Ultrasound for Neuraxial Anesthesia

[CharleyVCU1988]

What is everyone's opinion on using ultrasound to guide neuraxial placement on patients with difficult anatomy? (supermorbid obese, scoliosis, harrington rod, etc)

If you have colleagues that use ultrasound to guide neuraxial placement on difficult patients like the ones above, what is your opinion of their skill level?

(I have a Rivanna Accuro Ultrasound bought with my own money that I have used successfully on an obese patient and an individual with prior back surgery, both for spinals for knee replacements.)

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[dchz]

My opinion is that it is severely underutilized. Severely. It can reduce a lot of patient suffering and make you look like a rock star. It is especially helpful in difficult thoracic epidurals. If there was an ultrasound revolution for neuroaxial, it would start there. The lumbar target is too big and the cost of transitioning to ultrasound is too high for the current population of anesthesiologists to all of a sudden want to use ultrasound. But it is the future.

If i have a colleague that did it, i'd be the next one in line to out do him/her with an in-plane tuohy epidural technique. But unfortunately an in-plane tuohy technique is too "cowboy" at my institution. My opinion of their skill level is meh because it's not very difficult to do (unless they did the tuohy in plane).

 

[okayplayer]

Besides the fact our small community hospital does not have a Sonosite on the labor floor, it is too time consuming. Wouldn’t fly for my group. You have to be in and out of the room in 20-30min to move on to the next task (block, preanesthesia clinic pt, etc).

 

[CharleyVCU1988]

Besides the fact our small community hospital does not have a Sonosite on the labor floor, it is too time consuming. Wouldn’t fly for my group. You have to be in and out of the room in 20-30min to move on to the next task (block, preanesthesia clinic pt, etc).

please elaborate on what aspects of ultrasound are time consuming for plotting neuraxial placement.

 

[Arch Guillotti]

please elaborate on what aspects of ultrasound are time consuming for plotting neuraxial placement.

Going to get it. Hauling it to labor and delivery. Booting it up. Hauling it back from where you got it.

 

[CharleyVCU1988]

Going to get it. Hauling it to labor and delivery. Booting it up. Hauling it back from where you got it.

I see. I have the Accuro portable ultrasound that is the size of a cellphone or laptop charger brick. I realize not everyone may have one or depend on the OB's ultrasound if needed.

 

[facted]

I think it can be helpful in super obesity. Scoliosis you can often feel things just fine, but placement may be difficult, though in general I don't find scoliosis to be very problematic. As for rods, there is no easier spinal. The surgeon has marked midline for you and done a laminectomy to give you easy access. Epidural in this population at the level of the rods is contra indicated because of defacement and fusion of the epidural space.

The ultimate utility of ultrasound depends on your skill level and your patient population. If you have aton of super obese pts, then I could see it. But otherwise I think it's overkill. I'm in and out of the L&D room within 15 minutes on over 90% of my pts... Why on Earth would I add scanning time, finding the ultrasound, etc...?

 

[CharleyVCU1988]

The ultimate utility of ultrasound depends on your skill level and your patient population. If you have aton of super obese pts, then I could see it. But otherwise I think it's overkill. I'm in and out of the L&D room within 15 minutes on over 90% of my pts... Why on Earth would I add scanning time, finding the ultrasound, etc...?

Would you think any less of a colleague who used it on super obese patients or patients he/she had difficulty feeling the midline or spinous processes on?

 

[okayplayer]

Would you think any less of a colleague who used it on super obese patients or patients he/she had difficulty feeling the midline or spinous processes on?

Yes

What’s your goal here?

 

[CharleyVCU1988]

Yes

What’s your goal here?

I'm curious about the perception about the use of ultrasound guidance for neuraxial anesthesia. My department is looking into getting an Accuro. Everyone in the department has done epidurals blindly. They all say the obese patients are difficult and take the longest and the longer it takes for epidurals the lower patient satisfaction there is.

Why would an anesthesiologist's perceived skill at placing neuraxial anesthesia be less if they use ultrasound for guidance?

 

[ZzzPlz]

to me, using ultrasound for neuraxial anesthesia seems a lot like using ultrasound to identify the trachea before intubating someone—sure it doesn’t hurt anything, but it’s unnecessary, time consuming, and would make me look dumb

 

[CharleyVCU1988]

to me, using ultrasound for neuraxial anesthesia seems a lot like using ultrasound to identify the trachea before intubating someone—sure it doesn’t hurt anything, but it’s unnecessary, time consuming, and would make me look dumb

How would using an ultrasound for intubation even give you information on how far back to place the head in a sniffing position or decide to go for indirect laryngoscopy?

I guess it might help for doing triple blocks for an awake fibreoptic on someone with a thick neck...

 

[anbuitachi]

when you guys use ultrasound are you just finding midline or are you actually putting a probe cover and watching the needle go in

 

[CharleyVCU1988]

when you guys use ultrasound are you just finding midline or are you actually putting a probe cover and watching the needle go in

just finding midline and interspace between spinous processes for me.

Although I believe some people have done neuraxial in real-time in plane.

 

[Twiggidy]

please elaborate on what aspects of ultrasound are time consuming for plotting neuraxial placement.

The fact that I could be done by the time someone goes to get the ultrasound. For the price vs how fast I can place greater than 90% of my blocks it’s not worth it.

 

[Twiggidy]

just finding midline and interspace between spinous processes for me.

Although I believe some people have done neuraxial in real-time in plane.

I think it’s just fine for super obese patients to find midline. I just find that if I’m struggling with a big lady and hitting bone then it’s time for me to go paramedian and usually when I make that decision I get the epidural placed fairly quickly. The ultrasound is in the back of my head but usually once I’ve thought about it I’ve get the space. I’ve done A LOT of epidurals so at this point I feel my technique doesn’t necessitate it.

 

[facted]

Would you think any less of a colleague who used it on super obese patients or patients he/she had difficulty feeling the midline or spinous processes on?

I just don't think it adds much for the vast majority of pts. The question is if it's worth it for whatever it costs... To help with a handful of pts a year?

I CERTAINTLY don't think it should be routinely used or needed. If so, the procedurslist needs a crash course on epidurals.

 

[Noyac]

I’ve never even seen US used for neuraxial blocks. I guess I’d be impressed if I did see it.

I also guess you can call it a “blind” procedure but I don’t “see” it that way. You need to be able to see 3D with your mind. That’s not a joke. You must feel the IC’s and come across to the middle of the spine then slowly palpate the spinous processes. Take your time here. Then use your local injection to find the plane you are aiming for. Then make absolutely certain you are in the interspinous ligament when advancing. If you pop out of the ligament then redirect. Think and see with your mind and your hands as much as your eyes. It seems silly but it is real.

I always think, wow she’s a bigunn. This might be tough. Then I seem to focus more and bam I’m in. Usually.

 

[Mman]

I'm curious about the perception about the use of ultrasound guidance for neuraxial anesthesia. My department is looking into getting an Accuro. Everyone in the department has done epidurals blindly. They all say the obese patients are difficult and take the longest and the longer it takes for epidurals the lower patient satisfaction there is.

Why would an anesthesiologist's perceived skill at placing neuraxial anesthesia be less if they use ultrasound for guidance?

The average 300 lb labor patient probably takes me about 20-30 seconds of needle work to get LOR, maybe less. Of the 5-10 minutes it takes to do a labor epidural, the majority of the time is spent opening the kit, prepping the back, cracking open the vials of local and/or saline or whatever else and then threading the catheter and hooking up the connector and aspirating and giving the test dose.

The only part of that process the U/S can help with is from needle insertion to LOR. That's it. And that is such a short duration of time already in the overwhelming majority of patients that it's a waste of time to do it routinely.

You've got a 600 lber with rods in their spine and want to give it a go with the U/S? Be my guest.

 

[Psai]

I'm curious about the perception about the use of ultrasound guidance for neuraxial anesthesia. My department is looking into getting an Accuro. Everyone in the department has done epidurals blindly. They all say the obese patients are difficult and take the longest and the longer it takes for epidurals the lower patient satisfaction there is.

Why would an anesthesiologist's perceived skill at placing neuraxial anesthesia be less if they use ultrasound for guidance?

Well maybe they should have thought about that before deciding to be fat

 

[Orin]

https://www.dotmed.com/images/news/stories/39423.jpg

To be clear, this is with a handheld portable system. Pull out your toy and use it. We all love toys.

Then get off my lawn you whippersnapper.

Seriously though, the learning curve for ultrasound based neuraxial procedures has been shown to be harder than peripheral nerve blocks. I see the benefit in select patient populations though, and I would love to have a portable setup like the Accuro or Clarius to use.

 

[Twiggidy]

I’ve never even seen US used for neuraxial blocks. I guess I’d be impressed if I did see it.

I also guess you can call it a “blind” procedure but I don’t “see” it that way. You need to be able to see 3D with your mind. That’s not a joke. You must feel the IC’s and come across to the middle of the spine then slowly palpate the spinous processes. Take your time here. Then use your local injection to find the plane you are aiming for. Then make absolutely certain you are in the interspinous ligament when advancing. If you pop out of the ligament then redirect. Think and see with your mind and your hands as much as your eyes. It seems silly but it is real.

I always think, wow she’s a bigunn. This might be tough. Then I seem to focus more and bam I’m in. Usually.

Some of my biggest have also been some of my fastest.

(Go ahead @SaltyDog I know you have a joke lined up, so just let 'er rip)

 

[Twiggidy]

https://www.dotmed.com/images/news/stories/39423.jpg

To be clear, this is with a handheld portable system. Pull out your toy and use it. We all love toys.

Then get off my lawn you whippersnapper.

Seriously though, the learning curve for ultrasound based neuraxial procedures has been shown to be harder than peripheral nerve blocks. I see the benefit in select patient populations though, and I would love to have a portable setup like the Accuro or Clarius to use.

Careful. You could get written up for that and I would only recommend if the husband is into that sort of thing.....lol. i'm here all week.

 

[deleted162650]

(Go ahead @SaltyDog I know you have a joke lined up, so just let 'er rip)

Ya, but I thought it’d be better to use it for this one:

I always think, wow she’s a bigunn. This might be tough. Then I seem to focus more and bam I’m in. Usually.

 

[Aether2000]

Ultrasound defines spinous processes, and in some the interlaminar window. It is not useful beyond this point since you cannot define the epidural space, the interspinous ligament cleft, or observe real time dispersion of injected fluid due to bone echogenicity of the lamina. It certainly is not routinely necessary.

 

[dhb]

The patient population in which it might be useful is the same population in which your US image is going to be the most difficult to obtain and interpret.

In patient with arthrosis i highly doubt US is going to be a magical tool to gide you through a fused spine.

 

[T-burglar]

Ultrasound defines spinous processes, and in some the interlaminar window. It is not useful beyond this point since you cannot define the epidural space, the interspinous ligament cleft, or observe real time dispersion of injected fluid due to bone echogenicity of the lamina. It certainly is not routinely necessary.

I watched a few YouTube videos and the people who are good at it are pretty impressive , at least in the mid thoracic spine where it is most difficult.


They demonstrate an in plane real time visualization of the needle advancing through the ligament and an ABSENCE of fluid appearing outside the epidural space with LOR injection.

If this becomes a new technique that most residents learn leaving training im going to try to get up to speed on it.

 

[Hoya11]

I watched a few YouTube videos and the people who are good at it are pretty impressive , at least in the mid thoracic spine where it is most difficult.


They demonstrate an in plane real time visualization of the needle advancing through the ligament and an ABSENCE of fluid appearing outside the epidural space with LOR injection.

If this becomes a new technique that most residents learn leaving training im going to try to get up to speed on it.

It wont.

Anyone using US for neuraxial is not understanding the limitations of US. And yes I would look at this person as not understanding. Neuraxial is either fluoro or blind. Same reason that I am skeptical of paravertbral blocks done under US. When you have experience with fluoro you realize US is probably worse than blind (where at least you are relying on feel instead of nebulous blobs 6cm deep that you are interpreting as whatever structure you would like)

 

[dchz]

I see. I have the Accuro portable ultrasound that is the size of a cellphone or laptop charger brick. I realize not everyone may have one or depend on the OB's ultrasound if needed.

Costs too much, you can do the same with a 2nd hand sonosite turbo which cost 1/2 the price (~$8k) and the sonosite with curve-linear probe is better resolution