Ultrasound-Guided Regional Anesthesia and Standard of Care

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To the Editor:
In their recent timely review articles on the benefits associated with the use of point-of-care ultrasound, Haskins et al1,2 assert that “UGRA (ultrasound-guided regional anesthesia) has essentially become the standard of care” and that “many would argue that UGRA is the standard of care due to the many benefits it has over traditional techniques.” Although we agree with the authors that UGRA offers many benefits over traditional techniques and that UGRA is currently the most commonly used method for nerve localization,3,4 we disagree that UGRA defines a standard of care. This is an expansive statement, given that the practice of regional anesthesia goes beyond the performance of peripheral nerve blocks and includes single and continuous neuraxial techniques, along with the recognition that the use of UGRA alone is associated with pitfalls and limitations.5
The standard of care for nerve localization and regional anesthesia is not defined by the use of ultrasound. Look no further than one of the supporting articles6 of the Second American Society of Regional Anesthesia and Pain Medicine (ASRA) Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia,3 which unequivocally states “…the absence of ultrasound (US) machines at all practice locations, the ongoing presence of anesthesiologists extremely experienced and proficient with non-US nerve localization techniques, and with the possible exception of local anesthetic systemic toxicity (LAST), the absence of definitive scientific proof of US's superiority make[s] it impossible to assert that US guidance has become the standard of care for nerve localization.”
Science does not recognize state boundaries; standard of care does. And yet physicians continue to conflate clinical practice guidelines and practice advisories with standard of care7 and do so at their peril.8 Standard of care is a legal definition, and plaintiff attorneys and their hired expert witnesses are all too eager to comb through the medical literature in search of casual and uniformed use of the phrase “standard of care” and unwittingly trap otherwise exemplary physicians contesting dubious malpractice claims.
While the legal definition may vary from jurisdiction to jurisdiction, the standard of care is broadly defined as requiring compliance with the generally recognized and accepted practices and procedures that would be followed by average competent practitioners in the physician's field of medicine, under the same or similar circumstances. This definition recognizes flexibility in tailoring clinical decision making to a variety of patient care scenarios.
Words matter. Let's be careful in our lexicon describing clinical practice and be mindful when using terminology such as “standard of care.” Leave it to lawyers and juries to ponder standard of care, while we focus our efforts on expanding our knowledge base and updating practice guidelines and advisories to best serve our physicians and their patients.

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