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.


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

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.

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

 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

 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

 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

 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.


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


 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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