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Third Edition
as
a
o l a
nd ay M , Ph
Professor of Clinical Anesthesia
Department of Anesthesia and Perioperative Care
School of Medicine
University of California, San Francisco
Staff Anesthesiologist
San Francisco General Hospital
San Francisco, California
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF ULTRASOUND-GUIDED REGIONAL ANESTHESIA,

THIRD EDITION ISBN: 978-0-323-50951-0
Copyright © 2019 by Elsevier, Inc. All rights reserved.

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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyright © 2013, 2010.
Library of Congress Cataloging-in-Publication Data
Names: Gray, Andrew T., author.

Title: Atlas of ultrasound-guided regional anesthesia / Andrew T. Gray.
Description: Third edition. | Philadelphia, PA : Elsevier, Inc., [2019] | Includes bibliographical
references and index.
Identifiers: LCCN 2017056978 | ISBN 9780323509510 (hardcover : alk. paper)
Subjects: | MESH: Anesthesia, Conduction | Ultrasonography, Interventional | Atlases
Classification: LCC RD84 | NLM WO 517 | DDC 617.9/640222–dc23
LC record available at https://lccn.loc.gov/2017056978
Publisher: Dolores Meloni

Senior Content Development Specialist: Anne Snyder
Publishing Services Manager: Catherine Jackson
Project Manager: Kate Mannix
Design Direction: Patrick Ferguson
Illustrations Manager: Lesley Frazier
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my family of writers: Mary, Sarah, Alex, and Anna.
Preface
The third edition of Atlas of Ultrasound-Guided Regional Anesthesia marks a change in format. There
are now many new chapters by contributing authors that vastly improve and expand the section of
topics from what would be possible with a single-author text. A wide variety of newly described techniques
are presented in this edition, and chapters from the previous editions underwent extensive editing and
updating. The new chapters are mostly dedicated to blocks in the trunk and head and neck regions.
The emphasis on safety continues, with a detailed contributed chapter that reviews large studies of rare
events. Also included is a chapter on limited resources that discusses techniques and alternatives in
different clinical settings.
We have tried to present clear and concise summaries of suggested techniques so that readers will
have the confidence and background they need to begin using the interventional procedures. Wide
fields of view, long axis views, three-dimensional imaging, and step-by-step instruction are all used to
improve the educational format and illustrate anatomic structures that lie near or outside the conventional
two-dimensional field of imaging. Where appropriate, chapters have additional sonograms that illustrate
variations of normal anatomy that one may encounter in clinical practice. New videos show the dynamics
of interventional acute pain medicine in stunning detail. All the chapters highlight recent advances and
techniques in the rapidly changing field of ultrasound-guided regional anesthesia.
Very special thanks to Allegra Greher (artwork), Tin-na Kan (sciatic nerve blocks), David Mai
(catheters), Ed Mathews (information technology), Stefan Simon (intercostal nerve blocks), Robin
Stackhouse and Susan Yoo (figures and media production), and Ranier Litz and Tim Maecken (organizing
the USRA Symposia at which much of this educational material was presented and discussed). We are
grateful to the anesthesiologists, CRNAs, anesthesia technicians, and perioperative nurses at Kaiser
Permanente hospitals in Oakland, Richmond, and San Francisco, California for their help with the
catheter sonograms and video clips.
Andrew T. Gray, MD, PhD

Contributors
Michael J. Barrington, MBBS, FANZCA, PhD Manfred Greher, MD, MBA
Associate Professor Hospital of the Sacred Heart of Jesus
Faculty of Medicine, Dentistry and Health Sciences Vienna, Austria
University of Melbourne Medical School Chapter 69: Greater Occipital Nerve Block
Parkville, Victoria, Australia;
Department of Anaesthesia and Acute Pain Medicine Peter Hebbard, MD
St. Vincent’s Hospital Melbourne Department of Anesthesia
Fitzroy, Victoria, Australia. University of Melbourne
Chapter 74: Safety: Practical Techniques to Prevent Wangaratta, Austalia
Complications During Ultrasound-Guided Nerve Blocks Chapter 59: Transversus Abdominis Plane Blocks
Gerald Dubowitz, MD Jens Kessler, MD

Associate Professor Department of Anesthesiology
Department of Anesthesia and Perioperative Care University Hospital Heidelberg
University of California, San Francisco Heidelberg, Germany
San Francisco, California Chapter 73: Stellate Ganglion Block
Chapter 75: Regional Anesthesia in Resource-Constrained
Environments Manoj Kumar Karmakar, MD, FRCA, DA (UK),
FHKCA, FHKAM
Urs Eichenberger, MD Professor, Consultant Anaesthesiologist and Director of Paediatric
Balgrist University Hospital Anaesthesia
Chair, Department of Anaesthesia Department of Anaesthesia and Intensive care
Zürich, Switzerland The Chinese University of Hong Kong
Chapter 58: Ilioinguinal and Iliohypogastric Nerve Blocks Prince of Wales Hospital
Shatin, Hong Kong, China
Hesham Elsharkawy, MD, MBA, MSc Chapter 61: Thoracic Paravertebral Block
Staff Departments of General Anesthesia and Pain Management,
Outcomes Research Bradley Lee, MD
Assistant Professor of Anesthesiology Department of Anesthesia and Perioperative Care
CCLCM of Case Western Reserve University University of California, San Francisco
Cleveland, Ohio San Francisco, California
Chapter 60: Quadratus Lumborum Blocks Chapter 47: Posterior Femoral Cutaneous Nerve Block
Jeffrey Ghassemi, MD, MPH Michael S. Lipnick, MD

Assistant Clinical Professor Assistant Professor
Department of Anesthesia and Perioperative Care Department of Anesthesia and Perioperative Care
University of California, San Francisco University of California, San Francisco
San Francisco, California; San Francisco, California
Chief of Anesthesia Chapter 75: Regional Anesthesia in Resource-Constrained
Diablo Service Area Environments
The Permanente Medical Group
Kaiser Petrmanente L. Stephen Long, MD
Walnut Creek, California Pediatric Anesthesiologist
Chapter 42: The Adductor Canal Block Children’s Anesthesia Medical Group
UCSF Benioff Children’s Hospital Oakland
Andrew T. Gray, MD, PhD Oakland, California
Professor of Clinical Anesthesia Chapter 62: Pudendal Nerve Block in Children
Department of Anesthesia and Perioperative Care
School of Medicine Daniel A. Nahrwold, MD
University of California, San Francisco; Assistant Professor
Staff Anesthesiologist Department of Anesthesia and Perioperative Care
San Francisco General Hospital University of California, San Francisco
San Francisco, California San Francisco, California
Chapter 14: Ultrasound-Guided Continuous Peripheral Nerve Blocks
Contributors
Ronald Seidel, MD
Department of Anaesthesiology and Intensive Care Medicine
HELIOS Medical Center Schwerin
Schwerin, Germany
Chapter 72: Cervical Plexus Block
Agnes Wabule, MMED

Head of Department
Department of Anesthesia and Critical Care
Mulago Hospital
Kampala, Uganda
Chapter 75: Regional Anesthesia in Resource-Constrained
Environments
Daniel M. Wong, MBBS, FANZCA

Honorary Clinical Senior Fellow
University of Melbourne Medical School
Parkville, Victoria, Australia;
Department of Anaesthesia and Acute Pain Medicine
St. Vincent’s Hospital Melbourne
Fitzroy, Victoria, Australia
Chapter 74: Safety: Practical Techniques to Prevent Complica-
tions During Ultrasound-Guided Nerve Blocks
Video Contents
INTRODUCTION TO ULTRASOUND IMAGING
Chapters 1-15
Video 1.1 Introduction to Ultrasound Imaging
Chapter 14
Video 14.1 Ultrasound-Guided Continuous Peripheral
Nerve Blocks
UPPER EXTREMITY BLOCKS

Chapter 28
Video 28.1 Interscalene and Supraclavicular Blocks
Chapter 32
Video 32.1 Infraclavicular Blocks
Chapter 33
Video 33.1 Axillary Block
Chapter 35
Video 35.1 Forearm Blocks
LOWER EXTREMITY BLOCKS

Chapter 40
Video 40.1 Fascia iliaca Block
Chapter 41
Video 41.1 Femoral Nerve Block
Chapter 42
Video 42.1 Adductor Canal Block
Chapter 43
Video 43.1 Obturator Nerve Block
Chapter 44
Video 44.1 Sciatic Nerve Block
Chapter 46
Video 46.1 Popliteal Nerve Block
Chapter 48
Video 48.1 Ankle Block
Chapter 49
Video 49.1 Saphenous Nerve Block
TRUNK BLOCKS
Chapters 57 and 58
Video 57.1 Truncal Blocks
Chapter 59
Video 59.1 Transversus Abdominis Plane (TAP) Block
Chapter 61
Video 61.1 Paravertebral Block
Chapter 63
Video 63.1 Neuraxial Block
HEAD AND NECK BLOCKS

Chapter 72
Video 72.1 Cervical Plexus Block
SAFETY ISSUES
Chapter 74
Video 74.1 Ultrasound Safety Issues
SECTION
1
Introduction to
Ultrasound Imaging
CHAPTER
1 Ultrasound
See Video 1.1 on ExpertConsult.com.
Ultrasound waves are high-frequency sound waves generated in specific frequency ranges and
sent through tissues.1 How sound waves penetrate a tissue depends on the range of the frequency
produced. Lower frequencies penetrate deeper than high frequencies do. The frequencies for
clinical imaging (1 to 70 MHz) are well above the upper limit of normal human hearing (15 to
20 KHz). Wave motion transports energy and momentum from one point in space to another
without transport of matter. In mechanical waves (e.g., water waves, waves on a string, and sound
waves), energy and momentum are transported by means of disturbance in the medium because
the medium has elastic properties. Any wave in which the disturbance is parallel to the direction
of propagation is referred to as a longitudinal wave. Sound waves are longitudinal waves of
compression and rarefaction of a medium such as air or soft tissue. Compression refers to high-
pressure zones, and rarefaction refers to low-pressure zones (these zones alternate in position).
As the sound passes through tissues, it is absorbed, reflected, or allowed to pass through,
depending on the echodensity of the tissue. Substances with high water content (e.g., blood,
cerebrospinal fluid) conduct sound very well and reflect very poorly and thus are termed echolucent.
Because they reflect very little of the sound, they appear as dark areas (hypoechoic). Substances
low in water content or high in materials that are poor sound conductors (e.g., air, bone) reflect
almost all the sound and appear very bright (hyperechoic). Substances with sound conduction
properties between these extremes appear darker to lighter, depending on the amount of wave
energy they reflect.
Audible sounds spread out in all directions, whereas ultrasound beams are well collimated.
The frequency of sound does not change with propagation unless the wave strikes a moving
object, in which case the changes are small. The product of the frequency and wavelength of
sound waves is the wave speed. Because the speed of sound in soft tissue is nearly constant,
higher-frequency sound waves have shorter wavelengths. Two adjacent structures cannot be
identified as separate entities on an ultrasound scan if they are less than one wavelength apart.
Therefore sound wave frequency is one of the main determinants of spatial resolution of
ultrasound scans.
Reference
1. Aldrich JE. Basic physics of ultrasound imaging. Crit Care Med. 2007;35:S131–S137.
2
CHAPTER
Speed of Sound 2
The speed of sound is determined by properties of the medium in which it propagates. The sound
velocity equals ( B rho) , where B equals the bulk modulus and rho equals density. The bulk
modulus is proportional to stiffness. Thus stiffness (change in shape) and wave speed are related.
Density (weight per unit volume) and wave speed are inversely related. The speed of sound in a
given medium is essentially independent of frequency.
Because the velocity of sound in soft tissue is 1540 m/s, 13 microseconds elapse for each
centimeter of tissue the sound wave must travel (the back-and-forth time of flight). Speed-of-sound
artifacts relate to both time-of-flight considerations and refraction that occurs at the interface of
tissues with different speeds of sound.1-3
References
1. Scanlan KA. Sonographic artifacts and their origins. AJR Am J Roentgenol. 1991;156:1267–1272.
2. Fornage BD. Sonographically guided core-needle biopsy of breast masses: the “bayonet artifact”. AJR Am J Roentgenol.
1995;164:1022–1023.
3. Gray AT, Schafhalter-Zoppoth I. “Bayonet artifact” during ultrasound-guided transarterial axillary block. Anesthesiology.
2005;102:1291–1292.
3
4 Introduction to Ultrasound Imaging
Bayonet artifact
A
Bayonet artifact
C
FIGURE 2.1 Bayonet artifacts during popliteal block (A and B). Because the speed of sound
is not necessarily homogeneous in soft tissue, the needle can sometimes appear
to bend, similar to a bayonet. Actual mechanical bending of the needle typically
appears as gentle bowing of the needle (C).
CHAPTER
Attenuation 3
Attenuation is a decrease in wave amplitude as it travels through a medium. The attenuation of

ultrasound in soft tissue is approximately 0.5 to 0.75 dB/(MHz-cm), indicating that the extent of
attenuation depends on the distance traveled and the frequency of insonation. The units of the
attenuation coefficient directly show the greater attenuation of high-frequency ultrasound beams.
In soft tissue, 80% or more of the total attenuation is caused by absorption of the ultrasound
wave, thereby generating heat.
Time gain compensation (TGC) adjusts for attenuation of an ultrasound beam as a function
of depth. When TGC is properly adjusted, images of similar reflectors appear the same regardless
of depth.
An acoustic shadow is said to exist when a localized object reflects or attenuates sound to
impede transmission. Bone is a strong absorber of ultrasound waves. Therefore shadowing occurs
deep to bony structures (“bone shadow”).
When a nonattenuating fluid (e.g., blood or injected local anesthetic) lies within an attenuating
sound field (e.g., soft tissue), enhancement of echoes deep to the fluid occurs. This phenomenon,
originally described as posterior acoustic enhancement (also called increased through-transmission),
is due to lack of absorption of the sound waves by the fluid.1 This attenuation artifact is a potential
source of problems, especially during regional blocks where nerves are situated close to blood
vessels.
Clinical Pearls
• In general, the highest frequency capable of adequate penetration to the depth of interest
should be used for imaging.
• Decibels (dB) are a relative logarithmic measure of sound wave intensity.
Reference
1. Filly RA, Sommer FG, Minton MJ. Characterization of biological fluids by ultrasound and computed tomography.
Radiology. 1980;134:167–171.
5
Ulna
FIGURE 3.1 Acoustic shadowing by bone. In this sonogram from the forearm, the acoustic
shadowing by the ulna is evident. The bright cortical line of the surface of the
bone is followed by extinction of the sound wave below.
CHAPTER
Reflection 4
Ultrasonography measures the amplitude of the return echo as a function of time.1 Sound waves
are reflected at the interface of tissues with different acoustic impedances. The acoustic impedance
(kg/[m2-s]) is the product of the density (kg/m3) and velocity (m/sec). The extent of reflection is
governed by the reflection coefficient: R = (Z1 − Z2)/(Z1 + Z2). If Z1 = Z2, there is no reflected
wave.2 Ultrasound characteristics of biologic tissue and interventional materials are summarized
in Table 4.1.
Reflections off a smooth surface are called specular. If two specular reflectors are close to each
other, reverberation within the sound field can result, displayed as parallel, equally spaced lines
deep to the reflectors. Csomet-tail artifact, which is a form of reverberation artifact, is caused by
multiple internal reflections from a small, highly reflective interface.3,4
Clinical Pearls
• The normal pleural line is thin and smooth, which generates a few comet-tail artifacts (between
one and three artifacts per intercostal space scan). In the presence of parenchymal lung
disease, the pleural line is irregular and thickened, generating many more comet-tail artifacts.5
• No comet-tail artifact is observed from the lung when pneumothorax is present.
• Hyperechoic reverberation artifacts are seen with metallic foreign bodies such as block needles.
Ultrasound Characteristics of Biologic Tissue and Interventional

TABLE 4.1 Materials
Attenuation (dB/ Impedance
Substance Velocity (m/s) [MHz-cm]) (mrayls × 10–6)
Air 330 7.5 0.0001
Water 1480 0.0022 1.5
Soft tissue 1540 0.75 1.7
Blood 1575 0.15 1.6
Bone 4080 15 8
Stainless steel 5790 0.2 47
Data from Ziskin MC. Fundamental physics of ultrasound and its propagation in tissue. Radiographics. 1993;13:705–
709; Ziskin MC, Thickman DI, Goldenberg NJ, Lapayowker MS, Becker JM. The comet tail artifact. J Ultrasound
Med. 1982;1:1–7; Gawdzinska K. Investigation into the propagation of acoustic waves in metal. Metalurgija.
2005;44:125–128; Smith SW, Booi RC, Light ED, Merdes CL, Wolf PD. Guidance of cardiac pacemaker leads using
real time 3D ultrasound: feasibility studies. Ultrason Imaging. 2002;24:119–128.
7
References
1. Ziskin MC. Fundamental physics of ultrasound and its propagation in tissue. Radiographics. 1993;13:705–709.
2. Ziskin MC. Equation governing the transmission of ultrasound. J Clin Ultrasound. 1982;10:A21.
3. Ziskin MC, Thickman DI, Goldenberg NJ, Lapayowker MS, Becker JM. The comet tail artifact. J Ultrasound Med.
1982;1:1–7.
4. Thickman DI, Ziskin MC, Goldenberg NJ, Linder BE. Clinical manifestations of the comet tail artifact. J Ultrasound
Med. 1983;2:225–230.
5. Reissig A, Kroegel C. Transthoracic sonography of diffuse parenchymal lung disease: the role of comet tail artifacts.
J Ultrasound Med. 2003;22:173–180.
Reverberation artifact
FIGURE 4.1 Reverberation artifact from a block needle placed nearly parallel to the active
face of the transducer.
Comet-tail
artifact
FIGURE 4.2 Comet-tail artifact from the peritoneum during rectus sheath block. The peritoneum
and pleura have similar appearances on ultrasound scans.
Reflection 9
Air
FIGURE 4.3 A strong echo and acoustic shadowing are observed when air is inadvertently
injected during musculocutaneous nerve block in the axilla. Sonograms before
injection (A) and after injection (B) are shown.
Steroid
suspension
FIGURE 4.4 Acoustic properties of a steroid suspension. Although the local anesthetic injected
for most regional blocks is anechoic, the particles of this steroid suspension are
sufficiently large to produce a strong echo.
CHAPTER
Beam Width (Slice Thickness)

5
Ultrasound systems assume all reflectors lie directly along the main axis of the ultrasound beam
(i.e., the acoustic axis or central ray)1; however, ultrasound beams have a finite size. The out-of-plane
beam width (slice thickness) can be measured with a diffuse scattering plane.2 The plane is oriented
at a 45-degree angle so that the displayed echoes are equal to the out-of-plane echoes. Ultrasound
beams can be focused to reduce the out-of-plane beam width and thereby improve image quality.
References
1. Goldstein A, Madrazo BL. Slice-thickness artifacts in gray-scale ultrasound. J Clin Ultrasound. 1981;9:365–375.
2. Goldstein A. Slice thickness measurements. J Ultrasound Med. 1988;7:487–498.
FIGURE 5.1 Out-of-plane slice thickness. Ultrasound scan of a diffuse scattering plane
(a sheet of sandpaper).
11
140
120
100
80
Pixel intensity
60
40
20
3 2 1 0 1 2 3 4
Out-of-plane distance (mm)
FIGURE 5.2 The beam profile is shown as a function of the distance from the central ray.
Because needle diameters are substantially less than those of the slice plane, a
strong relationship between needle diameter and visibility is expected.
CHAPTER
Anisotropy 6
Isotropic means equal in all directions. Anisotropic implies angle dependence. The latter term
has been used to indicate the change in amplitude of received echoes from a structure when the
angle of insonation is changed. Anisotropy is a discriminating feature between nerves and tendons.
Tendons are more anisotropic than nerves are, meaning that smaller changes in angle (approximately
2 degrees) alter the echoes from tendons than the changes in angle (approximately 10 degrees)
that alter the echoes from nerves. The anisotropy of nerves also is important because during
interventions it can be challenging to maintain nerve visibility while manipulating the transducer
to image the block needle.1 With training, practitioners learn to naturally manipulate the transducer
to fill in the received echoes from nerves. The amplitude of the received echoes from peripheral
nerves is usually largest when the sound beam is perpendicular to the nerve path. Other structures,
such as muscle, also exhibit anisotropy.2
Clinical Pearls
• Anisotropy means that the backscatter echoes from a specimen depend on the directional
orientation within the sound field.
• Anisotropy can be quantified by specifying the transducer frequency and the decibel change in
backscatter echoes with perpendicular and parallel orientation of the specimen.
• Nerves, tendons, and muscle all exhibit anisotropy. Of these structures, tendon echoes are the
most sensitive to transducer manipulation.
References
1. Soong J, Schafhalter-Zoppoth I, Gray AT. The importance of transducer angle to ultrasound visibility of the femoral
nerve. Reg Anesth Pain Med. 2005;30:505.
2. Rubin JM, Carson PL, Meyer CR. Anisotropic ultrasonic backscatter from the renal cortex. Ultrasound Med Biol.
1988;14:507–511.
13
Median nerve
FIGURE 6.1 Anisotropy of the median nerve (A and B). With inclination of the transducer
(tilting), the received echoes from the median nerve disappear.
CHAPTER
Spatial Compound Imaging 7

In conventional sonography, tissue is insonated from a single direction. Spatial compound imaging
combines multiple lines of sight to form a single composite image at real-time frame rates. The
ultrasound beam is steered by a different set of predetermined angles, typically within 20 degrees
from the perpendicular.
One benefit of the use of spatial compound imaging is the reduction of angle-dependent
artifacts (Table 7.1). Speckle is the granular appearance of a sonographic image that results from
scattering of the ultrasound beam from small tissue reflectors. This speckle artifact results in the
grainy appearance observed on sonograms, representing noise in the image. Improved image
quality may be obtained by using spatial compound imaging, which can reduce speckle noise.
There is a central triangular region of overlap within the field of view where all angles mesh
together for full compounding. The corners of the image receive only a subset of all the lines of
sight; therefore not all the benefits of spatial compounding are manifest. Some machines allow
the stray lines of sight (those off the rectangular field of view) to form a trapezoidal image format.
This is sometimes useful to view the approaching needle with in-plane technique.
Spatial compound imaging was first designed to eliminate angle-dependent artifacts. 1 This can
be accomplished with a narrow range of beam angles. The larger the range of angles subtended
by spatial compounding, the smaller the region within the field of imaging that will receive all
the lines of sight (i.e., the region of full compounding).
Ultrasound imaging near bone may be improved by spatial compound imaging. This has
relevance to imaging for some blocks (e.g., neuraxial, paravertebral, lumbar plexus, intercostals,
sacroiliac joint). Although ultrasound waves cannot penetrate mature bone (even with low-frequency
ultrasound), spatial compound imaging allows better definition of the bone surface.
Linear test tool images can be used to reveal the number of lines of sight used in spatial
compound imaging. These images are generated with a smooth metal surface, such as that of a
paper clip, solid metal stylet, or a US nickel. Metal is used because it is relatively nonattenuating,
TABLE 7.1 Advantages and Disadvantages of Spatial Compound Imaging

Advantages Disadvantages
Reduction of angle-dependent artifacts (e.g., Frame averaging (persistence or motion blur
posterior acoustic enhancement and speckle) effect)
Needle tip imaging Limited range of angles (typically <20
degrees)
Nerve border definition
Fascia contours
Imaging around bone
Wider field of view with stray lines of sight
15
yet produces an echo. Smooth metal is used so that the test tool does not damage the transducer.
For these measurements, high receiver gain and a single focal zone near the surface are used. As
long as the test tool contact is less than the receiver aperture, the width of the displayed echoes
will not change.
Clinical Pearls
• The use of spatial compound imaging can improve imaging of nerve borders and the block
needle tip.
• One potential disadvantage of compound imaging is that needle reverberations occur over a
broader range of angles and can prevent imaging of deeper structures.
• Compound imaging is being developed for both linear and curved arrays.
• Sliding the transducer along the known course of the nerve is a well-established technique to
improve small nerve imaging. However, frame rate reduction that occurs with spatial compound
imaging can cause problems with this technique.
• If compound imaging is not an advantage for a particular imaging situation, it can be turned off.
Reference
1. Baad M, Lu ZF, Reiser I, Paushter D. Clinical significance of US artifacts. Radiographics. 2017;37:1408–1423.
Spatial Compound Imaging 17
FIGURE 7.1 Spatial compound imaging. Some forms of ultrasound imaging use multiple lines
of sight by electronically steering the beam to different angles. This sonogram
was obtained by placing a linear array test tool (the solid metal stylet of a 17-gauge
epidural needle) over the active face of the transducer to isolate a single element
(A and B). The displayed test tool image consists of the receiver apertures of the
transducer. In this case, five lines of sight are used to form a compound image.
0 D
Fully
x
compounded
region
Transducer
max max
zmax
z Scan lines
FIGURE 7.2 Conceptual illustration of transducer and associated scan lines for recording of
three single-angle images. (Adapted from Jespersen SK, Wilhjelm JE, Sillesen
H. In vitro spatial compound scanning for improved visualization of atherosclerosis.
Ultrasound Med Biol. 2000;26:1357–1362.)
CHAPTER
Doppler Imaging 8
The Doppler shift is the change in frequency of sound when the sound wave strikes a moving
object. This means the frequencies of the transmitted and reflected sound waves are not the same.
Doppler shifts in clinical imaging are in the audible range (±10 KHz). Red blood cells are the
primary reflectors that produce Doppler shifts. Ultrasound machines can color-encode the mean
velocity (color Doppler), variance within the sample volume (variance Doppler), and power
spectrum of the frequency shift (power Doppler).1
The optimal spectral Doppler angle is 30 to 60 degrees. Doppler angles greater than 60 degrees
result in small Doppler shifts. Doppler angles less than 30 degrees result in loss of signal due to
refraction.
Aliasing (incorrect or ambiguous estimation of the velocity) occurs when the velocity scale is
set too small relative to the actual velocities. Wraparound transition between positive and negative
velocity on spectral Doppler tracings indicates aliasing; therefore the peak velocities are off scale
and not accurately estimated. This occurs because the pulse repetition frequency is insufficiently
low relative to the frequency of the Doppler signal (a consequence of the sampling or Nyquist
theorem).
Color Doppler is traditionally shown with the Nyquist velocity limits. Color aliasing is displayed
as reversed flow within laminar flow areas, with no intervening black stripe between them. With
true flow reversal, the transition has an intervening black stripe, indicating no flow estimation.
This narrow colorless area occurs because of the absence of a Doppler shift where flow is per-
pendicular to the angle of insonation.
Clinical Pearls
• Blood has a low ultrasound attenuation coefficient. Red blood cells are the primary reflectors
within blood.
• In power Doppler the gain threshold can be adjusted to the level at which there is no observed
signal in bone.2
• In low-flow states (e.g., heart failure or atrial arrhythmias), aggregates of red blood cells can
cause spontaneous echo contrast within blood vessels.
References
1. Bude RO, Rubin JM. Power Doppler sonography. Radiology. 1996;200:21–23.
2. Rubin JM. Musculoskeletal power Doppler. Eur Radiol. 1999;9(suppl 3):S403–S406.
19
FIGURE 8.1 An example of color Doppler imaging during axillary block. A short-axis view of
the neurovascular bundle is displayed.
FIGURE 8.2 Long-axis view of the axillary artery and its profunda branch in conventional
B-mode imaging (A) and with power Doppler (B).
CHAPTER
Ultrasound Transducers 9
Ultrasound transducers consist of arrays of piezoelectric crystals that produce high-frequency

sound waves in response to an electrical signal. These crystals interconvert electrical and mechanical
energy, allowing for both transmission and reception of sound waves. The piezoelectric element
vibrates to produce ultrasound. Piezoelectric crystals change shape under the influence of an
electric field. The thickness of the crystal and the propagation speed within determine the frequency.
With some transducers, the sonographer can select different crystals within the assembly to
produce a different frequency.
The first ultrasound transducers were made using natural piezoelectric crystals (quartz, Rochelle
salts, tourmaline). Modern transducers use synthetic crystals, such as PZT (lead zirconate titanate),
that have high density, velocity, and acoustic impedance.1
Linear arrays typically produce a rectangular image format. The piezoelectric crystals are
arranged in a straight line. Curvilinear arrays produce images in sector format (that do not
originate from a single point). The range of angles with curved arrays (typically, 0 to 60 degrees)
is much larger than with beam steering for spatial compound imaging (typically, 0 to 20 degrees).
Most regional blocks are performed with linear transducers because the high scan line density
produces the resolution necessary for direct nerve imaging. Small curved probes are useful for
infraclavicular and suprascapular nerve blocks because working room is limited. With curved
probes, inaccurate estimation of needle tip location can occur despite complete line-up due to
the different angles at which the ultrasound beam hits the needle.
FIGURE 9.1 Ultrasound transducers for regional blocks. The photograph includes (left to right) broad linear, small
footprint linear, curved, sector, and hockey stick transducers.
Reference
1. Szabo TL, Lewin PA. Ultrasound transducer selection in clinical imaging practice. J Ultrasound Med.
2013;32:573–582.
21
CHAPTER
10 Transducer Manipulation
Nomenclature for transducer manipulation has been previously established.1,2 Note that this
nomenclature does not include specification of direction (e.g., rock back, rotate clockwise, tilt
proximal). To control the transducer for interventions, the hands of the operator must be very
close to the skin surface. The ulnar aspect of the transducer hand should rest on the skin of the
patient.
References
1. AIUM technical bulletin. Transducer manipulation. American Institute of Ultrasound in Medicine. J Ultrasound Med.
1999;18:169–175.
2. Bahner DP, Blickendorf JM, Bockbrader M, et al. Language of transducer manipulation: codifying terms for effective
teaching. J Ultrasound Med. 2016;35:183–188.
22
Transducer Manipulation 23
A B
C D
E F
G
FIGURE 10.1 To optimally display anatomy for image presentation, the transducer must be
manipulated. Transducer manipulation can be broken down into five basic
movements: sliding (A), tilting (B), rocking (C and D), rotating (E and F), and
compressing (G). Combining these movements allows for smooth scanning
motion and anatomy visualization. (Adapted from AIUM technical bulletin.
Transducer manipulation. American Institute of Ultrasound in Medicine. J Ultra-
sound Med. 1999;18:169–175.)
CHAPTER
11 Needle Imaging
Needle tip visibility is critical to the success and safety of regional block interventions. It is
imperative to identify the needle tip before advancing the needle. The cut on the bevel is the best
identifier of the needle tip for a beveled needle. Partial line-ups (so that the needle tip is not
within the plane of imaging but some of the needle shaft is) are a source of false reassurance with
in-plane technique. A number of factors have been reported to influence needle tip visualization
under clinical imaging conditions (Table 11.1).
INSERTION ANGLE (ANGLE OF INSONATION)

Needle tip imaging is optimal when the needle is parallel to the active face of the transducer. The
cleanest needle echo is from a conventional needle at or near parallel. One study found a linear
correlation between angle of incidence (measured from 0 to 75 degrees) and the mean needle tip
brightness.1
NEEDLE GAUGE
There are multiple advantages to using a large needle for regional block. Needles as large as
17 gauge have been used to improve needle tip visibility for regional blocks.2 Alignment of
a large needle is faster with in-plane technique. An additional advantage of a large needle
is the ability to redirect the needle within the scan plane. A large needle tip can be used to
displace structures (e.g., arteries or nerves) before advancing. The disadvantages of the large
needle are patient discomfort and the consequences of unintended puncture (e.g., of vessels,
nerves), which are typically worse. In addition, the soft tissue properties (tent and recoil)
are more noticeable with large needles. With finer needle tips, the hand motion and needle
tip motion are more closely matched, and it is easier to place a fine needle tip within a thin
fascial plane.
BEVEL ORIENTATION
Needle bevel orientation is important for needle tip visibility (Table 11.2).3 The bevel should be
facing the transducer to enhance needle tip imaging.
TABLE 11.1 Factors Reported to Influence Needle Tip Visibility

Angle of insonation
Needle gauge
Bevel orientation
Receiver gain
Needle motion and test injections
Echogenic modifications
Spatial compound imaging
24
Needle Imaging 25
TABLE 11.2 Influence of Bevel Orientation on Needle Tip Visibility

Angle (Degrees) Poor Fair Good
0 0.14 0.45 0.41
90 0.33 0.51 0.17
180 0.14 0.45 0.41
270 0.25 0.52 0.23
From Hopkins RE, Bradley M. In-vitro visualization of biopsy needles with ultrasound: a comparative study of
standard and echogenic needles using an ultrasound phantom. Clin Radiol. 2001;56:499–502.
RECEIVER GAIN
The overall two-dimensional receiver gain should be reduced to improve visibility of the needle
tip. However, a competing consideration is the visibility of other structures, such as the local
anesthetic injection and blood vessels.
NEEDLE MOTION AND TEST INJECTIONS

Some clinicians move the needle slightly or use small-volume test injections of fluid (<1 mL) to
improve the needle tip visibility.4 Because regional anesthesia interventions are performed near
reactive structures, if needle motion is used, it should be small and slow (avoid rapid jabbing
motions, which may cause puncture or paresthesia).
ECHOGENIC MODIFICATIONS
McGahan roughened up the surface of needles with a No. 11 surgical blade to improve the needle
tip visibility.5 Historically, this was one of the first echogenic needle designs. When the angle of
approach is more the 30 degrees, an echogenic needle is of benefit because the roughened surface
sends echoes back to the transducer.6
SPATIAL COMPOUND IMAGING

With an increasing angle of incidence, the decrease in needle visibility is more pronounced for
single-line ultrasound than for compound imaging. However, at angles of incidence of more than
30 degrees, the needle was barely visible with either method of imaging.7
Clinical Pearls
• Among specialized needles used for regional blocks, Hustead needle tips tend to have better
ultrasound visibility.
• Side-port needles for regional block do not appear to exhibit isotropic diffraction, which has
been reported to enhance the ultrasound visibility of similar needles.8
• Large-bore needles can be used as nerve retractors, pushing or pulling nerves out of the way
of the advancing needle.
• Bevel orientation should be toward the nerve (so that the needle will pass the nerve rather than
puncture it).
• When navigating the block needle between two nerves, the bevel should be rotated to face the
closer of the two. This helps the block needle shoot the intervening gap and makes the closer
nerve roll to the side as the needle is advanced. The same bevel orientation strategy can be
used when placing the block needle between a nerve and an artery.
References
1. Bondestam S, Kreula J. Needle tip echogenicity: a study with real-time ultrasound. Invest Radiol. 1989;24:555–560.
2. Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth. 2002;89:254–259.
3. Hopkins RE, Bradley M. In-vitro visualization of biopsy needles with ultrasound: a comparative study of standard
and echogenic needles using an ultrasound phantom. Clin Radiol. 2001;56:499–502.
4. Feller-Kopman D. Ultrasound-guided internal jugular access: a proposed standardized approach and implications for
training and practice. Chest. 2007;132:302–309.
5. McGahan JP. Laboratory assessment of ultrasonic needle and catheter visualization. J Ultrasound Med. 1986;5:373–377.
6. Deam RK, Kluger R, Barrington MJ, et al. Investigation of a new echogenic needle for use with ultrasound peripheral
nerve blocks. Anaesth Intensive Care. 2007;35:582–586.
7. Cohnen M, Saleh A, Luthen R, et al. Improvement of sonographic needle visibility in cirrhotic livers during transjugular
intrahepatic portosystemic stent-shunt procedures with use of real-time compound imaging. J Vasc Interv Radiol.
2003;14:103–106.
8. Hurwitz SR, Nageotte MP. Amniocentesis needle with improved sonographic visibility. Radiology. 1989;171:576–577.
A B
C D
FIGURE 11.1 Influence of angle of insonation on needle tip visibility. When the needle is nearly parallel, the tip is
easily identified (A). When the needle is at an angle, needle tip visibility is difficult (B). Echogenic needles
can help improve needle tip visibility at steep angles under some clinical imaging conditions (C and D).
Needle Imaging 27
FIGURE 11.2 Influence of bevel orientation on needle tip visibility: bevel up (A) and bevel
down (B).
A B
C D
FIGURE 11.3 Photomicrographs of needles used for regional block. A plain conventional needle (A) and echogenic
designs (B, C, and D) are shown. A smooth needle may not generate a recordable echo because its
rounded shaft reflects most incident sound away from the source. A variety of textured surfaces are
manufactured and marketed to improve needle tip detection on acquired sonograms.
CHAPTER
12 Approach and Techniques
OFFLINE MARKINGS
Offline techniques involve external skin markings from ultrasound scans without imaging during
needle placement.1 Changes in patient position, mobility of the skin, and dynamic changes with
needle placement and injection limit the utility of this approach, but this approach can be used
for neuraxial blocks. The skin adjacent to the sides of the transducer can be marked. Alternatively,
a paper clip or solid metal stylet (preferably with dull ends) can be used to create artifact within
the field to mark the position of the object. For this technique, spatial compound imaging can
be turned off to enhance the artifact.2 The M-mode center line can be used to facilitate offline
markings in the center of the field.
ONLINE GUIDANCE
There are two basic approaches to online ultrasound guidance (imaging during the intervention).
With the out-of-plane technique, the needle tip crosses the plane of imaging as an echogenic dot.
With the in-plane approach, the entire tip and shaft of the advancing needle are visible.
OUT-OF-PLANE APPROACH
There are several advantages to the out-of-plane approach to regional block (Table 12.1). This
approach is most similar to traditional approaches to regional block guided by nerve stimulation
or palpation. Therefore the out-of-plane approach provides a natural transition from one form
of guidance to another. The out-of-plane approach uses a shorter needle path than do in-plane
approaches. If short-axis views of the nerve are used, an out-of-plane approach results in catheter
placement that is guided along the path of the nerve. One disadvantage of the out-of-plane
TABLE 12.1 Comparison of Out-of-Plane and In-Plane Approaches

Approach Advantages Disadvantages
Out-of-plane Most similar to other Unimaged needle path, crossing the plane of
(OOP) approaches to regional block imaging without recognition
(nerve stimulation or palpation)
Shorter needle path than with
in-plane approaches
Along the nerve path (catheters)
In-plane (IP) Most direct visualization Partial line-ups (creating a false sense of security
when the needle tip is not correctly identified)
Some unimaged needle path occurs with IP
approach, but typically less than with OOP
approach
Longer paths and therefore more structures to
cross with the block needle
28
Approach and Techniques 29
approach is the extent of the unimaged needle path (structures that may lie short of or beyond
the scan plane). If the needle tip crosses the scan plane without recognition, it can be advanced
beyond the scan plane into undesired tissue.
IN-PLANE APPROACH
There are several advantages to the in-plane approach. It provides the most direct visualization
of the needle tip and injection. The amount of unimaged needle path is typically small. The needle
tip is visualized before advancement. One disadvantage is the long needle path, which results in
more tissue for the needle to cross. Large-bore needles are often used with this approach to
facilitate alignment. Partial line-ups (visualization of the needle shaft without visualization of the
needle tip in the scan plane) create a false sense of security and therefore compromise safety of
the technique.
External marks on the transducer can be used to initially guide needle placement for in-plane
technique. However, the mechanical axis of the transducer and its acoustic axis are not always
precisely aligned.3 The traditional teaching is that watching your hands during ultrasound-guided
regional anesthesia is a quality-compromising behavior. However, recent evidence suggests that
initial visual guidance can improve the speed of subsequent sonographic guidance for regional
anesthesia interventions.4 Furthermore, in-plane lineups of novices are typically better when the
visual axis and needle path are aligned.5
NEEDLE REDIRECTION DURING IN-PLANE TECHNIQUE

The traditional teaching is that it is difficult to redirect the needle after it is placed within muscle
and that it is necessary to pull it back to the subcutaneous tissue to effectively change the needle
trajectory. However, there are some maneuvers that will influence the needle path when the needle
is deep within soft tissue. Rotating the needle will change the bevel orientation and have a small
effect on the trajectory. Quincke tip needles deflect away from the bevel surface.6,7 Controlling
the amount of transducer compression can alter the needle path, with more compression forcing
a slightly steeper approach.8 In some cases, injecting fluid can create a more favorable needle path
if unintended (and displaceable) targets lie in the path.
Hand-on-needle hub provides better needle control for in-plane technique. This is important
for blocks above the clavicle where the injection hand is stabilized. Hand-on-syringe provides
the ability to control needle movement and injection by a single operator.
Skill is more important than approach alone. There will probably never be a good study comparing
the two approaches (out-of-plane versus in-plane) because of strong institutional biases and effort
dependence regarding how to perform regional blocks.
By musculoskeletal convention, the long-axis images are shown with the proximal side on the
left and the distal side on the right. Long-axis views are useful for demonstrating longitudinal
distribution of local anesthetic along the nerve path in one image. However, in clinical practice,
it is usually easier to view the nerve in short axis and slide along the nerve path in a proximal-distal
fashion to assess the longitudinal distribution.
References
1. Manickam BP, McDonald A. Surface marking technique to locate needle insertion point of ultrasound-guided neuraxial
block. Br J Anaesth. 2016;116(4):568–569.
2. Gabriel H, Shulman L, Marko J, et al. Compound versus fundamental imaging in the detection of subdermal contraceptive
implants. J Ultrasound Med. 2007;26:355–359.
3. Goldstein A, Parks JA, Osborne B. Visualization of B-scan transducer transverse cross-sectional beam patterns. J
Ultrasound Med. 1982;1:23–35.
4. Lam NC, Fishburn SJ, Hammer AR, et al. A randomized controlled trial evaluating the see, tilt, align, and rotate
(STAR) maneuver on skill acquisition for simulated ultrasound-guided interventional procedures. J Ultrasound Med.
2015;34(6):1019–1026.
5. Speer M, McLennan N, Nixon C. Novice learner in-plane ultrasound imaging: which visualization technique? Reg
Anesth Pain Med. 2013;38(4):350–352.
6. Drummond GB, Scott DH. Deflection of spinal needles by the bevel. Anaesthesia. 1980;35(9):854–857.
7. Sitzman BT, Uncles DR. The effects of needle type, gauge, and tip bend on spinal needle deflection. Anesth Analg.
1996;82:297–301.
8. Hebbard PD, Barrington MJ, Vasey C. Ultrasound-guided continuous oblique subcostal transversus abdominis plane
blockade: description of anatomy and clinical technique. Reg Anesth Pain Med. 2010;35(5):436–441.
SAX OOP SAX IP
LAX OOP LAX IP
FIGURE 12.1 Schematic drawing of the short-axis (SAX) and long-axis (LAX) out-of-plane
(OOP) imaging (left panels), and SAX and LAX in-plane (IP) imaging (right panels).
(Adapted from Gray AT. Ultrasound-guided regional anesthesia: current state
of the art. Anesthesiology. 2006;104:368–373.)
FIGURE 12.2 Setup for regional block with hand-on-syringe or hand-on-needle approaches.
Approach and Techniques 31
Median nerve
A
Median nerve
B D
FIGURE 12.3 Median nerve viewed in short axis (A and B) and in long axis (C and D).
CHAPTER
Sonographic Signs of
13 Successful Injections
It seems simple enough to state that successful drug injections for regional blockade should
surround the peripheral nerve. However, studies have reported that the doughnut sign, previously
considered the gold standard for success, has a positive predictive value of only 90% for producing
surgical anesthesia.1 It is therefore important to carefully consider multiple factors that constitute
sonographic signs for success that can be evaluated after injection.
First, successful drug injections should clarify the nerve border. Most regional blocks are
performed with nerves viewed in short axis to evaluate the circumferential distribution. If more
than half of the nerve border is contacted by local anesthetic, it is unlikely there is an intervening
fascial plane that will serve as a barrier to diffusion. Therefore it is important that the injection
round the corner of the nerve so that there is demonstrated curvature of the injection.
Second, successful drug injections will track along the nerve. Although the longitudinal distribu-
tion can be imaged with the nerve viewed in long axis, it is usually easier to slide the transducer
along the nerve path with the nerve viewed in short axis (short-axis sliding assessment). If the
local anesthetic truly tracks along the nerve, it will track along nerve divisions as well. This sign
is especially useful for femoral and popliteal blocks because these block procedures are performed
near points of nerve branching.
Third, peripheral nerves are often connected to adjacent structures, such as arteries or other
peripheral nerves. Because they are covered in common connective tissue, successful injections
should separate the connected structures. This is why practitioners often perform infraclavicular
blocks or axillary blocks by placing the block needle tip between the axillary artery and the
adjacent nerves. Understanding these connective tissue layers can provide a means of keeping
the needle tip at a distance from the peripheral nerves.
Fourth, peripheral nerves are often more echogenic after injection of local anesthetic. This is
because anechoic fluid has been injected into an attenuating sound field. This is not a perfect
sign of success because anechoic fluid introduced anywhere between the nerve and the skin
surface can cause this same effect.
Reference
1. Perlas A, Brull R, Chan VW, McCartney CJ, Nuica A, Abbas S. Ultrasound guidance improves the success of sciatic
nerve block at the popliteal fossa. Reg Anesth Pain Med. 2008;33:259–265.
32
Sonographic Signs of Successful Injections 33
Common
Tibial peroneal
nerve nerve Needle tip
A B
Local Common
anesthetic peroneal nerve
C D
Tibial Needle Local anesthetic
nerve tip
Local anesthetic
E F
Local anesthetic Local anesthetic
FIGURE 13.1 Image sequence showing successful sciatic nerve block in the popliteal fossa. The tibial and common
peroneal contributions of the sciatic nerve are viewed in short axis before injection (A). An in-plane
approach is demonstrated where the needle tip is placed between the tibial and common peroneal
nerves (B). Local anesthetic is injected between the nerves (C). After injection, local anesthetic is distributed
around the nerves (D) and tracks along nerve branches (E). A long-axis view also verifies the local
anesthetic distribution along the sciatic nerve (F).
CHAPTER Ultrasound-Guided
14 Continuous Peripheral
Nerve Blocks
Daniel A. Nahrwold
See Video 1.1 and Video 14.1 on ExpertConsult.com.
INTRODUCTION
Ultrasound-guided continuous peripheral nerve blocks can be placed with high success rates and
low complication profiles in both adults and children.1,2 Peripheral nerve catheters are more
beneficial than traditional opioid-based analgesia and also are associated with improved pain
control, lower opioid requirements, less nausea, and greater patient satisfaction when compared
with single-shot blocks.3–5 Catheters are commonly placed at the interscalene, supraclavicular,
infraclavicular, sciatic, femoral, adductor canal, and popliteal sites. A short-axis in-plane approach
to peripheral nerve catheter insertion is popular, although out-of-plane techniques and long-axis
approaches also have been described.6
SUGGESTED TECHNIQUE
When placing peripheral nerve catheters, many practitioners use the same short-axis in-plane
approach that is commonly used for single-shot blocks.7 The clinician must demonstrate proper
hand hygiene and maintain sterile technique throughout the entire procedure.
After ultrasound imaging of the needle tip in close relation to the nerve has been obtained,
the proceduralist typically injects 10 to 20 mL of local anesthetic or saline to create space into
which the catheter can be advanced. The catheter is threaded through and then beyond the needle
tip, leaving the catheter either alongside or around the peripheral nerve. Catheter advancement
is usually accomplished without ultrasound guidance, although advances in ultrasound needle
guidance systems can allow for catheter advancement with real-time ultrasound assistance.8
The needle is now withdrawn over the catheter. The catheter is then viewed using ultrasound,
and tip placement can be confirmed by injecting 1 mL of air through the catheter.9 Based on
ultrasound interrogation, the catheter may be slightly withdrawn to an optimal location in close
proximity to the nerve. Additional local anesthetic may now be given through the catheter. The
catheter is then secured with a skin adhesive followed by transparent sterile dressing
placement.10
A long-axis in-plane approach to continuous peripheral nerve blocks has been described.11 In
this approach, the peripheral nerve, needle shaft, and catheter tubing can all be viewed in the
same ultrasound image. However, it can be difficult to manipulate the transducer to maintain all
three structures within the plane of imaging. One study found that the onset of sensory anesthesia
was faster only to be negated by a slower procedure time when using a long-axis in-plane approach
to femoral nerve catheter placement.6 No other advantages were described, and the complication
profile was similar to catheters placed with the short-axis in-plane technique. Subgluteal sciatic
nerve catheters seem particularly amenable to the long-axis in-plane approach when the patient
is placed in the prone position.
DISCUSSION
Placing peripheral nerve catheters with ultrasound guidance alone is faster, causes less procedure-
related pain, is more cost effective, and provides equivalent anesthesia when compared with
34
Ultrasound-Guided Continuous Peripheral Nerve Blocks 35
catheters placed with stimulating needles and stimulating catheters both with and without ultrasound
guidance.12–15 When injecting local anesthetic, similar times to sensory and motor anesthesia can
be achieved by injecting through the needle or the catheter.16,17 Catheter-insertion distance past
the needle does not appear to affect the quality of analgesia, and many practitioners aim to thread
the catheter 1 to 5 cm beyond the needle tip.18
A relatively new method for placing peripheral nerve catheters is known as the catheter-over-
needle (CON) technique. As its name suggests, the catheter is already loaded onto the block
needle, and once the needle/catheter unit is in proper location adjacent to the nerve, the practitioner
removes the needle as the catheter remains in place. As compared with the catheter-through-needle
(CTN) technique, the CON approach may cause less fluid leakage at the skin insertion site and
less catheter dislodgement. Further studies are in progress to evaluate these and other potential
differences between the techniques.
Catheter orifice configuration may influence the quality of nerve blockade, with multiorifice
catheters providing superior analgesia when compared with end-hole catheters.19 Finally, complica-
tions related to continuous peripheral nerve blocks, such as bleeding, infection, neurologic injury,
and local anesthetic toxicity, have been studied and remain relatively low.1,20
Clinical Pearls
• A successful peripheral nerve catheter program requires trust and collaboration between the
anesthesia team and clinicians from other medical and surgical specialties.
• Customized peripheral nerve catheter kits that bundle high-quality and validated supplies may
allow for greater efficiency and better results.
• In the short-axis in-plane approach to continuous peripheral nerve blocks, rotating the bevel of
the needle 90 degrees may allow the catheter to be positioned alongside the nerve rather than
above or below it. A styletted catheter is often easier to advance past the needle and into the
tissue adjacent to the nerve. After injecting local anesthetic or saline through the block needle,
withdrawing the needle slightly may allow the catheter to thread with more ease.
• Careful attention to ergonomics can lead to less fatigue and more success when placing
peripheral nerve catheters. Keep the ultrasound screen at eye level directly across from where
the block is being placed. Hold the ultrasound probe near its end, with the hand braced against
the patient’s skin. Be conscious of bed and procedure table height. Posture is particularly
important, and sitting may aid placement of some continuous blocks, especially popliteal
catheters.
• Dilute solutions of local anesthetics can be safely administered through peripheral nerve
catheters using commercially available delivery systems both in the hospital and at home.
Patient education including succinct written instructions must be provided to patients who will
be managing and removing their catheters at home.4
References
1. Borgeat A, Blumenthal S, Lambert M, Theodorou P, Vienne P. The feasibility and complications of the continuous
popliteal nerve block: a 1001-case survey. Anesth Analg. 2006;103(1):229–233.
2. Gurnaney H, Kraemer FW, Maxwell L, Muhly WT, Schleelein L, Ganesh A. Ambulatory continuous peripheral nerve
blocks in children and adolescents: a longitudinal 8-year single center study. Anesth Analg. 2014;118(3):621–627.
3. Williams BA, Kentor ML, Vogt MT, et al. Reduction of verbal pain scores after anterior cruciate ligament reconstruction
with 2-day continuous femoral nerve block: a randomized clinical trial. Anesthesiology. 2006;104(2):315–327.
4. Swenson JD, Cheng GS, Axelrod DA, Davis JJ. Ambulatory anesthesia and regional catheters: when and how. Anesthesiol
Clin. 2010;28(2):267–280.
5. Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with single-injection
peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med.
2012;37(6):583–594.
6. Mariano ER, Kim TE, Funck N, et al. A randomized comparison of long-and short-axis imaging for in-plane
ultrasound-guided femoral perineural catheter insertion. J Ultrasound Med. 2013;32(1):149–156.
7. Ilfeld BM, Fredrickson MJ, Mariano ER. Ultrasound-guided perineural catheter insertion: three approaches but few
illuminating data. Reg Anesth Pain Med. 2010;35(2):123–126.
8. Swenson JD, Klingler KR, Pace NL, Davis JJ, Loose EC. Evaluation of a new needle guidance system for ultrasound:
results of a prospective, randomized, blinded study. Reg Anesth Pain Med. 2016;41(3):356–361.
9. Kan JM, Harrison TK, Kim TE, Howard SK, Kou A, Mariano ER. An in vitro study to evaluate the utility of the “air
test” to infer perineural catheter tip location. J Ultrasound Med. 2013;32(3):529–533.
10. Gurnaney H, Kraemer FW, Ganesh A. Dermabond decreases pericatheter local anesthetic leakage after continuous
perineural infusions. Anesth Analg. 2011;113(1):206.
11. Koscielniak-nielsen ZJ, Rasmussen H. Hesselbjerg L. Long-axis ultrasound imaging of the nerves and advancement
of perineural catheters under direct vision: a preliminary report of four cases. Reg Anesth Pain Med. 2008;33(5):477–482.
12. Fredrickson MJ, Ball CM, Dalgleish AJ, Stewart AW, Short TG. A prospective randomized comparison of ultrasound
and neurostimulation as needle end points for interscalene catheter placement. Anesth Analg. 2009;108(5):1695–1700.
13. Mariano ER, Loland VJ, Sandhu NS, et al. Ultrasound guidance versus electrical stimulation for femoral perineural
catheter insertion. J Ultrasound Med. 2009;28(11):1453–1460.
14. Mariano ER, Loland VJ, Sandhu NS, et al. A trainee-based randomized comparison of stimulating interscalene
perineural catheters with a new technique using ultrasound guidance alone. J Ultrasound Med. 2010;29(3):329–336.
15. Farag E, Atim A, Ghosh R, et al. Comparison of three techniques for ultrasound-guided femoral nerve catheter
insertion: a randomized, blinded trial. Anesthesiology. 2014;121(2):239–248.
16. Slater ME, Williams SR, Harris P, et al. Preliminary evaluation of infraclavicular catheters inserted using ultrasound
guidance: through-the-catheter anesthesia is not inferior to through-the-needle blocks. Reg Anesth Pain Med.
2007;32(4):296–302.
17. Harrison TK, Kim TE, Howard SK, et al. Comparative effectiveness of infraclavicular and supraclavicular perineural
catheters for ultrasound-guided through-the-catheter bolus anesthesia. J Ultrasound Med. 2015;34(2):333–340.
18. Ilfeld BM, Sandhu NS, Loland VJ, et al. Ultrasound-guided (needle-in-plane) perineural catheter insertion: the effect
of catheter-insertion distance on postoperative analgesia. Reg Anesth Pain Med. 2011;36(3):261–265.
19. Fredrickson MJ, Ball CM, Dalgleish AJ. Catheter orifice configuration influences the effectiveness of continuous
peripheral nerve blockade. Reg Anesth Pain Med. 2011;36(5):470–475.
20. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic
surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416
patients. Anesthesiology. 2005;103(5):1035–1045.
Ultrasound-Guided Continuous Peripheral Nerve Blocks 37
FIGURE 14.1 The equipment necessary for ultrasound-guided peripheral nerve catheter
placement.
A B
FIGURE 14.2 External photographs showing the approach to popliteal catheter placement. The proceduralist shown
connects a 20-mL syringe directly to the Tuohy needle and advances into the popliteal fossa with
ultrasound guidance (A). The catheter is then threaded into and past the Tuohy needle (B). Catheter
placement is confirmed by sonographic assessment.
Common peroneal
Tibial nerve nerve
Common peroneal
Tibial nerve nerve
Medial
Medial
A B
Catheter Popliteal Catheter

Tibial nerve Catheter artery
Medial
Popliteal Popliteal Common

artery vein peroneal nerve
FIGURE 14.3 Ultrasound imaging of a peripheral nerve catheter in the popliteal fossa. The catheter is placed below
(A), between (B), or above (C) the common peroneal and tibial branches of the sciatic nerve. All catheters
were functional.
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mass was Tite Souris, her domino hanging in rags, her wings gone,
and her whole appearance very dilapidated and disorderly; but the
demon of greed was gleaming in her eyes, and her teeth were
showing in a fierce, white line, while she plunged and struggled and
battled for the root of all evil.
Tiburce’s first intention was to make a detour of the crowd; but just
as he was about to do so the gleam of a dime on the edge of the
sidewalk caught his eye, and, overcome by the spirit of avarice, he
forgot everything, and dropped Lady Jane’s hand to make a dive for
it.
Lady Jane never knew how it happened, but in an instant she was
whirled away from the Paichoux, swept on with the crowd that a
policeman was driving before him, and carried she knew not where.
At first she ran hither and thither, seizing upon every domino that
bore the least resemblance to her companions, and calling Tiburce,
Sophie, Nanette, in heartrending tones, until quite exhausted she
sank down in a doorway, and watched the crowd surge past her.
CHAPTER XX
LADY JANE DINES WITH MR. GEX
F OR some time Lady Jane sat in the doorway, not knowing just
what to do. She was very tired, and at first she was inclined to
rest, thinking that Tiburce would come back and find her there; then
when no one noticed her, and it seemed very long that she had
waited, she felt inclined to cry; but she was a sensible, courageous
little soul, and knew that tears would do no good; besides it was very
uncomfortable, crying behind a mask. Her eyes burned, and her
head ached, and she was hungry and thirsty, and yet Tiburce didn’t
come; perhaps they had forgotten her altogether, and had got into
the milk-cart, and gone home.
This thought was too much to bear calmly, so she started to her
feet, determined to try to find them if they were not coming to search
for her.
She did not know which way to turn, for the crowd confused her
terribly. Sometimes a rude imp in a domino would push her, or twitch
her sleeve, and then, as frightened as a hunted hare, she would dart
into the first doorway, and wait until her tormentor had passed. She
was such a delicate little creature to be buffeted by a turbulent
crowd, and had it not been for the disguise of the domino she would
soon have found a protector amongst those she fled from.
After wandering around for some time, she found herself very near
the spot she started from; and, thankful for the friendly shelter of the
doorway, she slipped into it and sat down to think and rest. She
wanted to take off her mask and cool her hot face, but she did not
dare to; for some reason she felt that her disguise was a protection;
but how could any one find her when there were dozens of little
figures flitting about in pink dominos?
While she sat there thinking and wondering what she should do,
she noticed a carriage drive up to the next door, and two gentlemen
got out, followed by a young man. When the youth turned his face
toward her, she started up excitedly, and holding out her hands she
cried out pitifully, “It’s me; it’s Lady Jane.”
The young fellow glanced around him with a startled look; he
heard the little cry, but did not catch the words, and it moved him
strangely; he thought it sounded like some small creature in pain, but
he only saw a little figure in a soiled pink domino standing in the next
doorway, some little street gamin, he supposed, and without further
notice he passed her and followed his companions up the steps.
It was the boy who gave Lady Jane the blue heron, and he had
passed her without seeing her; she had called to him, and he had
not heard her. This was too much, she could not bear it, and
withdrawing again into her retreat she sat down and burst into a
passion of tears.
For a long while she cried silently, then she fell asleep and forgot
for a time all her troubles. When she woke a rude man was pulling
her to her feet, and telling her to wake up and go home; he had a
stick and bright buttons on his coat. “A young one tired out and gone
to sleep,” he muttered, as he went on his way.
SHE CRIED OUT PITIFULLY, “IT’S LADY JANE”
Then Lady Jane began to think that that place was no longer a
safe refuge; the man with the stick might come back and beat her if
she remained there, so she started out and crept along close to the
high buildings. She wondered if it was near night, and what she
should do when it got dark. Oh, if Tante Modeste, Tiburce, or
Madelon would only come for her, or Tante Pauline,—even she
would be a welcome sight, and she would not run away from Raste,
although she detested him; he pulled her hair and teased her, and
called her “My Lady,” but still if he should come just then she would
not run away from him, she would ask him to take her home.
At that moment some one behind her gave her domino a violent
pull, and she looked around wildly; an imp in yellow and black was
following her. A strand of her bright hair had escaped from her hood
and fallen over her back; he had it in his hand, and was using it as a
rein. “Get up, my little nag,” he was saying, in a rude, impertinent
voice; “come, trot, trot.” At first she tried to jerk her hair away; she
was so tired and frightened that she could scarcely stand, but she
turned on her tormentor and bade him leave her alone.
“I’m going to pull off your mask,” he said, “and see if you ain’t Mary
O’Brien.” He made a clutch at her, but Lady Jane evaded it; all the
spirit in her was aroused by this assault, and the usually gentle child
was transformed into a little fury. “Don’t touch me,” she cried; “don’t
touch me,”—and she struck the yellow and black imp full in the face
with all her strength.
Now this blow was the signal for a battle, in which Lady Jane was
sadly worsted, for in a few moments the boy, who was older and of
course stronger, had torn her domino from her in ribbons, had
snatched off her mask, and pulled the hood from her head, which
unloosened all her beautiful hair, allowing it to fall in a golden shower
far below her waist, and there she stood with flashing eyes and
burning cheeks, quivering and panting in the midst of a strange, rude
crowd, like a little wild hunted animal suddenly brought to bay.
At that moment she saw some one leap on to the banquette, and
with one well-aimed and dexterous kick send her enemy sprawling
into the gutter, while all the bystanders shouted with laughter.
It was Gex, little Gex, who had come to her rescue, and never did
fair lady cling with greater joy and gratitude to the knight who had
delivered her from the claws of a dragon, than did Lady Jane to the
little horny hand of the ancient professeur of the dance.
For a moment she could not speak; she was so exhausted with
her battle and so overcome with delight that she had no voice to
express her feelings.
Gex understood the situation, and with great politeness and
delicacy led her into a pharmacy near, smoothed her disordered
dress and hair, and gave her a glass of soda.
This so revived the little lady that she found voice to say: “Oh, Mr.
Gex, how did you know where I was?”
“I didn’t, I didn’t,” replied Gex tremulously. “It vas vhat you call one
accident. I vas just going down the Rue Royale, vas just turning the
corner, I vas on my vay home. I’d finished my Mardi-gras, all I vant of
the noise and foolishness, and I vas going back to Rue des Bons
Enfants, vhen I hears one leetle girl cry out, and I look and saw the
yellow devil pull down my leetle lady’s hair. Oh, bon, bon, didn’t I
give him one blow!—didn’t I send him in the gutter flying!”—and Gex
rubbed his hands and chuckled with delight. “And how lucky vas I to
have one accident to find my leetle lady, vhen she vas in trouble!”
Then Lady Jane and Mr. Gex turned down Rue Royale, and while
she skipped along holding his hand, her troubles all forgotten, she
told him how it happened that she had been separated from Tiburce,
and of all her subsequent misadventures.
Presently, Gex stopped before a neat little restaurant, whose
window presented a very tempting appearance, and, looking at Lady
Jane with a broad, inviting smile, said, “I should like to know if my
leetle lady vas hungry. It is past four of the clock, and I should like to
give my leetle lady von Mardi-gras dinner.”
“Oh, thank you, Mr. Gex,” cried Lady Jane, delightedly, for the
smell of the savory food appealed to her empty stomach. “I’m so
hungry that I can’t wait until I get home.”
“Vell, you sha’n’t; this is one nice place, vairy chic and fashionable,
fit for one leetle lady, and you shall see that Gex can order one fine
dinner, as vell as teach the dance.”
When the quaint little old man, in his antiquated black suit, a relic
of other and better days, entered the room, with the beautiful child,
rosy and bareheaded, her yellow hair flying out like spun silk, and
her dainty though disordered dress plainly showing her superior
position, every eye was turned upon him, and Gex felt the stirrings of
old pride and ambition, as he placed a chair with great ceremony,
and lifted Lady Jane into it. Then he drew out his spectacles with
much dignity, and, taking the card the waiter handed him, waited,
pencil poised, for the orders of the young lady.
“If you please,” he said, with a formal bow, and an inviting smile,
“to tell me vhat you prefair.”
Lady Jane frowned and bit her lips at the responsibility of deciding
so important a matter; at length she said, with sparkling eyes and a
charming smile:
“If you please, Mr. Gex, I’ll take some—some ice cream.”
“But first, my leetle lady,—but first, one leetle plat of soup, and the
fish with sauce verte, and one leetle bird,—just one leetle bird vith
the petit pois—and one fine, good, leetle salad. How vould that suit
my leetle lady?”
“And ice cream?” questioned Lady Jane, leaning forward with her
little hands clasped primly in her lap.
“And after, yes, one crême à la glace, one cake, and one leetle
bunch of raisin, grape you say,” repeated Gex, as he wrote
laboriously with his old, stiff fingers. “Now ve vill have one fine leetle
dinner, my leetle lady,” he said, with a beaming smile, when he had
completed the order.
Lady Jane nodded an affirmative, and while they waited for their
dinner her bright eyes traveled over everything; at length they rested
on Mr. Gex with unbounded admiration, and she could not refrain
from leaning forward and whispering:
“Oh, Mr. Gex, how nice, how lovely you look! Please, Mr. Gex,
please don’t wear an apron any more.”
“Vell, if my leetle lady don’t vant me to, vell, I von’t,” replied Gex,
beaming with sudden ambition and pride, “and, perhaps, I vill try to
be one fine leetle gentleman again, like vhen I vas professeur of the
dance.”
CHAPTER XXI
AFTER THE CARNIVAL
I T was nearly dark, and the day had been very long to Pepsie,
sitting alone at her window, for Madelon must remain all day and
until late at night on the Rue Bourbon. A holiday, and especially
Mardi-gras, was a day of harvest for her, and she never neglected a
chance to reap nickels and dimes; therefore Pepsie began to look
anxiously for the return of the merry party in the milk-cart. She knew
they were not to remain to see the night procession; at least, that
had not been the intention of Tante Modeste when she left, and she
could not imagine what had detained them. And Tite Souris,—
ungrateful creature! had been told to return as soon as the
procession was over, in order to get Pepsie’s dinner. Owing to the
excitement of the morning, Pepsie had eaten nothing, and now she
was very hungry, as well as lonesome; and even Tony, tired of
waiting, was hopping about restlessly, straining at his cord, and
pecking the floor viciously.
Madame Jozain had returned some time before, and was even
then eating her dinner comfortably, Pepsie had called across to know
if she had seen anything of the Paichoux and Lady Jane; but
madame had answered stiffly that she had been in her friend’s
gallery all the time, which was an intimation that she had been in no
position to notice a milk-cart, or its occupants. Then she observed
indifferently that Madame Paichoux had probably decided to remain
on Canal Street in order to get good positions for the night
procession.
Pepsie comforted herself somewhat with this view of the case, and
then began to worry about the child’s fast. She was sure Tante
Modeste had nothing in the cart for the children to eat, and on Mardi-
gras there was such a rush that one could hardly get into a
restaurant, and she doubted whether Tante Modeste would try with
such a crowd of young ones to feed. At length when she had thought
of every possible reason for their remaining so late, and every
possible plan by which they could be fed, she began to think of her
own hunger, and of Tite Souris’s neglect, and had worked herself up
to a very unenviable state of mind, when she saw her ungrateful
handmaid plunging across the street, looking like a much-abused
scarecrow, the remnants of her tatters flying in the wind, and her
long black legs, owing to the unexpected abbreviation of her skirts,
longer and thinner than ever, while her comical black face wore an
expression impossible to describe.
“Oh, Miss Peps’,” she gasped, bursting into Pepsie’s presence like
a whirlwind, “Ma’m Paichoux done sont me on ahead ter tell yer how
Miss Lady’s done got lost.”
“Lost, lost?” cried Pepsie, clasping her hands wildly and bursting
into tears. “How, where?”
“Up yon’er, on Cunnul Street. We’s can’t find ’er nowhar.”
“Then you must have let go of her,” cried Pepsie, while her eyes
flashed fire. “I told you not to let go of her.”
“Oh laws, Miss Peps’, we’s couldn’t holp it in dat dar scrimmage;
peoples done bus’ us right apart, an’ Miss Lady’s so littl’ her han’ jes
slip outen mine. I’se tried ter hole on, but’t ain’t no use.”
“And where was Tiburce? Did he let go of her too?”
“He war dar, but Lor! he couldn’t holp it, Mars’ Tiburce couldn’t, no
more en me.”
“You’ve broken my heart, Tite, and if you don’t go and find her I’ll
hate you always. Mind what I say, I’ll hate you forever,” and Pepsie
thrust out her long head and set her teeth in a cruel way.
“Oh laws, honey! Oh laws, Miss Peps’, dey’s all a-lookin’, dey’s
gwine bring ’er back soon; doan’t git scart, dat chile’s all right.”
“Go and look for her; go and find her! Mind what I tell you; bring
her back safe or—” Here Pepsie threw herself back in her chair and
fairly writhed. “Oh, oh! and I must stay here and not do anything, and
that darling is lost, lost!—out in the streets alone, and nearly dark.
Go, go and look for her; don’t stand there glaring at me. Go, I say,”
and Pepsie raised her nutcracker threateningly.
“Yes, Miss Peps’, yes, I’ll bring ’er back shore,” cried Tite, dodging
an imaginary blow, as she darted out, her rags and tatters flying after
her.
When she had gone Pepsie could do nothing but strain her eyes in
the gathering darkness, and wring her hands and weep. She saw the
light and the fire in Madame Jozain’s room, but the door was closed
because the evening was chilly, and the street seemed deserted.
There was no one to speak to; she was alone in the dark little room
with only Tony, who rustled his feathers in a ghostly sort of way, and
toned dismally.
Presently, she heard the sound of wheels, and peering out saw
Tante Modeste’s milk-cart; her heart gave a great bound. How foolish
she was to take on in such a wild way; they had found her, she was
there in the cart, safe and sound; but instead of Lady Jane’s blithe
little voice she heard her Uncle Paichoux, and in an instant Tante
Modeste entered with a very anxious face.
“She hasn’t come home, has she?” were Tante Modeste’s first
words.
“Oh, oh!” sobbed Pepsie, “then you haven’t brought her?”
“Don’t cry, child, don’t cry, we’ll find her now. When I saw I couldn’t
do anything, I took the young ones home, and got your uncle. I said,
‘If I have Paichoux, I’ll be able to find her.’ We’re going right to the
police. I dare say they’ve found her, or know where she is.”
“You know I told you—” moaned Pepsie, “you know I was afraid
she’d get lost.”
“Yes, yes; but I thought I could trust Tiburce. The boy will never get
over it; he told me the truth, thank Heaven; he said he just let go her
hand for one moment, and there was such a crowd. If that fly-away
of a Tite had kept on the other side it wouldn’t have happened, but
she ran off as soon as they got on the street.”
“I thought so. I’ll pay her off,” said Pepsie vindictively.
“Come, come, Modeste,” called Paichoux from the door, “let’s be
starting.”
“Oh, uncle!” cried Pepsie, imploringly, “do find Lady Jane.”
“Certainly, child, certainly, I’ll find her. I’ll have her back here in an
hour or so. Don’t cry. It’s nothing for a young one to get lost Mardi-
gras; I dare say there are a dozen at the police stations now, waiting
for their people to come and get them.”
Just at that moment there was a sound of voices without, and
Pepsie exclaimed: “That’s Lady Jane. I heard her speak.” Sure
enough, the sweet, high-pitched little voice chattering merrily could
be distinctly heard; and at the same instant Tite Souris burst into the
room, exclaiming:
“Her’s here, Miss Peps’, bress der Lor’! I’s done found her”; and
following close was Lady Jane, still holding fast to little Gex.
“Oh, Pepsie! Oh, I was lost!” she cried, springing into her friend’s
arms. “I was lost, and Mr. Gex found me; and I struck a boy in the
face, and he tore off my domino and mask, and I didn’t know what to
do, when Mr. Gex came and kicked him into the gutter. Didn’t you,
Mr. Gex?”
“Just to think of it!” cried Tante Modeste, embracing her, and
almost crying over her, while Paichoux was listening to the modest
account of the rescue, from the ancient dancing-master.
“And I had dinner with Mr. Gex,” cried Lady Jane joyfully; “such a
lovely dinner—ice cream, and grapes—and cake!”
“And one leetle bird, vith a vairy fine salad, my leetle lady,—vasn’t
it—one vairy nice leetle bird?” interrupted Gex, who was unwilling to
have his fine dinner belittled.
“Oh, yes; bird, and fish, and soup,” enumerated Lady Jane, “and
peas, Pepsie, little peas.”
“Oh, mon Dieu! oh, leetle lady!” cried Gex, holding up his hands in
horror, “you have it vairy wrong. It vas soup, and fish, and bird. M.
Paichoux, you see the leetle lady does not vell remember; and you
must not think I can’t order one vairy fine dinner.”
“I understand,” said Paichoux, laughing. “I’ve no doubt, Gex, but
what you could order a dinner fit for an alderman.”
“Thank you, thank you, vairy much,” returned Gex, as he bowed
himself out and went home to dream of his triumphs.
CHAPTER XXII
PAICHOUX MAKES A PURCHASE
“J UST to think,” said Pepsie to her mother, the next morning,

“Madame Jozain wasn’t the least anxious last night about Lady.
I don’t believe she cares for the child, or she’d never be willing to let
her stay away from her the most of the time, as she does. She’s
always fussing about her great, overgrown son, if he’s out of her
sight.”
“And no wonder,” returned Madelon. “Poor woman, she has
trouble enough with him. She keeps it to herself and pretends to be
proud of him; but, my dear, he’s a living disgrace to her. I often hear
him spoken of on the Rue Bourbon; he dresses fine and never
works. Where does he get his money, ma petite? If people are poor
and don’t work they must steal. They may call it by some other
name, but I call it stealing. Madame Jozain can’t make money
enough in that little shop to support herself and keep that boy in
idleness. We mustn’t be too hard on her. She has trouble enough, I
can see it in her face; she looks worn out with worry. And we’ll do all
we can for that little darling. It’s a pleasure; she’s so sweet and
grateful. I only wish I could do more. I’d work my fingers to the bone
for you two, my darling.”
“Bonne maman,” said Pepsie, clinging to her neck, and kissing her
fondly, “have you thought of what I asked you—have you, mama?”
“Yes, my dear, I have, I’ve thought of it a great deal; but I don’t see
my way clear quite yet.”
“Why, you’ve got the money in the bank, mama?”
“I can’t touch that money, my dear; it’s for you. If anything should
happen to me, and you were left alone.”
“Hush, hush, mama; I shouldn’t need any money then, for I should
die too.”
“No, my dear, not if it was the good God’s will that you should live.
I don’t want to spend that; I want to feel that you’ve something. A
piano costs a great deal of money; besides, what would your uncle
and aunt think if I should do such a thing?”
“They’d think you did it because I wanted you to,” returned Pepsie
slyly.
“That would be a reason certainly,” said Madelon, laughing, “and
I’ll try to do it after a while. Have a little patience, dear, and I think I
can manage it without touching the money in the bank.”
“Oh, I hope you can, mama, because Mam’selle Diane says Lady
learns very fast, and that she ought to practise. I hate to have her
kept back for the need of a piano, and Madame Jozain will never get
one for her. You know you could sell it afterward, mama,”—and
Pepsie went on to show, with much excellent reasoning, that Lady
Jane could never make a great prima donna unless she had
advantages. “It’s now, while her fingers are supple, that they must be
trained; she ought to practise two hours a day. Oh, I’d rather go
without the money than to have Lady kept back. Try, bonne maman,
try to get a piano very soon, won’t you?”
And Madelon promised to try, for she was devoted to the child; but
Pepsie had begun to think that Lady Jane was her own—her very
own, and, in her generous affection, was willing to sacrifice
everything for her good.
And Madelon and Pepsie were not the only ones who planned and
hoped for the little one with almost a mother’s love and interest.
From the first day that Lady Jane smiled up into the sad, worn face
of Diane d’Hautreve, a new life had opened to that lonely woman, a
new hope, a new happiness brightened her dreary days; for the
child’s presence seemed to bring sunshine and youth to her. Had it
not been for her mother, she would have kept the gentle little
creature with her constantly, as the sweetest hours she knew, or had
known for many a weary year, were those she devoted to her lovely
little pupil. It was a dream of delight to sit at the tinkling piano with
Lady Jane nestled close to her side, the sweet, liquid notes mingling
with hers, as they sang an old-fashioned ballad, or a tender lullaby.
And the child never disappointed her; she was always docile and
thoughtful, and so quiet and polite that even Diane’s mother,
captious and querulous though she was, found no cause for
complaint, while the toleration with which she had at first received
Lady Jane was fast changing into affection. The more they became
interested in her, the more they wondered how she could be kin to
such a woman as Madame Jozain; for Mam’selle Diane had been
obliged to show how exclusive she could be in order to keep
madame where she belonged.
At first Madame Jozain had annoyed them greatly by trying to
intrude upon their seclusion; and it had taken several polite, but
unmistakable rebuffs to reach her that they were d’Hautreves, and
that the child would be received gladly where the aunt must not
expect to enter.
Madame swallowed her mortification and said nothing, but she
bided her time to take her revenge. “I’ll show them before long that I
know how poor they are; and that funny little story I got out of Tite
Souris, about Mam’selle Diane cleaning her banquette with a veil
over her face—every one in the neighborhood shall know it. Poor,
proud, old thing, she thought she could insult me and I wouldn’t
resent it!”
And while Madame was planning her little revenge, and rehearsing
her grievances to herself, Madame d’Hautreve and Mam’selle Diane
were wondering if something couldn’t be done to get the child out of
the clutches of such an aunt.
“It seems dreadful,” Mam’selle Diane would say, sadly, “to leave
her with that woman. I can’t think she has any right to her; there’s a
mystery about it, and it ought to be investigated. Oh, mama dear, if
we had some money I’d hire a lawyer to find out. If she really is the
child’s next-of-kin, I suppose she has a legal right to her, and that no
one could oblige her to relinquish that right; but one might buy the
child; I think she is just the woman to be moved by money. Oh,
mama, if our claim had only gone through! If we’d only got what we
ought to have had, I would try—if you had no objections—to get the
child.”
“Dear, dear, Diane, how absurd you are! What would you do with
her?”
“Why, you could adopt her, mama, and I could have the care of
her.”
“But, my child, that is all romancing. We have no money, and we
never shall have any. It is useless to think of that claim, it will never
be considered; and even if we had money, it would be a great risk to
take a child we know nothing of. I think with you that there’s some
mystery, and I should like to have it looked into, yet I don’t think it’s
worth while worrying about; we have troubles enough of our own.”
“Oh, mama, we need not be selfish because we are poor,” said
Diane, gently.
“We can’t help it, child; selfishness is one of the results of poverty.
It is self, self, constantly; but you are an exception, Diane. I will give
you the credit of thinking more of others’ interest than of your own.
You show it in everything. Now, about that bird. Madame Jourdain
should have paid you for it, and not thrown it on your hands.”
“Oh, mama, she couldn’t sell it,” said Mam’selle Diane, rejectedly.
“It wouldn’t be right to expect her to lose the price of it. She says it
didn’t ‘take’ as well as the ducks.”
“Well, she might have thrown in the wool,” insisted Madame
d’Hautreve, querulously, “she might have given the wool against your
time.”
“But she didn’t ask me to experiment with a new model, mama
dear. It wasn’t her fault if I didn’t succeed.”
“You did succeed, Diane. It was perfect; it was most life-like, only
people haven’t the taste to recognize your talent.”
“Madame Jourdain said that her customers didn’t like the bird’s
bill, and they thought the neck too long,” returned Mam’selle Diane,
humbly.
“There, there; that shows how little the best educated people know
of ornithology. It is a species of crane; the neck is not out of
proportion.”
“They thought so, mama, and one can’t contend with people’s
tastes and opinions. I shall not try anything new again. I shall stick to
my ducks and canaries.”
“You know I advised you to do so in the first place. You were too
ambitious, Diane, you were too ambitious!”
“Yes; you are right, mama, I was too ambitious!” sighed Mam’selle
Diane.
One morning in August, about a year from the time that Madame
Jozain moved into Good Children Street, Tante Modeste was in her
dairy, deep in the mysteries of cream-cheese and butter, when
Paichoux entered, and laying a small parcel twisted up in a piece of
newspaper before her waited for her to open it.
“In a moment,” she said, smiling brightly; “let me fill these molds
first, then I’ll wash my hands, and I’m done for to-day.”
Paichoux made no reply, but walked about the dairy, peering into
the pans of rich milk, and whistling softly.
Suddenly, Tante Modeste uttered an exclamation of surprise. She
had opened the paper, and was holding up a beautiful watch by its
exquisitely wrought chain.
“Why, papa, where in the world did you get this?” she asked, as
she turned it over and over, and examined first one side and then the
other. “Blue enamel, a band of diamonds on the rim, a leaf in
diamonds on one side, a monogram on the other. What are the
letters?—the stones sparkle so, I can hardly make them out. J, yes,
it’s a J, and a C. Why, those are the very initials on that child’s
clothes! Paichoux, where did you get this watch, and whose is it?”
“Why, it’s mine,” replied Paichoux, with exasperating coolness. He
was standing before Tante Modeste, with his thumbs in his waistcoat
pockets, whistling in his easy way. “It’s mine, and I bought it.”
“Bought it! Where did you buy a watch like this, and wrapped up in
newspaper, too? Do tell me where you got it, Paichoux,” cried Tante
Modeste, very much puzzled, and very impatient.
“I bought it in the Recorder’s Court.”
“In the Recorder’s Court?” echoed Tante Modeste, more and more
puzzled. “From whom did you buy it?”
“From Raste Jozain.”
Tante Modeste looked at her husband with wide eyes and parted
lips, and said nothing for several seconds; then she exclaimed, “I
told you so!”
“Told me what?” asked Paichoux, with a provoking smile.
“Why, why, that all those things marked J. C. were stolen from that
child’s mother; and this watch is a part of the same property, and she
never was a Jozain—”
“Not so fast, Modeste; not so fast.”
“Then, what was Raste Jozain in the Recorder’s Court for?”
“He was arrested on suspicion, but they couldn’t prove anything.”
“For this?” asked Tante Modeste, looking at the watch.
“No, it was another charge, but his having such a valuable watch
went against him. It seems like a providence, my getting it. I just
happened to be passing the Recorder’s Court, and, glancing in, I
saw that precious rascal in the dock. I knew him, but he didn’t know
me. So I stepped in to see what the scrape was. It seems that he
was arrested on the suspicion of being one of a gang who have
robbed a number of jewelry stores. They couldn’t prove anything
against him on that charge; but the watch and chain puzzled the
Recorder like the mischief. He asked Raste where he got it, and he
was ready with his answer, ‘It belonged to my cousin who died some
time ago; she left it to my mother, and my mother gave it to me.’”
“‘What was her name?’ asked the Recorder.
“‘Claire Jozain,’ the scamp answered promptly.
“‘But this is J. C.,’ said the Recorder, examining the letters closely.
‘I should certainly say that the J. came first. What do you think,
gentlemen?’ and he handed the watch to his clerk and some others;
and they all thought from the arrangement of the letters that it was J.
C., and while this discussion was going on, the fellow stood there
smiling as impudent and cool as if he was the first gentleman in the
city. He’s a handsome fellow, and well dressed, and the image of his
father. Any one who had ever seen André Jozain would know that
Raste was his son, and he’s in a fair way to end his days in Andre’s
company.”
“And they couldn’t find out where he got the watch?” interrupted
Tante Modeste impatiently.
“No, they couldn’t prove that it was stolen. However, the Recorder
gave him thirty days in the parish prison as a suspicious character.”
“They ought not to have let him off so easily,” said Tante Modeste
decidedly.
“But you know they couldn’t prove anything,” continued Paichoux,
“and the fellow looked blue at the prospect of thirty days. I guess he
felt that he was getting it pretty heavy. However, he put on lots of
brass and began talking and laughing with some flashy-looking
fellows who gathered around him. They saw the watch was valuable,
and that there was a chance for a bargain, and one of them made
him an offer of fifty dollars for it. ‘Do you think I’m from the West?’ he
asked, with a grin, and shoved it back into his pocket! ‘I’m pretty hard
up, I need the cash badly; but I can’t give you this ticker, as much as
I love you.’ Then another fellow offered him sixty, and he shook his
head. ‘No, no, that’s nowhere near the figure.’
“‘Let me look at the watch,’ I said, sauntering up. ‘If it’s a good
watch I’ll make you an offer.’ I spoke as indifferently as possible,
because I didn’t want him to think I was anxious, and I wasn’t quite
sure whether he knew me or not. As he handed me the watch he
eyed me impudently, but I saw that he was nervous and shaky. ‘It’s a
good watch,’ I said after I examined it closely; ‘a very good watch,
and I’ll give you seventy-five.’

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Anesthesia - eBook PDF

ATLAS OF ULTRASOUND-GUIDED REGIONAL ANESTHESIA,

Copyright © 2019 by Elsevier, Inc. All rights reserved.

Previous editions copyright © 2013, 2010.

Library of Congress Cataloging-in-Publication Data

Names: Gray, Andrew T., author.

Publisher: Dolores Meloni

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Andrew T. Gray, MD, PhD

Gerald Dubowitz, MD Jens Kessler, MD

Jeffrey Ghassemi, MD, MPH Michael S. Lipnick, MD

Agnes Wabule, MMED

Daniel M. Wong, MBBS, FANZCA

UPPER EXTREMITY BLOCKS

LOWER EXTREMITY BLOCKS

HEAD AND NECK BLOCKS

See Video 1.1 on ExpertConsult.com.

Attenuation is a decrease in wave amplitude as it travels through a medium. The attenuation of

Ultrasound Characteristics of Biologic Tissue and Interventional

Beam Width (Slice Thickness)

Spatial Compound Imaging 7

TABLE 7.1 Advantages and Disadvantages of Spatial Compound Imaging

Ultrasound transducers consist of arrays of piezoelectric crystals that produce high-frequency

See Video 1.1 on ExpertConsult.com.

See Video 1.1 on ExpertConsult.com.

INSERTION ANGLE (ANGLE OF INSONATION)

TABLE 11.1 Factors Reported to Influence Needle Tip Visibility

TABLE 11.2 Influence of Bevel Orientation on Needle Tip Visibility

NEEDLE MOTION AND TEST INJECTIONS

SPATIAL COMPOUND IMAGING

12 Approach and Techniques

See Video 1.1 on ExpertConsult.com.

TABLE 12.1 Comparison of Out-of-Plane and In-Plane Approaches

NEEDLE REDIRECTION DURING IN-PLANE TECHNIQUE

SAX OOP SAX IP

LAX OOP LAX IP

See Video 1.1 and Video 14.1 on ExpertConsult.com.

Catheter Popliteal Catheter

Popliteal Popliteal Common

“J UST to think,” said Pepsie to her mother, the next morning,

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