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Recommendations for anatomical structures to identify on ultrasound for the performance of intermediate and advanced blocks in ultrasound-guided regional anesthesia
  1. Toby Ashken1,
  2. James Bowness2,3,
  3. Alan James Robert Macfarlane4,5,
  4. Lloyd Turbitt6,
  5. Boyne Bellew7,8,
  6. Nigel Bedforth9,
  7. David Burckett-St Laurent10,
  8. Alain Delbos11,
  9. Kariem El-Boghdadly12,13,
  10. Nabil M Elkassabany14,
  11. Jenny Ferry3,
  12. Ben Fox15,
  13. James L H French16,
  14. Calum Grant17,
  15. Ashwani Gupta18,
  16. Rajnish K Gupta19,
  17. Yavuz Gürkan20,
  18. Nat Haslam21,
  19. Helen Higham22,
  20. Rosemary M G Hogg6,
  21. David F Johnston6,
  22. Rachel Joyce Kearns4,23,
  23. Clara Lobo24,
  24. Sonya McKinlay4,5,
  25. Edward R Mariano25,26,
  26. Stavros Memtsoudis27,28,
  27. Peter Merjavy29,
  28. Madan Narayanan30,
  29. J Alison Noble31,
  30. David Phillips3,
  31. Meg Rosenblatt32,
  32. Amy Sadler17,
  33. Maria Paz Sebastian33,
  34. Eric S Schwenk34,
  35. Alasdair Taylor17,
  36. Athmaja Thottungal35,
  37. Luis Fernando Valdés-Vilches36,
  38. Thomas Volk37,
  39. Simeon West1,
  40. Morné Wolmarans38,
  41. Jonathan Womack39 and
  42. Amit Pawa12,40
  1. 1 Department of Anaesthetics, University College London, London, UK
  2. 2 OxSTaR, Oxford University, Oxford, UK
  3. 3 Department of Anaesthesia, Aneurin Bevan Health Board, Newport, UK
  4. 4 Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
  5. 5 University of Glasgow, Glasgow, UK
  6. 6 Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
  7. 7 Department of Surgery and Cancer, Imperial College London, London, UK
  8. 8 Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
  9. 9 Department of Anaesthesia and Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
  10. 10 Department of Anaesthesia, Royal Cornwall Hospitals NHS Trust, Truro, UK
  11. 11 Department of Anesthesia, Clinique Médipole Garonne, Toulouse, France
  12. 12 Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
  13. 13 Centre for Human & Applied Physiological Sciences, King's College London, London, UK
  14. 14 Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
  15. 15 Department of Anaesthesia, Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
  16. 16 Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
  17. 17 Department of Anaesthesia, NHS Tayside, Dundee, UK
  18. 18 Anaesthetics, Gateshead Health NHS Foundation Trust, Gateshead, UK
  19. 19 Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  20. 20 Department of Anesthesiology and Reanimation, School of Medicine, Koç University, Istanbul, Turkey
  21. 21 Department of Anaesthesia, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
  22. 22 Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  23. 23 School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
  24. 24 Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
  25. 25 Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
  26. 26 Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
  27. 27 Department of Anesthesiology, Critical Care & Pain Management, Hospital for Specialist Surgery, New York City, New York, USA
  28. 28 Weill Cornell Medical College, New York City, New York, USA
  29. 29 Department of Anaesthesia, Craigavon Area Hospital, Portadown, UK
  30. 30 Department of Anaesthesia, Frimley Park Hospital, Frimley, UK
  31. 31 IBME, University of Oxford, Oxford, UK
  32. 32 Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Health System, New York City, New York, USA
  33. 33 Department of Anaesthetics, Royal National Orthopaedic Hospital NHS Trust, Stanmore, London, UK
  34. 34 Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  35. 35 Department of Anaesthesia & Pain Management, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
  36. 36 Anesthesia Department, Hospital Costa del Sol, Marbella, Andalucía, Spain
  37. 37 Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
  38. 38 Anaesthesiology, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
  39. 39 Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK
  40. 40 Faculty of Life Sciences and Medicine, King's College London, London, UK
  1. Correspondence to Dr James Bowness, OxSTaR Centre, Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK; james.bowness{at}


Recent recommendations describe a set of core anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia (UGRA). This project aimed to generate consensus recommendations for core structures to identify during the performance of intermediate and advanced blocks. An initial longlist of structures was refined by an international panel of key opinion leaders in UGRA over a three-round Delphi process. All rounds were conducted virtually and anonymously. Blocks were considered twice in each round: for “orientation scanning” (the dynamic process of acquiring the final view) and for “block view” (which visualizes the block site and is maintained for needle insertion/injection). A “strong recommendation” was made if ≥75% of participants rated any structure as “definitely include” in any round. A “weak recommendation” was made if >50% of participants rated it as “definitely include” or “probably include” for all rounds, but the criterion for strong recommendation was never met. Structures which did not meet either criterion were excluded. Forty-one participants were invited and 40 accepted; 38 completed all three rounds. Participants considered the ultrasound scanning for 19 peripheral nerve blocks across all three rounds. Two hundred and seventy-four structures were reviewed for both orientation scanning and block view; a “strong recommendation” was made for 60 structures on orientation scanning and 44 on the block view. A “weak recommendation” was made for 107 and 62 structures, respectively. These recommendations are intended to help standardize teaching and research in UGRA and support widespread and consistent practice.

  • regional anesthesia
  • ultrasonography
  • pain management
  • lower extremity (regional anesthesia)
  • upper extremity (regional anesthesia)

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors Study concept, design, and conduct: TA, BB, JSB, AJRM, AP, and LT. Data collection: all authors. Manuscript preparation: TA and JSB. Manuscript editing: TA, BB, JSB, AJRM, AP, and LT. Manuscript review and approval: all authors. Guarantor: JSB.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AD, YG, CG, LFV-V, TV, and MW are members of the Executive Board of the ESRA. NME, RKG, and MR are members of the Board of Directors of the ASRA. ERM, SM, and ESS sit on ASRA Committees. TA, AG, NH, DFJ, RJK, AJRM, AP, MPS, AT, LT, SW, and JW are members of the Board of RA-UK. KEB is the Scientific Officer for the Difficult Airway Society. JSB, DBSL, AJRM, DP, and AT declare honoraria and/or research funding from Intelligent Ultrasound. JAN is a Senior Scientific Advisor for Intelligent Ultrasound. AP declares honoraria from GE Healthcare, Butterfly Net, Sintetica UK, and Pacira.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.