U/s or no U/s on regional blocks?

[excalibur]

I am on a regional month at the VA. I have done the four upper extremity nerve blocks. I have done IS with and without U/S. I have done supraclavicular only with U/S.

When we have used U/S btw, we have also had a nerve stimulator, but only turned it on when we felt the needle was right where it was supposed to be on U/S.

With the limited experience I have, I feel it's much easier with U/S, b/c you can see where you're going, and you can tell when you're in the sheath which will give you a better block.

So I was curious...
Residents/Attdgs, do you prefer U/S or no U/S for your blocks? U/S for certain blocks? Have you noticed different success rates with one method over the other?

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[2ndyear]

Ultrasound is a great tool no doubt. Take every chance you can in residency to learn it and learn it well. It really only works, though, when you know what you're looking at reliably. I use it on just about every upper extremity block that I do. But I think you should still learn basic blocks using a nerve stimulator, if for no other reason than you may end up somewhere that does not have US and you want to be able to do the block. Same thing for central lines. I don't routinely use it for femoral blocks if I can feel the pulse. If body habitus makes this difficult, then I will use US to locate the artery and go from there.

Once you get comfortable with the US, I would encourage you to ditch the nerve stim. Choose an endpoint and stick with it. If your endpoint is visualizing the nerve/cord and you know what you're looking at, just put the local there and be done.

 

[Planktonmd]

Unfortunately if you are good with nerve stimulator and you know anatomy you will find that ultrasound only makes your procedure longer and more complicated.
On the other hand it is rapidly becoming the standard of care because there are increasing numbers of new guys who can't do blocks without it, and this is why you should learn it and be good at it because, soon organizations like JACHO and ACHA and Medicare will start penalize you if you don't use it.

 

[Jeff05]

if you read the new review of upper extremity regional anesthesia (ASRA) you will find that there are many anatomic variants of the brachial plexus. including differences in left vs. right in the same individual. so knowing the generic anatomy is not necessarily helpful.

ultrasound is a BETTER technique. multiple studies suggest increased block success rates. i think safety will be enhanced as well.

as far as block time...
i bet i can throw in an interscalene/supraclav/axillary faster than you can turn down the current and decide if you really wanna take that 0.5.

 

[Planktonmd]

if you read the new review of upper extremity regional anesthesia (ASRA) you will find that there are many anatomic variants of the brachial plexus. including differences in left vs. right in the same individual. so knowing the generic anatomy is not necessarily helpful.

ultrasound is a BETTER technique. multiple studies suggest increased block success rates. i think safety will be enhanced as well.

as far as block time...
i bet i can throw in an interscalene/supraclav/axillary faster than you can turn down the current and decide if you really wanna take that 0.5.

Sure, whatever you say.

 

[periopdoc]

Plank, honest question, do you feel like you can place a catheter with equal success/ speed with stim compared to someone who is very comfortable using u/s?

- pod

 

[Planktonmd]

Plank, honest question, do you feel like you can place a catheter with equal success/ speed with stim compared to someone who is very comfortable using u/s?

- pod

That's not what I said.
I said if you are good with anatomy and good with stimulator (been doing it for many years) then the only thing ultrasound is going to add to your procedure is more time and extra steps.
If you are a new guy that was trained to use ultrasound for every block then you should continue to do that because this is what you do best.
There is absolutely no evidence that ultrasound makes any block better in the hands of an experienced operator.

 

[Trisomy13]

That's not what I said.
I said if you are good with anatomy and good with stimulator (been doing it for many years) then the only thing ultrasound is going to add to your procedure is more time and extra steps.
If you are a new guy that was trained to use ultrasound for every block then you should continue to do that because this is what you do best.
There is absolutely no evidence that ultrasound makes any block better in the hands of an experienced operator.

That being said, I've seen very skilled and experienced U/S operators place blocks as quickly as any nerve stimulator operator. People speak of these "extra steps" and I assume they mean covering the U/S probe and plunking down some U/S jelly. Consider that you don't have to place your ekg pad to complete the stimulator circuit, dial down to 0.5 or 0.4, etc, and I see no net gain of "steps" if you use a true U/S technique.

I'm still early in my training and happy when I get a chance to do either, but that's take on it.

 

[cchoukal]

I've done a fair bit of both as a resident and I really feel that for the upper extremity, the u/s makes my blocks much more reliable, and the use of u/s has introduced me to the supraclavicular block. When I first started using ultrasound, it became clear that the nerve stimulator wasn't telling me the whole story. Moves of 0.5 mm would take you from a bounding twich to nothing; when you combine the stim with ultrasound and visualize the hydrodissection as you inject, you come to see the stimulator as a scared, spastic cat (okay, weird analogy). With the u/s, I can individually block all three cords and the musculocutaneous nerve in the axilla instead of relying on some mythical sheath to spread the local proximally to get the MC (the same is true at the femoral 3:1). It's fantastic for the supraclavicular, although, to be honest, I don't always find it helpful for the interscalene.

I've even started using it for lower extremity blocks. 30 seconds to find the pulse in a fatty is now 1 second with the u/s, and you'll start to see just how variable the anatomy is and realize why some of your blocks fail. I've even used it a few times for an anterior approach to the sciatic. It's cool getting the whole leg without making the patient roll over or lift their freshly blocked leg.

Anyway, it probably takes more time at first, and there is more setup, but it doesn't take many failed blocks that require conversion to GA to more than offset this.

 

[periopdoc]

That's not what I said.
I said if you are good with anatomy and good with stimulator (been doing it for many years) then the only thing ultrasound is going to add to your procedure is more time and extra steps.
If you are a new guy that was trained to use ultrasound for every block then you should continue to do that because this is what you do best.
There is absolutely no evidence that ultrasound makes any block better in the hands of an experienced operator.

That is exactly what I am asking. I assume that you are one of the experienced operators who is good with anatomy and with a stimulator and I am wondering if you feel that you can place a perineural catheter as quickly/ effectively as someone who was trained with ultrasound.

The reason I ask is that the individuals that I have encountered that place catheters with nerve stim seem to take significantly more time trying to get the catheter placed than the folks using ultrasound. I have not seen a significant difference in speed/ success for single shot blocks, but I have for catheter placement. That could be due to inexperience on the part of the folks I have seen using stim technique.

- pod

 

[Planktonmd]

That is exactly what I am asking. I assume that you are one of the experienced operators who is good with anatomy and with a stimulator and I am wondering if you feel that you can place a perineural catheter as quickly/ effectively as someone who was trained with ultrasound.

The reason I ask is that the individuals that I have encountered that place catheters with nerve stim seem to take significantly more time trying to get the catheter placed than the folks using ultrasound. I have not seen a significant difference in speed/ success for single shot blocks, but I have for catheter placement. That could be due to inexperience on the part of the folks I have seen using stim technique.

- pod

I place all my catheters (mostly femoral) using the old stimulator technique with excellent results.
The longest part of the procedure is taping the catheter to the skin.

 

[periopdoc]

I place all my catheters (mostly femoral) using the old stimulator technique with excellent results.
The longest part of the procedure is taping the catheter to the skin.

 

[BLADEMDA]

if you read the new review of upper extremity regional anesthesia (ASRA) you will find that there are many anatomic variants of the brachial plexus. including differences in left vs. right in the same individual. so knowing the generic anatomy is not necessarily helpful.

ultrasound is a BETTER technique. multiple studies suggest increased block success rates. i think safety will be enhanced as well.

as far as block time...
i bet i can throw in an interscalene/supraclav/axillary faster than you can turn down the current and decide if you really wanna take that 0.5.

You won't even have the probe on the skin before my block is finished.

Blade

 

[BLADEMDA]

if you read the new review of upper extremity regional anesthesia (ASRA) you will find that there are many anatomic variants of the brachial plexus. including differences in left vs. right in the same individual. so knowing the generic anatomy is not necessarily helpful.

ultrasound is a BETTER technique. multiple studies suggest increased block success rates. i think safety will be enhanced as well.

as far as block time...
i bet i can throw in an interscalene/supraclav/axillary faster than you can turn down the current and decide if you really wanna take that 0.5.

Here is my 2 cents: (you can disregard my "flippant" response earlier)

1. Interscalene- Easy block with nerve stimulator. 99.5% success rate and speed is not an issue with nerve stimulator. 3-5 minute block max.
U/S not needed unless you want to practice.

2. Supraclavicular- Easy block but pneumothorax is a risk. Since U/S decreases that risk substantially most would use it here. Speed is about the same compared to nerve stimulator.

3. Axillary- You should learn multiple techniques. All have high success rate in experience hands. Transarterial useful when no U/S or nerve stimulator avail.

4. Femoral- Give me a break. You need U/S to find the femoral nerve? A Doppler can locate the artery easily even in the largest patients. As for Continuous catheters I doubt your speed is any faster with or without U/S once you have performed about a 1,000 or more.


In the end technology will improve, probes will get smaller and pictures will get better. The trend will be towards U/S guided blocks over the next ten years. But, until the literature PROVES U/S is superior in all blocks I will stick with nerve stimulator for Interscalene and Femoral blocks. Why fix it if it isn't broken?

 

[Noyac]

You won't even have the probe on the skin before my block is finished.

Blade

Ditto

 

[Noyac]

I would caution residents that think US is the only way to go. It is better for inexperienced practitioners but unlikely to change the practice of an experienced person. We have interviewed new grads that have never used the NS for blocks. THey did every block with US. We don't have an US so how are they going to do blocks here? Do we need to teach them. I'm not really interested in teaching a new grad how to use a NS when I need to be doing my case.

 

[huktonfonix]

When you guys are doing your catheters with nerve stim are you just inserting the catheter when you have a good twitch with the needle, or are you using the stimulating catheters and wait until you have a good twitch with the catheter?

 

[Noyac]

When you guys are doing your catheters with nerve stim are you just inserting the catheter when you have a good twitch with the needle, or are you using the stimulating catheters and wait until you have a good twitch with the catheter?

I give at lest half my bolus (usually all of it) thru the touhy needle then pass the cath. It works every time.

 

[huktonfonix]

I give at lest half my bolus (usually all of it) thru the touhy needle then pass the cath. It works every time.

thanks. During residency we used to get a good twitch with the Tuohy, then attach the stim to the catheter and manipulate it until we got a good twitch with the catheter. That part seemed to take the most time. In PP it seems that everyone threads the cath into the Tuohy once they get a good twitch with the needle. Both seem to work well but the latter is a lot quicker.

 

[USAnesthesiaDoc]

For what it's worth, I finished residency in 2004, right before u/s started to be used for regional, so I learned parethesia technique and mostly nerve stim technique as a resident. I've been in PP since, and did LOTS of regional with just nerve stim for the 1st 2 years (upper and lower extremity blocks but no catheters). Started going to conferences, learned more about u/s guided blocks. Started dabbling with it on an old sonosite that the hospital already had, and then was able to convince the hospital to spring for new u/s machines just for anesthesia that wouldn't have to be shared with breast and vascular surgeons. For the last year, have been using u/s for all blocks. I've been using nerve stim less and less in combination with u/s. For the most part on single shot blocks, I just use u/s unless the image is questionable and I'm not sure if what I'm aiming it is really the nerve (usually this only happens with interscalene and popliteal/subgluteal sciatic).

I've also been doing lots of femoral nerve catheters in the past year, used stimulating and non-stimulating needles and catheters, different catheter brands, different approaches, with and without u/s. My favorite technique, which for me, has given me the fastest and most reliable/successful catheters has been: localize nerve with u/s, place needle out of plane under u/s guidance, then stimulate with needle and then place stimulating catheter. I then inject through the catheter under u/s to demonstrate appropriate local distribution and place before and after images on the patient's chart.

 

[jd1572]

Due to the disturbing trend that many patients are obese, I have found that ultrasound has helped a great deal. If you can't palpate an axillary or femoral artery, then ultrasound can guide your block needle. In addition, I have had patients with so much adipose on their neck that there are no landmarks to palpate.

Back in the day when people were mostly doing the paresthesia technique for nerve blocks, I wonder if they all said "Why do we need nerve stimulators?"

 

[pgg]

Back in the day when people were mostly doing the paresthesia technique for nerve blocks, I wonder if they all said "Why do we need nerve stimulators?"

Yeah, I'm sure PlanktonmdSenior scoffed at young Planktonmd using that weenie stimulator crutch when his own paresthesia technique was well honed and quick.

100% of the blocks I did my CA1 & 2 years were with nerve stimulators. I'm comfortable doing them, and reasonably efficient given my n<100 with them. This month I'm doing nothing but regional, using ultrasound for all of the blocks. I'm not as fast as I was (yet) but I don't see myself going back to using a nerve stimulator. The blocks are all just too easy and too reliable with u/s. It's clearly headed toward becoming the standard of care. I just don't see the point in using the stim anymore if u/s is available.

 

[periopdoc]

Ultrasound $25,000

Maintenance and repair of U/S unknown

Nerve stim $200

Increased income per block performed with u/s vs nerve stim $25-$35

Number needed to treat with u/s vs stim to prevent one injury unknown.

Economic reality, it will be a long time before u/s becomes ubiquitous much less "standard of care."

- pod

 

[pgg]

Ultrasound $25,000

Maintenance and repair of U/S unknown

Nerve stim $200

Increased income per block performed with u/s vs nerve stim $25-$35

Number needed to treat with u/s vs stim to prevent one injury unknown.

Economic reality, it will be a long time before u/s becomes ubiquitous much less "standard of care."

- pod

Point made, but the same arguments used to be made about ... well, every single new technology introduced into the medical field.

How much did the first nerve stims cost? Increased income per block performed with a nerve stim in those days: $0. The paresthesia method is free - where was the economic rationale behind starting to use nerve stimulators?

And who says any of this has to make economic sense? Technology more than anything else has driven healthcare costs higher. It's why those costs are spiraling out of control. Automatic LPs and head CTs for headaches don't make economic sense or even medical sense, but show me an ER doc who won't reward a couple of vague headache buzzwords in the chief complaint with a stab in the back and a trip to the scanner.

30 years ago, I imagine the average family doc would have been quite speedy and proficient at slapping a plaster cast on a kid's uncomplicated ulnar fracture ... and would never have believed that films read by a radiologist and treatment by an orthopedic surgeon would ever become standard of care. But here we are.

The evolution of "standard of care" doesn't seem to be influenced much by cost.

 

[OB1🤙]

As devices like these- http://mjperry.blogspot.com/2009/04/markets-in-everything-ultrasound.html - are perfected, things will trend more and more toward use of u/s.

I do not believe that ultrasound improves the time it takes to block a nerve for normally-sized patients. I do believe ultrasound improves the efficacy of blocks and reduces the incidence of failed blocks, and makes things easier in the fluffier individuals.

 

[BLADEMDA]

As devices like these- http://mjperry.blogspot.com/2009/04/markets-in-everything-ultrasound.html - are perfected, things will trend more and more toward use of u/s.

I do not believe that ultrasound improves the time it takes to block a nerve for normally-sized patients. I do believe ultrasound improves the efficacy of blocks and reduces the incidence of failed blocks, and makes things easier in the fluffier individuals.

This is really speculative commentary. In my hands an Interscalene Block takes 3 minutes and has a 99.6% success rate. Even the 400 pounders can be blocked safely. So, perhaps experience plays a big role in technique and efficacy.

I agree the Supraclavicular Blocks are better performed with U/S. Axillary blocks are dealers choice (fat individuals much better with U/S).
As for Femoral Blocks a simple bedside doppler works just as well as U/S at a fraction of the price.

The literature hasn't proven U/S any safer for nerve blocks. Maybe, over time it will. For now, in my hands the interscalene and femoral blocks will still be nerve stimulator only.

 

[proman]

How about for interscalene catheters?

 

[sevoflurane]

How about for interscalene catheters?

How about the 225 kg fat neck or huge pannus? I've been trained both ways. Interscalene, supraclav... with proper nursing the block will be under a minute. Put the probe on.. hit the plexus. That easy. Try doing that with traditional approach with 3 inches of fat to go through... Sometimes not so easy to feel landmarks.

More importantly you can get epineuronaly placed LA. You can actually see the fascicles drifting away from each other as you inject your local. You can also reposition your needle and hit the plexus at different points. I'll have patients not be able to move their fingers (most inner part of the nerve bundle) within minutes of block completion. If you are outside or close to the nerve sheath you will often need 45 minutes for the block to set up.

As mentioned above... know both techniques. USD for me if it's there.

 

[cchoukal]

it is likely that one day soon the world (CMMS, The Man, etc.) will require central lines to be placed under ultrasound guidance, so you'll be spending the money on the equipment anyway. once it's there and available, the arguments about equipment costs will be moot.

 

[BLADEMDA]

How about the 225 kg fat neck or huge pannus? I've been trained both ways. Interscalene, supraclav... with proper nursing the block will be under a minute. Put the probe on.. hit the plexus. That easy. Try doing that with traditional approach with 3 inches of fat to go through... Sometimes not so easy to feel landmarks.

More importantly you can get epineuronaly placed LA. You can actually see the fascicles drifting away from each other as you inject your local. You can also reposition your needle and hit the plexus at different points. I'll have patients not be able to move their fingers (most inner part of the nerve bundle) within minutes of block completion. If you are outside or close to the nerve sheath you will often need 45 minutes for the block to set up.

As mentioned above... know both techniques. USD for me if it's there.

So, 10,000 plus blocks (probably many more) and where are all these "complications"? I haven't seen them. Again, theoretical B.S. that may not be relevant to clinical practice. In fact, we have done MILLIONS and MILLIONS of nerve blocks safely under nerve stimulator in the USA since the 1990's with extremely low morbidity.

As for "fatty" have someone hold the gut up while you use the doppler to locate the artery (femoral block). After a few thousand interscalene blocks even the 400-450 pounders can be done with nerve stimulator.

I am not criticizing the use of U/S. But, too many young residents don't wan't to learn the MORE DIFFICULT TECHNIQUE of nerve stimulation because it takes time and practice to get good. For a newbie U/S allows FASTER blocks because you don't need to practice the art of regional and get a good "feel" for the anatomy/needle.

Blade