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The present article details how our understanding of the basic concepts of regional anesthesia has recently evolved. We will appraise current technological advances and question the commensurate nature of the relationship between tradition and innovation.Ultrasound localization has enhanced our understanding of the needle–nerve relationship. Intraneural injection of local anesthetic may occur with greater frequency than previously thought without inevitably leading to neurological complications. The ratio of neural to non-neural tissue varies both between and within nerves and may be an important determinant of neural injury. Ultrasonographic evidence of intraneural injection is subject to observer expertise and the resolution of the ultrasound image. Current ultrasound resolution capability does not reliably permit differentiation between intrafascicular and extrafascicular drug injection. Perineural electrical impedance may be a determinant of current threshold and conceivably distinguish between intraneural and extraneural tissue. Technology that enhances the sonographic image of both procedure needle and target nerve is the focus of current endeavors in ultrasound innovation.There is inconclusive evidence that the use of ultrasound technology has reduced the incidence of local anesthetic toxicity. Lipid emulsion therapy is now an accepted treatment for systemic local anesthetic toxicity. There are new reports on the development of an ultra long-acting local anesthetic agent that would permit lower doses and superannuate catheter-based continuous regional anesthesia techniques.Over the past decade, our understanding of the fundamental concepts of regional anesthesia continues to be challenged by emerging experimental and clinical evidence.