Ultrasound-Guided Regional Anesthesia

42 Ultrasound-Guided Regional Anesthesia

Peripheral nerve blocks are frequently performed in children to provide anesthesia or analgesia during the perioperative period.13 Success depends on the ability to accurately place the needle and thereby the local anesthetic close to the target nerve without causing injury to the nerve or adjacent structures. Peripheral nerve blocks are not without risk and can pose a serious challenge even to the experienced anesthesiologist because they are usually performed after the child is anesthetized. In the past, clinicians relied on anatomic landmarks,13 fascial clicks,4 loss of resistance,5 or nerve stimulation6 to position the needle in the vicinity of the nerve (see Chapter 41). Anatomic landmarks provide valuable clues to the position of the nerve, but they are surrogate markers, lack precision,7 vary among children of different ages, and may be difficult to locate in obese children. Even nerve stimulation, which has been recommended as the gold standard for nerve localization, may not always elicit a motor response8 and its use does not guarantee success or preclude complications.9 Moreover, the accuracy of needle placement cannot be predicted with any of these methods,8 which may lead to multiple attempts to place the needle that may result in pain and possibly an incomplete or failed nerve block.

Various imaging modalities, such as fluoroscopy,10 computed tomography (CT),11 and magnetic resonance imaging (MRI),7 improve the accuracy of block placement in adults. However, these adjuncts are rarely used in children13 and are not practical in the operating room. Recently, increased interest has been shown in the use of ultrasound (US) to guide peripheral and central neuraxial blocks in both adults and children.1221 In this chapter, the basic principles of US imaging and US-guided regional anesthesia (USGRA) in children are described. It is assumed that the reader has a basic understanding of common landmark-based nerve block techniques in children.

The use of US for regional anesthesia dates to 1978, when La Grange and associates22 used a Doppler flow detector to locate the subclavian artery and guide supraclavicular brachial plexus blocks. In 1994, Kapral and colleagues23 published the first report on direct sonographic visualization in regional anesthesia. They used US to directly visualize the brachial plexus and observe the spread of the local anesthetic in real time during supraclavicular brachial plexus block. Today, US is used to guide peripheral nerve blocks and central neuraxial blocks in both adults and children.1221 This has become possible owing to improvements in US technology and the availability of portable US machines with high-resolution imaging capabilities. The ability to directly visualize the peripheral nerves and central neuraxial structures in children is truly exciting and can be compared to removing a blindfold from the anesthesiologist performing regional anesthesia. Currently, outcome data that prove US increases the safety and efficacy of regional anesthesia in children are rapidly accumulating. For example, when compared with nerve stimulation, US speeds the onset time of infraclavicular block.20 A greater success rate of pediatric truncal blocks is seen when US guidance is used.21

Principles of Ultrasound

Sound is a form of mechanical energy that propagates through a medium as a wave of alternating pressure, causing local regions of compression and rarefaction (Fig. 42-1). The frequency (f ) of sound is the number of cycles of oscillation per second made by the sound source and the particles in the medium through which it moves. It is expressed in hertz (Hz, cycles per second). Sound waves propagate symmetrically away from the source at a constant velocity (v), which is the speed of sound in the medium. Distance between the wavefronts is the wavelength (λ) of the sound. The speed of sound through a medium can thus be represented as:


Amplitude is the strength of a sound wave, and the unit used to describe it is decibels (dB). The velocity of transmission of sound through a medium depends on its acoustic impedance and is determined by factors such as the stiffness, elasticity, and density of the medium. This accounts for the varying velocity of sound transmission through different tissues in the human body (Table 42-1). The average velocity of sound transmission through biologic tissue is 1540 m/sec. If the time taken by the US signal to return to the transducer is known, the distance of the target from the transducer (depth) can be computed.

TABLE 42-1 Propagation Velocity of Sound in Body Tissues

Tissue Propagation Velocity of Sound (m/sec)*
Bone 4080
Muscle 1580
Blood 1570
Kidney 1560
Liver 1550
Soft tissue (average) 1540
Water 1480
Fat 1450
Lung 600
Air 330

m/sec, Meters per second.

*Medical ultrasound device measurements are based on an assumed average propagation velocity of 1540 m/sec.

The human ear can detect sound between 20 and 20,000 Hz. US is sound with a frequency beyond 20,000 Hz (20 KHz). For medical imaging, US typically uses a frequency between 1 million and 15 million Hz (megahertz [MHz]) and is produced by a piezoelectric crystal (element) within the transducer. Artificial ferroelectric materials, such as lead zirconate titanate or lead zirconium titanate (PZT), are commonly used as elements in transducers, and their thickness determines the resonant frequency. When an electrical field is applied to the surface of an element in a transducer, it undergoes dimensional changes that cause it to vibrate and produce sound. The element is typically driven by a pulsed alternating voltage. This results in the generation of short pulses of US that are emitted into body tissues. Between successive short pulses of US generation, the transducer does not transmit but rather functions as a receiver of the reflected US energy (i.e., the echoes). The percentage of time that a transducer is transmitting is termed the duty factor and is typically less than 1%. The US transducer thus has a dual function—it functions as both a transmitter and a receiver.

The emitted US signal travels through the tissue medium, and when it encounters a tissue interface it is reflected back. The degree of reflection of US from tissues is related to the changes in acoustic impedance (Z) between two tissue interfaces. The reflected echoes are detected by the transducer and converted into electrical energy; they are then processed by the US machine according to their strength and displayed as dots on the monitor. The brightness of each dot corresponds to the strength of the echo signal. Strong echoes produce bright white dots, weak echoes produce gray dots, and anatomic structures that do not reflect US appear as black dots. The position of the dot on the monitor represents the depth from which the echo is received. When all of these dots are combined, they produce a complete image of the area scanned.2426

Modes of Ultrasound

A-Mode (Amplitude)

In amplitude, or A-mode, the echoes from tissue interfaces are represented on the monitor as a spike, and the spike height represents the amplitude of the echo.27 The distance of the interface from the transducer is calculated from the time taken for the signal to be sent and received, the “round-trip time.” A-mode US imaging is rarely used and is considered obsolete.

B-Mode (Brightness or Two-Dimension Mode)

Brightness, or B-mode, is the most commonly used US mode. In this mode, the spike is converted to a dot and the brightness of the dot represents the amplitude of the returning signal.2426 The position of the dot on the display represents the depth from which the signal is returning and depends on the round-trip time of the US signal. Multiple scan lines across a plane are combined to produce a single two-dimensional (2D) image. A series of frames are then displayed in rapid succession to give the impression of constant motion, the quality of which depends on the number of images displayed per second, that is, the frame rate.

The Ultrasound Machine

US machines are either cart-based or portable systems. Irrespective of their shape or size, US machines are made up of the following components: a monitor (where the clinical images are displayed), the US unit (where the signals are processed), the control panel (with the knobs and controls), one or more transducers, and a data storage device.3335 For an anesthesiologist, the first encounter with an US machine can be quite intimidating. The wide array of knobs and controls that are available may be confusing. However, several controls are common in most US machines, and a clear understanding of their function (“knobology” ) is essential for optimal imaging.


The gain control adjusts the amplification of the returning acoustic signals and is used to optimize the US image (Fig. 42-3). Reduced gain produces a dark image (see Fig. 42-3, A) and detail is masked. In contrast, too much gain produces a white image and detail is saturated (see Fig. 42-3, B). In some US machines there are separate controls for overall gain and gain for the near and far fields. “Auto-gain,” by which the US machine automatically adjusts the gain, is also available in some machines.

Ultrasound Transducers

The transducer functions both as a transmitter and a receiver of the ultrasound signal.3335 Three types of transducers are currently used (Fig. 42-4): (1) in a linear-array transducer, the piezoelectric crystals are arranged in a linear fashion and sequentially fired to produce parallel beams of ultrasound in sequence, creating a field of view that is rectangular and as wide as the footprint of the transducer (see Fig. 42-4, A); (2) a curved linear-array transducer has a curved surface, creating a field of view that is wider than the footprint of the probe (see Fig. 42-4, B), but at the cost of reduced lateral resolution in the far field as the scan lines diverge; (3) a phased-array transducer has a small footprint, but the ultrasound beam is steered electronically to produce a sufficiently wide far field of view. The ultrasound beam diverges from virtually the same point in the transducer (see Fig. 42-4, C ). Phased-array transducers are routinely used for transthoracic echocardiography.34 The footprints of these transducers are small enough to fit between the ribs and still produce a wide far field of view to image the heart. US transducers serve either a single frequency or a range of frequencies (broadband). For example, a transducer with the notation HFL38/13-6 indicates that it is a high-frequency broadband (13-6 MHz) linear transducer with a 38-mm footprint. Note that the nomenclature used for transducers varies among manufacturers of US devices.

Essentials of Musculoskeletal Ultrasound Imaging

Axis of Scan

In diagnostic ultrasonography, scans are performed in the transverse, longitudinal (sagittal), oblique, or coronal axis. During a transverse (axial) scan the transducer is oriented at right angles to the target, producing a cross-sectional display of the structures (Fig. 42-5, A). During a longitudinal scan, the transducer is oriented parallel to and along the long axis of the target (e.g., a blood vessel or nerve) (see Fig. 42-5, B). During USGRA procedures, US scans are most commonly performed in the transverse axis. In this axis, the nerves, the adjoining structures, and the circumferential spread of the local anesthetic are easily visualized.

Axis of Intervention

The plane of US imaging is only 1 mm thick (Fig. 42-7); for a needle to be visible during US imaging it must lie within this narrow plane of imaging. During USGRA procedures, the block needle is inserted either outside of the plane (out-of-plane approach) (Fig. 42-8, A) or within the plane of the US beam (in-plane approach) (see Fig. 42-8, B). In the out-of-plane approach, the needle is inserted in the short axis and is initially outside the plane of imaging and therefore not visible. It becomes visible only when the needle crosses the plane of imaging and is seen as an echogenic dot on the monitor (see Fig. 42-8, A). It is important to note that this echogenic dot may be just the cross-sectional image of the shaft of the needle as it passes through the plane of the US beam and thus may not represent the tip of the needle. In the in-plane approach, the needle is inserted along the long axis of the transducer in the plane of imaging and therefore both the shaft and tip of the needle are visible on the monitor.

Both approaches are commonly used, and no data have shown that one is better than the other. Proponents of the out-of-plane approach13,14,36 have had great success with this method and claim that it causes less needle-related trauma and pain because the needle is advanced through a shorter distance to the target. However, critics of the short-axis approach express concerns that the inability to reliably visualize the needle and to use tissue movement as a surrogate marker to locate the needle tip during a procedure can lead to complications. The needle is better visualized in the in-plane approach,37,38 but this requires good hand and eye coordination and reverberation artifacts from the shaft of the needle can be problematic. Moreover, there are claims that the in-plane approach also causes more discomfort in awake patients because longer needle insertion paths are required.13,14,36

Needle Visibility

The ability to visualize the needle during a US-guided procedure is critical for precision, safety, and success. However, this is often limited by the dispersion of the reflected US signals away from the transducer. Several factors have been identified that can influence needle visibility. The shaft of the needle is better visualized in the long axis than in the short axis, and its visibility decreases linearly with steep angles of insertion and smaller needle diameters. The needle tip is better visualized when it is inserted in the long axis for shallow angle of insertion (less than 30 degrees) and in the short axis when the angle of insertion is steep (greater than 60 degrees). This is also true when the needle is inserted with its bevel facing the US transducer. To overcome the effect of angle on needle visibility, some high-end US machines allow the operator to steer the US beam toward the needle during steep needle insertions. However, this requires experience and decreases in needle visibility can still occur. Needle visibility is also enhanced in the presence of a medium-sized guidewire. Priming a needle with saline or air, insulating it, or inserting a stylet before insertion does not improve visibility.3941

We think that the anesthesiologist’s skill in aligning the needle along the plane of imaging is by far the most important variable influencing needle visibility because minor deviations of even a few millimeters from this plane will result in inability to visualize the needle. Even with experience, needle tip visibility is a problem when performing blocks at a depth in areas that are rich in fatty tissue. Under such circumstances, gently jiggling (rapid in-and-out movement) the needle and observing tissue movement or performing a test injection of saline or 5% dextrose (1 to 2 mL) and observing tissue distention can help locate the position of the needle tip. Five percent dextrose is preferred for the latter when nerve stimulation is used because it does not increase the electric current required to elicit a motor response.42


Anisotropy, or angular dependence, is a term used to describe the change in echogenicity of a structure with a change in the angle of insonation of the incident US beam (Fig. 42-9).43 It is frequently observed during scanning of nerves, muscles, and tendons. This occurs because the amplitude of the echoes returning to the transducer varies with the angle of insonation. Nerves are best visualized when the incident beam is at right angles (see Fig. 42-9, A); small changes in the angle away from the perpendicular can significantly reduce their echogenicity (see Fig. 42-9, B). Therefore, during USGRA procedures, the transducer should be tilted, from side to side, to minimize anisotropy and optimize visualization of the nerve.44 Although poorly understood, different nerves also exhibit differences in anisotropy, which may be related to the internal architecture of the nerve.

Identification of Nerves, Tendons, Muscle, Fat, Bone, Fascia, Blood Vessels, and Pleura


On a transverse scan, nerves appear round, oval, triangular, lip shaped, or even flat.45,46 Nerves also assume different shapes along their course depending on the surrounding structures. The echogenicity of nerves also varies and depends on the nerve and area scanned. They are generally hyperechoic and stand out in the background of the hypoechoic muscles (Fig. 42-10, A), but they can also appear hypoechoic with a hyperechoic rim (see Fig. 42-10, B). They also have been described to have a fascicular or honeycomb appearance (i.e., echogenic structures with internal punctate, echo-poor spaces) (see Fig. 42-10, C ). On longitudinal scan, the appearance of peripheral nerves has been likened to a “tram track”; that is, parallel hyperechoic lines are seen against a background of echo-poor space (see Fig. 42-10, D). Nerve motion also can be demonstrated on dynamic US imaging.


Tendons appear to have numerous fine parallel hyperechoic lines separated by fine hypoechoic lines (fibrillar pattern) on long-axis scans.46 Compared with nerves, tendons have more hyperechoic lines and move more than adjacent nerves when the corresponding muscle is contracted or passively stretched.


Muscle fibers are hypoechoic, but the connective tissue structure enveloping the entire muscle (epimysium) is hyperechoic.47,48 The perimysium that envelops individual muscle fascicles is also hyperechoic. Muscle fibers converge to become tendons or aponeurosis.


The pleura appear as a hyperechoic line on US imaging (see Fig. 42-11).4951 During scanning of the intercostal space, the pleural line is located slightly below the hyperechoic ribs. “Comet-tail” artifacts may be present as a series of vertical lines arising from the pleura. On real-time imaging, lung sliding movement between the parietal and visceral pleura can be discerned from movement of the comet-tail artifacts (“lung sliding sign”).

Special Techniques

Panoramic Imaging

B-mode (2D) ultrasonography has a limited field of view and allows visualization of only a small portion of any large structure. Panoramic imaging, as the name implies, is a technique used to extend the field of view so that larger structures and their surrounding tissues can be visualized together.56 During a panoramic scan, the operator slowly slides the US transducer across an area of interest. During this motion, multiple images are acquired from many different transducer positions across the area of interest. The registered image data are accumulated in a large buffer and then combined to form the composite panoramic image (Fig. 42-14). Although useful for annotation, documentation, teaching, and research, it is rarely used in children during USGRA procedures.


US artifacts are structures that are visible in the US image that do not correlate with any anatomic structure.57 The US machine makes the following assumptions when generating an image:

When a deviation from any of these assumptions occurs, the US machine is unable to determine it. This results in the display of an echo that has no relation with the interface that actually produced the echo; that is, an artifact is produced. Some artifacts are undesirable and interfere with interpretation, whereas others help identify certain structures. It is essential to recognize them to avoid misinterpretation. Therefore, when a structure appears abnormal on ultrasonography, it must be examined in two planes to avoid making a wrong interpretation. Real anatomic structures are visible in both planes of imaging, whereas artifacts are visible in only one plane.

Reverberation Artifact

Reverberation artifacts, also known as repetitive echoes, occur when repeated reflection of US occurs between two highly reflective surfaces.58 Some of the US signals returning to the transducer are reflected back, then strike the original interface, and are reflected back toward the transducer a second time. As a result, the first reverberation artifact is twice as far from the skin surface as the original interface. A second or third reverberation artifact also may be seen. Because of attenuation, the intensity of the artifacts decreases with increasing distance from the transducer. Reverberation artifacts are frequently seen during US-guided axillary brachial plexus block, particularly when the needle is inserted in the long axis.

Mirror Image Artifact

Mirror image artifact is a type of reverberation artifact that occurs at highly reflective interfaces.59 The first image is displayed in the correct position, and a false image is produced on the other side of the reflector because of its mirrorlike effect.

Propagation Speed Artifact

Propagation speed artifacts occur when the medium through which the US beam passes does not propagate at 1540 m/sec, resulting in echoes that appear at incorrect depths on the monitor. An example of propagation speed artifact is the “bayonet artifact,”60 which has been reported during an US-guided axillary brachial plexus block. The shaft of the needle appeared bent when it accidentally traversed the axillary artery. This happens because of the difference in the velocity of sound between whole blood (1580 m/sec) and soft tissue (1540 m/sec).

Acoustic Shadowing

Acoustic shadow is an echo-free area behind surfaces that are highly reflective or attenuating, such as bone (see Fig. 42-11) or metallic implants. The implication for regional anesthesia is that tissues in the area of the shadow cannot be imaged.

Scanning Routine

Being able to consistently produce high-quality images of the area scanned is vital for safety and success during any USGRA procedure. Without optimal images, it is not possible to accurately identify musculoskeletal structures or perform interventions with precision. We have found that following a “scanning routine” or a set of simple steps, which is repeatable, is essential for optimal imaging; the routine that we follow is outlined in Table 42-2. Although the suggested routine may appear complicated at first, with repetition these steps are gradually internalized. Attaching a card with the scanning routine to the US machine facilitates easy recall.

TABLE 42-2 Scanning Routine

Scout Scan

The aim of the scout scan, or the preintervention scan, as the name implies, is to examine the area of interest before the intervention. This has also been referred to as a “mapping scan.” During the scout scan, steps 8 and 9 described in Table 42-2 are performed, the sonoanatomy of the area is visualized, and the image is optimized. Once an optimal view with the target structure is obtained and the best possible site for needle insertion is determined, it is advisable to mark the position44 of the transducer on the patient’s skin so the transducer can be returned to the same position after sterile preparations have been completed. It is common to diagnose anatomic variations during the scout scan. The operator can then decide whether to continue with the block in the same location or to choose an alternative approach or technique that may be safer. This assessment of anatomic variation is one of the major benefits of using US for regional anesthesia.

General Considerations in Children

Preparations for an ultrasound-guided nerve block should begin during the preoperative visit by adequately explaining the technique, its benefits and risks, and, more importantly, the possibility of a failed block to the parents. In the event of failure, a contingency plan to quickly convert to general anesthesia or another form of postoperative analgesia must always be in place. In children, most regional anesthetic procedures are performed while the child is anesthetized. However, in a cooperative child or under special circumstances, such as in a child with difficult airway or a child predisposed to malignant hyperthermia, it is possible to perform the block after light sedation. We find that it is easy to explain the procedure to children who are older than 8 years of age. Some of them may even express a wish to stay awake and observe the US images during the block. Eutectic mixture of local anesthetic (EMLA) cream applied an hour before the procedure to the skin over the area where the block needle and the intravenous catheter are to be inserted helps reduce needle-related pain. Parental presence during the nerve block may also be helpful. In older children, allowing the child to listen to favorite music through a personal stereo or watch a video are useful distraction techniques that make the whole experience a more pleasant one for the child. We have connected a DVD player to our US machine, and this is used to play movies or cartoons through the monitor during the surgical procedure (E-Fig 42-1).


Before any USGRA procedure, intravenous access is established, standard monitoring is applied, and equipment and drugs appropriate for the child are prepared. Aseptic precautions are maintained, and the skin over the needle puncture site is prepared with antiseptic solution in the usual fashion. The US probe is prepared by covering the footprint with a sterile transparent dressing. It is important to avoid trapping any air between the transparent dressing and the footprint. This is done by gently stretching the transparent dressing before applying it on the footprint. The transducer and cable are then covered using a sterile plastic cover. We use the same plastic cover that our surgeons use to cover their laparoscopic camera.

Tips and Tricks for Success

Certain steps are common to all US-guided procedures, and, if followed, they may increase success. The lights in the room must be dimmed to avoid any glare or reflection from the US monitor. The operator must assume a comfortable position (Fig. 42-15). For upper extremity blocks, the operator sits at the ipsilateral head end of the child and the US machine is placed directly in front. For lower extremity blocks, such as femoral nerve block, the operator stands on the ipsilateral side of the child and the US machine is placed on the opposite side. For lower extremity or central neuraxial blocks in the lateral position, the operator sits behind the child and the US machine is placed in front, with the monitor in the line of view of the operator. Because of the small muscle bulk in young children the nerves are relatively superficial and can most frequently be easily visualized using high-frequency linear transducers. The exact choice of transducer depends on the area scanned, but a high-frequency linear transducer with a small footprint (13-6 MHz, 25-mm footprint) is particularly suited for young children. The 15-6–MHz broadband linear-array transducer, which has recently become available, is also useful for most blocks in young children. In older children, a 10-7–MHz broadband linear-array transducer, which allows greater flexibility with the depth of scan, is adequate for most procedures. Low-frequency (5-2 MHz) curved-array transducers are rarely used in children but are useful for imaging deeper structures such as the lumbar plexus and sciatic nerve in older children.

To improve dexterity, hold the transducer with the nondominant hand and perform interventions with the dominant hand. Holding the transducer steady for even short periods can be quite testing. We have found that gently resting the hand that is holding the transducer on the child during a procedure helps to keep the transducer steady (see Fig. 42-15). It is important to maintain light contact between the transducer and the skin because excessive pressure in a child will cause the veins to collapse or distort the anatomy of the area of interest. Always apply liberal amounts of US gel to maintain adequate acoustic coupling between the skin and the transducer because even small amounts of air trapped between the two can result in artifacts. We use sterile US gel from single-use sachets for all US-guided peripheral nerve blocks. At any given time during an US-guided intervention either the transducer or the needle must be moved. It is impossible to maintain the needle within the plane of imaging if both are moving, a common error by novices. This results in an inability to visualize the needle. If the needle is not visible in the US image, a good strategy is to keep the needle steady and manipulate the transducer (slide, tilt, or rotate) until the needle becomes visible on the monitor. Thereafter the transducer should be held steady and the needle should be gently advanced to the target nerve, maintaining it in the imaging plane. When the angle of insertion of the needle is steep (greater than 60 degrees), it is preferable to introduce the needle in the short axis using the out-of-plane technique. However, if the in-plane approach is used for all US-guided interventions, as in our case, inserting the needle a few centimeters away from the edge of the transducer may improve needle visibility by decreasing the angle between the needle and the imaging plane.

Injecting air into the area of the intervention must be avoided at all cost because air bubbles in the field of imaging will degrade the US image. We routinely introduce the needle into the subcutaneous tissue and then purge it with saline or the local anesthetic to remove any air from the shaft of the needle, extension, and syringe system before proceeding with the block. An assistant aids with the injection. When the needle tip is close to the target nerve, the assistant gently aspirates to exclude unintended intravascular placement. The assistant must avoid generating excessive negative pressure because small blood vessels are prone to collapse. A short length of extension tubing attached between the needle and the local anesthetic syringe allows the operator to hold the needle steady while the assistant performs the injection.61 We routinely perform a test injection with 1 to 2 mL of saline or 5% dextrose (when nerve stimulation is also used) and visualize the distribution of the injectate in real time before injecting the local anesthetic. Failure to visualize the injectate in the US image indicates that the needle is not in the plane of imaging or it is intravascular until proven otherwise. No further injection should be made until the needle is repositioned and the distribution of the injectate is confirmed.

May 25, 2016 | Posted by in ANESTHESIA | Comments Off on Ultrasound-Guided Regional Anesthesia

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