Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND Despite the growing interest in the use of ultrasound (US) imaging to guide performance of regional anaesthetic procedures such as peripheral nerve blocks, controversy still exists as to whether US is superior to previously developed nerve localization techniques such as the use of a peripheral nerve stimulator (PNS). We sought to clarify this issue by performing a systematic review and meta-analysis of all randomized controlled trials that have compared these two methods of nerve localization. METHODS We searched Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and Google Scholar databases and also the reference lists of relevant publications for eligible studies. A total of 13 studies met our criteria and were included for analysis. Studies were rated for methodological quality by two reviewers. Data from these studies were abstracted and synthesized using a meta-analysis. RESULTS Blocks performed using US guidance were more likely to be successful [risk ratio (RR) for block failure 0.41, 95% confidence interval (CI) 0.26-0.66, P<0.001], took less time to perform (mean 1 min less to perform with US, 95% CI 0.4-1.7 min, P=0.003), had faster onset (29% shorter onset time, 95% CI 45-12%, P=0.001), and had longer duration (mean difference 25% longer, 95% CI 12-38%, P<0.001) than those performed with PNS guidance. US guidance also decreased the risk of vascular puncture during block performance (RR 0.16, 95% CI 0.05-0.47, P=0.001). CONCLUSIONS US improves efficacy of peripheral nerve block compared with techniques that utilize PNS for nerve localization. Larger studies are needed to determine whether or not the use of US can decrease the number of complications such as nerve injury or systemic local anaesthetic toxicity.

[1]  S. Kapral,et al.  Ultrasonographic Guidance Improves Sensory Block and Onset Time of Three-in-One Blocks , 1997, Anesthesia and analgesia.

[2]  K. Dickersin,et al.  Systematic Reviews: Identifying relevant studies for systematic reviews , 1994 .

[3]  T. Wallner,et al.  Ultrasonographic Guidance Reduces the Amount of Local Anesthetic for 3‐in‐1 Blocks , 1998, Regional anesthesia and pain medicine.

[4]  José Domingo Álvarez,et al.  A Comparison of Single Versus Multiple Injections on the Extent of Anesthesia with Coracoid Infraclavicular Brachial Plexus Block , 2004, Anesthesia and analgesia.

[5]  A. Hadžić,et al.  Intensity of the Stimulating Current May Not Be a Reliable Indicator of Intraneural Needle Placement , 2007, Regional Anesthesia & Pain Medicine.

[6]  A. Stubhaug,et al.  Electrical Nerve Stimulation or Ultrasound Guidance for Lateral Sagittal Infraclavicular Blocks: A Randomized, Controlled, Observer-Blinded, Comparative Study , 2008, Anesthesia and analgesia.

[7]  M. Baciarello,et al.  A Prospective, Randomized Comparison between Ultrasound and Nerve Stimulation Guidance for Multiple Injection Axillary Brachial Plexus Block , 2007, Anesthesiology.

[8]  S. Kapral,et al.  Ultrasonographic guidance for sciatic and femoral nerve blocks in children. , 2007, British journal of anaesthesia.

[9]  S. Sharp,et al.  Explaining heterogeneity in meta-analysis: a comparison of methods. , 1999 .

[10]  X. Paqueron,et al.  Ultrasound‐ or Nerve Stimulation‐Guided Wrist Blocks for Carpal Tunnel Release: A Randomized Prospective Comparative Study , 2008, Regional anesthesia and pain medicine.

[11]  F. Lippert,et al.  Readiness for surgery after axillary block: single or multiple injection techniques. , 1997, European journal of anaesthesiology.

[12]  N. Laird,et al.  Meta-analysis in clinical trials. , 1986, Controlled clinical trials.

[13]  P. Lui,et al.  Efficacy of ultrasound-guided axillary brachial plexus block: a comparative study with nerve stimulator-guided method. , 2005, Chang Gung medical journal.

[14]  A. Karabinis,et al.  Limitations and Technical Considerations of Ultrasound‐Guided Peripheral Nerve Blocks: Edema and Subcutaneous Air , 2008, Regional anesthesia and pain medicine.

[15]  J. Neal,et al.  A tale of two needle passes. , 2008, Regional anesthesia and pain medicine.

[16]  G. Fanelli,et al.  Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications. Study Group on Regional Anesthesia. , 1999, Anesthesia and analgesia.

[17]  A. Borgeat,et al.  Ultrasound guidance and success rates of axillary brachial plexus block - I , 2007, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[18]  Stephan R Williams,et al.  Ultrasound Guidance Speeds Execution and Improves the Quality of Supraclavicular Block , 2003, Anesthesia and analgesia.

[19]  P. Marhofer,et al.  Ultrasound and the Femoral Three-in-One Nerve Block: Weak Methodology and Inappropriate Conclusions , 1998 .

[20]  Thomas Grau,et al.  Ultrasound imaging improves learning curves in obstetric epidural anesthesia: a preliminary study , 2003, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[21]  P. Hopkins Ultrasound guidance as a gold standard in regional anaesthesia. , 2007, British journal of anaesthesia.

[22]  M. Neuburger,et al.  Elektrische Nervenstimulation in Abhängigkeit von der benutzten Impulsbreite Eine quantitative Untersuchung zur Annäherung der Nadelspitze an den Nerven , 2001, Der Anaesthesist.

[23]  S. Kapral,et al.  Ultrasound guidance for infraclavicular brachial plexus anaesthesia in children , 2004, Anaesthesia.

[24]  Stephan R Williams,et al.  Complication during ultrasound-guided regional block: accidental intravascular injection of local anesthetic. , 2008, Anesthesiology.

[25]  C. McCartney,et al.  Ultrasound Guidance Improves the Success of Sciatic Nerve Block at the Popliteal Fossa , 2007, Regional Anesthesia & Pain Medicine.

[26]  Z. Koscielniak-Nielsen,et al.  Comparison of transarterial and multiple nerve stimulation techniques for an initial axillary block by 45 mL of mepivacaine 1% with adrenaline , 1998, Acta anaesthesiologica Scandinavica.

[27]  G. Fanelli,et al.  Nerve Stimulator and Multiple Injection Technique for Upper and Lower Limb Blockade: Failure Rate, Patient Acceptance, and Neurologic Complications , 1999 .

[28]  Anthony R. Brown,et al.  Interscalene Block With a Nerve Stimulator: A Deltoid Motor Response Is a Satisfactory Endpoint for Successful Block , 2000, Regional Anesthesia & Pain Medicine.

[29]  R. J. Hayes,et al.  Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. , 1995, JAMA.

[30]  S. Kapral,et al.  Ultrasonographic Guidance Improves the Success Rate of Interscalene Brachial Plexus Blockade , 2007, Regional Anesthesia & Pain Medicine.

[31]  D. Altman,et al.  Measuring inconsistency in meta-analyses , 2003, BMJ : British Medical Journal.

[32]  S. Sia,et al.  A Comparison of Proximal and Distal Radial Nerve Motor Responses in Axillary Block Using Triple Stimulation , 2005, Regional Anesthesia & Pain Medicine.

[33]  G. Fanelli,et al.  Interscalene brachial plexus anaesthesia with small volumes of ropivacaine 0.75%: effects of the injection technique on the onset time of nerve blockade , 2001, European journal of anaesthesiology.

[34]  C. Franco,et al.  1,001 Subclavian Perivascular Brachial Plexus Blocks: Success With a Nerve Stimulator , 1999, Regional Anesthesia & Pain Medicine.

[35]  Dan Benhamou,et al.  Ultrasound guidance for axillary plexus block does not prevent intravascular injection. , 2008, Anesthesiology.

[36]  Jeffrey A. Cohen,et al.  Severe brachial plexopathy after an ultrasound-guided single-injection nerve block for total shoulder arthroplasty in a patient with multiple sclerosis. , 2008, Anesthesiology.

[37]  Christopher H Schmid,et al.  In an empirical evaluation of the funnel plot, researchers could not visually identify publication bias. , 2005, Journal of clinical epidemiology.

[38]  O. Fourcade,et al.  A Modified Mid-Femoral Approach to the Sciatic Nerve Block: A Correlation Between Evoked Motor Response and Sensory Block , 2007, Anesthesia and analgesia.

[39]  S. Selfa,et al.  Ultrasound Guidance for Lateral Midfemoral Sciatic Nerve Block: A Prospective, Comparative, Randomized Study , 2007, Anesthesia and analgesia.

[40]  S D Walter,et al.  Effect sizes can be calculated for studies reporting ranges for outcome variables in systematic reviews. , 2007, Journal of clinical epidemiology.

[41]  H. T. Lee Ultrasound guidance improves success rate of axillary brachial plexus block , 2008 .