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Trousseau’s sign related to upper arm tourniquet following brachial plexus blockade

We agree with Pappin and Christie [1] that ultrasound-guidance (when properly used) is the gold standard for peripheral regional anaesthesia [2]. We have also developed a novel grip to allow needle insertion and local anaesthetic injection by a single operator during ultrasound-guided regional anaesthesia. We grip the needle between index finger and thumb, and depress the syringe plunger using the middle and ring fingers and the palm of the hand (Fig. 3). The use of a Luer lock syringe prevents disconnection of the needle assembly from the syringe during injection. We are able to use this technique from the start of the block, so do not necessarily need to stop after needle insertion to pick up the syringe. We find the grip works equally well for in-plane or out-of-plane (with respect to the ultrasound beam) needling approaches. We do not routinely aspirate on the syringe before injection (our technique does not easily allow this, unlike Pappin and Christie’s grip), but as we only inject very small aliquots of local anaesthetic under direct vision, we do not believe this makes our technique unsafe. Indeed, we have performed several thousand nerve blocks using this grip and have had no incidences of local anaesthetic toxicity. We agree with Drs Pappin and Christie that a single-handed technique is preferable, giving the operator continuous, sensitive feedback of pressure during injection of local anaesthetic, and also allowing for delicate adjustment of needle tip position during injection to optimise anaesthetic spread without wasting volume. We have also found this technique has helped us to lower our injected anaesthetic volumes while maintaining efficacy of our blocks. The drawback to these techniques may be that they require more skill than simply guiding the needle without the syringe in-hand.