Defining the Reliability of Sonoanatomy Identification by Novices in Ultrasound-Guided Pediatric Ilioinguinal and Iliohypogastric Nerve Blockade

BACKGROUND: The ilioinguinal (II)/iliohypogastric (IH) nerve block is a safe, frequently used block that has been improved in efficacy and safety by the use of ultrasound guidance. We assessed the frequency with which pediatric anesthesiologists with limited experience With Ultrasound-guided regional anesthesia could correctly identify anatomical structures within the inguinal region. Our primary outcome was to compare the frequency of correct identification of the transversus abdominis (TA) muscle with the frequency of correct identification of the II/IH nerves. We used 2 ultrasound machines with different capabilities to assess a potential equipment effect on success of structure identification and time taken for structure identification. METHODS: Seven pediatric anesthesiologists with <6 mo experience with ultrasound-guided regional anesthesia performed a total of 127 scans of the II region in anesthetized children. The muscle planes and the II and IH nerves were identified and labeled. The Ultrasound images were reviewed by a blinded expert to mark accuracy of structure identification and time taken for identification. Two ultrasound machines (Sonosite C180plus and Micromax, both from Sonosite, Bothell, WA) were used. RESULTS: There was no difference in the frequency of correct identification of the TA muscle compared with the II/IH nerves (chi(2) test, TA versus II, P = 0.45; TA versus IH P = 0.50). Ultrasound machine selection did show a nonsignificant trend in improving correct II/IH nerve identification (II nerve chi(2) test, P = 0.02; IH nerve chi(2) test, P = 0.04; Bonferroni corrected significance 0.17) but not for the muscle planes (chi(2) test, P = 0.83) or time taken (1-way analysis of variance, P = 0.07). A curve of improving accuracy with number of scans was plotted, with reliability of TA recognition occurring after 14-1.5 scans and II/IH identification after 18 scans. CONCLUSIONS: We have demonstrated that although there is no difference in the overall accuracy of muscle plane versus II/IH nerve identification, the muscle planes are reliably identified after fewer scans of the inguinal region. We suggest that a reliable end point for the inexperienced practitioner of ultrasound-guided II/IH nerve block may be the TA/internal oblique plane where the nerves are reported to be found in 100% of cases. (Anesth Analg 2009:109:1793-8)