Paul J. Zetlaoui

Ultrasound Guidance for Axillary Plexus Block Does Not Prevent Intravascular Injection

DIRECT visualization of anatomy by ultrasound during regional anesthesia was considered to likely minimize the incidence of complications of regional anesthesia due to needle misplacement. Neural impalements have been reported under direct vision of the brachial plexus. We report a case of inadvertent vascular puncture leading to a seizure during an ultrasound-guided axillary block.

A Modified Coracoid Approach to Infraclavicular Brachial Plexus Blocks Using a Double-Stimulation Technique in 300 Patients

Infraclavicular brachial plexus block is used less than other techniques of regional anesthesia for upper-limb surgery. We describe a modified coracoid approach to the infraclavicular brachial plexus using a double-stimulation technique and assess its efficacy. Patients undergoing orthopedic surgery of the upper limb were included in this prospective study. The landmarks used were the coracoid process and the clavicle. The needle was inserted in the direction of the top of the axillary fossa (in relation to the axillary artery), with an angle of 45 degrees. Using nerve stimulation, the musculocutaneous nerve was identified first and blocked with 10 mL of 1.5% lidocaine with 1:400,000 epinephrine. The needle was then withdrawn and redirected posteriorly and medially. The radial, ulnar, or median nerve was then blocked. The block was tested every 5 min for 30 min. The overall success rate, i.e., adequate sensory block in the 4 major nerve distributions at 30 min, was 92%, and 6% of the patients required supplementation. Five patients required general anesthesia. No major complications were observed. This modified infraclavicular brachial plexus block using a double-stimulation technique was easy to perform, had frequent success, and was safe in this cohort.

Ultrasound guidance for difficult lateral popliteal catheter insertion in a patient with peripheral vascular disease.

Objective Interest in ultrasound-guided nerve block is increasing, but clinical utility still is being determined. We report a case in which ultrasound imaging aided nerve localization during popliteal block. Case Report We report a case in which failure of nerve stimulation to locate the sciatic nerve at the popliteal fossa in a patient with underlying neuropathy was overcome by ultrasound guidance, which allowed quick and easy catheter placement. After failure of the stimulation technique, ultrasound permitted us to observe advancement of the needle, placement of the catheter, and spread of local anesthetic around the nerve. Conclusion Ultrasound guidance can facilitate lateral popliteal catheter insertion in patients in whom electrolocation has failed.

Lateral approach to the sciatic nerve at the popliteal fossa combined with saphenous nerve block

The lateral approach to the sciatic nerve block at the popliteal level is a recently described, innovative technique. Compared with other approaches, it has the advantage of being performed with the patient supine and of preserving hamstring function. Moreover, a lateral approach rather than a posterior approach at the popliteal fossa reduces the hazard of vascular puncture and improves patients safety. All these advantages should increase the popularity of the block, which currently remains underused by many anesthesiologists. For painful stimuli involving the medial side of the leg, a saphenous nerve block may be combined with the block of the sciatic nerve. This article describes and compares a simple technique using easily identified anatomic landmarks, with more classical approaches.

Where do ultrasounds have to go

Alilet et al. [1] performed a comparative study between a landmark-based and an ultrasound (US) guided intermediate cervical plexus block (ICPB). They report no difference in terms of global success rate between a blind approach and an US-guided block, and following the conclusion of this study, some anaesthesiologists perhaps would consider that, to perform an ICPB, there is no advantage to use USG. The study by Menacé et al. [2] compared three methods of UGS (traditional 2D, multiplanar and GPS needletracking) for the epidural approach in a phantom model. In this second study, the authors also report no significant difference between the three techniques in the time to perform the block. The conclusions of these two studies are apparently not positive. Reading the results of these two studies with a different point of view, i.e. patient safety, slightly different conclusions could be drawn. First, Alilet et al. [2] rightly point out that their ‘‘study was probably underpowered to detect any difference’’ in rate of success between the two techniques. However, the authors report on a significant difference between the total amounts of local anaesthetic (LA) injected to achieve a surgical block. This is, to my point of view, a key difference between the two techniques. Reducing harm for patients is probably the most important step provided by US in RA. The recent report by Neal et al. [3] on the evidence-based assessment of ultrasound guided RA stated that ‘‘. . .compared with peripheral nerve stimulation, USG lowers the risk of unintended vascular puncture, a surrogate outcome for LAST (level Ia evidence)’’. In this specific block, i.e. the ICPB, which is an interfacial space block where there is no targeted nerve and where large amount of drugs are needed, reducing the risk of inadvertent intravascular injection, or reducing the total amounts of injected LA, is crucial for patient safety. Furthermore, as evoked in the discussion section of this study, some anaesthesiologists, to improve the efficacy of the ICPB in carotid surgery, perform an injection in the sheath of the carotid artery. Obviously, USG can facilitate the performance and improve the safety of this specific additional block [4], and this is one reason additional to perform these two blocks under USG. Furthermore in very high-risk patients, US guidance may facilitate

Ultrasonographic Appearance of the Cricothyroid Membrane

for delayed functional recovery is an important step toward providing individualized, effective, cost-conscious, and high-value care in the context of the perioperative surgical home.7 While we agree that the blood test used an external or “artificial” TLR4 ligand (lipopolysaccharide) that may not recapitulate biology as it unfolds during surgery, the use of lipopolysaccharide to activate a specific signaling pathway does not negate the predictive value of the test. The scientific endeavor never stops, and interesting results will always trigger the next set of important questions. While our strong correlative findings provide a link to relevant biology, we agree that they do not prove cause and effect—and we never in our report suggested such a relationship. This is the next obvious question that we need to address. The prospect of validating TLR4 as a therapeutic target is exciting in light of preclinical studies, suggesting that preemptive dampening of TLR4 with a nontoxic agonist attenuated proinflammatory events and enhanced host resistance to infection and survival in models of burn injury and systemic infection.8,9 There is certainly important work ahead of us and room to improve on all fronts. However, our bets have been placed, and we see a clear light at the end of the tunnel.