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In this article, the author discusses the death of a patient by the administration of a local anaesthetic injection through a catheter placed adjacent to the interscalene brachial plexus. The developmentof brachial plexus catheterisation allowed prolongation of the beneficial effects of the block. The local anaesthetic drugs injected through the needle or catheter help in access to the epidural or subarachnoid spaces.

The use of ultrasound guidance for regional anaesthesia has gained enormous popularity in the last 10 yr. The first part of this review article provided information on safety, technical developments, economic aspects, education, advantages, needle guidance techniques, and future developments in ultrasound. The second part focuses on practical and technical details of individual ultrasound-guided nerve blocks in adults. We present a comprehensive review of the relevant literature of the last 5 yr with a commentary based on our own clinical experience in order to provide information relevant to patient management. Upper limb blocks, including interscalene, supra- and infraclavicular, and axillary approaches, are described and discussed. For the lower limb, psoas compartment, femoral, obturator, sciatic, and lateral cutaneous nerve blocks are described, as are some abdominal wall blocks. The potential role of ultrasound guidance for neuraxial block is addressed. The need for further large-scale studies of the role of ultrasound is emphasized. [ABSTRACT FROM PUBLISHER]

Ultrasound guidance for regional anaesthesia has gained enormous popularity in the past decade. The use of ultrasound guidance for many regional anaesthetic techniques is common in daily clinical practice, and the number of practitioners using it is increasing. However, alongside the enthusiasm, there should be a degree of informed scepticism. The widespread use of the various techniques of ultrasound-guided regional blocks without adequate training raises the danger of malpractice and subsequent impaired outcome. Adequate education in the use of regional block techniques under ultrasound guidance is essential. This review article addresses ultrasound guidance for regional anaesthesia, and is divided into two parts because of the size of the topic and the number of issues covered. This first part includes a review and preview of ultrasound guidance in regional anaesthesia and discusses all aspects of ultrasound for regional anaesthesia with a focus on recent technical developments, the positive implications in economics, further potential advantages (e.g. detection of anatomical variants, painless performance of blocks) and education. It also attempts to define a ‘gold standard’ in regional anaesthesia with the most recent findings in adequate volumes of local anaesthetics for peripheral nerve blocks. This standard should include an extraneural needle position, a high success rate, and wide application of ultrasound guidance in regional anaesthesia. The second part describes the impact of ultrasound on the development of nerve block techniques in the past 5 yr. [ABSTRACT FROM PUBLISHER]

Gathering evidence from animal experiments, an editorial in this journal and published human case reports culminated in the Association of Anaesthetists of Great Britain and Ireland recommending in August 2007 that lipid emulsion be immediately available to all patients given potentially cardiotoxic doses of local anaesthetic drugs. This development offered an opportunity to track the adoption of an innovation by anaesthetists in the UK and to gauge the effects of guidelines. Two surveys, each of 66 NHS hospitals delivering acute care within London and its penumbra, examined the adoption of lipid emulsion therapy. After the publication of the editorial in autumn 2006, the spread of ‘lipid rescue’ was rapid. The timing of the adoption and the impetus for innovation varied substantially between the sampled hospitals. When the formal guidelines were published, approximately half of the hospitals surveyed did not have lipid rescue. Of those that subsequently adopted it, half attributed their decision to the guidelines. At the end of 2007, there remained a small number of hospitals that had yet to adopt lipid rescue. Lipid rescue’s adoption by anaesthetists in the UK offers a rare example of swift uptake of an innovation. National guidelines accelerated the adoption of innovation by some hospitals. [ABSTRACT FROM AUTHOR]

Responds to the comments of A.M. Troy and B. Kinirons on a case report on the use of a vertical infraclavicular anesthetic block in a patient with myasthenia gravis, published in volume 56 of the journal 'Anaesthesia.' Choice of approach to brachial plexus in patient needing elbow surgery; Incidence of phrenic nerve paralysis; Minimization of proximal spread of local anesthetic.

The author reflects on the past, present, and future developments in lipid emulsion as treatment to drug overdose in Great Britain. He comments on the past perception regarding the use of intravenous lipid emulsion in treating overdoses of local anesthetic drugs. He also mentions the other beneficial effects of lipid on cardiac arrhythmia attributed to local anesthetic toxicity. He argues that the widespread acceptance of lipid must be followed with advanced developments on the use of lipid.

A response by N. M. Denny and colleagues to a letter to the editor regarding their new guidelines for the management of severe local anaesthetic toxicity is presented.