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Ultrasound Guidance Enhances Regional Anesthesia

New York (May 25, 2010)

an operating room

Global positioning systems have transformed the way many drivers get around today, allowing them to see exactly where they are on a map and how far they may be from a destination. Similarly, advances in ultrasound technology have vastly improved the ability of NewYork-Presbyterian Hospital anesthesiologists to deliver local anesthetics directly to nerves, enabling them to practice regional anesthesia more quickly and efficiently than ever before. The approach is especially useful for patients undergoing orthopedic or vascular surgeries.

"Ultrasound-guided regional anesthesia is becoming the gold standard in our field," said Tiffany Tedore, M.D., a regional anesthesiologist specializing in orthopedic and breast surgeries. "It may prove to be the safer way to deliver nerve block anesthesia."

Tiffany Tedore, MD
Tiffany Tedore, M.D.

Ultrasound has been available for years, but recent advances in the ability to visualize the nerves with higher resolution led to its increased application to regional anesthesia over the last five to ten years. Ultrasound for nerve imaging is typically in the frequency range of 2 to 15 MHz, depending on the depth of penetration required.

Regional anesthesiologists have traditionally relied on blind techniques such as paresthesia and nerve stimulation, in which surface landmarks are used to locate the nerves to be anesthetized. Paresthesia requires the patient to tell the anesthesiologist when he or she feels a small shock, and this need for feedback prohibits the patient from being sedated during anesthesia delivery. During nerve stimulation, an insulated needle is used to deliver a small electric current, and the anesthesiologist looks for a muscle twitch to indicate when the target nerve has been located.

A. Robin Brown, M.B.Ch.B., F.F.A.
A. Robin Brown, M.B.Ch.B.,
F.F.A.

With the newer approach, the anesthesiologist uses ultrasound to locate the nerve and its roots. The ultrasound machine is portable – some models are housed on a cart, while others are as small as a laptop – so the unit can be transported from one operating room to another. This approach offers a number of advantages over conventional regional anesthesia:

  • No requirement for patient feedback: Because the anesthesiologist can see the nerve clearly, the patient does not have to provide feedback during the procedure and can be sedated.
  • Visualization of anatomy: There is no need to rely on surface landmarks. "Moreover, variations in anatomy from one patient to the next occur surprisingly frequently," said regional anesthesiologist A. Robin Brown, M.B.Ch.B., F.F.A. "Ultrasound guidance enables us to see the nerve and the needle as it is being advanced in real-time."
  • Such visualization also reduces the likelihood of the needle hitting another anatomical structure. "Ultrasound guidance gives us the ability to direct the needle to the nerve and avoid other structures such as blood vessels or the lungs," added Dr. Tedore.
  • Visualization of anesthetic spread: With ultrasound guidance, the anesthesiologist can see the spread of the local anesthetic as it is occurring. "You get instant feedback showing that you are surrounding the specific nerve with local anesthetic," said Dr. Brown. This benefit also allows the anesthesiologist to withdraw and reinsert the needle as necessary to reach nerve roots that may not have been bathed in anesthetic during the first application.
  • Faster onset and longer duration of anesthetic effect: Because the anesthesiologist can direct the anesthetic to the target nerve, the desired anesthetic effect begins sooner and lasts longer. Anesthesiologists sometimes combine this approach with catheter-delivered anesthesia for surgeries that require a longer duration of anesthesia. "Faster onset of anesthesia can result in time-savings," noted Dr. Tedore.
  • Use of less anesthetic: Because the target nerve can be accessed more quickly and specifically, the anesthesiologist can achieve sufficient nerve blockage with less local anesthetic – as little as 5 mL.

At both NewYork-Presbyterian Hospital campuses, the approach is routinely used for orthopedic surgeries (such as shoulder surgery performed with an interscalene block), to deliver pain control after breast surgery (via paravertebral block), vascular surgery (such as grafts – the sympathetic block approach dilates the blood vessels and makes the surgery easier), and for the transverse abdominus plane block to deliver analgesia after abdominal surgery.

Ultrasound-guided nerve block anesthesia is the only approach now used at NewYork-Presbyterian Hospital/Columbia University Medical Center and is used for many surgeries at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

Ultrasound-guided regional anesthesia is not universally used in all hospitals, for a number of reasons:

  • Cost: The unit costs between $30,000 and $50,000, a price out of reach of some hospitals.
  • Requirement for training: Ultrasound-guided anesthesia requires specialized training.
  • Reluctance to switch: Some anesthesiologists may be hesitant to train in the new technique. Dr. Brown once felt that way himself. "But I went to a training course and I changed my mind overnight," he added.

The application of ultrasound to regional anesthesia is revolutionizing the field. As patients become aware of advances in regional anesthesia, they are increasingly requesting it for procedures for which it is appropriate. "Patients who had prior unpleasant experiences with general anesthesia, such as nausea and vomiting, are more likely to inquire about regional anesthesia," explained Dr. Tedore.

"Ultrasound has really opened our eyes about how we deliver regional anesthesia," concluded Dr. Brown. "It's a major technological advance."

Faculty contributing to this article:

Tiffany Tedore, M.D. is Director of Regional Anesthesia at NewYork-Presbyterian/Weill Cornell Medical Center, and an Assistant Professor of Anesthesiology at Weill Cornell Medical College.

A. Robin Brown, M.B.Ch.B., F.F.A. is Director of Orthopedic & Regional Anesthesia at NewYork-Presbyterian Hospital/Columbia University Medical Center, and a Clinical Professor of Anesthesiology at Columbia University College of Physicians and Surgeons.

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