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A N ever increasing demand for regional anesthesia from both patients and surgeons matches the growing realization that both peripheral and neuraxial blockade can provide superior pain management and perhaps improve patient outcomes, to meet evolving expectations for ambulatory, cost-effective surgery. Our aging population presents with an increasing range of co-morbid-ities, demanding a wider choice of surgical anesthesia options, including the use of a variety of regional techniques in conjunction with general anesthesia, to optimize clinical care, while at the same time reducing the risks of complications. Regional anesthesia with single-shot or continuous peripheral nerve blocks (PNB) can provide superior analgesia and a lower incidence of side effects compared to parenteral anesthetics (e.g., patient-controlled opioid analgesia). 3–5 However, both single shot and continuous techniques are highly dependent on the accurate delivery of a correct dose of local anesthetic to attain success, and to avoid rare but potentially devastating nerve damage. 6,7 This dependency remains a concern, particularly as many anesthesia training programs are not providing the necessary resources for practitioners to develop the requisite skills and confidence with regional anatomy to performing PNBs on a routine basis. One of the principal challenges of regional anesthesia is the unreliability of conventional modalities for confirming precise nerve localization. Such conventional modalities include electrical stimulation (ES) and patient-reported paresthesiae which rely on surface landmark identification. Both techniques are highly dependent on inter-individual anatomical and physiological variations and, in the case of ES, equipment accuracy. 10–12 Thus, despite its scientific foundations, the practice of regional anesthesia remains an " art " for many practitioners , and consistent success with these techniques often appears to be limited to anesthesiologiosts who are regional anesthesia enthusiasts. Nevertheless, the introduction some 30 years ago of an objective means for identifying needle-nerve proximity, ES, was an integral step towards transforming regional anesthesia into a " science ". Nerve stimulation , however, also has its limitations. The technique relies on physiological responses of neural structures to ES, for which there is considerable inter-individual variation. Accordingly, it is fitting to question the significance of the commonly accepted threshold current of 0.5 mA to ensure block success, when a range of current thresholds more realistically reflects normal physiological variability. Furthermore, ES responses are influenced by the interplay of injectates, physiolog-ic solutions (e.g., blood) and disease. Not surprisingly, the introduction of ES failed to result in a renewed interest in regional anesthesia. One …

Ultrasound-guidance and nerve stimulation: implications for the future practice of regional anesthesia