Ultrasound-guided peripheral nerve blockade of the upper extremity

Is ultrasound guidance changing the practice of upper extremity regional anesthesia? This review will aim to describe the findings published in the literature during the previous 18 months.

In some approaches to brachial plexus blockade, local anesthetic volumes may be reduced without deterioration of analgesic effect. However, even 10 ml of local injected into the interscalene space may result in diaphragmatic paresis. High-resolution ultrasonography has revealed anatomical variations of C5, C6 and C7 nerve roots in almost half of the patients examined, without negative block effectiveness. The addition of dexamethasone may prolong analgesia after single-shot interscalene and supraclavicular blocks. Insertion of brachial plexus perineural catheters using ultrasound guidance can be successful and provides better postoperative analgesia than single-shot blocks for up to 24 h postoperatively. Infraclavicular catheters provide superior analgesia when compared with supraclavicular catheters. Multiple-site injections of local offer no advantage over a single-site injection during an infraclavicular block. Ultrasound guidance compared with neurostimulation may reduce patient discomfort during axillary blocks compared with neurostimulation. Intra-epineural injections are common during an interscalene blockade, but the incidence of neurological injury remains low. There is an ongoing debate on the effectiveness and safety of ultrasound-guided intra-epineurial injections.

Current literature suggests a reduction of the volume of local anesthetics used for ultrasound-guided upper extremity blockades. Dexamethasone may prolong duration of brachial plexus blocks and more frequent use of perineural catheters is encouraged. Controversy over intra-epineurial injections exists and requires additional large-scale studies.