To the Editor:—

I read with much dismay the article by Boezaart1regarding perineural infusion of local anesthetics. As a practicing anesthesiologist at a teaching hospital, it was concerning to see the flagship journal of our specialty present a review of perineural catheter placement with such little regard for emerging technology. Many who practice regional anesthesia on a daily basis consider ultrasound to be the most significant advance in several decades. Boezaart, however, dismisses ultrasound as a technique that “works well for superficial nerves (when it is not really needed) . . . [but] is not sufficient to identify deeper nerves, especially in very obese patients (where it is most needed).” The author goes on to say that ultrasound is “not likely to replace nerve stimulation for continuous nerve block.”

I would encourage the author to review a number of quality publications by Marhofer et al. ,2–4Chan et al. ,5and Sandhu and Capal,6to name a few, which demonstrate the superiority of ultrasound techniques when compared with nerve stimulation. At the University of Utah (Salt Lake City, Utah), we no longer use or teach nerve stimulator techniques. More than 2 yr ago, our techniques were completely transitioned to ultrasound guidance. Our residents perform more than 3,000 blocks per year (more than 1,000 indwelling catheters) using only ultrasound guidance, with satisfying results both for the resident and for the patient.

Certainly, when discussing perineural local anesthetic infusions, ultrasound deserves a little more respect.

University of Utah Orthopaedic Center, Salt Lake City, Utah.


Boezaart AP: Perineural infusion of local anesthetics. Anesthesiology 2006; 104:872–80
Marhofer P, Schrögendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N: Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 1997; 85:854–7
Marhofer P, Schrögendorfer K, Wallner T, Koinig H, Mayer N, Kapral S: Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998; 23:584–8
Marhofer P, Sitzwohl C, Greher M, Kapral S: Ultrasonographic guidance for infraclavicular plexus anaesthesia in children. Anaesthesia 2004; 59:642–6
Chan VW, Perlas A, Rawson R, Odukoya O: Ultrasound guided supraclavicular brachial plexus block. Anesth Analg 2003; 97:1514–7
Sandhu NS, Capal LM: Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002; 89:254–9