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1
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Dedicated to my parents who supported me always
This page intentionally left blank
 Contents

Acknowledgements xi
Foreword by Professor Admir Hadzic xiii
Foreword by Professor Narinder Rawal xv
Foreword: The surgeon’s view by Professor Christian Fialka xvii
Contributors xix
How to use this book xxi
Abbreviations xxiii

1 Basic principles of ultrasonography 1

1.1 Nature of sound waves 1
1.2 Piezoelectric effect 2
1.3 Pulse-echo instrumentation 2
1.4 Resolution and electronic focusing 4
1.5 Time-gain compensation 6
1.6 Measuring velocity with pulsed ultrasound 8
1.7 Ultrasound imaging modes 9
1.8 Common image artefacts 14
1.9 Needle visualization 16
1.10 Equipment needed for ultrasound imaging 18
2 The scientific background of ultrasound guidance in regional
anaesthesia 21
3 Initial considerations and potential advantages of regional
anaesthesia under ultrasound guidance 23
3.1 History of ultrasound-guided regional anaesthesia 23
3.2 Possible advantages of ultrasound-guided regional anaesthesia 24
4 Technique limitations and suggestions for a training concept 33
4.1 Technical limitations 33
4.2 Non-technical limitations 33
4.3 Suggestions for a training concept in ultrasound-guided regional
anaesthesia 34
viii CONTENTS

5 Have we reached the gold standard in regional anaesthesia? 37

6 Technical and organization prerequisites for
ultrasonographic-guided blocks 41
6.1 Technical considerations 41
6.2 Organization 53
6.3 Post-operative observation 54
6.4 Other considerations 54
7 Ultrasound-guided regional anaesthetic techniques in children:
current developments and particular considerations 57
7.1 Management of minor trauma in children 58
8 Ultrasound appearance of nerves and other anatomical or
non-anatomical structures 63
8.1 Appearance of nerves in ultrasonography 63
8.2 Strategies when nerves are not visible 66
8.3 Appearance of neuronal-related structures in ultrasonography 67
8.4 Appearance of other anatomical structures in ultrasound 71
8.5 Appearance of artefacts in ultrasound 76
9 Needle guidance techniques 81
9.1 Out-of-plane (OOP) needle guidance technique 82
9.2 In-plane (IP) needle guidance technique 82
9.3 How to approach a nerve? 85
10 Pearls and pitfalls 87
10.1 Setting and orientation of the probe 87
10.2 Pressure during injection 87
10.3 Jelly pad for extreme superficial structures 88
11 Nerve supply of big joints 89
11.1 Shoulder joint 89
11.2 Elbow joint 89
11.3 Wrist 90
11.4 Hip joint 90
11.5 Knee joint 91
11.6 Ankle 91
12 Neck blocks 93
12.1 General anatomical considerations 93
12.2 Deep cervical plexus blockade 93
12.3 Superficial cervical plexus blockade 95
12.4 Implication of neck blocks in children 100
 CONTENTS ix

13 Upper extremity blocks 101

13.1 General anatomical considerations 101
13.2 Interscalene brachial plexus approach 102
13.3 Supraclavicular approach 108
13.4 Infraclavicular approach 111
13.5 Axillary approach 114
13.6 Suprascapular nerve block 120
13.7 Median nerve block 122
13.8 Ulnar nerve block 125
13.9 Radial nerve block 128
13.10 Implications of upper limb blocks in children 130
14 Lower extremity blocks 133
14.1 General anatomical considerations 133
14.2 Psoas compartment block 133
14.3 Femoral nerve block 137
14.4 Saphenous nerve block 140
14.5 Lateral femoral cutaneous nerve block 145
14.6 Obturator nerve block 148
14.7 Sciatic nerve blocks 151
14.8 Ankle blocks 163
14.9 Implications of lower limb blocks in children 169
15 Truncal blocks 173
15.1 General anatomical considerations 173
15.2 Intercostal blocks 173
15.3 Ilioinguinal-iliohypogastric nerve blocks 176
15.4 Rectus sheath block 178
15.5 Transversus abdominis plane (TAP) block 183
15.6 Implications of truncal blocks in children 184
16 Neuraxial block techniques 189
16.1 General considerations 189
16.2 Epidural blocks 189
16.3 Paravertebral blocks 193
16.4 Implications in children 196
17 Peripheral catheter techniques 203
18 Future perspectives 205
18.1 Regional blocks for particular patient populations 205
18.2 Education 205
18.3 Technical developments 206
x CONTENTS

Appendix 1 Zuers Ultrasound Experts regional anaesthesia

statement 209
Appendix 2 Vienna score 219
Appendix 3 Guidelines for the management of severe local
anaesthetic toxicity according to the Association
of Anaesthetists of Great Britain and Ireland
(2007) 221
Appendix 4 Definition of specific terms 225

Index 227
 Acknowledgements

A book project like this can never be

undertaken alone. Therefore, the
author gratefully thanks:
Dr Lukas Kirchmair for his invalua-
ble continuous cooperation, his excel-
lent anatomy knowledge, the designing
of anatomical cross-sectional images
to perfectionism and proofreading of
the entire manuscript. Thank you,
Lukas!
Mitchell Kaplan for his excellent
physics chapter. Even I understand
ultrasound physics now. Thank you,
Mitch!
Professor Bernhard Moriggl for
patiently answering hundreds of anat-
omy questions over the past years. Thank you, Bernhard!
Professor Anette-Marie Machata and Professor Dr.Stephan Kettner for their
excellent hand skills during the preparation of photographs. Thank you,
Anette-Marie and Stephan!
Readers of the first edition for their constructive criticism.
Finally, all my colleagues who have been working with me for many years for
resisting my (sometimes) crossness, and my wife, Daniela, for giving me the
encouragement to complete such a project.
This page intentionally left blank
 Foreword
Professor Admir Hadzic

The practice of regional anaesthesia

and peripheral nerve blocks in par-
ticular has changed substantially
over the past decade. In fact, it would
not be an overstatement to say that
the new technical developments
in the field tether of making some of
the old teaching to the brink of
obsolete. Most significant develop-
ments are the results of technical
advances or, more specifically, the
introduction of ultrasound moni-
toring for the placement of needles
and catheters. The ability to monitor
the disposition of the local anesthet-
ic is now a key factor in acquiring an
unprecedented control over tech-
nique execution. Ultrasound monitoring gives the practitioner insight into the
block dynamics and disposition of the local anesthetics around peripheral
nerves and plexuses. All of this new information has had a cumulative impact
on our understanding of the mechanisms of neural blockade and the relation-
ship between the volume of local anesthetics and a successful blockade. The
idiosyncrasy of nerve stimulation, which was the gold standard for nerve
localization prior to the introduction of ultrasound, is also much better
understood.
However, ultrasound guidance during the administration of peripheral
nerve blocks and increasingly, other regional anaesthesia techniques, was not
an overnight success. Significant efforts were expended, both in advancing and
improving on the ultrasound technology, to provide an image quality level
that allows reliable imaging of the peripheral nerves and needle visualization.
The industry clearly deserves accolades for their efforts to bring this technol-
ogy within the reach of practising clinicians. However, these developments
would not have been possible without the pioneering efforts of an
xiv FOREWORD

international group of anaesthesiologists with extraordinary technical knowl-

edge and drive. Indeed, it was the regional anaesthesiologists who fervently
guided the industry to improve the equipment, and who then used every
advance to test the applicability of the new technology for use in neural imag-
ing and the administration of regional anaesthesia. It is for this reason that
compendiums of knowledge from these very think tank echelons are particu-
larly valuable. Professor Peter Marhofer and his Viennese group of collaborators
are uniquely suited to create such a text. They have worked at the forefront to
steer the ultrasound industry and the focus of clinical practice towards the appli-
cation of ultrasound for use in regional anaesthesia since the mid-nineties.
This second edition of the well-received Ultrasound Guidance in Regional
Anaesthesia: Principles and Practical Implementation expands on the first
edition to include nearly all areas of clinical relevance. The second edition
features some 200 photographs, including cross-sectional views of anatomy in
human cadavers. A new chapter in this edition is ‘Implications in children’
which bridges the information gap on implementing the described technique
in this population as well. Several useful appendices, such as expert consensus
and the management of local anaesthetic toxicity, are also added.
Professor Marhofer and the contributors in Austria (Lukas Kirchmair, MD
and Stephan Kettner, MD), bolstered by the engineering advice from Mitchell
S. Kaplan, PhD, created a uniquely comprehensive, authoritative book on the
use of ultrasound guidance in regional anaesthesia. The use of ultrasound
guidance in regional anaesthesia has allowed for a myriad of modifications and
variations of techniques, indications, and pharmacologic approaches, which
inevitably vary from institution to institution. Not surprisingly, this volume
represents the views and teaching methods of the fabled Viennese school. As
leaders in the specialty of regional anaesthesia and the application of ultra-
sound, Professor Marhofer and the contributors compiled a uniquely out-
standing and an authoritative text based on 16 years of clinical experience and
decades of original research by the group. I wish to sincerely congratulate the
authors and thank them for their immense contribution to the body of knowl-
edge and pursuit of education in ultrasound-guided regional anaesthesia and
beyond.

Admir Hadzic, MD
Professor of Clinical Anaesthesiology
College of Physicians and Surgeons, Columbia University,
Director of Regional Anaesthesia, St. Luke’s-Roosevelt Hospital Centre,
New York, New York, USA
 Foreword
Professor Narinder Rawal

In recent decades, the role of

regional anaesthesia has advanced
significantly. Currently, it is widely
practised for surgery in adults and
children and also for the manage-
ment of post-operative and labour
pain. Improvements in nerve
localization techniques such as
nerve stimulation and ultrasound-
guided blocks and the availability
of stimulating catheters have
improved needle and catheter
placement. The accuracy and safe-
ty has evolved to such an extent
that perineural catheter tech-
niques are being increasingly used
to treat post-operative pain at
home after ambulatory surgery.
During the last decade, the
explosion of interest in ultrasound visualization to guide local anaesthetic
injection has been truly remarkable. Multiple national and international annu-
al congresses, large numbers of dedicated ultrasound courses in various parts
of the world, sold-out workshops at the European Society of Regional
Anaesthesia and Pain Therapy (ESRA) annual and zonal meetings and other
regional anaesthesia society congresses, the increasing number of publications
on the topic, and the addition of a special section in the journal Regional
Anaesthesia and Pain Medicine in 2007, all testify to the enormous increase in
interest in ultrasonography in regional anaesthesia.
Ultrasonography allows the operator to visualize in real time the relevant anato-
my, the nerve, the needle placement, and the spread of local anaesthetic. The enthu-
siasts claim that ultrasound-guided peripheral nerve blocks are safer because they
have higher success rates and lower rates of complications, are non-invasive (as
opposed to paraesthesia or nerve stimulation techniques), require reduced doses of
local anaesthetics by about 30% or more, provide a faster onset and prolonged
xvi FOREWORD

duration of blocks, and allow the detection of anatomical variations. However,

there are others who are less impressed and have justifiably asked for good quality
evidence to support these claims. This topic is a regular feature for ‘pros and cons’
debates in many congresses. There is a need for safety studies, efficacy studies, and
equivalence studies of ultrasonic guidance versus conventional techniques for
regional anaesthesia. In developing countries, the high cost of equipment is a major
drawback. One may be for or against ultrasound-guided blocks and the jury is still
out, but it is increasingly difficult to ignore the technique, especially in teaching
institutions. It is also a generational issue that trainees everywhere seem to be asking
for this technology. In short, ultrasonography in regional anaesthesia is here to stay
and we can expect an increasing number of clinicians to practise this technique.
Controlled studies to address the above issues can be expected to become gradually
available which will establish the proper place of ultrasonography in regional anaes-
thesia in our armamentarium.
A good knowledge of sonoanatomy is crucial for a successful use of the tech-
nique. Acquiring technical skills is a major task and a correct needle-transducer
alignment is the commonest error seen in the novices. This book by one of the
pioneers in ultrasound in regional anaesthesia has now come out in its second edi-
tion. The first edition was published in September 2008 to critical acclaim. The
author takes up the above issues of benefits and limitations of ultrasound-guided
blocks. The 18 chapters also cover everything from the basic principles of ultra-
sonography and technical issues to blocks in different parts of the body, including
neck, joint, and trunk blocks in addition to the obligatory upper and lower extrem-
ity blocks. In this second edition, Professor Marhofer has added new material
which includes organizational and economic issues, paediatric applications, and
the use of ultrasonography in neuraxial blocks. The overall quality of figures is bet-
ter than in the first edition and cross-sectional anatomical illustrations are also
included. There is a section on recommendations for the use of ultrasound-guided
regional anaesthesia by a panel of experts from Europe, North America, and Japan.
Professor Marhofer himself is one of the original experts with an experience extend-
ing to more than 15 years. His widespread experience in participating in ultrasound
workshops in many parts of the world has been distilled into this new book.
In this book, every aspect of ultrasound-guided blocks has been covered in
detail with emphasis on educating the reader for a safe and effective use of
regional anaesthesia for surgery and pain management. This book will be a major
source for trainees as well as experienced clinicians who will appreciate the wealth
of information it provides for all practitioners of regional anaesthesia.

Professor Narinder Rawal MD, PhD, FRCA (Hons)

Department of Anaesthesiology and Intensive Care,
University Hospital Örebro,
Örebro, Sweden
 Foreword: The surgeon’s view
Professor Christian Fialka

Regional anaesthesia in muscu-

loskeletal surgery today represents
the gold standard for a great variety
of procedures. At our institution, we
have the privilege to work with the
group of anaesthetists who pio-
neered the field of ultrasound-guid-
ed regional anaesthesia, especially
the senior author of this textbook.
Therefore, over the years, it has
become a safe and reliable method
for almost all extremity surgical
procedures.
In the early days, regional anaes-
thesia was not very popular in the
surgical community. Neither land-
mark-guided nor electro-stimula-
tion-guided techniques for regional
anaesthesia could be used without
showing a significant number of failures such as a delayed or incomplete effect
and the need for an intraoperative conversion to general anaesthesia. Since we
benefit from the development of the ultrasound-guided technique, the latter
cases have become rare exceptions.
Other historical concerns such as the fear of delay due to prolonged prepara-
tion time before surgery, especially when compared to cases under general
anaesthesia, disappeared during the past decade because of the positive experi-
ence from thousands of cases.
Today, ultrasound-guided regional anaesthesia is favoured not only during
the time of surgery, but also because it provides a good post-operative pain
care. For example, patients who are scheduled for arthroscopic shoulder pro-
cedures are provided with a single opiate administration subcutaneously
(7.5mg Piritramid), 8 to 10 hours past the end of the procedure, using the ris-
ing analgesic effect of the opiate just before the block loses its effect and the
xviii FOREWORD: THE SURGEON’S VIEW

pain level increases. Following this protocol, the amount of post-operative

pain medication can be reduced significantly.
In summary, surgeons can recommend ultrasound-guided regional anaes-
thesia to all patients with standard procedures in bone and joint surgery. These
patients are provided with a safe and reliable anaesthesia procedure as well as
with a satisfying post-operative pain management.

Christian Fialka, MD
Professor of Trauma Surgery
Department of Trauma Surgery,
Medical University of Vienna,
Vienna, Austria