To the Editor: —In the April issue of Anesthesiology, Loubert et al.  1and Zetlaoui et al.  2reported about possible intravascular injection after an ultrasound-guided axillary block. Their reports highlight the need for vigilance in the performance of ultrasound-guided blocks. This and similar reports of complications3–5after ultrasound-guided regional blocks reinforce the need for proper training, and the understanding that ultrasound, after all, is only a tool. Any tool should be used with full cognizance of its limitations. The major limitations of ultrasound-guided blocks are technical,6including the angle of incidence, needle visualization, and possibly artifacts.7,8Training in the proper holding of the probe while analyzing and while injecting help overcome some of the complications. Sometimes even with proper training, complications do occur.4 

The reports1,2have similarities and differences besides the ultrasound-guided axillary block and intravascular complication leading to seizure. One of them described the changes in vital signs,1and the other reports some technical difficulties in getting the data.2Needle visualization was an issue in both reports. Using an out-of-plane approach may have prevented proper needle visualization because only a cross section of the needle anywhere in the length of the needle may be seen and mistaken for the tip, although tissue movement may have been seen. With the in-plane approach used in the other report, needle artifacts may have prevented proper visualization, which will only be discerned when the injectate spread is noticed. Both reports mention distortion of tissues, one due to probe pressure and the other due to local anesthetic already injected.

There is no documentation in either of the reports of having seen other vessels in the proximity before the actual needle placement. Assuming they used color flow Doppler, the default settings for the color Doppler cannot detect small vessels unless the color velocity range and the angle of steering are adjusted. It is possible that they did not visualize the needle during the performance of the block and hence did not adhere to one of the safety principles that they have mentioned. Any of these situations could have led to the complication. Most importantly, they were both performed by residents.

My practice is to perform a preliminary scout scan, including a color flow study, to visualize the target and its associated neighboring structures and demonstrate to the trainee. This permits proper guidance during the actual performance of the block. Could they have avoided the intravascular injection by using landmarks or nerve stimulation? Probably not.

To elevate ultrasound-guided to the next level and call it a “bulletproof technique” by the more “vocal proponents”6is a dream awaiting fruition with some more technological advancements and changes in needle design. In the meantime, adhering to some basic principles will avoid potential complications. To blame the ultrasound for complications due to technical and possibly inadequate training is, in my opinion, tarnishing a useful technique without understanding its advantages and mainly its limitations. There is an increasing need for a proper curriculum and training to fully understand the technique, the potential pitfalls, and the complications of ultrasound-guided blocks.9 

Clement Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee, Wisconsin.


Loubert C, Williams SR, Helie F, Arcand G: Complication during ultrasound-guided regional block: Accidental intravascular injection of local anesthetic. Anesthesiology 2008; 108:759–60
Zetlaoui PJ, Labbe JP, Benhamou D: Ultrasound guidance for axillary plexus block does not prevent intravascular injection. Anesthesiology 2008; 108:761
Russon K, Blanco R: Accidental intraneural injection into the musculocutaneous nerve visualized with ultrasound. Anesth Analg 2007; 105:1504–5
Schafhalter-Zoppoth I, Zeitz ID, Gray AT: Inadvertent femoral nerve impalement and intraneural injection visualized by ultrasound. Anesth Analg 2004; 99:627–8
Koff MD, Cohen JA, McIntyre JJ, Carr CF, Sites BD: Severe brachial plexopathy after an ultrasound-guided single-injection nerve block for total shoulder arthroplasty in a patient with multiple sclerosis. Anesthesiology 2008; 108:325–8
Hadzic A, Sala-Blanch X, Xu D: Ultrasound guidance may reduce but not eliminate complications of peripheral nerve blocks. Anesthesiology 2008; 108:557–8
Sites BD, Brull R, Chan VW, Spence BC, Gallagher J, Beach ML, Sites VR, Hartman GS: Artifacts and pitfall errors associated with ultrasound-guided regional anesthesia, part I: Understanding the basic principles of ultrasound physics and machine operations. Reg Anesth Pain Med 2007; 32:412–8
Sites BD, Brull R, Chan VW, Spence BC, Gallagher J, Beach ML, Sites VR, Abbas S, Hartman GS: Artifacts and pitfall errors associated with ultrasound-guided regional anesthesia, part II: A pictorial approach to understanding and avoidance. Reg Anesth Pain Med 2007; 32:419–33
Tsui BC: “Credentials” in ultrasound-guided regional blocks. Reg Anesth Pain Med 2006; 31:587–8