U/S guided regional blocks

[VentdependenT]

I honestly will have a hard time going back to the stimulating needle after having used U/S.

How are experiences with this technique going with my fellow residents? Attendings?

Today we did about 8 supraclavicular and 2 axillary under U/S. Nailed everyone of them. Little excuse not too. I haven't had much experience outside of today with BP U/S blocks but I'm freaking sold on em.

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[FuzzyBK]

I really can't see how this won't become more prevalent. I used the U/S a ton on my "regional" month. What surprised me was the amount of "anomalous" anatomy I've seen. I was surprised at the number of people with very high take-offs for their profunda artery when doing femoral blocks. If you were coming at it with a stimulator, you'd never avoid it, and likely keep piercing it. We've also seen lots of people with "extra" axillary veins, etc.

I also think it gives you a better appreciation for the spacial relationships. I don't think you actually realize how close the posterior cord can be to the pleura when doing an infraclavicular block. You see lots of patients were they are probably touching each other. It also helps to demonstrate how just moving 1 cm lateral can make a huge difference in the depth of the pleura to the skin. After using the U/S, it suprises me that there aren't more pneumothoraces with upper extremity blocks.

As you can tell i'm a big proponent of the U/S.

 

[Ferdie]

U/S is great. I'm a med student, and even I have had a pretty easy time doing femoral nerve blocks, thanks to that little machine. Plus, it's very satisfying to watch that nice doughnut of local form around the nerve.

I'm on a surgery rotation right now, and this morning my resident was trying to place a femoral art line in a lady in the ICU who weighs about 350 lbs. They were having a hard time finding the pulse and stuck the vein once or twice. Little ol' me, the med student, perks up and asks if they want me to go get the u/s. The attending thought that was the best idea he'd ever heard (they hadn't thought of it I guess), and now I'm teacher's pet, thanks to what I learned in anesthesia (all this after they spent a little time this morning ripping on anesthesia/anesthesiologists)

 

[VentdependenT]

U/S is great. I'm a med student, and even I have had a pretty easy time doing femoral nerve blocks, thanks to that little machine. Plus, it's very satisfying to watch that nice doughnut of local form around the nerve.

I'm on a surgery rotation right now, and this morning my resident was trying to place a femoral art line in a lady in the ICU who weighs about 350 lbs. They were having a hard time finding the pulse and stuck the vein once or twice. Little ol' me, the med student, perks up and asks if they want me to go get the u/s. The attending thought that was the best idea he'd ever heard (they hadn't thought of it I guess), and now I'm teacher's pet, thanks to what I learned in anesthesia (all this after they spent a little time this morning ripping on anesthesia/anesthesiologists)

We rip on them too

 

[InductionAgent]

I like U/S for the supraclavicular blocks, which to me seems like overall the preferable technique for brachial plexus block.

I've done enough axillary blocks with the stimulator that I'm still more comfortable with that technique. The one time I tried the U/S for axillary was on an obese patient - a lot of redundant tissue to look through, couldn't get a great view with the SonoSite. Used the stimulator and got it fine.

Overall, I like U/S-guided blocks, especially since they help you deliver the entire 40ml of local in the right spot, not just the first 1ml before the twitch is lost. It's so ridiculous when doing a stimulator block and the attending is admonishing you to hold the needle perfectly still during the whole injection. U/S shows that the needle gets pushed away from the nerve during injection as one would expect.

 

[thegasman]

We are using it a lot for femoral catheters and this works great - much faster than stimulator once you get the hang of it. I didn't like it at first - the us seemed awkward - but after doing a few it is great. We don't do much upper extremity - mostly interscalene with the stimulator for shoulders. Our hand guys usually don't want blocks. But we did a supraclav the other day with the us and it was pretty sweet. If I got some practice with it I could get pretty slick.

 

[gasnewby]

this is probably an uninformed question.

my experience with US in the groin has only been for line placement. if i can't get a line in the groin, it's usually bc of habitus. in those cases the US doesn't add much b/c even looking through the groin crease, there's too much fat to visualize the vessels. the penetration seems pretty low.

when you guys use it for blocks, are you putting it in the groin crease or more distally- someone mentioned seeing the profunda takeoff, which is a little more distally that i would look for a line. or do you use a different US with greater depth of penetration? thanks in advance.

 

[Ferdie]

this is probably an uninformed question.

my experience with US in the groin has only been for line placement. if i can't get a line in the groin, it's usually bc of habitus. in those cases the US doesn't add much b/c even looking through the groin crease, there's too much fat to visualize the vessels. the penetration seems pretty low.

when you guys use it for blocks, are you putting it in the groin crease or more distally- someone mentioned seeing the profunda takeoff, which is a little more distally that i would look for a line. or do you use a different US with greater depth of penetration? thanks in advance.

Like I mentioned above, we used u/s yesterday to place a femoral line in a lady who was about 350 lbs (and not a basketball player, I'm guessing BMI of about 42-45ish) because her habitus was such that we were having a tough time finding her femoral pulse (plus, she was in the ICU, intubated and sedated with propofol, so her pressure was only like 90/60). with u/s we could identify the vessels at the groin crease, but we had to increase the depth on the u/s machine. Also, it did not look like I'm used to seeing in our usual patients, who are only borderline obese (this is the midwest...). The vein and artery were MUCH further apart (because of that, the color doppler feature was helpful in this instance. Yeah, the vein was still collapsable and all, but the anatomy just looked a little different than we were used to), and there was no nice little hyperintense triangle lateral to the artery where the nerve would be (not that we were doing a block anyway) - I don't know if this would be the case with most morbidly obese folks, but it was my experience yesterday.

 

[CremeSickle]

Last time I did one with a needle was as a CA1. I do everyting, CVLs, blocks and even difficult IV sticks on known hard patients with the u/s. Why not? its not only idiot proof but it provides one more layer of saftey (and less sticks) for the pt.

 

[Planktonmd]

Last time I did one with a needle was as a CA1. I do everyting, CVLs, blocks and even difficult IV sticks on known hard patients with the u/s. Why not? its not only idiot proof but it provides one more layer of saftey (and less sticks) for the pt.

And what are you going to do in the future if you find yourself practicing in a place where there is no ultrasound?

 

[Dejavu]

U/S guided blocks are great, they provide another option for pt care when an "old-fashioned" technique may be contra-indicated (like when you don't want to use Epi in the solution or something like that).

Two thoughts:

I don't believe there is evidence, yet, of increased efficacy or decreased risk. I may be wrong.

Also, if you work in a teaching institution, someone needs to teach Non-U/S blocks, for now anyway, so that your grads can do the blocks if they get a job in a practice where there is no U/S machine. It isn't standard-of-care yet.

All that being said, it is comforting to see the nerve being surrounded by injectate.

 

[gasnewby]

with u/s we could identify the vessels at the groin crease, but we had to increase the depth on the u/s machine. Also, it did not look like I'm used to seeing in our usual patients, who are only borderline obese (this is the midwest...). The vein and artery were MUCH further apart (because of that, the color doppler feature was helpful in this instance.

ah, you have one of the fancy machines...we have the little box on wheels without the bells and whistles. works great for IJs but that's it.

 

[CremeSickle]

Honestly plank i just dont know.

Where i am its "standard" to use the u/s. Im sure I could do the lines and likely i could manage a femoral since you dont need u/s for that anyway but id have to do some serious review before attempting anything else.

With the way things are changing i wonder how many people are in the same situation as i am?

And what are you going to do in the future if you find yourself practicing in a place where there is no ultrasound?

 

[VentdependenT]

Honestly plank i just dont know.

Where i am its "standard" to use the u/s. Im sure I could do the lines and likely i could manage a femoral since you dont need u/s for that anyway but id have to do some serious review before attempting anything else.

With the way things are changing i wonder how many people are in the same situation as i am?

You take a 3 day course.

 

[bostonblaz]

where i am now we have a very good u/s( ibelive it is a ge). we do almost all regional with it and it has made a huge difference in success of block( aproaching 99%) and duration of analgesia( approx 16-18 hrs with bup .375%). we do however have a group of attendings who will not let you use the u/s at all and it has to be done with nerve stim only. i now feel quite comfortable with both but if i had to have it done to myself it would be u/s.