Assessment of Ultrasound-Guided Regional Anesthesia
Publication Date: April 1, 2016
Last Updated: March 14, 2022
Recommendations
Evidence-Based Recommendations to Enhance Detection of Needle-to-Nerve Proximity
Needle Tip Presentation
- Needle-probe alignment and needle tip identification improve with operator competency (level IIa).
- Educational tools such as phantoms and simulation facilitate skill acquisition, needle-probe alignment, and needle tip detection (level IIa).
- Transducer manipulation improves needle tip visualization (level IIb).
- Needle manipulation to alter the angle of insonation can improve needle tip visibility (level III).
- Needle manipulation to alter bevel orientation improves needle tip visibility (level IIb).
- Larger needle gauge increases US beam reflectiveness and may facilitate needle tip detection (level III).
- Echogenic needles improve needle tip visibility (level IIa).
- Needle priming and pumping assist in needle and needle tip detection (level IIb).
- Needle guides assist in needle tip visualization (level IIb).
- Beam steering enhances needle tip visibility (level IIb).
- Image compounding technology enhances the sonographic presentation of block needles (level IIa).
- Needle recognition software facilitates identification of needle tip position (level IIb).
- Vibrating devices and Doppler effect permit estimation of needle tip position (level III).
- Coupling US with magnetic resonance imaging improves the accuracy of needle tip detection (level IIb).
- Needle-integrated optical fiber hydrophone can facilitate needle tip identification (level III).
- Photoacoustic tracking may facilitate needle and catheter detection (level III).
- Three-dimensional US imaging facilitates needle tip visualization (level IIb).
- Four-dimensional US imaging can facilitate needle tip tracking (level III).
- High definition US imaging improves needle tip visibility (level IIb).
- Robotic-assisted guidance can improve needle tip recognition (level III).
- Operator competency enhances needle tip recognition (level IIa).
- Tissue movement is a surrogate measure of needle tip position (level III).
- Hydrolocation is useful to estimate needle tip position (level IIb).
- Bubble injection can facilitate needle tip recognition (level III).
- Needle tracking assists in interpreting needle trajectory and needle tip recognition (level III).
- Tissue harmonic imaging can enhance nerve visualization (level III).
- Spatial compound imaging can improve nerve presentation (level III).
- Nerve swelling is indicative of intraneural injection (level IIb).
- Development of concentric hypoechoic halo in the targeted nerve is indicative of intraneural injection (level IIb).
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Effect of USG on Upper- and Lower-Extremity PNB Characteristics
- US improves onset of block (1b-A)
- US improves quality of block (1b-A)
- US does not improve duration of block (1b-A)
562
Summary Statements Comparing USG to an Alternative Peripheral Nerve Localization Technique for Lower-Extremity Regional Anesthesia
- Decreased block performance time (vs PNS) A: Supportive of USG, Ib
- Decreased block onset time A: Supportive of USG, Ib
- Decreased local anesthetic requirements A: Supportive of USG, Ib
- Addition of concurrent PNS to USG A: Not supportive of benefit for addition of concurrent PNS to USG, Ib
- Increased block success (rate of complete sensory block) A: Supportive of USG, Ib
- Improved postoperative analgesia for perineural catheters A: Not supportive of benefit for USG, Ib
562
Outcome Comparisons of USG Versus Other Nerve Localization Methods for Upper Extremity Regional Anesthesia
- Block performance time (A: Supportive of US )
- No. of needle passes (A: Supportive of US)
- Vascular puncture (A: Supportive of US)
- Procedure pain (I*)
- Sensory onset (A: Supportive of US)
- Motor onset (I)
- Block success (I)
- Block duration (I)
* I indicates insufficient or conflicting evidence not allowing a recommendation for or against intervention.
562
Effect of USG on Upper- and Lower-Extremity PNB Characteristics
- US improves onset of block (1b-A)
- US improves quality of block (1b-A)
- US does not improve duration of block (1b-A)
562
Summary Statements Comparing USG to an Alternative Peripheral Nerve Localization Technique for Lower-Extremity Regional Anesthesia
- Decreased block performance time (vs PNS) A: Supportive of USG, Ib
- Decreased block onset time A: Supportive of USG, Ib
- Decreased local anesthetic requirements A: Supportive of USG, Ib
- Addition of concurrent PNS to USG A: Not supportive of benefit for addition of concurrent PNS to USG, Ib
- Increased block success (rate of complete sensory block) A: Supportive of USG, Ib
- Improved postoperative analgesia for perineural catheters A: Not supportive of benefit for USG, Ib
562
Evidence-Based Recommendations for USG Truncal Block Block
- Thoracic paravertebral (B/IIb-III)
- PECS (A/Ib-III)
- Intercostal (C/III)
- TAP (A/Ia-IIb)
- Rectus sheath (A/I)
- Transversalis fascia (B/III)
- II/IH (A/Ib-IIb)
562
Evidence-Based Recommendations for US-Assisted Neuraxial Block
- Increased accuracy of lumbar interspace identification (B-IIa)
- Accurate measurement of the depth of the epidural and intrathecal space (A--Ia)
- Improved efficacy of neuraxial anesthesia (A-Ia)
- Improved safety of neuraxial anesthesia (B-III)
562
Evidence-Based Recommendations for USG Pediatric Regional Anesthesia
PNBs
Block performance time
Neuraxial blockade
Block performance time
Pediatric regional anesthesia
Safety and complications
Block performance time
- US-guided blocks are quicker to perform than blocks using the nerve stimulation technique (Ib-B)
- US-guided blocks may require more time to perform when compared with landmark-based techniques (Ib-B)
- No evidence found
- Block success is higher with USG compared with the nerve stimulation technique (Ib-A)
- Block success with USG is not higher than landmark-based techniques†(Ib-B)
- Opioid consumption is less in USG blocks compared with general anesthesia alone (Ib-A)
- Opioid consumption is less when comparing USG to the landmark technique (Ib-B)
- Analgesia consumption is not different when comparing USG blocks to nerve stimulation (Ib-C)
- US guidance prolongs block duration when compared with the landmark technique, nerve stimulation technique, and local anesthetic wound infiltration Ib-A)
- US guidance provides excellent pain relief compared with the landmark technique (Ib-A)
- US guidance provides excellent pain relief compared with local anesthetic wound infiltration (Ib-A)
- US guidance may not be superior to nerve stimulation with respect to pain relief (Ib-C)
- Local anesthetic spread can be visualized with USG (III-B)
- There is no correlation between local anesthetic dose and no. of dermatomes blocked for TAP blocks (III-C)
- US guidance allows for visibility of anatomical structures, needle, and catheter (Ib-A)
Neuraxial blockade
Block performance time
- Neuraxial needling time is shorter when US is used (Ib-A)
- US imaging of neuraxial structure allows the operator to perform blocks more easily, but does not necessarily increase block success (Ib-B)
- US imaging allows real-time visualization of local anesthetic spread in neuraxial blockade (Ib-A)
- Caudal spread of local anesthetic has an inverse relationship with regard to physical characteristics (age, height, and weight) (III-B)
- US imaging can detect variations in anatomical structure and visualize the catheter (III-B)
- US imaging can predict epidural depth (Ib-A)
- Epidural blocks are sufficient at providing analgesia (III-B)
Pediatric regional anesthesia
Safety and complications
- Pediatric regional anesthesia has a low incidence of adverse events and complications (IV-B)
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The Effect of USG on Patient Safety
PONS (III)
LAST (Ia and III)
HDP (Ib and IV)
Pneumothorax (III)
- Proving statistical differences in nerve injury as a function of nerve localization technique is likely futile
- Underpowered results from RCTs, registries, and large case series find no difference in surrogate markers of nerve injury, such as paresthesia during or immediately after block placement or transient PONS (level III evidence)
- UGRA appears to be associated with PONS at an incidence similar to historical reports of nerve injury associated with PNS (level III evidence)
LAST (Ia and III)
- Compared with PNS, USG lowers the risk of unintended vascular puncture, a surrogate outcome for LAST (level Ia evidence)
- Registry data provide strong support to the statement that USG reduces the incidence of LAST across its clinical continuum (level III evidence)
- US guidance does not completely eliminate the risk of LAST, therefore practitioners should remain vigilant and use other preventive and/or diagnostic modalities as appropriate (grade B recommendation)
HDP (Ib and IV)
- RCTs confirm the ability of low-volume USG to reduce (but not eliminate) the incidence and severity of HDP using the interscalene approach. The incidence of HDP ranges from nearly 0% to 34% with the USG supraclavicular approach (level Ib evidence)
- No RCTs or case reports address the role of USG brachial plexus blockade in patients at risk of pulmonary compromise from underlying severe pulmonary disease. Because HDP can still occur unpredictably, caution is warranted in any patient unable to withstand a 25% diminution of pulmonary function (grade C recommendation)
Pneumothorax (III)
- No adequately powered studies directly address the risk of pneumothorax with US-guided regional anesthesia
- Registry data and case reports describe the occurrence of pneumothorax despite the use of UGRA (level III evidence)
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Recommendation Grading
Overview
Title
Assessment of Ultrasound-Guided Regional Anesthesia
Authoring Organization
American Society of Regional Anesthesia and Pain Medicine
Publication Month/Year
April 1, 2016
Last Updated Month/Year
July 7, 2022
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
In 2009 and again in 2012, the American Society of Regional Anesthesia and Pain Medicine assembled an expert panel to assess the evidence basis for ultrasound guidance as a nerve localization tool for regional anesthesia.
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Hospital, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D000758 - Anesthesia, D000772 - Anesthesia, Local
Keywords
anesthesia, anesthesia and analgesia, ultrasound
Source Citation
Neal JM, Brull R, Horn J, et al
The Second American Society of Regional Anesthesia and Pain Medicine Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia: Executive Summary
Regional Anesthesia & Pain Medicine 2016;41:181-194.