and meta-analysis. Front Med. 2022;8:771859
36. Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) block for hip fracture. Regional Anesthesia and Pain Medicine. 2018;43:859-63
37. Pascarella G, Costa F, Del Buono R, Pulitano R, Strumia A, Piliego C et al. Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial. Anaesthesia. 2022;76:1492-8
38. Teles AS, Altinpulluk EY, Sahoo RK, Galluccio F, Simón DG, İnce İ et al. Beyond the Pericapsular Nerve Group (PENG) block; a narrative review. Turk J Anaesthesiol Reanim. 2022;50(3):167-72.

How to Cite this Article: Gupta A, Kaushal M, Malviya A, Kumar S, Diwan S | Current Concepts in Postoperative Pain Management Surgeries of Hip Joint: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 49-55.

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Time to adequately heed Acute Pain in the Emergency Department – More Regional Blocks Warranted

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Vol 3 | Issue 2 | July-December 2022 | Page 37-41 | Tom C. R. V. Van Zundert, André A. J. Van Zundert

DOI: 10.13107/ijra.2022.v03i02.054

Authors: Tom C. R. V. Van Zundert [1, 2], André A. J. Van Zundert [2, 3]

[1] Department of Emergency Medicine, Holy Heart Hospital, Mol, Belgium.
[2] Udayana University, Bali, Indonesia.
[3] Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital and The University of Queensland, Brisbane, QLD, Australia.

Address of Correspondence
Professor André A.J. Van Zundert,
Professor and Chair of Anaesthesiology, Royal Brisbane and Women’s Hospital & The University of Queensland, Brisbane, QLD, Australia.
E-mail: vanzundertandre@gmail.com

Introduction

All healthcare stressors converge in the emergency department (ED), which sees an annual increase of 6-7% with more than 25 million patient visits in the UK. This translates to 44,435 attendances per 100,000 population in the period 2019-2020 [1]. Acute pain is the primary reason patients seek emergency medical care. Consequently, substandard acute pain treatment is one of the most frequently heard complaints and has been labelled as a public health problem [2]. Pain remains under-acknowledged, -assessed and -treated, mainly in case of overcrowding in the ED and especially in the more vulnerable groups, including the elderly and children. Many patients express an initial pain score of 10 out of 10 on the visual analogue scale (VAS) in the ED. Generally, initial pain treatment combines oral acetaminophen, NSAID and/or (IV) opioids. Nevertheless, despite these pain killers, most patients continue to suffer and score their pain at 8/10 or higher. Untreated pain can have both short- and long-term effects, including sensitisation to pain episodes in later life [3].

Most visits to the emergency department involve patients with conditions that include: a) injuries and trauma from (motor vehicle) accidents, physical assaults or falls, with or without circulatory shock; b) cardiovascular and cerebral attacks or loss of consciousness; c) severe pain of diverse causes, both acute and chronic origin; d) acute worsening of a serious illness or disease, including problems with breathing and bleeding; e) mental illness; f) burns; g) anaphylactic and allergic reactions; g) drug overdoses and poisoning; and h) pregnancy-related complications. In most of these cases, patients present with pain as a substantial factor.

Keywords: Emergency department, Hip fracture, Pain, Regional anaesthesia, Nerve blocks, Ultrasonography

References

1. NHS Report. Hospital Accident & Emergency Activity 2020-21. 30.09.2021. https://digital.nhs.uk/data-and-information/publications/statistical/hospital-accident–emergency-activity/2020-21# (accessed 20.05.2022).
2. Keating L, Smith S. Acute Pain in the Emergency Department: The Challenges. Rev Pain. 2011;5(3):13-17.
3. Duggan NM, Nagdev A, Hayes BD, Shokoohi H, Selame LA, Liteplo AS, Goldsmith AJ. Perineural Dexamethasone as a Peripheral Nerve Block Adjuvant in the Emergency Department: A Case Series. J Emerg Med. 2021 Nov;61(5):574-580.
4. Verbeek T, Adhikary S, Urman R, Liu H. The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery. Curr Pain Headache Rep. 2021 Mar 11;25(4):22.
5. Veronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury 2018;49:1458-1460.
6. Amin NH, West JA, Farmer T, Basmajian HG. Nerve Blocks in the Geriatric Patient With Hip Fracture: A Review of the Current Literature and Relevant Neuroanatomy. Geriatr Orthop Surg Rehabil. 2017 Dec;8(4):268-275.
7. Salottolo K, Meinig R, Fine L, Kelly M, Madayag R, Ekengren F, Tanner A, Roman P, Bar-Or D. A multi-institutional prospective observational study to evaluate fascia iliaca compartment block (FICB) for preventing delirium in adults with hip fracture. Trauma Surgery & Acute Care Open 2022;7:e000904.
8. Hao J, Dong B, Zhang J, Luo Z. Pre-emptive analgesia with continuous fascia iliaca compartment block reduces postoperative delirium in elderly patients with hip fracture. A randomized controlled trial. Saudi Med J. 2019 Sep;40(9):901-906.
9. Lee HK, Kang BS, Kim CS, Choi HJ. Ultrasound-guided regional anaesthesia for the pain management of elderly patients with hip fractures in the emergency department. Clin Exp Emerg Med. 2014 Sep 30;1(1):49-55.
10. Hards M, Brewer A, Bessant G, Lahiri S. Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review. Prehosp Disaster Med. 2018 Jun;33(3):299-307.
11. Okereke IC, Abdelmonem M. Fascia Iliaca Compartment Block for Hip Fractures: Improving Clinical Practice by Audit. Cureus. 2021;13:e17836. doi: 10.7759/cureus.17836
12. Nice Guidelines. The management of hip fracture in adults. Updated 2019. https://www.nice.org.uk/guidance/cg124/evidence/full-guideline-pdf-183081997 (accessed 24.05.2022).
13. Butler MM, Ancona RM, Beauchamp GA, Yamin CK, Winstanley EL, Hart KW, Ruffner AH, Ryan SW, Ryan RJ, Lindsell CJ, Lyons MS. Emergency Department Prescription Opioids as an Initial Exposure Preceding Addiction. Ann Emerg Med. 2016 Aug;68(2):202-8.
14. Ketelaars R, Stollman JT, van Eeten E, Eikendal T, Bruhn J, van Geffen G-J. Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in The Netherlands. Int J Emerg Med 2018;11:12.
15. Reavley P, Montgomery AA, Smith JE, Binks S, Edwards J, Elder G, Benger J. Randomised trial of the fascia iliaca block versus the ‘3-in-1’ block for femoral neck fractures in the emergency department. Emerg Med J. 2015;32:685-689.
16. Nagel EM, Gantioque R, Taira T. Utilizing Ultrasound-Guided Femoral Nerve Blocks and Fascia Iliaca Compartment Blocks for Proximal Femur Fractures in the Emergency Department. Adv Emerg Nurs J. 2019 Apr/Jun;41(2):135-144.
17. Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med. 2018 Aug;36(8):1391-1396.
18. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM. 2016 Jan;18(1):37-47.
19. Jaffe TA, Shokoohi H, Liteplo A, Goldsmith A. A Novel Application of Ultrasound-Guided Interscalene Anaesthesia for Proximal Humeral Fractures. The Journal of Emergency Medicine. 2020;59:265-269.
20. De Buck F, Devroe S, Missant C, Van de Velde M. Regional anaesthesia outside the operating room: indications and techniques. Curr Opin Anaesthesiol. 2012 Aug;25(4):501-7.
21. Steenberg J, Møller AM. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation. Br J Anaesth. 2018 Jun;120(6):1368-1380.
22. Scarpa J, Wu CL. The role for regional anaesthesia in medical emergencies during deep space flight. Reg Anesth Pain Med. 2021 Oct;46(10):919-922.
23. Cappelleri G, Fanelli A, Ghisi D, Russo G, Giorgi A, Torrano V, Lo Bianco G, Salomone S, Fumagalli R. The Role of Regional Anaesthesia During the SARS-CoV2 Pandemic: Appraisal of Clinical, Pharmacological and Organizational Aspects. Front Pharmacol. 2021 Jun 4;12:574091.
24. Wiercigroch D, Ben-Yakov M, Porplycia D, Friedman SM. Regional anaesthesia in Canadian emergency departments: Emergency physician practices, perspectives, and barriers to use. CJEM. 2020 Jul;22(4):499-503.
25. Herring AA. Bringing Ultrasound-guided Regional Anaesthesia to Emergency Medicine. AEM Educ Train. 2017 Mar 29;1(2):165-168.

How to Cite this Article: Van Zundert TCRV, Van Zundert AAJ | Time to Adequately Heed Acute Pain in the Emergency Department- More Regional Blocks Warranted | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 37-41.

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Clinical Pearl for a Successful and Safe PNS Guided Peripheral Nerve Block

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Vol 2 | Issue 2 | July-December 2021 | Page 143-144  | Ritesh Roy, Himjyoti Das, Neha Singh, Surajit Giri, Hetal Vadera, Vrushali Ponde

DOI: 10.13107/ijra.2021.v02i02.044

Authors: Ritesh Roy [1], Himjyoti Das [2], Neha Singh [3], Surajit Giri [4], Hetal Vadera [5], Vrushali Ponde [6]

[1] Department of Anaesthesia and Pain management Care Hospitals, Bhubaneswar, Odisha, India.
[2] Anesthesia and Critical care, Nazareth Hospital, Shillong, Assam, India.
[3] Department of Anesthesiology and Critical care, AIIMS, Bhubaneswar, Odisha, India.
[4] Department of Anesthesia, Pragati Hospital, Sivasagar, Assam, India.
[5] Department of Anaesthesia, Sterling Hospital, Rajkot, Gujarat, India.
[6] Department Anesthesiology, Surya Children Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Vrushali Ponde,
Consultant Paediatric Anaesthesiologist, Surya Children Anaesthesia Services, Mumbai, Maharashtra, India.
E-mail: vrushaliponde@yahoo.co.in

Clinical Pearl for a Successful and Safe PNS Guided Peripheral Nerve Block

PRE OP PREPARATION
 Pre-procedural evaluation with history of antiplatelet or antithrombotic drug use
 Assess neurological status in patient with trauma and neuropathy
 Explain the procedure and complications
 Possibilities of failure of the procedure, multiple injections and conversion to GA must be explained
 Obtain informed written consent

PRE PROCEDURE PREPARATION ( AORA Check list)
 Perform the block in a dedicated block room or in OT
 Confirm the site before starting the procedure
 Block room must be equipped with monitoring devices and equipment
 Ensure all resuscitative emergency drugs, equipment and Intralipid present in the cart
 Secure venous access before performing the procedure
 Connect monitor for ECG, Non-invasive blood pressure (NIBP), and peripheral oxygen saturation

BEFORE GIVING BLOCK
 STOP BEFORE YOU BLOCK: Confirm again about patient and site of block
 Calculate and keep drugs needed for block in labelled syringes ready before the procedure
 Maintain asepsis throughout the procedure
 A small dose of sedative / anxiolytic may be necessary for anxious patients. Infiltrate the injection site with lignocaine.
 Positive electrode is Red, and negative is Black (Positive is attached to patient, negative end is attached to the Needle). Machines may have different colour coding for the electrodes
 PNS stimulation is not possible in patient receiving neuromuscular blocking agent
 Presence of neuraxial anaesthesia doesn’t affect the stimulation of intact motor unit by PNS

BLOCK PROCEDURE
 Always use insulated needle
 For superficial blocks: Use 50 mm needle, current at 1.0 mA.
 For deeper blocks: Use 100 mm needle, current at 1.5 mA
 Set PNS in 0.2ms current duration & frequency at 2 Hz.
 End motor response (EMR) between 0.3mA to 0.5mA is considered safe and ideal (except lumbar plexus block where below 0.5mA is unsafe).
 For children 25mm needle is preferred.
 Repeated aspiration before injection of drug at 3-5ml aliquot is a safe practice.
 Never try to inject against high resistance, use of injection pressure monitoring device is advisable.
 Keep talking to the patient while injecting the drug for early detection of the signs of the toxicity.
 Injection of Dextrose solution is preferred over sodium chloride for hydro dissection as saline will abolish muscle twitches.

DESIRABLE END MOTOR RESPONSE

Nerve Block Response
Interscalene Brachial plexus block Any two contractions of pectoralis major, deltoid, triceps or biceps.
Supraclavicular Brachial plexus block Finger or wrist twitches (flexion or extension)
Infraclavicular Brachial Plexus Block Posterior cord response is desirable (Extension of wrist and fingers)
Axillary Brachial Plexus Block Median nerve- Flexion of first three fingers

Musculocutaneous nerve- Elbow flexion Radial nerve- Fingers extension

Ulnar nerve- Flexion of fourth &little finger along with apposition of thumb towards little finger
Femoral Nerve Block Dancing of patella (Twitches of quadriceps muscle)
Sciatic Nerve Block Planter flexion or dorsi flexion
Lumbar Plexus Block Quadriceps contraction
Ilioinguinal & Iliohypogastric Nerve Block Lower Abdominal muscle & Inguinal region Twitches (T10-L1 territory)
Thoracic Paravertebral Block Corresponding intercostal muscles twitches
Serratus Anterior Plane (SAP) Block Serratus anterior muscle twitches/ Dancing of Scapula.
PEC1 Block Pectoralis Major muscle twitches

AFTER PROCEDURE

 Document the procedure. Date, Time, Needle type, size, disappearance of EMR at what current, setting of the PNS before injection of the drug, injection resistance or ease of injection, tingling or numbness during or immediately after injection, vitals etc.
 Assessment of Dermatome, Myotome and osteotome at 30minute. If all are blocked, then only we can proceed for incision and surgery

 

How to Cite this Article: Roy R, Das H, Singh N, Giri S, Vadera H, Ponde V | Clinical Pearl For A Successful And Safe PNS Guided Peripheral Nerve Block | July-December 2021; 2(2): 143-144.

 

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A Quick Guide: Ultrasound Guided Nerve Blocks

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Vol 2 | Issue 1 | January-June 2021 | Page 02-03 | Vrushali Ponde, Kapil Gupta, Neha Singh

DOI: 10.13107/ijra.2021.v02i01.016

Authors: Vrushali Ponde [1], Kapil Gupta [2], Neha Singh [3]

[1] National President and Ex founder secretary, Academy of Regional Anaesthesia, India.
[2] Department of Anaesthesia, V.M.M.C & Safdarjung Hospital, New Delhi, India.
[3] Department of Anaesthesia, AIIMS, Bhubaneshwar, Odisha, India.

Address of Correspondence
Dr. Vrushali Ponde,
National President and Ex founder secretary, Academy of Regional Anaesthesia, India.
E-mail: vrushaliponde@gmail.com

Ultrasound Machine and Image Acquisition Scanning Preparation
1. Obtain written informed consent for the block- AORA Written Consent Form
2. Re-examine the patient before administering the block
3. Checklist ticked before the block –(anaesthesiologist and nurse to be present)

AORA Checklist
– Ensure we have correct patient/block and marked site/side of block
– Check Documents and Equipment before initiating the procedure
– I.V cannula secured before performing the block
-Minimum ASA standard monitoring (pulse oxymeter, NIBP, ECG) started

4. Ergonomics- Ultrasound machine should be in direct line of sight of the anaesthesiologist performing the block
5. Selection of Pre-Set in certain machines to better visualize that structure (eg: Nerves/ Musculoskeletal/Vascular)
6. Probe selection – High frequency probe (13-6 MHz) for superficial nerves/structures and Low frequency probe (5-2 MHz) for deeper nerves/structures and neuraxial blocks
7. Tegaderm, Cling Wrap or Camera Cover wrapped around the probe for sterility
8. Oxygen administration via ventimask /nasal prongs
9. I.V. sedation like Midazolam /Fentanyl I.V. before initiating the block, but after finishing timeout/checklist
10. Maintenance of strict asepsis during the block procedure- AORA Sterility Precautions
11. Skin infiltration with 1% Lignocaine 1 min before inserting the needle; at the site of needle entry
12. Probe holding: Pen holding method is preferable for most blocks
13. At end of procedure- probe should be cleaned with Soap and water

Image Optimisation
The following movements of the probe can be utilized for optimization of image:
Transducer Movements:
1. Sliding
2. Tilting
3. Rocking
4. Rotation
5. Compression

Needle Approaches
In Plane- Whole length of the needle is visualized
Out of Plane- Only needle tip is visualized

Clinical Pearls
1. Optimize the image by setting the appropriate focus, depth and gain
2. Focus the target in centre of the screen
3. Ensure that the skin sterilizing solution has dried, before inserting the needle for block, as contact of sterilizing solution with the nerve can lead to nerve injury (neuropraxia /neurotemesis /axonotemesis)
4. Incremental injection of Local Anaesthetic in 2-3 ml aliquots after repeated aspiration
5. Stop administration of perineural drug, if the patient complains of pain during injection; as it can be a feature of intraneural injection of drug and lead to nerve injury
6. When using peripheral nerve stimulator, never inject the drug, if muscle contraction occurs at current less than 0.3 MA; as it can be a feature of intraneural (intrafascicular) administration of drug and cause nerve injury
7. Scan with the Colour Doppler while doing Brachial Plexus Block (especially Interscalene and Infraclavicular blocks); to avoid inadvertent intravascular injection
These practical tips decrease the potential complications, making ultrasound guided regional anaesthesia a safer technique. Acquisition of a better image improves the success rate of the block.

From the protocols and guidelines committee of AORA

Dr. Kapil Gupta
Professor, Anesthesiology,
V.M.M.C & Safdarjung Hospital, New Delhi, India.

Dr. Neha Singh
Additional Professor, Anesthesiology,
AIIMS, Bhubaneshwar, Odisha, India.

How to Cite this Article: Ponde V, Gupta K, Singh N | A Quick Guide: Ultrasound-Guided Nerve Blocks | International Journal of Regional Anaesthesia | January-April 2021; 2(1): 02-03.

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