Stellate Ganglion Block (cervical sympathetic chain block) with ultrasound guidance; in-plane or out of plane?

[Ligament]

Assuming one starts at C6 or C7, Seems to me using an out of plane approach makes a lot of sense, for the following reasons:
1. easier to avoid vessels
2. If standing at head, and needle trajectory is from cranial to caudal trajectory, could push meds further caudal to stellate ganglion.

thoughts and preferences?

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[callmeanesthesia]

In-plane combined fluoro and ultrasound.

 

[hyperalgesia]

I still just use fluoro but the 3 guys I work with use in-plane. I'm still more comfortable with fluoro but feeling old.

 

[Ducttape]

in plane. I feel more comfortable viewing the entire length of the needle during the procedure. ...

 

[drusso]

In-plane.

 

[DOctorJay]

also in plane
combined fluoro and ultrasound

 

[willabeast]

Whatever you do, use a test dose!

 

[soccrwz]

Used to do ultrasound, now do fluoroscopy based off the techniques learned here. Inplane is the way to do it, to may vital structures in the area if you do out of plane

 

[Baron Samedi]

I'm not sure I'd ever consider doing out of plane, especially since pneumothoraxic is historically among the most common complications of SGBs.

I do 100% of mine with fluoro now in an oblique trajectory view, and I do a lot. I've been fortunate to have great responses to treatment and no serious complications. Way faster and you dont have the time constraint of a rapidly degrading quality image with ultrasound. Also less rearranging the procedure room.

 

[DODOCSS]

I'm not sure I'd ever consider doing out of plane, especially since pneumothoraxic is historically among the most common complications of SGBs.

I do 100% of mine with fluoro now in an oblique trajectory view, and I do a lot. I've been fortunate to have great responses to treatment and no serious complications. Way faster and you dont have the time constraint of a rapidly degrading quality image with ultrasound. Also less rearranging the procedure room.

u don't worry more about spinal or seizure? pneuma is self limiting (imc)

 

[Baron Samedi]

u don't worry more about spinal or seizure? pneuma is self limiting (imc)

Of course, but that's why I use an epi wash, very slow injection, midazolam in room, and every patient has IV access.

 

[deleted131481]

Used to do ultrasound, now do fluoroscopy based off the techniques learned here. Inplane is the way to do it, to may vital structures in the area if you do out of plane

I'm assuming you mean used to do in-plane US but now just fluoro? If you're ok with fluoro, why are you worried about in-plane with US? You can't see any of the vital structures on fluoro anyways. I use in-plane US - can see the vessels and where I'm going and active spread. Main advantage of fluoro I see is much faster. I suspect the incidence of vessel entry (not final point but puncture) in fluoro is higher than we think but probably insignificant with a 25g needle.

Why do some use combined fluoro and ultrasound? I don't see any advantage over ultrasound only.

 

[tmvguy03]

I'm assuming you mean used to do in-plane US but now just fluoro? If you're ok with fluoro, why are you worried about in-plane with US? You can't see any of the vital structures on fluoro anyways. I use in-plane US - can see the vessels and where I'm going and active spread. Main advantage of fluoro I see is much faster. I suspect the incidence of vessel entry (not final point but puncture) in fluoro is higher than we think but probably insignificant with a 25g needle.

Why do some use combined fluoro and ultrasound? I don't see any advantage over ultrasound only.

I prefer a 27g if using fluoro

 

[callmeanesthesia]

I'm assuming you mean used to do in-plane US but now just fluoro? If you're ok with fluoro, why are you worried about in-plane with US? You can't see any of the vital structures on fluoro anyways. I use in-plane US - can see the vessels and where I'm going and active spread. Main advantage of fluoro I see is much faster. I suspect the incidence of vessel entry (not final point but puncture) in fluoro is higher than we think but probably insignificant with a 25g needle.

Why do some use combined fluoro and ultrasound? I don't see any advantage over ultrasound only.

My ultrasound isn’t very good. I’m the only one in the practice who uses ultrasound and I don’t do enough to justify shelling out for a good unit, so I make do with a very old unit they picked up for about $2,000. Does the job for most nerve blocks but for the stellate I like the backup of checking spread and needle position on fluoro.

 

[deleted131481]

My ultrasound isn’t very good. I’m the only one in the practice who uses ultrasound and I don’t do enough to justify shelling out for a good unit, so I make do with a very old unit they picked up for about $2,000. Does the job for most nerve blocks but for the stellate I like the backup of checking spread and needle position on fluoro.

Great point. I am in academics and at least as far as ultrasounds am spoiled - readily available latest model ones that I'm sure cost $$$. I've used older ones that I couldn't even put a central line in with in residency.

 

[callmeanesthesia]

Great point. I am in academics and at least as far as ultrasounds am spoiled - readily available latest model ones that I'm sure cost $$$. I've used older ones that I couldn't even put a central line in with in residency.

God I miss the $100,000 unit we had sitting in PACU. The clarity for nerve blocks was amazing.

 

[Ligament]

Guys remember u/s will show vascular uptake just great, as long as you don't care for any vasculature outside a 2mm field of view! Don't be fooled into thinking you are ruling out vascular uptake with u/s. Only fluoro will, preferably with DSA.

 

[soccrwz]

I'm assuming you mean used to do in-plane US but now just fluoro? If you're ok with fluoro, why are you worried about in-plane with US? You can't see any of the vital structures on fluoro anyways. I use in-plane US - can see the vessels and where I'm going and active spread. Main advantage of fluoro I see is much faster. I suspect the incidence of vessel entry (not final point but puncture) in fluoro is higher than we think but probably insignificant with a 25g needle.

Why do some use combined fluoro and ultrasound? I don't see any advantage over ultrasound only.

in plane for U/S, I use fluoro technique I learned from here, I want to see the inferior spread and know the levels, much faster as well