Anesthesia Patient Safety Podcast

#290 From Blind Needles To Ultrasound: The Safety Revolution In Regional Anesthesia

• Anesthesia Patient Safety Foundation • Episode 290

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A remarkable safety story runs through regional anesthesia, from the era of blind needle placement to a modern practice guided by real-time ultrasound, lipid rescue, and reliable team checklists. We walk through the key milestones that cut complications, accelerated block onset, and lowered conversion to general anesthesia, while keeping a clear eye on the hazards that remain. Along the way, we explain how a simple seven-point timeout helps prevent wrong-sided blocks and why ultrasound has reshaped dosing, local anesthetic spread confirmation, and failure rates.

We also dig into the numbers around local anesthetic systemic toxicity and neurologic injury, translating data into everyday decisions at the bedside. You’ll hear how improved dosing protocols, reduced volumes with ultrasound guidance, and rapid access to lipid therapy drive cardiac toxicity toward zero. We unpack the real contributors to failed blocks—anatomic variation, communication barriers, obesity, surgical factors, and experience—and share practical, high-yield steps for safer performance, from short-bevel needle selection to injection pressure monitoring and clear patient counseling.

Looking forward, we explore the next wave of tools transforming the block room: 3D and 4D ultrasound for richer visualization, needle tip tracking for faster and steadier trajectories, and pressure monitoring that warns before harm. We spotlight how AI could assist with ultrasound interpretation, trajectory planning, and complication prediction, while wearables and high-fidelity simulation extend safety beyond the procedure to early detection and better training. If you care about preventing never events, reducing LAST, and building a resilient regional anesthesia workflow, this conversation lays out what works now and what’s coming next.

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For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/290-from-blind-needles-to-ultrasound-the-safety-revolution-in-regional-anesthesia/

© 2026, The Anesthesia Patient Safety Foundation

SPEAKER_00:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel, and I'm your host. Thank you for joining us for another show. Have you done a nerve block or neuraxial procedure recently? We have come a long way when it comes to regional anesthesia, from an early safety focus on avoidance of high spinal anesthesia, nerve injury, and local anesthetic systemic toxicity to routine use of ultrasound guidance, safer local anesthetics, lipid emulsion therapy, and standardized protocols for last. The future directions for regional anesthesia include optimized training, expanding use in high-risk patients, and integrating safety with multimodal perioperative care. Our work has helped to prevent catastrophic complications and move on to refining best practices, minimizing toxicities, and improving patient outcomes. Before we dive further into the episode today, we'd like to recognize Blink, a major corporate supporter of APSF. Blink has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Blink. We wouldn't be able to do all that we do without you. So fire up your ultrasound and grab your block needle because our featured article today is from the October 2025 APSF newsletter. It is The Evolution of Patient Safety in Regional Anesthesia: A Journey of Progress by Shams and colleagues. To follow along with us, head over to APSF.org and click on the newsletter heading. First one down is the current issue. From there, scroll down to our featured article today, and I will include a link in the show notes as well. Let's take a trip to the past and explore the early days of regional anesthesia. The year is 1884, and Carl Kohler discovered that cocaine could be used as a local anesthetic for the eye, which kickstarted the modern era of local anesthetics and the field of regional anesthesia. Local anesthetics allowed localized pain control right from the beginning during surgery. The early days of regional anesthesia included serious complications such as spinal headache, nerve injury, and local anesthetic toxicity. Let's meet one of the founding fathers of regional anesthesia, Gaston Labay, a French surgeon. Surgeons were often involved in regional anesthesia at first, performing blocks and surgeries at the same time. There was no ultrasound back then, so blocks were performed with a blind technique using surface anatomy landmarks to guide needle placement. Early blocks were operator dependent, had varying outcomes, and a high risk for inadvertent intravascular injections and local anesthetic toxicity. Now we're going to fast forward a bit. Wrong-sided regional blocks are a never event. Did you know that this never event occurs at a rate of 0.5 to 5.7 per 10,000 blocks performed? One way to prevent wrong-sided blocks is with procedural timeouts. And in 2014, the American Society of Regional Anesthesia and Pain Medicine instituted a procedural timeout with these seven components: patient identification, procedure and site verification, imaging and equipment preparation, local anesthetic verification, emergency preparedness, team communication and alignment, and documentation. Do you use this simple and effective intervention to help prevent wrong-sided blocks in your practice? This is a time to use communication skills and teamwork to improve patient safety and prevent this never event. The last time you performed a regional block, you also probably reached for a newer piece of equipment, an ultrasound machine. This may be the most significant advancement in regional anesthesia. First introduced in the late 20th century with widespread use in the 21st century, this machine provides real-time imaging of nerves, blood vessels, and surrounding tissue with precise needle placement. Ultrasound guided nerve blocks have made regional anesthesia safer and more effective with confirmation of spread of the local anesthetic in the appropriate location, decreased block failure rates, faster time to block onset, and decreased time required to perform the blocks. The ultrasound ushered in another patient safety advancement by allowing less local anesthetic to be used in nerve blocks, which helped to decrease the risk for local anesthetic systemic toxicity. And speaking of LAST, this is a rare and serious complication due to inadvertent intravascular injection of local anesthetic. The incidence of this complication has decreased from 7.5 to 20 per 10,000 blocks to 0.8 to 8.7 per 10,000 blocks, with the incidence of serious cardiac toxicity falling to nearly zero in the past 30 to 40 years. These improvements were due to improved local anesthetic dosing protocols, decreased local anesthetics required for ultrasound guided blocks, and of course, lipid emulsion therapy and last treatment guidelines. We have some important digital tools in the regional anesthesia toolbox, including smartphone applications and online resources. Anesthesia professionals may be reaching for their phones to access information on nerve lock techniques, local anesthetic dosages, and anticoagulation guidelines. These are important resources for anesthesia professionals to review ultrasound images, instructional videos, and interactive decision-making algorithms while staying up to date on guidelines and best practices. We hope that you will check out ASRA Coags and timeout applications. ASVRA CoAGs provides a quick reference for the ASRA pain medicine anticoagulation guidelines and drug-specific summary information. With so many anticoagulation medications in use today, this app provides essential information for timing of neuraxial and regional procedures for patients on anticoagulation medications. The ASRA Timeout app offers a quick and easy way to perform a pre-procedure timeout before you begin a regional block. As you can see, we have come a long way with regional anesthesia, but there is still more work to be done until no patient is harmed by regional anesthesia procedures. We are going to discuss some of these remaining threats to patient safety now, starting with wrong-sided blocks and failed blocks. Procedural timeouts have greatly reduced the risk for wrong-sided blocks, but these never events may still occur. Contributing factors include the following production pressure, poor communication, distractions, rushed or absent timeouts, absent sight markings, and patient repositioning. We must remain vigilant and continue to improve our system processes to help keep patients safe from wrong-sided blocks going forward. Ultrasound guidance has greatly reduced the risk for block failure by more than 50% and decreased the risk for conversion to general anesthesia. But it is likely that this risk will never be completely eliminated. Factors contributing to failed blocks include the following anatomical variations, communication barriers, obesity or other anatomic factors, surgical factors, and proceduralist experience. Another important complication from regional anesthesia is the risk for neurologic injury. Once again, there has been improvements in imaging and needle guidance, but keep in mind that long-term neurological injury still occurs at a rate of 2 to 4 in 10,000 blocks. Even though we can now see the nerves and often fascicles and avoid direct contact with needle visualization, nerve injury can still occur. Let's review table one in the article for a review of the components of nerve injury. First up, there are a couple of host factors. Preexisting neuropathy, including diabetic neuropathy, peripheral vascular disease, chemotherapy-induced neuropathy, and neurologic diseases such as multiple sclerosis and lupus, and surgical elements, including trauma surgery, prolonged tourniquet time, high levels of neural stretch, and surgical type. Next, there are the causative agents, needle trauma, with considerations for the presence of paresthesia during the procedure, and short versus long bevel shape, and pressure injury, since higher injection pressures may indicate intraneural needle location. Finally, there are environmental factors including ultrasound versus nerve stimulation. Keep in mind that there are no differences in neurologic complications, but approved efficacy and decreased failure rates with ultrasound use. And injection pressure monitoring, which may help decrease the risk of intrafascicular injection. The risk for nerve injury may not be eliminated completely. It may be that just injecting local anesthetic, which is a neurotoxic substance near nerves in patients who are susceptible to nerve injury, may lead to long-term neurological dysfunction. But there are steps that anesthesia professionals can take to help decrease the risk going forward, including using a short beveled needle, appropriately dosing local anesthetics, visualizing the nerves directly with ultrasound, using injection pressure monitoring, and providing appropriate patient counseling. The future is exciting for regional anesthesia with important emerging technologies. Right now, we are using 2D ultrasound imaging with a flat cross-sectional view. 3D imaging reconstructs anatomical structures in three dimensions to allow a more comprehensive view of the target area. 4D imaging provides real-time visualization of moving structures such as blood vessels and nerves. These advanced imaging modalities will help to improve the precision and safety of regional anesthesia. Widespread use of these advanced imaging technologies may lead to new standards and allow for a reduced learning curve for complex nerve blocks and other challenging regional procedures. Another exciting development is a needle guidance technology, which can be integrated with ultrasound machines to provide real-time feedback on needle positioning. These systems use electromagnetic or optical tracking to determine the path of the needle and help make sure it remains on course. For more information, check out the 2019 article, Needle Tip Tracking for Ultrasound Guided Peripheral Nerf Blocks, an observer-blinded randomized controlled crossover study on a phantom model. This study involved 40 anesthesiologists who performed in-plane and out-of-plane simulated blocks with and without the needle guidance technology. For out-of-plane procedures, the needle guidance reduced the procedure time and number of hand movements, while no significant differences were found for in-plane blocks. I will include the citation in the show notes as well. Needle guidance technology has the potential to make regional anesthesia safer and more accessible going forward. Pressure injection monitoring is another way to improve patient safety during blocks by monitoring the pressure exerted during the injection of local anesthetic. This provides an early warning if the needle tip is in the intraneural or intravascular space. There is an association between high injection pressures and the risk of nerve injury, so this can really help to prevent complications. So, where are we going from here? The authors report that the future promising areas currently under development include the following artificial intelligence and the development of AI algorithms to help with ultrasound interpretation, needle trajectory planning, and complication prediction. This use of AI has the potential to provide personalized recommendations for each patient to optimize safety and efficacy, and wearable sensors that could be used to monitor patient physiology in real time and provide early warnings of complications such as last or nerve injury and support intervening and treatment without delay. And finally, high-fidelity simulation training to allow anesthesia professionals to become proficient in complex flocks in a risk-free environment. This is vital to ensure competency while minimizing errors. The authors leave us with this conclusion that I'm going to read now. The evolution of patient safety in regional anesthesia has been nothing short of remarkable. From the early days of blind techniques and rudimentary safety measures to the modern era of real-time ultrasound guidance, interlipid therapy, and advanced imaging, the field has made tremendous strides. Each innovation has brought us closer to the ideal of a safe, effective, and patient-centered practice. As we look to the future, the integration of emerging technologies such as 3D, 4D imaging, AI, and needle guidance systems promises to further enhance safety and precision. By continuing to prioritize patient safety and embrace innovation, regional anesthesia will continue to remain an important subset of the field of anesthesiology. If you have any questions or comments from today's show, please email us at podcast atapsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apf.org for detailed information and check out the show notes for links to all the topics we discussed today. If you found this discussion useful, please take a moment to subscribe to the podcast and follow us wherever you listen. Sharing the show with a colleague or leaving a review really helps us reach more clinicians committed to patient safety. Thanks for listening, and we look forward to having you back for the next episode. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.