Helpful tips for regional anesthesia?

[Sleeplessbordernights]

Soon to be third year anesthesiology resident here, I think im doing decent in most things but lately I have been struggling with regional anesthesia, I feel too clumsy holding the us probe and because of that the needlee often drifts out of plane, any helpful tips from the regional wizards around here would be greatly appreciated.

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[D P356]

Stabilize the ultrasound hand by placing it on the pt while holding the probe.

Watch every block you can to see how other people do it.

Move the probe hand OR the needle hand.
Not both at the same time.

Know when not to place a certain block

Get a lot of Reps.

 

[GassYous]

Hold the probe with the thumb, pointer and/or middle finger. Rest the pinky side of your hand on the patient. Find where you want to poke and then don't move. Aim your needle into your desired target in plane.

 

[Straight2eight]

If they have a practice device like a blue phantom spend some time practicing needling with that. Hold the probe like in the above post picture b) not a). Practice bringing the needle to the probe rather than the probe to the needle. In other words find your picture and don’t move away from it — bring the needle into that view. Chasing the needle will always take you somewhere you aren’t planning.

There will be some blocks where there is one good image/path to the target and you need to be able to keep the needle passing along that single trajectory. Tissue is pretty mobile under the skin so when you advance the needle and notice that it is wandering away from the beam of the ultrasound (losing needle visibility), pushing or pulling the needle left or right can drag the needle back under the beam of the ultrasound (imagine the center of the probe is the center of a clock face, you are moving the needle hub clockwise and counter clockwise along the face). The deeper you go the more locked into trajectory the needle gets so sometimes you have to pull back to redirect. Notice which way you have to push/pull the needle to make it show up on the screen and it will tell you which way you need to aim to align better with the u/s beam.

 

[Mman]

In other words find your picture and don’t move away from it — bring the needle into that view. Chasing the needle will always take you somewhere you aren’t planning.

caveat to that is don't get jabbing the needle around when you can't see it solely for the sake of holding probe steady. Either start over on a new trajectory or hold needle still and move the probe slightly to find the needle.

 

[nimbus]

Or ask @DrAmir0078 to send you one of his 3D printed needle guides!

 

[DrAmir0078]

Or ask @DrAmir0078 to send you one of his 3D printed needle guides!

Thanks for the mention Dr. @nimbus ; I will be more than happy to help and send you the sample I created for beginners for this purpose from Baghdad Iraq, hopefully will fit in your probe as it works for Ezono linear probe and I am not sure would fit in your OR probe model.
If you want to see the design, you can hire a 3D printer geek to make you one with suitable materials and make sure of providing the hygiene, or you can use it as disposable (it won't cost a lot per piece).
Here is the guide USGNAD I created and there are a thread in the private forum too about it.
It really helps in your first TAPs...
Beside, if you have simulation labs or an US machine you can play with, bring a raw chicken - fresh not frozen - and try in plane with it in different angles and follow the up pictures of how to fix your hand and the probe.
Or you can buy online from Civco company (Ultra-Pro II In-Plane Ultrasound Needle Guides-Multi-Angle) and there are plenty of such products out there depending on the probe - device model !
It will be easy with the time !
Peace out

 

[ethilo]

When you see the WHOLE needle, you are in plane and you are free to advance/move needle at will. When you see a small section or piece of the needle then rotate probe until your see the WHOLE needle.

You can imagine the needle is it's very own "vector" and the ultrasound is another "vector." Try to make the vectors parallel. Once they are parallel then you can play all day with that needle. If they are not parallel stop everything, make them parallel, then continue to play all day.

 

[deleted875186]

Positioning, You should hold the probe such that the probe is perpendicular to your body, so you should be looking down the plane of the ultrasound and the needle should be heading away from you. This in my mind helps to keep the needle from wandering out of plane from the US beam.

 

[lunaire]

I think practicing on an ultrasound phantom model would do you a lot of good. Like the people above mentioned, you can move the needle OR the probe to obtain an in-plane view. I used to use spam for this, but I would think you'd be able to find something better in your program.

As an alternative path to improvement, seek out experience doing focused ultrasound exams in your non-regional rotation (especially Cardiac and ICU). A lot of the ultrasound skills in various ultrasound-guided exam/procedures cross-over pretty well.

 

[Mman]

I think practicing on an ultrasound phantom model would do you a lot of good. Like the people above mentioned, you can move the needle OR the probe to obtain an in-plane view. I used to use spam for this, but I would think you'd be able to find something better in your program.

As an alternative path to improvement, seek out experience doing focused ultrasound exams in your non-regional rotation (especially Cardiac and ICU). A lot of the ultrasound skills in various ultrasound-guided exam/procedures cross-over pretty well.

ultrasound yourself. As a resident I spent plenty of downtime scanning my brachial plexus and popliteal fossa and what not just to get used to what it looks like.

 

[Twiggidy]

Soon to be third year anesthesiology resident here, I think im doing decent in most things but lately I have been struggling with regional anesthesia, I feel too clumsy holding the us probe and because of that the needlee often drifts out of plane, any helpful tips from the regional wizards around here would be greatly appreciated.

Same way you get to Carnegie Hall.......practice

 

[nimbus]

ultrasound yourself. As a resident I spent plenty of downtime scanning my brachial plexus and popliteal fossa and what not just to get used to what it looks like.

It’s one thing to scan and identify structures and it is mandatory to get that foundation.

However, it is an additional necessary skill to be able to coordinate position of the probe and the needle simultaneously to get structure of interest and the needle in the same plane. Practice with a phantom (or on patients) is the only way to learn that.

 

[kidthor]

As a resident I spent plenty of downtime scanning my brachial plexus

“Scanning your brachial plexus” eh?

 

[Ravenclaw90]

If they have a practice device like a blue phantom spend some time practicing needling with that. Hold the probe like in the above post picture b) not a). Practice bringing the needle to the probe rather than the probe to the needle. In other words find your picture and don’t move away from it — bring the needle into that view. Chasing the needle will always take you somewhere you aren’t planning.

There will be some blocks where there is one good image/path to the target and you need to be able to keep the needle passing along that single trajectory. Tissue is pretty mobile under the skin so when you advance the needle and notice that it is wandering away from the beam of the ultrasound (losing needle visibility), pushing or pulling the needle left or right can drag the needle back under the beam of the ultrasound (imagine the center of the probe is the center of a clock face, you are moving the needle hub clockwise and counter clockwise along the face). The deeper you go the more locked into trajectory the needle gets so sometimes you have to pull back to redirect. Notice which way you have to push/pull the needle to make it show up on the screen and it will tell you which way you need to aim to align better with the u/s beam.

I’m a resident. Your explanation using the clock face really helped me. But how do you have confidence dragging the needle back under the beam in order to get it parallel when you can’t see where the needle is traversing? Your knowledge of anatomy and what structures are in the area? It’s not always practical to start over.

Any advice on how to get better lining up the probe and needle when the block isn’t set up like a pool shot? For example, interscalene or infraclavicular

 

[Straight2eight]

I’m a resident. Your explanation using the clock face really helped me. But how do you have confidence dragging the needle back under the beam in order to get it parallel when you can’t see where the needle is traversing? Your knowledge of anatomy and what structures are in the area? It’s not always practical to start over.

Any advice on how to get better lining up the probe and needle when the block isn’t set up like a pool shot? For example, interscalene or infraclavicular

As long as you aren’t advancing the needle, dragging it into view doesn’t really move the needle in relationship to the surrounding tissue but instead brings the surrounding tissue along with it. I guess the needle tip could be scraping along the interface of the engaged and non-engaged tissue but by design the needle is fairly blunt. This is also not a maneuver that is necessary or functional when you are close to the target. Usually you can do this up to about half the depth of your target, maybe 3/5ths and then the amount of tissue you have engaged gets to be too much to drag effectively. But that also means that your needle is less likely to wander off trajectory moving forward so if you have achieved a good alignment with the probe it’s harder to lose your view.

You can technically line up an infraclav like a pool shot but lots of practice is the key really. Take a moment to orient your brain to “the controls” if you will. On an interscalene where the needle travels parallel to your chest remind yourself that lifting the needle hub toward the probe is the way to angle down on the screen and to angle more shallow you need to make the opposite move. Your brain will see the needle on screen and be inclined to steepen your angle by lifting the needle hub up toward the head because that plane is parallel to the screen you are looking at. But as that’s really the dragging move we were discussing it will move the needle out of view.

For upper extremities hold the probe with the hand closest to the patient’s feet. You will often use your non-dominant hand to needle but it avoids awkward body contortions which will make lining up your planes more challenging.

Make sure you take time to position the patient well. It might seem like it adds time to the block but it can be a lot harder and slower to block a poorly positioned patient.

For an interscalene pick a needle insertion point that is somewhat above the perceived middle of the probe.

Practice.

 

[deleted875186]

I’m a resident. Your explanation using the clock face really helped me. But how do you have confidence dragging the needle back under the beam in order to get it parallel when you can’t see where the needle is traversing? Your knowledge of anatomy and what structures are in the area? It’s not always practical to start over.

Any advice on how to get better lining up the probe and needle when the block isn’t set up like a pool shot? For example, interscalene or infraclavicular

Always line up the probe and needle like a pool shot, ideal with US screen directly in front of you. Sit at the head of the bed for most interscalene, supraclav, infraclav.

 

[D P356]

Always line up the probe and needle like a pool shot, ideal with US screen directly in front of you. Sit at the head of the bed for most interscalene, supraclav, infraclav.

Assuming you’re right handed, For RUE blocks, stand behind pts right shoulder. Move the bed away from wall if needed. That’s what I do.
Insert needle as close to probe so you can see it right away. Lining it up like a pool shot is a great way to describe it as well.

 

[Twiggidy]

I’m a resident. Your explanation using the clock face really helped me. But how do you have confidence dragging the needle back under the beam in order to get it parallel when you can’t see where the needle is traversing? Your knowledge of anatomy and what structures are in the area? It’s not always practical to start over.

Any advice on how to get better lining up the probe and needle when the block isn’t set up like a pool shot? For example, interscalene or infraclavicular

As said above, when getting things lined up only move one thing, either the probe or the needle. Preferably, I'd get the probe where I want it first, ie, with the anatomy visualized, keep the probe in that spot. If you don't see the needle, move the needle (or reinsert) until you see the needle in plane on the screen and adjust from there.

Remember, the probe sends out a beam so if you're needle isn't aligned with the beam, then you wont see it. It's pretty much the same principles you use when using an ultrasound to place a CVP or A-line, except this time the target isn't a vessel.

 

[Twiggidy]

Assuming you’re right handed, For RUE blocks, stand behind pts right shoulder. Move the bed away from wall if needed.
Insert needle as close to probe so you can see it right away. Lining it up like a pool shot is a great way to describe it as well.

Exactly. I'm a lefty so every time I do something it looks backwards. For right shoulders I stand in front of the patient and for left shoulders I stand behind them.

Take home point: Always be in a comfortable position, just like when the surgeons are constantly asking us to move the table.

 

[hiyaman]

It might also be helpful to imagine the plane of the beam in your mind. I used to see junior residents have their beam angled but their needle would be directly under the probe. would often have to remind them of where the plane is projecting which seemed to help some of them re-orient themselves.

 

[nimbus]

It might also be helpful to imagine the plane of the beam in your mind. I used to see junior residents have their beam angled but their needle would be directly under the probe. would often have to remind them of where the plane is projecting which seemed to help some of them re-orient themselves.

It’s absolutely helpful to imagine where the scanning plane is before inserting the needle.

 

[deleted875186]

It might also be helpful to imagine the plane of the beam in your mind. I used to see junior residents have their beam angled but their needle would be directly under the probe. would often have to remind them of where the plane is projecting which seemed to help some of them re-orient

Agreed. Unless your needle is entirely visualized the whole time, your eyes should be moving from US screen, back to hand to confirm needle is grossly in plane, back to US, and back and forth as needed. Part of the reason to ensure US screen, probe, and your body are all aligned in front of each other.