Do W e Need Ultrasound Guidance for Regional Anesthesia ??

2. Director: Peripheral nerve Analgesia Director: regional anesthesia Fellowship Section Head: Orthopedic Anesthesia Cleveland Clinic Loran Mounir Soliman M.D Do We Need Ultrasound Guidancefor Regional Anesthesia??

3. Goals and Objectives 1 3 2 Why to use Ultrasound versus Not?? Another View Is there any evidence? Do we need Ultrasound for regional Anesthesia??

4. 1 Advantage of UGRA…….. We talked about them before

5. Advantages of UGRA Safe Technology Non-invasive. Real- time pictures Reproducible results Seeing is believing. Higher Resolution Portable machines Better picture enhansmentsoftwares Needle Guiding softwares Better sonographic needles Easy to use interface

6. Why to change?? Needextratraining Long history of experience and safety of conventionaltechniques Need to reducecost & expenses

7. 2 Is There Enough Evidence? What type of outcomes are we looking at??

8. Better Outcomes? Did UGRA resulted in…….

9. Types of outcomes Quicker blocks Faster Onset Lesser attempts Better Success rate Longer duration Patient Satisfaction Vascular puncture Pneumothorax Diaphragmatic paresis Post Operative Neurologic Symptoms (PONSs) Local Anesthetic Systemic Toxicity (LAST)

10. Has it been that long? 1. Kirvela O, Svedstrom E, Lundbom N. Ultrasonic guidance of lumbar sympathetic and celiac plexus block: a new technique. Reg Anesth. 1992;17:43Y46. 2. Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to landmark-guided approaches. Reg Anesth Pain Med. 2000;25:600Y604. 3. Kapral S, Krafft P, Eibenberger K, et al. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg. 1994;78:507Y513. 4. Ting PL, Sivagnanaratnam V. Ultrasonographic study of the spread of local anaesthetic during axillary brachial plexus block. Br J Anaesth. 1989;63:326Y329.

11. complications Less volume New approach

12. Is one study is enough? Meta Analysis 1999

13. Succesfull Block equals Surgical anesthesia (No GA, Spinal nor suplementationblocks) Succesfull Block equals Surgical anesthesia (No GA, Spinal nor suplementation blocks)

14. US provided more successful blocks with risk ratio for block failure 0.41 No significant difference in success rate of US guided blocks Other benefits of Ultrasound included: faster onset, longer duration and higher patient satisfaction. No single report suggesting that Ultrasound is inferior to other techniques or carry a higher risk.

16. US faster in 15 studies 19 Studies US slower in One study Performance time of the block Same in 2 studies

17. US for upper extremity Blocks is found also to have :Faster Sensory onsetHigher Success RateLess Complication Rate

18. Only 7 Studies found US faster onset and higher success rate

19. Neuraxial Ultrasound is superior than landmarks in determination of the midline, identification of the level and the depth from the skin Ultrasound is better than Anatomical method but inferior to radiology imaging

20. Interventional Pain

21. Not Enough Data from the small studies in pediatrics. Trend toward faster blocks and lower volumes

22. Conclusion

23. What About Safety?????

24. Ultrasound Has to be safer ….. Seeing has to be better than blind techniques Complications of Regional Anesthesia

25. Complications • Less with Ultrasound • Pneumothorax • Hemidiaphragmatic paresis • Vascular Puncture • No Difference • LAST (local Anesthetic Systemic toxicity) • Peripheral Nerve injuries • 17,000 cases reviewed

26. There are no RCT data that unequivocally supportsuperior safety outcomes consequent to the use of UGRACase reports emphasize that absolute elimination of these seriouscomplications has not occurred.

27. Local Anesthetic toxicity Seizure 0.8%(one case) Cardiac toxicity 0 cases

28. Could this one case had been avoided

29. Skills needed

31. The Risk is not still eliminated Nerve injury 1.8% neurological symptoms lasting more than 5 days 0.9% lasting longer than 6 months

32. Nerve Injury is Multi Factorial • Preexisting lesions • Surgical techniques • Position details • Volume of local anesthetics • Needle trauma • Regional Anesthesia & Pain Medicine.Sept 2012 p490 • Reported the incidence of perioperative nerve injury after total shoulder is 2.2% with no additional increase of risk with ISB

33. 3 Another Vision for Ultrasound

34. Remote Blocks!!!!!!

37. 3 Another Vision for Ultrasound

38. 3 Another Vision for Ultrasound 16.5%

40. Thank You