Accidental intravascular injection of local anesthetic?

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” is 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.