How to use nerve stimulator?

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osoprop28

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I was taught regional skills without using nerve stimulators, but everybody at my new job seems to be using it. I know the cathode (black) attaches to the needle, but where do you usually put the anode (red) sticker on the patient? Say for brachial plexus or lower extremity blocks? do you put them distally in the arm/leg or certain sites depending on the block?
 
I was taught regional skills without using nerve stimulators, but everybody at my new job seems to be using it. I know the cathode (black) attaches to the needle, but where do you usually put the anode (red) sticker on the patient? Say for brachial plexus or lower extremity blocks? do you put them distally in the arm/leg or certain sites depending on the block?

Anywhere. But only the weak use the nerve stimulator.
 
Anywhere. But only the weak use the nerve stimulator.
Haha I definitely agree with you there, and I don't plan on using it much, but I figured I might as well know how since I didn't really learn it.

So when you say anywhere... It's really anywhere?? Like I don't have to place it on same limb or anything??
 
Haha I definitely agree with you there, and I don't plan on using it much, but I figured I might as well know how since I didn't really learn it.

So when you say anywhere... It's really anywhere?? Like I don't have to place it on same limb or anything??

Anywhere. As long as you complete the circuit.

If you don’t really do landmark approach for regional, there isn’t much of a reason to use nerve stimulator.
 
I personally use it not to identify the nerve but verify that i am not too close to the nerve. Just a preference. I always like to have more than less information.

I also use BIS, CVP, PAP, and other non-standard monitors for specific cases.
 
I personally use it not to identify the nerve but verify that i am not too close to the nerve. Just a preference. I always like to have more than less information.

I also use BIS, CVP, PAP, and other non-standard monitors for specific cases.

If you see the tip..... but I suppose you can never be too careful
 
I have found the stimulator useful for thick legs for high sciatic or femoral nerve blocks. Yes ultrasound has made it easier for these but the tissues can still look deceiving in large patients. For that certain patient who I just don’t want to intubate for an AKA/BKA (home O2, BMI>age, on anticoagulants precluding spinals, bad heart disease), I can’t afford to miss my target. I place the lead anywhere, just need to complete the circuit. I set it to about 0.7mA, and for documentation purposes I lower it to 0.3 or less to show loss of twitch response.
 
Definitely learn how to use it, you'll find you don't need it with ultrasound for most routine blocks. Look up 'NYSORA and nerve stimulation' they have a full review of it. Stim can be helpful for anatomically difficult patients, size can be an issue but most of the time it's a small nerve or another structure that looks like a nerve. Most of the time slow, deliberate scanning eliminates any doubt. For axillary blocks I usually use it to find the musculocutaneous nerve, it usually has hyper-echoic fascia in a bundle that has the nerve close by but nerve stim can reassure you're close enough. The other time to use it is with surgeons that have higher than normal nerve injury, only had this issue with one surgeon, used a pressure monitor and nerve stim for all their patients
 
I was taught regional skills without using nerve stimulators, but everybody at my new job seems to be using it. I know the cathode (black) attaches to the needle, but where do you usually put the anode (red) sticker on the patient? Say for brachial plexus or lower extremity blocks? do you put them distally in the arm/leg or certain sites depending on the block?

They must be old like me. We didn’t have ultrasound while I was in training so we learned regional with landmarks and nerve stimulator. But I stopped using nerve stimulation 10-15 years ago. Before ultrasound, I must have done hundreds of intraneural injections.
 
I haven't used nerve stim in a very long time. I have partners that use it, but that in no way pushes me towards its use at all. Nurses tell me it's pretty uncomfortable for patients.
 
Sticker goes anywhere. I almost never use it with the exception of that rare patient where I want extra confirmation in addition to ultrasound
 
Have you ever tried a train of four on yourself? It's not exactly painful but it sucks. I will never use nerve stim. If I am unsure I will take an extra minute to scan around and also give more volume.
 
I thought everyone threw these archaic things in the bin when ultrasound became widely available. Haven't they been proven to be inferior in every way? And also not associated with decreased complications when used as an adjunct to ultrasound?
 
I thought everyone threw these archaic things in the bin when ultrasound became widely available. Haven't they been proven to be inferior in every way? And also not associated with decreased complications when used as an adjunct to ultrasound?
I agree it likely doesn’t decrease complications but you are already there and the documentation is easy to say you did it (CYA).
 
I agree it likely doesn’t decrease complications but you are already there and the documentation is easy to say you did it (CYA).

I don't think it adds anything as far as CYA.

I pull it out once in a blue moon however half of that time I wonder to myself why am I using it?
 
Just checked. My current hospital doesn't even own one 🤣
 
I use the stimulator to confirm that I’m seeing what I think I’m seeing on US. When things don’t look quite right I can fool myself into thinking something is a nerve that isn’t, but there’s no mistaking the muscle contraction with the stimulator.

In my current job I only do a handful of blocks a year, so I don’t mind hooking up the stimulator even if it’s a sign of weakness. If I start doing more regional in the future I might go back to straight ultrasound.
 
Wow, surprising to see the anti-nerve stimulator sentiment on here. I’m pretty young to be a dinosaur but I must be.

I feel it adds a few extra seconds and zero cost to the procedure (literally. I tell the RN or anesthesia tech to start at 1.0 when I am right next to the target and then quickly go down to 0.5-0.6 and call it good). There have certainly been times I had a vigorous twitch down to 0.2-0.3 and pulled the needle back a bit.

IMO, pop NB can be the easiest or hardest block in the world based on u/s image and it can’t always be predicted by pt habitus. I find nerve stimulator to be very helpful in these instances.

Whatever you guys are comfortable with. Speaking as a guy in PP for while, I think the main thing is that your blocks are reliably placed and done in 5-10 min max. How you get there is your business.
 
I have never seen the nerve stim add anything but pain for the patient. If you can't visualize, practice US.
 
I have never seen the nerve stim add anything but pain for the patient. If you can't visualize, practice US.

I use it every now and then for a popliteal block when the leg is the size of a tree. I have never seen a patient complain about it hurting either, just weird for them when something starts jumping.
 
It’s never the fatties that give me trouble with pop blocks. There’s a pretty good density difference between nerve and fat that shows up well on ultrasound. I find the trickiest ones to be the young athletes whose muscle density has almost the same echogenicity as nerve tissue. Playing with the cant on the probe (cephalad/caudad) makes a huge difference. Just makes sure to account for the cant on your needle entry point.
 
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