No. VII
Nerve Location –
The Art and Science of Finding
Peripheral Nerves.
Already published:
No. I Continuous Regional post-operative Analgesia:
Breaking up some Taboos
XVII. ESRA Congress, Geneva, September 1998
Local anaesthetic blockade of peripheral nerves was first accom- The chronaxie is the stimulus duration needed for impulse gene-
plished using infiltration or direct vision at operation. Then, per- ration using a current strength of twice the rheobase.
cutaneous techniques were developed in which paraesthesia was Comparison of chronaxies is a useful way of comparing the sen-
sought as an endpoint. These three techniques are still used suc- sitivities of different nerve fibres.
cessfully today.
Myelinated fibres are more sensitive requiring less electrical ener-
In the 1960’s several researchers developed electrical nerve sti- gy for stimulation and having shorter chronaxie then unmyelina-
mulation techniques to aid percutaneous location of peripheral ted fibres.
nerves. In subsequent decades with the advent of microprocessors
- small, accurate, battery operated, hand held devices were intro- Nerve fibre type Chronaxie in msecs
duced which now offer very sophisticated help in finding peri- unmyelinated C 0.4 - 1
pheral nerves1,3. myelinated A 0.17
myelinated A 0.05 – 0.1
Pros and cons
Inspection of the table above will reveal that selecting a short
Peripheral nerve stimulator (PNS) is helpful because: impulse duration of 0.1 msecs will allow motor nerve stimulation
without initiating painful C fibre activity – a fact exploited in
1. It provides objective evidence that the needle tip is close to the modern PNS devices.
nerve (and no intention to make physical contact with the
nerve)
2. It is not usually painful (whereas paraesthesia may be so) Polarity
3. Amount of charge required is related to distance from nerve Less electrical energy is required if the cathode (negative) is close
which improves accuracy to the nerve since with a negative stimulating needle the direction
4. It may be used in the unconscious patient e.g. anaesthetised of current flow (of itself) induces some depolarisation making it
children easier to stimulate the nerve.
5. The nature of the endpoint is a valuable training aid. The reverse is true with an anodal (positive needle) since the
direction of flow in this instance (again of itself) induces hyper-
polarisation of the target nerve close to the needle tip. This makes
PNS is limited because it more difficult to stimulate the nerve and a higher current is
therefore required to produce an action potential.
1. It is only applicable to peripheral nerves (not relevant to In most modern PNS the needle is negative by default and cannot
central axis blockade) be changed by the operator.
2. The aim is to stimulate motor nerves which largely limits its
use to mixed peripheral nerves (its use for pure sensory nerves Distance
has been described, but is unusual in clinical practice) Coulombs law relates the effect on a nerve of constant current sti-
3. It has implications for staff and equipment costs mulus and the distance of the stimulus source from the nerve:
4. It cannot be used after paralysis with neuro-muscular blocking
drugs Stimulus intensity required 1 / (distance) 2
PNS is not a substitute for a proper anatomical knowledge of the As a result, provided the current is not excessive, a nerve will only
nerves being sought. It is a powerful tool for guiding the needle be stimulated when the needle is close to it. Consequently confu-
through the final 5 mm or so of an approach to a nerve but in nor- sing muscle twitches are unlikely to occur when the needle tip is
mal clinical practice will give little indication of proximity to a too far from the nerve. The initial current should therefore be set
nerve from distances greater than 1cm. at 1-2 mA (with an impulse duration of 0.1 msec and a negative
needle). Theoretically this would be expected to produce a
Electrophysiology response when the needle is some 5 to 10 mm from the nerve.
With most needles a muscle twitch initiated at a current of around
Energy 0.5 mA suggests that the needle tip is 1-2 mm from the motor
The amount of electrical energy required to propagate a nerve nerve and that injection of local anaesthestic solution is likely to
impulse is a product of the stimulus strength (mAmps) and current provide a satisfactory block.
duration (msecs). For any nerve type there is a minimum current
strength required, to generate an impulse – the rheobase. Below If a muscle twitch is generated at a current strength of less that
this level, an impulse will not be generated; no matter for how 0.2mA, there is strong possibility that the needle has penetrated
long the current is applied. the epineurium. This is too close and there is a risk of intraneural
Inhalt_ESRA_VII 04.09.2003 8:06 Uhr Seite 2
injection, which may cause temporary or permanent nerve dama- Many case reports detailing damage resulting from local anaes-
ge. It is therefore important to check that the muscle twitch disap- thetic blockade reveal, on careful reading, problems arising from
pears at or before a current of 0.2mA. points 1 to 7 listed above.
Stimulus frequency
As the needle is advanced, a muscle twitch provoked by the The future
stimulating current warns that the needle is approaching the target There is still much debate about how close the needle tip should
nerve. If the frequency of the stimulating current is too low (and be to the target nerve with the principle questions being:
the speed of the advancing needle to high) then the nerve may be How close is close enough (will it work ?) and how close is too
impaled between impulses. If the frequency is too high, painful close (will it cause damage ?). We are just beginning to see stu-
muscle twitches (approaching tetany) may be induced. A frequen- dies aimed at answering these questions2.
cy of 2 Hz is a good compromise and a needle advancement speed Similarly, electronic advances mean that the manufacturers are
of around 1mm per sec is suggested when in close proximity to able to offer us increasingly complex stimulators (at a price) and
the nerve. at a time when their products are coming under increasing scruti-
ny3 they are looking to the clinicians to help determine the balan-
Summary ce between cost and useful function.
A peripheral nerve stimulator should provide as a minimum The role of adjuncts such as ultrasound guidance are being explo-
red and novel strategies such as percutaneous electrode guidance
1 a square wave impulse with a duration of 0.1 msec (PEG) are being developed so the next decade promises to be
2 the negative lead connected to the stimulating needle interesting.
3 2 Hz frequency
4 initial current level of 1-2 mA seeking the nerve
5 a final current level of 0.3 – 0.6 mA positioning the needle tip Reference
6 current delivery down to 0.1-0.2 mA ensure no stimulation
1. C Pither et al. The use of peripheral nerve stimulators for regional
additional safety features include anaesthesia. A review of experimental characteristics, techniques and
clinical applications.
1 accurate current delivery in the range 0-5 mA Reg Anesth 1985;10:49-58
2 constant current square wave pulse
3 display of current flowing in the patient and that delivered 2 A Choyce et al What is the relationship between paraesthesia and nerve
internally from the device stimulation for axillary brachial plexus block ?
4 open circuit alarm Reg Anesth 2001;26(2):100-4
5 excess impedance alarm
6 low battery alarm 3 A Hadzic et al Nerve Stimulators used for peripheral nerve blocks vary
7 internal malfunction alarm in their electrical characteristics.
Anesth 2003;98:969-74
Avoiding intraneural injection
1 Equipment checks
2 Appropriate anatomical knowledge
3 Threshold – no muscle twitch at or below 0.2 mA if not STOP
4 Twitch disappears immediately injection starts if not STOP
5 Minimal resistance to injection if not STOP
6 Watch the patient for signs of pain on injection if so STOP
awake - verbal report
asleep - reflex action
7 If things do not feel/look right then STOP (don’t persist in numerous
attempts)
cal anesthesia rate with both the supraclavicular and axillary tech- Anesthesiology 1981; 55: 603
niques - while anesthesia was only partial in the remaining 5% of 5.-Ting RL, Sivagnanaratnam V. Ultrasonographic study of the spread of local
cases. No complications attributable to the techniques were obser- anaesthetic during axillary brachial plexus block. Br J Anaesth 1989; 63:
ved. 326–9
Ootaki et al.13, using real-time ultrasound guidance for plexus 6.-Kestembaum AD, Steuer M, Marano M. Doppler guided axillary block in a
block at infraclavicular level, concluded that the approach can be burn patient. Anesthesiology 1990; 73: 586–7
7.-Friedl W, Fritz T. Ultrasound assisted brachial plexus anesthesia. Chirurg
used as an alternative to the anatomical reference or landmark-
1992; 63: 759-760
guided technique. Attached to the ultrasound transducer (7.0
8.-Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C.
MHz), and for effective needle manipulation, the authors used a
Ultrasound guided supraclavicular approach for regional anesthesia of the bra-
needle guide, keeping needle pass within the ultrasound beam
chial plexus. Anesth Analg 1994; 78: 507-513.
(UAGV021A-Toshiba). For plexus block, a 23G 60-mm needle 9.-Marhofer P, Schrögendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N.
was inserted toward the medial aspect of the subclavian artery Ultrasonographic guidance improves sensory block and onset time of three-in-
under real-time ultrasound guidance, and the local anesthetic was one blocks. Anesth Analg 1997; 85: 854–7
injected near the subclavian artery, 15 mm medial and 15 mm 10.-Marhofer P, Schrögendorfer K, Wallner T, Koinig H, Mayer N, Kapral S.
lateral to the vessel. Complete sensory block was achieved in Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1
100% of patients for the musculocutaneous and medial antebra- blocks. Reg Anesth Pain Med 1998; 23: 584–8
chial cutaneous nerves, in 96.7% for the median nerve, and in 11.-Sheppard DG, Iyer RB, Fenstermacher MJ. Brachial plexus: demonstra-
95% for the ulnar and radial nerves. In turn, complete motor block tion at US. Radiology 1998; 208: 402-406.
was achieved in 100% of patients for the musculocutaneous 12.-Yang WT, Chui PT, Metreweli C. Anatomy of the normal brachial plexus
nerve, in 96.7% for the median nerve, in 90% for the ulnar nerve, revealed by sonography and the role of sonographic guidance in anesthesia of
and in 93.3% for the radial nerve. No complications were recor- the brachial plexus. Am J Roentgenol 1998; 171: 1631-1636.
ded. 13.-Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular bra-
Greher et al 18 have revisited the landmarks proposed by Kilka et chial plexus block: an alternative technique to anatomical landmark-guided
al 25 in the performance of vertical infraclavicular brachial plexus approaches. Reg Anesth Pain Med 2000; 25: 600-604.
block. According their results originally proposed landmarks are 14.-Retzl G, Kapral S, Greher M, Mauritz W. Ultrasonographic findings of the
not ideal in all sizes of patient, and may decrease the margin of axillary part of the brachial plexus. Anesth Analg. 2001;92:1271-5. 15.-
safety by allowing the close approach of a needle to the pleura and Kovacs P, Gruber H, Piegger J, Bodner G. New, simple, ultrasound-guided
infiltration of the pudendal nerve: ultrasonographic technique. Dis Colon
vessels. Their recommendation is that ultrasound guidance be
Rectum. 2001; 44:1381-5. 16.-Kapral S, Marhofer P .Ultrasound in local ana-
used when performing this block or that their modification of the
esthesia. Part II: ultrasound-guided blockade of peripheral nerve channels.
anatomical landmarks be used if ultrasound is not available.
Anaesthesist. 2002; 51:1006-14 17.-Sandhu NS, Capan LM. Ultrasound-gui-
Recently, Sandhu et al 17, have published the largest prospective
ded infraclavicular brachial plexus block. Br J Anaesth 2002; 89: 254–259
series published on ultrasound-guided brachial plexus block. In 18.-Greher M, Retzl G, Niel P, Kamolz L, Marhofer P, Kapral S.
this study authors used 2.5 MHz visualized the axillary artery and Ultrasonographic assessment of topographic anatomy in volunteers suggests a
the three cords of the brachial plexus posterior to the pectoralis modification of the infraclavicular vertical brachial plexus block. Br J
minor muscle, and the deposit of the local anaesthetic around each Anaesth. 2002;88 :632-6. 19.-Peterson MK, Millar FA, Sheppard DG.
of the three cords. This paper suggest that ultrasound guidance has Ultrasound-guided nerve blocks. Br J Anaesth. 2002; 88:621-624.
the potential to improve success rate, time of onset and of perfor- 20.-Perlas A, Chan VW, Simons M.Brachial plexus examination and localiza-
mance of the block, and to decrease complications such as vascu- tion using ultrasound and electrical stimulation: a volunteer study.
lar puncture. Nevertheless limitations of the technique, have been Anesthesiology. 2003;99:429-35.
arised by Nadig et al 26 as regards the definition provided for a 2.5 21.-Fornage BD. Musculoskeletic ultrasound. In: Mittelstaldt CA. General
MHz probe instead of the commonly used 7.5 MHz probe, regar- Ultrasound. Ed: Churchill Livingstone Inc. New York 1994: 1-17.
ding the capacity to identify small structures such as the cords of 22.-Van Holsbeeck M, Introcaso JH. Musculoskeletal ultrasonography. Radiol
the brachial plexus. Clin North Am 1992; 30: 907-925.
23.-Kirchmair L, Entner T, Kapral S, Mitterschiffthaler G.Ultrasound guidan-
In conclusion, ultrasound guidance for accessing the brachial ple- ce for the psoas compartment block: an imaging study. Anesth Analg. 2002;
xus is undoubtedly finding a place in plexus anesthesia - for the 94: 706-10 24.-Kirchmair L, Entner T, Wissel J, Moriggl B, Kapral S,
teaching of anesthetic techniques, application to concrete clinical Mitterschiffthaler G.
situations (involving patients in which the classical anatomical A study of the paravertebral anatomy for ultrasound-guided posterior lumbar
plexus block. Anesth Analg. 2001;93:477-481 25.-Kilka HG, Geiger P,
landmarks for blind puncture are difficult to identify), or for syste-
Mehrkens HH. Infraclavicular vertical brachial plexus blockade. A new
matic application in clinical practice. According the accummula-
method for anesthesia of the upper extremity. An anatomical and clinical
ted results the use of ultrasound can diminish accidental puncture
study. Anaesthesist 1995; 44: 339-344.
of blood vessels and the pleura. The most currently used device
26.-Nadig M, Ekatodramis G, Borgeat A. Ultrasound-guided infraclavicular
for nerve location today is a nerve stimulator.Certainly, the use of brachial plexus block. Br J Anaesth. 2003;90:107-8
a nerve stimulator does not eliminate the risk of nerve damage,
but has been claimed to reduce. Perhaps in the close future the
combined use of nerve stimulator and ultrasound maintaining
same levels of success might help more specifically in preventing
nerve damage.
References
1.-De Andrés J, Sala-Blanch X. Peripheral Nerve stimulation in the practice of
brachial plexus anesthesia: A review. Regional Anesthesia and Pain
Medicine.2001; 26:478-483
2.-De Andrés J, Sala-Blanch X.Ultrasound in the practice of brachial plexus
anesthesia. Reg Anesth Pain Med. 2002;27: 77-89
3.-La Grange P, Foster P, Pretorius L. Application of the Doppler ultrasound
blood flow detector in supraclavicular brachial plexus block. Br J Anaesth
1978; 50: 965–7
4.-Abramowitz HB, Cohen CH. Use of Doppler for difficult axillary block.
Inhalt_ESRA_VII 04.09.2003 8:06 Uhr Seite 5
Conventionally, location of a nerve or neural plexus for local reported on the use of a modified electrocardiographic electrode
anesthetic blockade has involved searching for the nerve by inva- of 0.5 cm diameter with adherent gel to assist in the performance
sive needle exploration. This sometimes requires multiple need- of interscalene block. The electrode was coupled to a nerve sti-
le passes to elicit the sought-after response from the nerve, such mulator and was “passed along the skin” to locate the optimal
as a paresthesia or motor response to electrical nerve stimulation. entry point for needle insertion. Urmey (2) proposed the use of
With appropriate technique, such responses constitute evidence an exploring skin electrode on a theoretical basis to help find the
that the tip of the block needle is in contact with, or very close to, interscalene groove in patients with difficult anatomy.
the targeted nerve. When using electrical nerve stimulation to
seek a motor response, a weak direct current (DC) electrical cur- Use of transcutaneous stimulation to elicit a sensory response
rent is supplied to the block needle by an oscillating (square- (paresthesia) to electrical nerve stimulation of a purely sensory
wave) current generator (i.e., a nerve stimulator). The current is nerve (the lateral femoral cutaneous nerve) was reported by
pulsed, typically at a frequency (f) of 1 – 2 Hz. A starting current Shannon et al. (3). These investigators used a handheld electrical
amplitude (amperage) of 1 – 2 mA with a pulse duration of 0.1 to nerve stimulator to elicit sensory paresthesias, following which
0.2 ms is typically applied to the block needle, which is inserted they made measurements to determine the nerve’s location and
through the skin and underlying tissues toward the targeted nerve. injected, based upon these measurements, to block the nerve.
When approximate motor contractions, which correspond to the Similar to Ganta et al., Shannon et al. used an electrode that was
muscular innervation of the designated nerve occur, the current is approximately 0.5 cm diameter.
slowly decreased in amperage while the needle is used to search
for the nerve. Motor contractions that occur at low amperage Urmey and Grossi recently described a technique called percut-
(usually 0.2 – 0.5 mA) indicate that the needle tip is very close to aneous electrode guidance (PEG) of the block needle (4). PEG
or contacting the nerve. Injection can thus be made in the imme- utilizes transcutaneous electrical stimulation to noninvasively
diate vicinity of the nerve, the objective, resulting in anesthesia or pre-locate the desired nerve or neural plexus. By contrast to the
analgesia, with a very high success rate. above transcutaneous techniques, the PEG technique uses an
unprecedented cylindrical transcutaneous electrode with a minu-
Conventional methodology for nerve location therefore begins by te (less than 1 mm) metallic tip. The electrode is used to indent
identification of anatomical landmarks. These landmarks consti- the skin and underlying subcutaneous tissues toward the nerve,
tute an approximate starting point for invasive needle explora- thus decreasing the tissue electrical impedance as well as the
tion. The endpoint of the needle search can be an anatomical distance to the targeted nerve or nerves. The electrode is electri-
endpoint (e.g. transarterial axillary block or ultrasonographic cally shielded and sterile. This technique was recently improved
imaging) or a functional endpoint (e.g. sensory response to and simplified, while maintaining the original concept (5). The
mechanical stimulation, i.e. paresthesia, or motor response to stimulator needle tip was used as both the cutaneous and invasi-
electrical nerve stimulation). ve electrode by encasing the needle in a rounded plastic noncon-
ductive sterile encasement that converts the needle tip, itself, to a
The problem with designated anatomical landmarks is that they smooth cutaneous electrode. (Figure 1). The needle can be exten-
are variable from patient to patient and do not always correlate ded through the encasement toward the targeted nerve (Figure 2).
with the location of the underlying nerve or neural plexus. In
addition, landmark measurements are often complicated, requi-
ring linear measurements with a ruler, bisecting lines, and fre- Figure 1. Illustration of the percutane-
quently a “one size-fits all” philosophy. For many blocks, accep- ous electrode guidance (PEG) electro-
ted descriptions of the technique include insertion of the block de. The conductive tip of the needle
needle a number of centimeters from a designated palpable land- itself is converted to a smooth cutane-
mark, neglecting patient size or body habitus. Dexterity and deli- ous electrode by flush-mounting the
cate proprioception are often required to be successful at block needle in plastic encasement. The elec-
placement. Finally, search with a sharp needle can pierce or trode can be used to indent the skin
damage vessels, nerves, or other underlying anatomical structu- painlessly for transcutaneous stimula-
res. tion, followed by needle advancement
through the skin for ultimate nerve
Transcutaneous electrical stimulation, by contrast to an imaging location and blockade.From Urmey
technique such as ultrasonography, utilizes a functional endpoint, WF. Tech Reg Anesth Pain Med 2003
a motor or sensory response to electrical stimulation of the under- (in press)
lying nerve. Transcutaneous electrical stimulation to elicit a
motor response has been used to assist in determination of the
optimal entry point for needle insertion, thereby narrowing the
invasive search for the nerve with the needle. Ganta et al. (1)
Inhalt_ESRA_VII 04.09.2003 8:01 Uhr Seite 6
(B)
distance of the electrode to nerve by indentation of the overlying By contrast to traditional needle tip location, where a very short
skin and subcutaneous tissues toward the targeted nerve, and to pulse duration is desirable for precise location with the needle-
use a pinpoint electrode to maximize specificity. tip, cutaneous stimulation benefits from longer pulse durations
(0.2-1.0 msec). Higher pulse duration allows for motor response
at lower amperage. Indentation of the skin (in some cases seve-
Tissue Electrical Impedance ral centimeters is necessary) brings the cutaneous electrode into
fairly close proximity of the nerve or neural plexus. Since much
The final variable which effects the ability to elicit a motor of the locating is done by the probe, which indents the skin
response to electrical nerve stimulation is the electrical impedan- toward the nerve, the needle tip typically travels only a short
ce of the skin and underlying tissues. In general, the higher the distance to the nerve (Table 1).
water/lipid ratio of the tissue, the lower the electrical impedance.
Skin is characterized by very high electrical impedance. Table 1. Block characteristics. From Urmey WF and Grossi P.
Condensing the tissues by indentation of the skin toward the Reg Anesth Pain Med 2002;27:261-7.
nerve, serves to decrease electrical impedance, or conversely sta-
ted, increases the electrical conductance of the tissues, making it Patient Nerve Minimal Electrode Minimal Needle Needle
easier to elicit a motor response at a given amperage and pulse No. Block Electrode Motor Needle Motor Depth
duration. Current Response Current Response
(A)
Initial Clinical Experience with the PEG Technique
endpoint). In only one case was it necessary to increase the need- References
le amperage above 0.5 mAmp (Patient 2, Table 1). Targeted ner- 1. Ganta R, Cajee R, Henthorn R. Use of a transcutaneous nerve stimulation
ves were found easily within seconds of the start of indentation to assist interscalene block. Anesth Analg 1993;76:914-5.
and exploration of the skin with the cutaneous electrode.
Minimal transcutaneous stimulation current in mAmp correlated 2. Urmey W. Upper extremity blocks. In: Brown D, ed. Regional Anesthesia
directly with the measured needle depth (beyond the probe tip). and Analgesia. Philadelphia: WB Saunders; 1996:254-78.
Maximal needle protrusion depth in these initial patients was 2
3. Shannon J, Lang S, Yip R. Lateral femoral nerve block revisited: A nerve
cm. Thus the technique is more useful for blocking superficial
stimulator technique. Reg Anesth 1995;20:100-4.
nerves or plexuses. These include 1) brachial plexus block, 2)
midhumeral block, 3) wrist block, 4) femoral nerve block, 5)
4. Urmey W, Grossi P. Percutaneous electrode guidance (PEG): A noninva-
popliteal fossa block and, 6) posterior tibial nerve block. sive technique for pre-location of peripheral nerves to facilitate nerve block.
Reg Anesth Pain Med 2002;27:261-67.
PEG is in its infancy and has tremendous potential to make peri-
pheral nerve blocks less intimidating to the beginning practitio- 5. Urmey W, Grossi P. Percutaneous electrode guidance (PEG) and subcut-
ner. PEG may decrease time for block performance and increase aneous stimulating electrode guidance (SSEG): modifications of the original
safety of peripheral nerve blockade by decreasing the number of technique. Letter to the Editor. Reg Anesth Pain Med 2003;28:253-5.
invasive needle passes. The probe has been successfully used to
teach in workshop settings. Further clinical studies are certainly
indicated.
Inhalt_ESRA_VII 04.09.2003 8:01 Uhr Seite 9
Most anaesthesiologists assume that PNB catheters lie parallel 1. What are the limits of electrical charge needed for a success-
and close to the nerves located by stimulating needles. This belief ful perineural placement?
is based on the fact that most peripheral nerves are surrounded by 2. How saline expansion of the perineural space influences this
a loose connective tissue and on the belief in concept of neuro- charge?
vascular sheaths. However, recent researches questioned the exi- 3. Which design of catheter tip (single or multiple holes) gives
stence of a tubelike, tight, fascial sheaths around brachial and best clinical results ?
lumbar plexuses (1,2). More or less blind insertions resulted often 4. Will Tuohy type needle facilitate correct catheter positioning?
in aberrant placement of the excessive lengths of catheters (3) 5. Are there any dangers of nerve damage during repositioning
with subsequent poor or patchy block, and/or failure of post-ope- of these catheters ?
rative analgesia in up to 10% of patients (4). Unpublished reports 6. Do they improve the quality of post-operative care?
and expert opinions suggest that the secondary block failure
during continuous LA infusion reaches 30-40%. This is in accor- In these hard times of evidence based medicine and economic
dance with the very recent study of Pham-Dang et al. (4), where cuts we must answer these questions by large randomised clinical
37% of catheters initially did not achieve the desired perineural studies. Improved post-operative patient care (better analgesia,
positions. These are alarming numbers, which may be reduced by improved rehabilitation and shortened sick-leave) will no doubts
more controlled catheter insertion. justify the slightly higher costs of stimulating catheters.
Biographies
Nicholas Denny, MD, PhD, FRCA, is a Consultant Anaesthetist William F Urmey, MD, is a Staff Anesthesiologist at The
at The Queen Elizabeth Hospital, Kings Lynn, UK. He qualified Hospital for Special Surgery, New York USA, and Assistant
from St Thomas’ Hospital Medical School in 1974 and trained in Clinical Professor of Anesthesiology, Cornell University Medical
anaesthesia at Kingston Hospital, Kingston-on-Thames and St College. He studied medicine at Harvard Medical School,
Thomas’ Hospital, London, before becoming a senior registrar at Boston, and qualified in 1983. He trained in Anaesthesia there
Addenbrookes Hospital Cambridge in 1984. Dr Denny also spent and at The Brigham and Women’s Hospital, before becoming
a year as a Visiting Assistant Professor at the University of Chief Resident in Anaesthesia at the Brigham’s Hospital. He was
Illinois, Chicago; where Alon P Winnie was chairman and head appointed to his current posts in 1988. He has published widely
of department of Anesthesiology, before being appointed to his and is well known for his lecturing and teaching on Regional
current post in 1989. His main interests are practising and tea- Anaesthesia, both nationally and internationally.
ching regional anaesthesia with particular interests in peripheral
blocks and continuous spinal anaesthesia. Zbigniew Koscielniak-Nielsen, MD, PhD, FRCA, is an
Assistant Professor in the University Department of Anaesthesia
David Tew, BSc, FRCA, is a consultant anaesthetist at Centre for Orthopedics, Rigshospital, Copenhagen, Denmark.
Addenbrookes Hospital, Cambridge, UK. He qualified from He graduated from Warsaw University Medical School, Poland in
Charing Cross Hospital Medical School, London in 1984. He 1978 and started his anaesthetic training in Warsaw before being
trained in Anaesthesia in the South Coast of England and appointed a registrar the Glasgow University Hospitals, Scotland.
Brompton Cardiothoracic Hospital, London, before becoming a He passed his FRCA exam in 1987, and obtained a senior regi-
Senior Registrar at Addenbrookes Hospital Cambridge. He was strar post in Anaesthesia at Rigshospital, Denmark in 1988. He
appointed a Consultant in Intensive Care and Orthopaedics at became a Fellow at McGill University Montreal, Canada in 1992
Swindon Hospital in 1995 before moving to Addenbrookes before becoming a consultant in the University Dept of
Hospital Cambridge in 1996. He is interested in Upper and Lower Anaesthesia Rigshospital, Denmark in 1993. He was granted his
limb regional anaesthesia and has taught and demonstrated on PhD thesis on Axillary brachial plexus blocks in 2002. He has
regional and national courses as well as lecturing at national mee- published over 21 original articles and teaches and lectures both
tings. nationally and internationally.
Notes
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Umschl_ESRA_VII 04.09.2003 7:26 Uhr Seite 2
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