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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Ultrasound and Modern Regional Anaesthesia

Vol 2 | Issue 2 | July-December 2021 | Page 100-101  | T.V.S.Gopal

DOI: 10.13107/ijra.2021.v02i02.035

Authors: T.V.S. Gopal [1, 2, 3]

[1] Managing Director, Axon Anaesthesia Associates, Hyderabad, Telangana, India.
[2] Clinical Director, Anaesthesiology, General O.T.& C.O.P.Complex, Care Hospitals, Hyderabad, Telangana, India.
[3] Chairperson, Past Academic Director & President AORA India.

Address of Correspondence
Dr. T.V.S Gopal,
Managing Director, Axon Anaesthesia Associates, Hyderabad, Telangana, India.
Clinical Director, Anaesthesiology, General O.T.& C.O.P.Complex, Care Hospitals, Hyderabad, Telangana, India.


Lazzaro Spallanzani, an 18th century Italian biologist, is credited with the discovery of ultrasound, which he coined ‘echolocation’. [1] Little may he have realized then that his revelation would transform into an all pervading technology in modern science. Though La Grange and colleagues, in 1978, were the first to employ ultrasonic blood flow detector to locate insertion point for the supraclavicular brachial plexus block, ultrasound guidance in real time motion was first utilized by S. Kapral et al for the same block in a series of forty patients in 1994, thus, heralding a fresh epoch in regional anaesthesia. [2, 3] As is often the case with the introduction of new technologies, ultrasound guidance was also met with cynicism and disdainful resistance. However, not much later, ultrasound guidance was being hailed as the ‘gold standard’ for regional anaesthesia, and it was proclaimed that the search for the elusive ‘holy grail’ had ended. [4]
Among the first nerve/plexus blocks to find wider acceptance with the adoption of ultrasound guidance was the supraclavicular brachial plexus block. The fear of arterial puncture and accidental pneumothorax magically seemed to vanish into thin air. Correlation between clinical and sono-anatomy led to a better understanding of interscalene, infraclavicular and axillary approaches to the brachial plexus. [5] Lower limb blocks began to witness a renaissance due to the widespread prescription of antiplatelet drugs as part of preventive cardiology. Though deeper to the skin in comparison to the upper limb, ultrasound guidance improved identification of neural structures.
It was reported in literature that ultrasound improves patient comfort, block acceptance, onset of block, quality of block, permits the injection of lower local anaesthetic volumes, and thereby, the potential for LAST, and reduces the incidence of certain complications that may be attributed to the block procedure. [6] However, given the resolution of current portable ultrasound machines, and the huge numbers required to reflect a statistical difference in favour of ultrasound, the rate of neurological complications seems to be comparable to other guidance techniques. Such are the rigours of evidence-based medicine!!
Familiarity with ultrasound offered precision with blocks of the brachial plexus, for eg., intertruncal blockade, combination of superior truncal and cervical plexus block (SCUT), costoclavicular approach to the infraclavicular plexus, and identification of inadvertent targets “in the path”, namely, the long thoracic and dorsal scapular nerves. [7, 8] Not surprisingly, ultrasound guidance was utilized for deeper blocks such as lumbar and sacral plexus, giving impetus to the term, “dual guidance” technique. A “window of opportunity” led to description of neuraxial sonoanatomy and the various benefits of ultrasound assistance for neuraxial blocks were widely appreciated. [9] Nearly seven decades after Mario Dogliotti invented the loss of resistance technique for identification of the epidural space, another guidance tool was incorporated. Newer approaches to older blocks were introduced, such as the suprainguinal fascia iliaca plane block. Differential blocks limited to sensory desensitization alone came into vogue, viz. PENG (Pericapsular Nerve Group), iliopsoas plane block & the i-PACK. [10, 11]
Perhaps, the most significant shift in regional anaesthesia was the introduction of interfascial plane blocks that abandoned the “search” for neural structures by beckoning regional anaesthesia enthusiasts to deposit large volumes of local anaesthetic solutions into fascial planes. What began with the ultrasound guided TAP block in 2007, rapidly found application in a variety of truncal fascial planes. The interfascial plane block added a new dimension to the multimodal analgesia regime. Simplicity of performance and safety was the overriding factor that appealed to anaesthesiologists. With some blocks, the drug was confined to the point of injection. With several others, the propensity of aponeurotic fascia to communicate with other fascial planes facilitated the theoretical spread of drug to sites far removed from the point of injection. Though conjecture exists with respect to the mechanism of action of blocks such as the QLB, future studies should put an end to controversies. [12]
The erector spinae block, first published by Forero et al, in 2016, set the world of regional anaesthesia literally on fire. [13] In the past five years, several publications, mostly case reports and limited case series, eulogizing the virtues of, the potential for, the clinical applications for, and the possible mechanism of action of this popular block, have emerged in scientific literature. [14] Currently, this ESP block, due to a lack of credible evidence on the mechanism of action, has the naysayers clamouring for this block to be rested in peace. [15] Given that the ESP has been in existence for less than five years, it is sincerely hoped that concrete studies may demystify this esoteric block.
In addition to regional anaesthesia, the appeal of modern, portable ultrasound places the FOCUS firmly on POCUS or Point Of Care Ultrasound. Today, regional anaesthesiologists are comfortable with fancy acronyms like FATE, FEEL, FAST etc. The integration of Artifical Intelligence to ultrasound technology imparts further precision. High resolution ultrasound as a diagnostic and therapeutic tool with multiple applications for clinicians is here to stay. The chorus for fusion of ultrasound into clinical practice is based on the edifice of evidence, ubiquity and durability, and NOT on the caprice of an elite core of die-hard proponents. The sooner anaesthesiologists jump on the bandwagon and hitch a ride, the better.
It is my sacred duty, as Chairperson of AORA INDIA, to place on record my appreciation to the editorial board of the International Journal of Regional Anaesthesia for embarking on this challenging journey of enlightening readers with advances in the exciting field of regional anaesthesia. In years to come, this online, peer reviewed journal will hopefully have made entry into the pantheon of impactful regional anaesthesia journals worldwide. Indeed, as the famous quote goes, “the purpose of education is to turn mirrors into windows”.

Chairperson, Past Academic Director & President


1. Kaproth-Joslin KA, Nicola R, Dogra VS. The History of US: From Bats and Boats to the Bedside and Beyond: RSNA Centennial Article. Radiographics. 2015; 35:960-70.
2. la Grange P, Foster PA, Pretorius LK. Application of the Doppler ultrasound bloodflow detector in supraclavicular brachial plexus block. Br J Anaesth. 1978; 50:965-7.
3.Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg. 1994; 78:507-13.
4.Horlocker TT, Wedel DJ. Ultrasound-guided regional anesthesia: in search of the holy grail. Anesth Analg 2007; 104:1009–11.
5.Sites BD, Spence BC, Gallagher J, Beach ML, Antonakakis JG, Sites VR, Hartman GS. Regional anesthesia meets ultrasound: a specialty in transition. Acta Anaesthesiol Scand. 2008; 52:456-66.
6.Neal JM. Ultrasound-Guided Regional Anesthesia and Patient Safety: Update of an Evidence-Based Analysis. Reg Anesth Pain Med. 2016; 41:195-204.
7.Karmakar MK, Pakpirom J, Songthamwat B, Areeruk P. High definition ultrasound imaging of the individual elements of the brachial plexus above the clavicle. Reg Anesth Pain Med. 2020; 45:344-50.
8.Hanson NA, Auyong DB. Systematic ultrasound identification of the dorsal scapular and long thoracic nerves during interscalene block. Reg Anesth Pain Med. 2013; 38:54-7.
9.Kalagara, H., Nair, H., Kolli, S. et al. Ultrasound Imaging of the Spine for Central Neuraxial Blockade: a Technical Description and Evidence Update. Curr Anesthesiol Rep.2021; 11: 326–39.
10. Bugada D, Bellini V, Lorini LF, Mariano ER. Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiol Clin. 2018; 36:403-15..
11.Tran J, Giron Arango L, Peng P, Sinha SK, Agur A, Chan V. Evaluation of the iPACK block injectate spread: a cadaveric study. Reg Anesth Pain Med. 2019: rapm-2018-100355.
12. 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: 47-53.
13. 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; 41:621-7.
14. Chin KJ, Versyck B, Elsharkawy H, Rojas Gomez MF, Sala-Blanch X, Reina MA. Anatomical basis of fascial plane blocks. Reg Anesth Pain Med. 2021; 46:581-99.
15. Lonnqvist PA, Karmakar MK, Richardson J, Moriggl B. Daring discourse: should the ESP block be renamed RIP II block? Reg Anesth Pain Med. 2021; 46:57-60.

How to Cite this Article: Gopal TVS | Ultrasound and Modern Regional Anaesthesia | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 100-101.

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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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