Adjuvants in Peripheral Nerve Blocks

Vol 2 | Issue 1 | January-June 2021 | Page 63-66 | Rudra Deshpande, Harshal Wagh, Satish Kulkarni

Authors: Rudra Deshpande [1], Harshal Wagh [2], Satish Kulkarni [1]

[1] Department of Anaesthesia, Lilavati Hospital & Research Centre, Mumbai, Maharashtra, India.
[2] Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Satish Kulkarni,
Consultant, Department of Anaesthesia, Lilavati Hospital & Research Centre, Mumbai, Maharashtra, India.


An increase in the use of peripheral nerve blocks (PNBs) has been noted in recent years. Not only do these blocks provide adequate anaesthesia intraoperatively, but they are also now the cornerstone of perioperative pain management. Superior pain control, a significant decrease in opioid requirements as well as opioid-related side effects, improved patient satisfaction, earlier discharge from hospital and increasing use with the advancement of ultrasound technology have contributed to the increasing use of peripheral nerve blocks [1-4].
Regional anaesthesia techniques including PNBs have also become the need of the hour in recent times of the Covid19 pandemic. As per recent practice recommendations (American Society of Regional Anaesthesia May 2020), Regional anaesthesia is preferred to avoid aerosol-generating procedures associated with General anaesthesia [5].

For postoperative pain management, PNBs are used as a single injection or as a continuous catheter infusion. Single-injection nerve blocks are more commonly done as they are technically easier and quicker. They provide superior analgesia in the immediate postoperative period for various procedures in which the pain intensity is high initially and reduces over significantly over time. Oral analgesics may be effective by then as the effect of PNBs is wearing off gradually over 12 to 24 hours. Rebound pain can however be a significant problem [6]. Continuous catheter techniques are not only technically challenging but require greater monitoring and are prone to secondary block failures due to catheter blockage and displacement [7]. They are labour and resource intensive. Hence the need for adjuvants that will help prolong the duration of PNBs and avoid the placement of continuous catheters has been part of the quest of regional anaesthesiologists. Multiple classes of drugs have been tested as adjuvants in the past. Some have stood the test of time and helped improve the practice of regional anaesthesia while others proved more detrimental. Discussed below are some of the adjuvants that have been successfully used (Table 1).


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2. Liu Q, Chelly JE, Williams JP, Gold MS. Impact of peripheral nerve block with low dose local anesthetics on analgesia and functional outcomes following total knee arthroplasty: a retrospective study. Pain Med. 2015;16(5):998-1006.
3. Lenart MJ, Wong K, Gupta RK, Mercaldo ND, Schildcrout JS, Michaels D, et al. The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery. Pain Med. 2012;13(6):828-34.
4. Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev. 2014;2014(5):Cd009941.
5. Uppal V, Sondekoppam RV, Lobo CA, Kolli S, Kalagara HK. Practice recommendations on neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic. ASRA/ESRA COVID-19 Guidance for Regional Anesthesia March. 2020;31.
6. Nobre LV, Cunha GP, Sousa P, Takeda A, Cunha Ferraro LH. [Peripheral nerve block and rebound pain: literature review]. Rev Bras Anestesiol. 2019;69(6):587-93.
7. Ahsan ZS, Carvalho B, Yao J. Incidence of failure of continuous peripheral nerve catheters for postoperative analgesia in upper extremity surgery. J Hand Surg Am. 2014;39(2):324-9.
8. Karaman S, Kocabas S, Uyar M, Hayzaran S, Firat V. The effects of sufentanil or morphine added to hyperbaric bupivacaine in spinal anaesthesia for Caesarean section. Eur J Anaesthesiol. 2006;23(4):285-91.
9. Axelsson K, Johanzon E, Essving P, Weckström J, Ekbäck G. Postoperative extradural analgesia with morphine and ropivacaine. A double-blind comparison between placebo and ropivacaine 10 mg/h or 16 mg/h. Acta Anaesthesiologica Scandinavica. 2005;49(8):1191-9.
10. Flory N, Van-Gessel E, Donald F, Hoffmeyer P, Gamulin Z. Does the addition of morphine to brachial plexus block improve analgesia after shoulder surgery? British Journal of Anaesthesia. 1995;75(1):23-6.
11. Alemanno F, Ghisi D, Fanelli A, Faliva A, Pergolotti B, Bizzarri F, et al. Tramadol and 0.5% levobupivacaine for single-shot interscalene block: effects on postoperative analgesia in patients undergoing shoulder arthroplasty. Minerva Anestesiol. 2012;78(3):291-6.
12. Kesimci E, Izdes S, Gozdemir M, Kanbak O. Tramadol does not prolong the effect of ropivacaine 7.5 mg/ml for axillary brachial plexus block. Acta Anaesthesiologica Scandinavica. 2007;51(6):736-41.
13. Fanelli G, Casati A, Magistris L, Berti M, Albertin A, Scarioni M, et al. Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anaesthesia performed with ropivacaine. Acta Anaesthesiol Scand. 2001;45(5):590-4.
14. Jain N, Khare A, Khandelwal S, Mathur P, Singh M, Mathur V. Buprenorphine as an adjuvant to 0.5% ropivacaine for ultrasound-guided supraclavicular brachial plexus block: A randomized, double-blind, prospective study. Indian Journal of Pain. 2017;31(2):112-8.
15. Tulsyan V, Singh J, Thakur L, Verma V, Minhas A. A comparative study of buprenorphine in two different doses as an adjuvant to levobupivacaine in US-guided lumbar plexus block for postoperative analgesia. Ain-Shams Journal of Anesthesiology. 2021;13(1):7.
16. Virk MS, Arttamangkul S, Birdsong WT, Williams JT. Buprenorphine is a weak partial agonist that inhibits opioid receptor desensitization. J Neurosci. 2009;29(22):7341-8.
17. Schoenmakers KPW, Fenten MGE, Louwerens JW, Scheffer GJ, Stienstra R. The effects of adding epinephrine to ropivacaine for popliteal nerve block on the duration of postoperative analgesia: a randomized controlled trial. BMC Anesthesiology. 2015;15(1):100.
18. Dogru K, Duygulu F, Yildiz K, Kotanoglu MS, Madenoglu H, Boyaci A. Hemodynamic and blockade effects of high/low epinephrine doses during axillary brachial plexus blockade with lidocaine 1.5%: A randomized, double-blinded study. Reg Anesth Pain Med. 2003;28(5):401-5.
19. Schoenmakers KP, Vree TB, Jack NT, van den Bemt B, van Limbeek J, Stienstra R. Pharmacokinetics of 450 mg ropivacaine with and without epinephrine for combined femoral and sciatic nerve block in lower extremity surgery. A pilot study. Br J Clin Pharmacol. 2013;75(5):1321-7.
20. Weber A, Fournier R, Van Gessel E, Riand N, Gamulin Z. Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block. Anesth Analg. 2001;93(5):1327-31.
21. Tschopp C, Tramèr MR, Schneider A, Zaarour M, Elia N. Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses. Anesth Analg. 2018;127(1):228-39.
22. Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology. 2009;111(2):406-15.
23. Chakraborty S, Chakrabarti J, Mandal MC, Hazra A, Das S. Effect of clonidine as adjuvant in bupivacaine-induced supraclavicular brachial plexus block: A randomized controlled trial. Indian J Pharmacol. 2010;42(2):74-7.
24. McCartney CJL, Duggan E, Apatu E. Should We Add Clonidine to Local Anesthetic for Peripheral Nerve Blockade? A Qualitative Systematic Review of the Literature. Regional Anesthesia & Pain Medicine. 2007;32(4):330-8.
25. El-Boghdadly K, Brull R, Sehmbi H, Abdallah FW. Perineural Dexmedetomidine Is More Effective Than Clonidine When Added to Local Anesthetic for Supraclavicular Brachial Plexus Block: A Systematic Review and Meta-analysis. Anesth Analg. 2017;124(6):2008-20.
26. Sachdev S, Sharma V, Malawat A, Jethava D, Moin K. Comparison of levobupivacaine alone and levobupivacaine with dexmedetomidine in supraclavicular brachial plexus block: A prospective randomized clinical trial. Indian Journal of Clinical Anaesthesia. 2020;7(1):16-22.
27. Lundblad M, Trifa M, Kaabachi O, Ben Khalifa S, Fekih Hassen A, Engelhardt T, et al. Alpha-2 adrenoceptor agonists as adjuncts to peripheral nerve blocks in children: a meta-analysis. Pediatric Anesthesia. 2016;26(3):232-8.
28. Ray A, Kulkarni S, Kaur K, Paul D, Singh S, Khan S. Comparative study of two different doses of dexmedetomidine as an adjuvant to bupivacaine in the peripheral nerve block. Journal of Marine Medical Society. 2020;22(2):161-5.
29. Xue X, Fan J, Ma X, Liu Y, Han X, Leng Y, et al. Effects of local dexmedetomidine administration on the neurotoxicity of ropivacaine for sciatic nerve block in rats. Mol Med Rep. 2020;22(5):4360-6.
30. Sehmbi H, Brull R, Ceballos KR, Shah UJ, Martin J, Tobias A, et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus block. Anaesthesia. 2020. doi: 10.1111/anae.15288. Online ahead of print
31. Albrecht E, Vorobeichik L, Jacot-Guillarmod A, Fournier N, Abdallah FW. Dexamethasone Is Superior to Dexmedetomidine as a Perineural Adjunct for Supraclavicular Brachial Plexus Block: Systematic Review and Indirect Meta-analysis. Anesth Analg. 2019;128(3):543-54.
32. Choi S, Rodseth R, McCartney CJ. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2014;112(3):427-39.
33. Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev. 2017;11(11):Cd011770.
34. Marhofer P, Columb M, Hopkins PM, Greher M, Marhofer D, Bienzle M, et al. Dexamethasone as an adjuvant for peripheral nerve blockade: a randomised, triple-blinded crossover study in volunteers. Br J Anaesth. 2019;122(4):525-31.
35. Golwala M, Swadia V, Dhimar AA, Sridhar N. Pain relief by dexamethasone as an adjuvant to local anaesthetics in supraclavicular brachial plexus block. J Anaesth Clin Pharmacol. 2009;25(3):285-8.
36. Liu J, Richman KA, Grodofsky SR, Bhatt S, Huffman GR, Kelly IV JD, et al. Is there a dose response of dexamethasone as adjuvant for supraclavicular brachial plexus nerve block? A prospective randomized double-blinded clinical study. Journal of clinical anesthesia. 2015;27(3):237-42.
37. Williams BA, Hough KA, Tsui BY, Ibinson JW, Gold MS, Gebhart G. Neurotoxicity of adjuvants used in perineural anesthesia and analgesia in comparison with ropivacaine. Regional Anesthesia & Pain Medicine. 2011;36(3):225-30–30.
38. Attardi B, Takimoto K, Gealy R, Severns C, Levitan E. Glucocorticoid induced up-regulation of a pituitary K+ channel mRNA in vitro and in vivo. Receptors & channels. 1993;1(4):287-93.
39. Chong MA, Berbenetz NM, Lin C, Singh S. Perineural versus intravenous dexamethasone as an adjuvant for peripheral nerve blocks: a systematic review and meta-analysis. Regional Anesthesia & Pain Medicine. 2017;42(3):319-26.
40. Zhao W-L, Ou X-F, Liu J, Zhang W-S. Perineural versus intravenous dexamethasone as an adjuvant in regional anesthesia: a systematic review and meta-analysis. Journal of Pain Research. 2017;10:1529-43.
41. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, et al. IV and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. British journal of anaesthesia. 2013;111(3):445-52.
42. Zorrilla-Vaca A, Li J. Dexamethasone Injected Perineurally is More Effective than Administered Intravenously for Peripheral Nerve Blocks. The Clinical journal of pain. 2018;34(3):276-84.
43. Tien M, Gan T, Dhakal I, White W, Olufolabi A, Fink R, et al. The effect of anti‐emetic doses of dexamethasone on postoperative blood glucose levels in non‐diabetic and diabetic patients: a prospective randomised controlled study. Anaesthesia. 2016;71(9):1037-43.
44. Kassem H, Urits I, Viswanath O, Kaye AD, Eskander JP. Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair. Cureus. 2020;12(12):e11917-e.
45. Zusman RP, Urits I, Kaye AD, Viswanath O, Eskander J. Synergistic Effect of Perineural Dexamethasone and Dexmedetomidine (Dex-Dex) in Extending the Analgesic Duration of Pectoral Type I and II Blocks. Cureus. 2020;12(9):e10703-e.
46. Lee IO, Kim WK, Kong MH, Lee MK, Kim NS, Choi YS, et al. No enhancement of sensory and motor blockade by ketamine added to ropivacaine interscalene brachial plexus blockade. Acta Anaesthesiol Scand. 2002;46(7):821-6.
47. Nishiyama T, Matsukawa T, Hanaoka K. Continuous epidural administration of midazolam and bupivacaine for postoperative analgesia. Acta Anaesthesiol Scand. 1999;43(5):568-72.
48. Malinovsky JM, Cozian A, Lepage JY, Mussini JM, Pinaud M, Souron R. Ketamine and midazolam neurotoxicity in the rabbit. Anesthesiology. 1991;75(1):91-7.
49. Demirel E, Ugur HC, Dolgun H, Kahilogullari G, Sargon ME, Egemen N, et al. The neurotoxic effects of intrathecal midazolam and neostigmine in rabbits. Anaesth Intensive Care. 2006;34(2):218-23.
50. Mukherjee K, Das A, Basunia SR, Dutta S, Mandal P, Mukherjee A. Evaluation of Magnesium as an adjuvant in Ropivacaine-induced supraclavicular brachial plexus block: A prospective, double-blinded randomized controlled study. J Res Pharm Pract. 2014;3(4):123-9.
51. Jebali C, Kahloul M, Hassine NI, Jaouadi MA, Ferhi F, Naija W, et al. Magnesium Sulfate as Adjuvant in Prehospital Femoral Nerve Block for a Patient with Diaphysial Femoral Fracture: A Randomized Controlled Trial. Pain Research and Management. 2018;2018:2926404.
52. Hung Y-C, Chen C-Y, Lirk P, Wang C-F, Cheng J-K, Chen C-C, et al. Magnesium Sulfate Diminishes the Effects of Amide Local Anesthetics in Rat Sciatic-Nerve Block. Reg Anesth Pain Med. 2007;32(4):288-295.
53. Kerry Brandis. Alkalinisation of local anaesthetic solutions. Australian Prescriber Vol 34 / Number 6 / December 2011.

How to Cite this Article: Deshpande R, Wagh H, Kulkarni S | Adjuvants in Peripheral Nerve Blocks | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 63-66.


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Four Important Blocks of The Last Decade

Vol 2 | Issue 1 | January-June 2021 | Page 54-62 | J Balavenkatasubramanian, Gurumoorthi Palanichamy, Senthil Kumar Balasubramanian, Madhanmohan Chandramohan, Vinoth Kumar Subramanian, Satish Raja Selvam Parameswaran

Authors: J Balavenkatasubramanian [1], Gurumoorthi Palanichamy [1], Senthil Kumar Balasubramanian [1], Madhanmohan Chandramohan [1], Vinoth Kumar Subramanian [1], Satish Raja Selvam Parameswaran [3]

[1] Department of Anaesthesia, Ganga Hospital, Coimbatore, Tamil Nadu, India.

Address of Correspondence
Dr. Gurumoorthi Palanichamy, Ganga Hospital, Coimbatore, Tamil Nadu, India.


Ultrasonography (USG) guided regional anaesthesia has become the standard practice due to its improved success rate and decreased complications. With the advent of USG regional anaesthesia has flourished in a way that every surgery can be supplemented with a regional block as a part of multimodal analgesia. USG guided regional anaesthesia became rampant in the last decade with many newer inter-fascial plane blocks involving the paraspinal, chest wall and abdominal wall being introduced. Also new approaches for the plexus blocks are being established with improved safety and success. Here in this educational article, we are discussing the intricacies of the USG guided Costoclavicular approach of brachial plexus block, PEricapsular Nerve Group (PENG) block, Serratus Plane block (SPB) and Supra inguinal Fascia Iliaca Block (SIFICB). The costoclavicular approach for brachial plexus block is phrenic nerve sparing and still consistently block all the nerves arising from the cords, making it a safer option in certain population of patient with respiratory compromise. PENG block was introduced in the last decade for providing analgesia for the hip orthopedic procedures and advantage of this block is that there is no motor involvement without any major complications. The SPB is a one of chest wall block used for providing analgesia to the anterolateral chest especially for breast surgery and pain management in rib fractures. Being superficial and technically easier using USG, SPB has been included in the standard pain management for chest trauma. USG guided SIFICB introduced was introduced in 2011 as a novel approach to block the major nerves of lumbar plexus anteriorly but it gained popularity in the recent past for its ability to block femoral nerve, lateral femoral cutanoues nerve and possibly obturator nerve. With this block the above mentioned nerves can be blocked easily without any complications of classical approach for lumbar plexus block.

1- Costoclavicular Brachial Plexus Block– A Phrenic Nerve Sparing Novel Block

2- Serratus Plane Block

3-  PENG [PEricapsular Nerve Group] Block

4- Suprainguinal Fascia Iliaca Block– Is It The True 3 In 1 Block?


Costoclavicular Brachial Plexus Block– A Phrenic Nerve Sparing Novel Block
1. Silva MD. The costoclavicular syndrome: a ‘new cause’. Ann Rheum Dis. 1986; 45: 916-20
2. Li JW, Songthamwat B, Samy W, Sala-Blanch X, Karmakar MK. Ultrasound-Guided Costoclavicular Brachial Plexus Block: Sonoanatomy, Technique, and Block Dynamics. Reg Anesth Pain Med. 2017 Mar/Apr;42(2):233-240.
3. Wong MH, Karmakar MK, Mok LYH, Songthamwat B, Samy W. Minimum effective volume of 0.5% ropivacaine for ultrasound-guided costoclavicular brachial plexus block: A dose finding study. Eur J Anaesthesiol. 2020 Sep;37(9):780-786. doi: 10.1097/EJA.0000000000001287. PMID: 32740321.
4. Koyyalamudi V, Langley NR, Harbell MW, Kraus MB, Craner RC, Seamans DP. Evaluating the spread of costoclavicular brachial plexus block: an anatomical study. Reg Anesth Pain Med. 2021 Jan;46(1):31-34. doi: 10.1136/rapm-2020-101585. Epub 2020 Oct 6. PMID: 33024005.
5. Oh C, Noh C, Eom H, Lee S, Park S, Lee S, Shin YS, Ko Y, Chung W, Hong B. Costoclavicular brachial plexus block reduces hemidiaphragmatic paralysis more than supraclavicular brachial plexus block: retrospective, propensity score matched cohort study. Korean J Pain. 2020 Apr 1;33(2):144-152.

Serratus Plane Block
1. Blanco R, Parras T, McDonnell JG, et al. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68:1107-1113
2. Piracha MM, Thorp SL, Puttanniah V, et al. ‘‘A tale of two planes’’: deep versus superficial serratus plane block for postmatectomy pain syndrome. Reg Anesth Pain Med. 2017;42:259-262
3. Jadon A, Jain P. Serratus Anterior Plane Block-An Analgesic Technique for Multiple Rib Fractures: A Case Series. American J Anesth Clin Res. 2017;3(1): 001-004
4. Mayes J, Davison E, Panahi P, et al. An anatomical evaluation of the serratus anterior plane block. Anaesthesia. 2016;71:1064-1069
5. ChinKJ.Thoracic wall blocks: from paravertebral to retrolaminar to serratus to erector spinae and back again—a review of evidence. Best Pract Res Clin Anaesthesiol. 2019;33:67-77
6. Sayan Nath, Devesh Bhoj, Virender Kumar mohan et al. USG-guided continuous erector spinae block as a primary mode of perioperative analgesia in open posterolateral thoracotomy: A report of two cases. Saudi J Anaesthesia,2018 July-Sep;12(3):471-474
7. Chong M, et al. The serratus plane block for postoperative analgesia in breast and thoracic surgery: a systematic review and meta- analysis Reg Anesth Pain Med 2019;44:1066–1074. doi:10.1136/rapm-2019-100982

PENG [PEricapsular Nerve Group] Block
1. Bugada D, Bellini V, Lorini LF, Mariano ER. Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiol Clin. 2018;36(3):403-415. doi:10.1016/j.anclin.2018.04.001
2. Short AJ, Barnett JJG, Gofeld M, et al. Anatomic Study of Innervation of the Anterior Hip Capsule: Implication for Image-Guided Intervention. Reg Anesth Pain Med. 2018;43(2):186-192. doi:10.1097/AAP.0000000000000701
3. Nielsen TD, Moriggl B, Søballe K, Kolsen-Petersen JA, Børglum J, Bendtsen TF. A cadaveric study of ultrasound-guided subpectineal injectate spread around the obturator nerve and its hip articular branches. Reg Anesth Pain Med. 2017;42(3):357-361. doi:10.1097/AAP.0000000000000587
4. Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med. 2018;43(8):859-863. doi:10.1097/AAP.0000000000000847
5. Bilal B, Öksüz G, Boran ÖF, Topak D, Doğar F. High volume pericapsular nerve group (PENG) block for acetabular fracture surgery: A new horizon for novel block. J Clin Anesth. 2020;62. doi:10.1016/j.jclinane.2020.109702
6. Kukreja P, Avila A, Northern T, Dangle J, Kolli S, Kalagara H. A Retrospective Case Series of Pericapsular Nerve Group (PENG) Block for Primary Versus Revision Total Hip Arthroplasty Analgesia. Cureus. 2020;12(5). doi:10.7759/cureus.8200
7. Acharya U, Lamsal R. Pericapsular Nerve Group Block: An Excellent Option for Analgesia for Positional Pain in Hip Fractures. Case Rep Anesthesiol. 2020;2020:1-3. doi:10.1155/2020/1830136
8. Mistry T, Sonawane KB, Kuppusamy E. PENG block: Points to ponder. Reg Anesth Pain Med. 2019;44(3):423-424. doi:10.1136/rapm-2018-100327
9. Enes Aydin M, Borulu F, Ates I, Kara S, Ahiskalioglu A. Letters to the Editor A Novel Indication of Pericapsular Nerve Group (PENG) Block: Surgical Anesthesia for Vein Ligation and Stripping. J Cardiothorac Vasc Anesth. 2020;34:843-845. doi:10.1053/j.jvca.2019.08.006
10. Yu HC, Moser JJ, Chu AY, Montgomery SH, Brown N, Endersby RVW. Inadvertent quadriceps weakness following the pericapsular nerve group (PENG) block. Reg Anesth Pain Med. 2019;44(5):611-613. doi:10.1136/rapm-2018-100354
11. Morrison C, Brown B, Lin DY, Jaarsma R, Kroon H. Analgesia and anesthesia using the pericapsular nerve group block in hip surgery and hip fracture: A scoping review. Reg Anesth Pain Med. 2021;46(2):169-175. doi:10.1136/rapm-2020-101826

Suprainguinal Fascia Iliaca Block– Is It The True 3 In 1 Block?
1. Hebbard P, Ivanusic J, Sha S. Ultrasound-guided suprainguinal fascia iliaca block: a cadaveric evaluation of a novel approach. Anaesthesia 2011; 66: 300e5.
2. 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: 705e13.
3. Stevens M, Harrison G, McGrail M. A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty. Anesth Intensive Care 2007; 35: 949e52
4. Vermeylen K, Soetens F, Leunen I, Hadzic A, Van Boxtael S, Pomés J, Prats-Galino A, Van de Velde M, Neyrinck A, Sala-Blanch X. The effect of the volume of supra-inguinal injected solution on the spread of the injectate under the fascia iliaca: a preliminary study. J Anesth. 2018 Dec;32(6):908-913. doi: 10.1007/s00540-018-2558-9. Epub 2018 Sep 24. PMID: 30250982.
5. Singh, Harsimran, Jones, David. Hourglass-Pattern Recognition Simplifies Fascia Iliaca Compartment Block. Reg Anesth Pain Med. 2013;38(5):467-8. doi:10.1097/AAP.0b013e3182a1f772.

How to Cite this Article: Balavenkatasubramanian J, Palanichamy G, Balasubramanian S, Chandramohan M, Subramanian VK, Parameswaran SRS | Four Important Blocks of The Last Decade | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 54-62.


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Regional Anaesthesia for Breast Surgery

Vol 2 | Issue 1 | January-June 2021 | Page 40-46 | Anjolie Chhabra, Divya Sethi, Abhijit Nair

Authors: Anjolie Chhabra [1], Divya Sethi [2], Abhijit Nair [3]

[1] Department of Anaesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.
[2] Department of Anaesthesia, Employees’ State Insurance Cooperation Postgraduate Institute of Medical Sciences and Research, New Delhi, India.
[3] Department of Anaesthesia, Ibra Hospital, North Sharqiya Governorate, Ibra-414, Sultanate of Oman.

Address of Correspondence
Dr. Anjolie Chhabra,
Professor, Department of Anaesthesiology, AIIMS, New Delhi, India.


Innervation of the breast:
The breast receives innervation mainly from the 2 to 6 thoracic (T2-6) spinal nerves. The thoracic spinal nerves after emerging from the intervertebral foramina divide into dorsal and ventral ramii [1]. The dorsal ramii provide innervation to the skin and the muscles of the medial back. Each ventral ramus continues anteriorly as an intercostal nerve, accompanied by an intercostal artery and vein lying between the innermost and the internal intercostal muscle along the inferior borders of the respective ribs. Near the midpoint of the hemithorax corresponding to the midaxillary line, each intercostal nerve gives a lateral cutaneous branch that further divides into an anterior and posterior branch. Sensory supply of lateral aspect of breast is provided by the anterior divisions of the lateral cutaneous branches of T2–T6 intercostal nerves with contributions from T1 and T7 nerves. The intercostal nerves interconnect providing overlapping nerve supply to the breast. The main intercostalnerve continues anteriorly and terminates as an anterior cutaneous branch that further divides into a medial and lateral divisions which provide cutaneous innervation over the sternum and medial part of the breast respectively [2-4] (Figure 1) [5].
The intercostobrachial nerve (T2) mainly provides cutaneous innervation to the axillary tail of the breast, the axilla, and the medial upper arm. The medial cutaneous nerve of the arm (branch of the brachial plexus) may also supply the roof of the axilla and may receive contributions from T1 and T3 nerves. The supraclavicular nerves of the cervical plexus provide sensory supply to the infraclavicular or supramammary area [6, 7], (Figure 1).
The muscles of chest wall underlying the breast, the pectoralis major (PMM) and pectoralis minor (PmM) are innervated by mixed motor and sensory nerves, the lateral pectoral nerves (LPN) (C5-7, lateral cord) and the medial pectoral nerves (MPN) (C7-T1, medial cord), branches of the brachial plexus. These nerves also possess proprioceptive and nociceptive fibres and thus traction, stretching or muscle spasm of these muscles can lead to dull, aching perioperative pain. In addition, the long thoracic nerve (LTN) (C5-7) and the thoracodorsal nerve (TDN) (C6-8, posterior cord) branches of the brachial plexus innervate the serratus anterior (SAM) and the latissimus dorsi (LD) muscles, that form part of the axilla [8].
Therefore, the breast, axilla and the surrounding tissues are supplied by interconnected network of T2-T6 intercostal nerves, branches of the brachial plexus and the lower branches of the cervical plexus (Figure 1) [5].


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How to Cite this Article: Chhabra A, Sethi D, Nair A | Regional Anaesthesia for Breast surgery | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 40-46.

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Future Directions of Regional Anaesthesia

Vol 2 | Issue 1 | January-June 2021 | Page 17-18 | André van Zundert, Sandeep Diwan

Authors: André van Zundert [1], Sandeep Diwan [2]

[1] Department of Anaesthesiology, The University of Queensland, Brisbane, Australia.
[2] Department of Anaesthesiology, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Prof. André van Zundert,
Professor & Chairman Discipline of Anaesthesiology, The University of Queensland, Brisbane, Australia.

Since the 19th century, we have seen general and regional anaesthesia develop as complementary fields rather than opponents to provide high-quality anaesthesia and analgesia for patients. Combination of the two techniques often results in better outcomes with decreased incidence of adverse effects. General and regional anaesthesia, or loco-regional anaesthesia alone provide patient benefits including a pain free recovery.

Anaesthesiologists would want to be acquainted with regional techniques that would benefit the patient and cause the least harm. In fact, the key question is what the best solution is for a particular patient considering current problems, the type of surgical intervention, the available skills and support from the surgeon and anaesthetist. Many surgeons are unaware of the possibility of combining regional and general anaesthesia. Also, local practice differs in different parts in the world. In some countries, patients are well-informed and know what to expect during regional anaesthesia blocks and stay awake during the whole procedure (regional block and surgical intervention), or appreciate some distraction using a headphone with their favourite music. In other countries, patients want to receive sedation or even general anaesthesia during the regional anaesthesia procedure and/or during the surgical intervention as they prefer to be unaware of the whole procedure.

Nevertheless, patients expect to get superb service from a skilled and experienced anaesthetist in a wide range of regional anaesthesia techniques demonstrating extensive knowledge in applied anatomy, pharmacology, toxicology, monitoring, and expect no less than a perfect pain-free technique without complications and a quick recovery. However, regional anaesthesia is not always perfect. In general anaesthesia, any deviation from the normal can easily be managed in the unconscious patient. In awake patients undergoing regional anaesthesia, complications of regional blockade may be recognized by the patient, which could be stressful for the patient.

In learning regional anaesthesia techniques, there is no substitute for personal tuition while performing numerous interventions from experienced practitioners. However, trainees need to study textbooks and attend workshops and conferences on regional anaesthesia to perfect techniques, as well as accessing online courses, seminars, video clips, apps, guidelines from professional societies (e.g. AORA) and journal articles.

Ultrasound-guided techniques are preferredare preferred and superior to blind techniques, allowing more precise localisation of nerves (peripheral nerve blocks) or location of the subarachnoid and epidural space (central neuraxial anaesthesia). The International Journal of Regional Anaesthesia (IJRA), an official publication of AORA is such a specialised journal offering peer-reviewed articles on a variety of topics focused on local-regional anaesthesia and pain with an emphasis on visualisation of the technique using colourful imaging to illustrate anatomical and other practical aspects. As the scope of the IJRA expands, the Editorial Board aims to bring up-to date reliable and practical information for the practitioner with clinical articles, review articles, Letters-to-the Editor, but also on updates of books, e-books, atlases, apps, videos, infograms and provide website links to guidelines, useful for the practicing on regional anaesthesia.

Newer block techniques have evolved over time including use of ultrasound techniques. Anaesthetists need to master a variety of regional blocks including central neuraxial and peripheral nerve blocks to be qualified in regional anaesthesia.

Regional anaesthesia plays an essential role in our practice. Some golden rules apply to maximise safety and efficacy: a) Discuss the regional blockade with the patient, explaining benefits and risks and obtain informed written consent; b) Discuss with the surgeon what procedure you intend to perform and the site of incision; c) Discuss with the patient any potential complication/side effect and document these in your anaesthesia chart; d) Perform the regional block with the best intention for the patient, not for the best interest of the anaesthetist; e) Perform regional anaesthesia blocks in an appropriate setting (well-equipped, adequately-staffed, safe environment) capable of handling complications (ventilator at hand; resuscitation drugs/equipment/Intralipid at hand) with intravenous access in situ, applying adequately-monitored according standards; f) Always fractionate any doses, check their impact on the patient, and respect dose limits; g) Document the surgical intervention, positioning of the patient on the operating table and record any problem/complication (e.g., haemorrhage, pneumothorax and paraesthesia); h) In case of a neurological complication check the patient yourself and refer to a neurologist at an early stage; and i) Always have a plan B, in case of an unsuccessful block. Infrastructure and ergonomics play an important part in success of the block. SimilarlySimilarly, important is to avoid wrong-route, wrong-dose, wrong-side, wrong-site injections and to carefully label all connections and tubing. Management of paediatric patients requires even greater efforts as children cannot be relied upon to ask for analgesia during a procedure. Regional anaesthesia techniques are excellent tools also in children, but these procedures themselves can be painful. In obstetric anaesthesia, pain relief during childbirth may be stressful with the woman in full labour requiring an immediate epidural.

The growing popularity of ultrasonography is a very welcome addition to regional anaesthesia and allows more precision application in regional anaesthesia, in particular peripheral nerve blocks. It provides bedside imaging and dynamic assessment for nerve localisation and target-specific injections, visualising needle advancement in real time and observation of local anaesthetic spread around nerve structures. Use of ultrasound is an evolving aspect of our specialty, offering major advantages and superiority over blind techniques, such as real-time visualisation of soft tissues, muscles, nerves, veins and arteries, improving safe practice. Shortcomings with ultrasound include limited resolution at deep levels especially in the obese, and artefacts created by bone structures. Anaesthetists practising regional anaesthesia with ultrasound need to know the basic principles of ultrasound imaging and knobology, regional anatomy specifically related to interventional procedures, ultrasound scanning and image interpretation and the technical considerations for needle insertion and injection (step-by-step, easy-to-follow, how-to-do-it instructions). Whether ultrasonography can be further improved in obtaining the best possible resolution of the area, ruling out the need for extra monitoring devices (e.g., nerve stimulator) and landmark techniques is still under debate. It is wise however, to limit the injection pressure to 15 psi using an injection pressure monitor device.

NYSORA (New York Society of Regional Anaesthesia) recently introduced the Next Level CMETM programme ( under the inspirational leadership of Professor Admir Hadzic. This educational and technology entity provides a personalised and boutique learning experience for medical practitioners utilising a custom-built eLearning platform and a range of propriety cognitive aids, illustrations and animations. The aim is to have all your study materials organised in one place, accessible anytime anywhere. NexLevel CMETM allows the practitioner to create their own customised and condensed study scripts (personal, departmental, region, country) in minutes to make learning faster and more engaging. The focus is on an in-depth, customised complete training portfolio in anaesthesia, for point of care ultrasound and pain and perioperative medicine, which allows control of learning processes.

IJRA is a distinguished journal, carefully prepared by the Editorial team of dedicated anaesthetists interested in regional anaesthesia, for those medical practitioners who want to learn extra steps in regional anaesthesia practice for them and patients’ benefit.

We hope you’ll find in this issue of IJRA comprehensive, inspiring and practical information about regional anaesthesia and nerve block techniques with clinical applicability that will influence the professional lives of many colleagues. It is important to remember that injection of the local anaesthetic drugs is just the beginning and not the end of the anaesthetic. When this approach is followed considerable benefits can accrue to the patient.

A special thanks goes to…..

Chairman: Dr. TVS Gopal, Dr. J Balvenkatasubramanian,
President: Dr. Vrushali Ponde,
Vice President: Dr Sudhakar Koppad,
AORA Core Committee: Dr. Satish Kulkarni, Dr. Ashit Mehta, Dr Javed Khan.
AORA Executive committee.
Editorial Team, Editorial Committee Members, International Executive Committee Members,
Author & Contributor to the Articles.
Dr. Ashok Shyam,
Journal Coordinator & Academic Research Group (Journal Publisher).


How to Cite this Article: Zundert AV, Diwan S | Future Directions of Regional Anaesthesia | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 17-18.

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Implications of Regional Anaesthesia for Favourable Postoperative Outcomes

Vol 2 | Issue 1 | January-June 2021 | Page 13-16 | Abhijit Nair, Sandeep Diwan

Authors: Abhijit Nair [1, 2], Sandeep Diwan [3]

[1] Department of Anaesthesia, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, Telangana State, India.
[2] Department of Anaesthesiology, Ibra Hospital, North Sharqiya Governorate, Ibra-414, Sultanate of Oman.
[3] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Abhijit Nair,
Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, Telangana State, India.
Ibra Hospital, North Sharqiya Governorate, Ibra-414, Sultanate of Oman.


Patient centered outcomes after surgery are described in terms of improving quality of life and functional status, prevent cognitive impairment, delirium, anxiety and depression and preserve organ function [1]. Regional anaesthesia (RA) when used solely or for postoperative analgesia with general anaesthesia (GA) indeed provides better quality of analgesia, lesser opioid consumption and lesser adverse events like postoperative nausea/vomiting (PONV) due to opioids, bleeding or renal toxicity (due to non-steroidal anti-inflammatory drugs). However, the benefits of RA are not just confined to providing opioid-sparing analgesia but many other important early and late postoperative outcomes which has established RA as an integral part of perioperative analgesia [2]. In this editorial, the term RA is used for central neuraxial blocks (spinal and epidural anaesthesia), the peripheral nerve blocks and the fascial plane blocks depending on the type of surgery and the purpose of RA i.e., surgical anaesthesia or postoperative pain relief.


1. Bowyer AJ, Royse CF. Postoperative recovery and outcomes–what are we measuring and for whom? Anaesthesia. 2016;71 Suppl 1:72-7.
2. Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome? Br J Anaesth. 2011;107 Suppl 1: i90-5.
3. Small C, Laycock H. Acute postoperative pain management. Br J Surg. 2020 ;107: e70-e80.
4. Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017; 10:2287-98.
5. Kessler J, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth. 2015; 114:728-45.
6. Milosavljevic SB, Pavlovic AP, Trpkovic SV, Ilić AN, Sekulic AD. Influence of spinal and general anesthesia on the metabolic, hormonal, and hemodynamic response in elective surgical patients. Med Sci Monit. 2014; 20:1833-40.
7. Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016; 33:160-71.
8. Moon YE. Postoperative nausea and vomiting. Korean J Anesthesiol. 2014; 67:164-170.
9. Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020; 131:411-48.
10. Li J, Zhu Y, Chen W, Zhao K, Zhang J, Meng H et al. Incidence and locations of deep venous thrombosis of the lower extremity following surgeries of tibial plateau fractures: a prospective cohort study. J Orthop Surg Res. 2020; 15:605.
11. Wang H, Kandemir U, Liu P, Zhang H, Wang PF, Zhang BF, Shang K, Fu YH, Ke C, Zhuang Y, Wei X, Li Z, Zhang K. Perioperative incidence and locations of deep vein thrombosis following specific isolated lower extremity fractures. Injury. 2018; 49:1353-7.
12. Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and Combined Neuraxial/General Anesthesia Compared to General Anesthesia for Major Truncal and Lower Limb Surgery: A Systematic Review and Meta-analysis. Anesth Analg. 2017; 125:1931-45.
13. Johnson RL, Kopp SL, Burkle CM, Duncan CM, Jacob AK, Erwin PJ, Murad MH, Mantilla CB. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth. 2016; 116:163-76.
14. Pozek JP, Beausang D, Baratta JL, Viscusi ER. The Acute to Chronic Pain Transition: Can Chronic Pain Be Prevented? Med Clin North Am. 2016; 100:17-30.
15. Ahuja V, Thapa D, Ghai B. Strategies for prevention of lower limb post-amputation pain: A clinical narrative review. J Anaesthesiol Clin Pharmacol. 2018; 34:439-49.
16. Wang W, Wang Y, Wu H, et al. Postoperative cognitive dysfunction: current developments in mechanism and prevention. Med Sci Monit. 2014; 20:1908-12.
17. Kotekar N, Kuruvilla CS, Murthy V. Post-operative cognitive dysfunction in the elderly: A prospective clinical study. Indian J Anaesth. 2014; 58:263-8.
18. Mason SE, Noel-Storr A, Ritchie CW. The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium: a systematic review with meta-analysis. J Alzheimers Dis. 2010;22 Suppl 3:67-79.
19. Davis N, Lee M, Lin AY, et al. Postoperative cognitive function following general versus regional anesthesia: a systematic review. J Neurosurg Anesthesiol. 2014; 26:369-76.
20. Zywiel MG, Prabhu A, Perruccio AV, Gandhi R. The influence of anesthesia and pain management on cognitive dysfunction after joint arthroplasty: a systematic review. Clin Orthop Relat Res. 2014; 472:1453-66.
21. Nair AS, Naik V, Saifuddin MS, Narayanan H, Rayani BK. Regional anesthesia prevents cancer recurrence after oncosurgery! What is wrong with the hypothesis? Indian J Cancer 2020; XX: XX-XX. 10.4103/ijc.IJC_331_20 (Accepted manuscript)
22. Divatia JV, Ambulkar R. Anesthesia and cancer recurrence: What is the evidence? J Anaesthesiol Clin Pharmacol 2014; 30:147–50.
23. Yap A, Lopez‑Olivo MA, Dubowitz J, Hiller J, Riedel B. Global Onco‑Anesthesia Research Collaboration Group. Anesthetic technique and cancer outcomes: A meta‑analysis of total intravenous versus volatile anesthesia. Can J Anaesth 2019; 66:546‑61.
24. Sessler DI, Pei L, Huang Y, Fleischmann E, Marhofer P, Kurz A et al; Breast Cancer Recurrence Collaboration. Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial. Lancet. 2019;394(10211):1807-15.
25. Neal JM. Ultrasound-Guided Regional Anesthesia and Patient Safety: Update of an Evidence-Based Analysis. Reg Anesth Pain Med. 2016; 41:195-204.
26. Topor B, Oldman M, Nicholls B. Best practices for safety and quality in peripheral regional anaesthesia. BJA Educ. 2020; 20:341-7.
27. Shivaprakash S, Diwan SM | Anatomy of Brachial Plexus Above The Clavicle |International Journal of Regional Anaesthesia | January-June 2021; 2(1): 29-34.
28. Sivashanmugam | Volume of Local Anaesthetic Agents and Block Efficacy in Blocks Above the Clavicle |International Journal of Regional Anaesthesia | January-June 2021; 2(1): 35-38.
29. Mirle R, Mukundan S | Cadaveric Workshop and Implications in Regional Anaesthesia | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 22-28.
30. Gopal TVS, Amjad Maniar A, Chakraborty A, Kulkarni R | Abdominal WallBlocks in Abdominal Surgery: An Update | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 47-53.
31. Sethi D, Nair A, Chhabra A | Regional Anaesthesia for Breast surgery |International Journal of Regional Anaesthesia | January-June 2021; (1): 40-46.
32. Giri S | Landmark and PNS Guided Forearm Blocks | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 67-71.
33. Murlitondebhavi | IAORA4U– A Regional Anaesthesia App for AORA Members | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 72-73.
34. Ponde V | Sterility Protocols During Regional Anaesthesia |International Journal of Regional Anaesthesia | January-June 2021; 2(1): 05-12.
35. Grewal A | Case Report: Pearls and Pitfalls | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 09-21.

How to Cite this Article: Nair A, Diwan S | Implications of Regional Anaesthesia for Favourable Postoperative Outcomes | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 13-16.

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AORA Checklist: First Confirm Then Perform

Vol 2 | Issue 1 | January-June 2021 | Page 04 | Archana Areti, Ritesh Roy, Kapil Gupta, Vrushali Ponde, Mohammad Azam Danish, Neha Singh, Amjad Maniar, Rammurthy Kulkarni

Authors: Archana Areti [1], Ritesh Roy [2], Kapil Gupta [3], Vrushali Ponde [4], Mohammad Azam Danish [5], Neha Singh [6], Amjad Maniar [7], Rammurthy Kulkarni [7]

[1] Department of Anaesthesia, Mahatma Gandhi Medical College Research Institute Puducherry, India.
[2] Associate Clinical Director and HOD, Care Hospitals, Bhubaneshwar, Odisha, India.
[3] Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India.
[4] Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
[5] Department of Anaesthesia, B. M. Jain Hospital, Bengaluru, Karnataka, India.
[6] Department of Anaesthesia, AIIMS, Bhubhaneshwar, Odisha, India.
[7] Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, Karnataka, India.

Address of Correspondence
Dr. Vrushali Ponde,
Director Child Anaesthesia Services, Mumbai, Maharashtra, India.

How to Cite this Article: Areti A, Roy R, Gupta K, Ponde V, Danish MA, Singh N, Maniar A, Kulkarni R| AORA Checklist: First Confirm Then Perform | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 04.

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A Quick Guide: Ultrasound Guided Nerve Blocks

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.

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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Abdominal Wall Blocks in Abdominal Surgery: An Update

Vol 2 | Issue 1 | January-June 2021 | Page 47-53 | TVS Gopal, Amjad Maniar, Arunangshu Chakraborty,
Rammurthy Kulkarni

Authors:  TVS Gopal [1], Amjad Maniar [2], Arunangshu Chakraborty [3], Rammurthy Kulkarni [2]

[1] Department of Anaesthesia, Care Hospitals, Banjara Hills, Hyderabad, Andhra Pradesh, India.
[2] Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, India.
[3] Department of Anaesthesia, Tata Medical Center, Kolkata, India.

Address of Correspondence
Dr. TVS Gopal,
Clinical Director, Care Hospitals, Banjara Hills, Hyderabad, Andhra Pradesh, India.


Abdominal wall blocks provide an alternative to the gold standard, epidural analgesia, as a part of a multimodal analgesic regime for pain relief following a variety of abdominal surgeries. The ubiquitous availability of ultrasound and the paradigm shift to deposition of local anaesthetic into interfascial planes popularized abdominal wall blocks. Over the years, a better understanding of cadaveric, clinical sonoanatomy, and techniques have emerged. However, with certain abdominal wall blocks, the spread of local anaesthetic is neither consistent nor predictable. This concise update presents details pertaining to ultrasound-guided abdominal wall blocks.


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4. Rafi AN. Abdominal field block ; a new approach via the lumbar triangle. Anaesthesia 2001; 56(10) : 1024-6.
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6. Hebbard P, Fujiwara Y, Shibata Y, Royse C. ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive care 2007 Aug; 35(4) : 616-7.
7. Ki Jinn Chin, John G McDonnell, Brendan Carvalho et al. essentials of our current understanding : abdominal wall blocks. Reg Anesth Pain Med 2017; 42 : 133-183.
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11. Melesse DY, Chekol WB, Tawuye HY, Denu ZA et al. Assessment of the analgesic effectiveness of rectus sheath block in patients who had an emergency midline laparotomy : prospective observational cohort study. International Journal of Surgery open 2020; 24 :27-31.
12. Lee THW, Barrington MJ, Tran TNM, Wong D, Hebbard P. Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block. Anaesthesia and Intensive care 2010 May; 38(3): 452-460.
13. Yoshiyoma S, Ueshima H, Sakai R, Otake H. A posterior TAP block provides more effective analgesia than a lateral TAP block in patients undergoing laparoscopic gynaecologic surgery : a retrospective study. Anesthesiology Research and Practice 2016; 2016 :1-5.
14. Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesthesia and Analgesia 2008; 106(2).
15. Klaassen Z, Marshall E, Tubbs RS, Louis RGJ et al. Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat. 2011 May; 24(4) : 454-61.
16. Hebbard P. Transversalis fascia plane block, a novel ultrasound guided abdominal wall nerve block. Can J Anesth. 2009 Aug; 56(8) :618-20.
17. Hesham Elsharkawy, Kariem El-Boghdadly, Michael Barrington. Quadratus lumborum block : anatomical concepts, mechanisms and techniques. Anesthesiology Feb 2019; Vol.130, No.2.
18. Sauter AR, Ullensvang K, Niemi G, Lorentzen HT, Bensten TF, Borglum J. The shamrock lumbar plexus block : a dose finding study. Eur J Anaesthesiol 2015; 32 : 764-70.
19. Murouchi T. Quadratus lumborum block intramuscular approach for pediatric surgery. Acta Anesthesiologica Taiwanica 2016.
20. TVS Gopal. Ultrasound guided transmuscular quadratus lumborum plane catheters : in the plane or out of it ? Editorial- Indian J Anaesth 2019; 63 :609-10.
21. Diwan S, Kulkarni M, Kulkarni N, Nair A. A radiological inquest to determine the destiny of ultrasound guided transmuscular quadratus lumborum plane catheters. Indian J Anaesth 2019; 63 : 667-70.
22. Lancaster P, Chadwick M. Liver trauma secondary to ultrasound-guided transversus abdominis plane block. Br J Anaesth. 2010 Apr;104(4):509–10.
23. Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block. Reg Anesth Pain Med. 2008 Jun;33(3):274–5.
24. Frigon C, Mai R, Valois-Gomez T, Desparmet J. Bowel hematoma following an iliohypogastric-ilioinguinal nerve block. Paediatr Anaesth. 2006 Sep;16(9):993–6.
25. Yuen PM, Ng PS. Retroperitoneal hematoma after a rectus sheath block. J Am Assoc Gynecol Laparosc. 2004 Nov;11(4):448.
26. Griffiths JD, Barron FA, Grant S, Bjorksten AR, Hebbard P, Royse CF. Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block. Br J Anaesth. 2010 Dec;105(6):853–6.
27. Hessian EC, Evans BE, Woods JA, Taylor DJ, Kinkel E, Bjorksten AR. Plasma ropivacaine concentrations during bilateral transversus abdominis plane infusions. British Journal of Anaesthesia. 2013 Sep 1;111(3):488–95.
28. Shivashanmugam T, Kundra P, Sudhakar S. Iliac compartment block following ilioinguinal iliohypogastric nerve block. Paediatr Anaesth. 2006 Oct;16(10):1084–6.
29. Ghani KR, McMillan R, Paterson-Brown S. Transient femoral nerve palsy following ilio-inguinal nerve blockade for day case inguinal hernia repair. J R Coll Surg Edinb. 2002 Aug;47(4):626–9.
30. Manatakis DK, Stamos N, Agalianos C, Karvelis MA, Gkiaourakis M, Davides D. Transient femoral nerve palsy complicating “blind” transversus abdominis plane block. Case reports in anesthesiology. 2013;2013:874215.
31. Quek KHY, Phua DSK. Bilateral rectus sheath blocks as the single anaesthetic technique for an open infraumbilical hernia repair. Singapore Med J. 2014 Mar;55(3):e39-41.
32. Rajwani KM, Butler S, Mahomed A. In children undergoing umbilical hernia repair is rectus sheath block effective at reducing post-operative pain? Best evidence topic (bet). International Journal of Surgery. 2014;12(12):1452–5.
33. Tudor ECG, Yang W, Brown R, Mackey PM. Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery. Ann R Coll Surg Engl. 2015 Oct;97(7):530–3.
34. Godden AR, Marshall MJ, Grice AS, Daniels IR. Ultrasonography guided rectus sheath catheters versus epidural analgesia for open colorectal cancer surgery in a single centre. Ann R Coll Surg Engl. 2013 Nov;95(8):591–4.
35. Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The Analgesic Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block in Adult Patients: A Meta-Analysis. Anesthesia & Analgesia. 2015 Dec;121(6):1640–54.
36. De Oliveira GS, Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus Abdominis Plane Block to Ameliorate Postoperative Pain Outcomes After Laparoscopic Surgery: A Meta-Analysis of Randomized Controlled Trials. Anesthesia & Analgesia. 2014 Feb;118(2):454–63.
37. Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anesth/J Can Anesth. 2012 Aug;59(8):766–78.
38. Hannallah RS, Broadman LM, Belman AB, Abramowitz MD, Epstein BS. Comparison of caudal and ilioinguinal/iliohypogastric nerve blocks for control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology. 1987 Jun;66(6):832–4.
39. Markham SJ, Tomlinson J, Hain WR. Ilioinguinal nerve block in children. A comparison with caudal block for intra and postoperative analgesia. Anaesthesia. 1986 Nov;41(11):1098–103.
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41. Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015 Nov;32(11):812–8.
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43. Ishio J, Komasawa N, Kido H, Minami T. Evaluation of ultrasound-guided posterior quadratus lumborum block for postoperative analgesia after laparoscopic gynecologic surgery. J Clin Anesth. 2017 Sep;41:1–4.
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45. Aditianingsih D, Pryambodho, Anasy N, Tantri AR, Mochtar CA. A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy. BMC Anesthesiology. 2019 Dec 5;19(1):221.

How to Cite this Article: Gopal TVS, Maniar A, Chakraborty A, Kulkarni R | Abdominal Wall
Blocks in Abdominal Surgery: An Update | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 47-53.

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Sterility Protocols During Regional Anaesthesia: An AORA Initiative

Vol 2 | Issue 1 | January-June 2021 | Page 05-12 | Rammurthy Kulkarni, Amjad Maniar, Neha Singh, Vrushali Ponde, Kapil Gupta, Mohammad Azam Danish, Ritesh Roy, Archana Areti

Authors: Rammurthy Kulkarni [1], Amjad Maniar [1], Neha Singh [6], Vrushali Ponde [4], Kapil Gupta [3], Mohammad Azam Danish [5], Ritesh Roy [2], Archana Areti [7]

[1] Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, Karnataka, India.
[2] Department of Anaesthesia, AIIMS, Bhubhaneshwar, Odisha, India.
[3] Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
[4] Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India.
[5] Department of Anaesthesia, B. M. Jain Hospital, Bengaluru, Karnataka, India.
[6] Associate Clinical Director and HOD, Care Hospitals, Bhubaneshwar, Odisha, India.
[7] Department of Anaesthesia, Mahatma Gandhi Medical College Research Institute Puducherry, India.

Address of Correspondence
Dr. Vrushali Ponde, Director Child Anaesthesia Services, Mumbai, Maharashtra, India.


The frequency of infection following peripheral nerve block (PNB) is not very clear. The major reason for the paucity of literature is under-reporting of infectious complications. Though rare, the infectious complications associated with peripheral nerve blocks can be devastating and occasionally fatal.1 One case of necrotising fasciitis following an axillary approach to brachial plexus blockade for carpal tunnel release has been reported where the PNB was directly attributed to the infection. With the increase in the number of peripheral nerve block procedures being performed (both single injection and continuous techniques), it is expected that the infectious complication rate may also increase.
There is no uniform consensus amongst anaesthesiologists across the globe regarding the appropriate sterile technique that should be practised during the administration of regional anaesthesia. In a UK and Ireland based survey of obstetric anaesthesiologists, only half of the responders wore a face mask for both neuraxial (spinal and epidural) techniques. One-third of those who did not wear a mask believed that the mask actually increased the risk of infection.2 It can be easily assumed that a similar attitude is present while performing PNBs.
The aseptic chain starts right from hand washing and ends after the block needle has been taken out from the patient’s body (in a single injection technique) or till the perineural catheter is completely removed (in a continuous technique). Any breach in this chain may increase the chances of introducing infection.


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How to Cite this Article: Kulkarni R, Maniar A, Singh N, Ponde V, Gupta K, Danish MA, Roy R, Areti A | Sterility Protocols During Regional Anaesthesia: An AORA Initiative | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 05-12.

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Anatomy of Brachial Plexus Above The Clavicle

Vol 2 | Issue 1 | January-June 2021 | Page 29-34 | Shivaprakash S, Georg Feigl, Sandeep M. Diwan

Authors: Shivaprakash S [1], Georg Feigl [2], Sandeep M. Diwan [3]

[1] Department of Anatomy, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India.
[2] Private Universitat Witten/Herdecke gGmbH Alfred-Herrhausen-StraBe 50, D-58448 Witten.
[3] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Sandeep Diwan,
Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.


The neck is a compact structure which hosts the aero-digestive and neurovascular structures. Nerve roots arising from the spinal cord form an important network of nerves the ‘Brachial Plexus (BP)’ that innervates the upper limb and lies partly in the posterior triangle of neck and partly in the axilla. The BP is complex matrix sandwiched between muscles proximally and muscles and vessels distally at and above the level of clavicle. It consists of roots, trunks, cords & branches (figure 1). Roots and trunks are supraclavicular, divisions are retro clavicular, cords and their branches are infraclavicular. The position of the plexus relative to the clavicle varies, it is higher in the erect position and lower when recumbent [1]. It is broad and presents little of a plexiform arrangement at its commencement, is narrow opposite the clavicle, divides opposite the coracoid process into numerous branches and becomes broad and forms a denser interlacement in the axilla [2]. Brachial plexus is formed by the ventral rami of lower four cervical nerves and the first thoracic spinal nerves with variable contribution (slender twigs) from the fourth cervical and second thoracic nerve.


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(2) Henry Gray F.R.S. Gray’s Anatomy: Descriptive and Surgical. London. Parragon . book;2001( Reprint). Brachial plexus; 521-2.
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How to Cite this Article: Shivaprakash S, Feigl G, Diwan SM | Anatomy of Brachial Plexus Above The Clavicle | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 29-34.

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