Ultrasound is the bomb

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jetproppilot

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Yeah, at forty-six years old I'm older than most of you young studs out there (even though I can certainly put you to shame on the SQUAT RACK UNLESS YOU CAN SQUAT 405 TO THE FLOOR WHICH IS WAYYYYYY BELOW THE "PARALLEL" FREQUENTLY QUOTED AS THE "OPTIMAL ENDPOINT" OF SQUATTING BY (NAIVE) PERSONAL TRAINERS):D,

BUT AN OLD DOG CAN LEARN NEW TRICKS!!!

I transitioned to a physician owned boutique hospital February 1st that does primarily spines, ortho, and bariatrics. Formed my own group. Partnered with a buddy. Hired 5 great CRNAs.

Things couldn't be better. The future couldn't look brighter.

Cuppla years ago tried to introduce ultrasound guided peripheral nerve blocks to the large hospital I worked at. Went to Houston and watched a guru for several days.

Came back invigorated, ready to start. It never happened. Too many road blocks.

FAST FORWARD TO CURRENT DAY,

the first few months at my new gig were spent on pressing issues like efficiency, flow of the operating room, turnover time, etc.

We purchased an ultrasound machine way back when the building was still unfinished.

Last week we fired up the ultrasound.

To be honest, I was kinda intimidated since it had been so long since I'd used one. Nevertheless, Friday of last week we had four shoulders. We have a Mind Ray machine, so the company flew in an ultrasound tech to assist with our startup.

I was amazed at how fast I caught on.

I did two blocks.

My partner did two blocks.

We saw the anatomy, guided the needle under ultrasound guidance to the desired position, and

BOOM.

Four. Great. Blocks!!!

After hours we used each other's legs to visualize a popliteal block since we had a couple on the books. Yeah, I could see the sciatic nerve with the rep's help but didnt feel super confident.

On Monday we had two popliteal blocks.

I did one; my partner did one.

BOOM!

We saw the anatomy with ultrasound, guided the needle. At this stage we are "cheating:" i.e. using a Stimuplex needle attached to a nerve stimulator. I'm telling you, as soon as the needle tip (under ultrasound) reached the structure I had identified as the sciatic nerve, appropriate twitches were observed!!!!

I truly am amazed at how fast my partner and I are acquiring this new technology! Well, new to me anyway.

I'm pretty deft with the nerve stimulator, yet now realize how much better ultrasound guided nerve block is.

For anyone out there still using (only) nerve stimulation for nerve blocks....for whatever reason....dudes...it's incredible....you will pick up the technique CDAZY FAST...

Tomorrow another four shoulders...

and I CAN'T WAIT!!!

I am no longer intimidated.

I am GIDDY.

I know what you young stallions out there are saying:

"JET, WTF? I'VE BEEN DOING ULTRASOUND IN MY SLEEP FOR YEARS!!!"

I hear you man.

I'm joining you.

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Welcome to the party.

Ultrasound is amazing for peripheral nerve blocks (and central lines while we're at it :) ) I do recommend beginners continue to use the stimluator in addition to the ultrasound until they get comfortable enough with the picture that the stimulation becomes superfluous. Eventually you just ditch the stimulation all together.


It's fast. It's easy. IT WORKS!

Your success rate for upper extremity blocks will rapidly approach 100%. I'm talking 99+%. I think I've had one block fail in my last 500.
 
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It's fast. It's easy.

So easy - even an EM-trained doc can do it!

Sorry, I had to stir the pot a bit.

...but, honestly, jet: I feel your energy...I still have a similar response after my first few UTS-guided PNBs.

Although I was never trained to use stim and I already have a huge interest in ultrasound for procedural assistance and diagnostics (esp in resus), I just don't understand why one wouldn't use the ultrasound for PNB.

I reallly think it will eventually be the standard of care...not now, but eventually.

I'll hedge a bit: maybe not the standard of care in anesthesiology (although I think it should be +/- stim), it certainly will be in EM...I see in 10+ years many "procedural sedations" being replaced with PNB.

HH
 
Yeah, the ultrasound is pretty cool for blocks. The femoral and sciatics are a piece of cake. Have never seen a single diaphragmatic paralysis with the interscalenes. Very easy to use for paravertebrals and TAPs. I find it satisfying to do all of mine "in plane" (i.e. visualizing the whole needle); some people do some of their blocks "out of plane" (i.e. at 90 degrees to the ultrasound probe). At some point you'll likely get comfortable enough to stop using the nerve stimulator.

Using the ultrasound for IJ lines is a given. More recently I've rescued some "difficult" subclavian lines under ultrasound guidance, though my practice is generally to do these by landmark the traditional way.
 
Just one thing to keep in mind for those in residency....

You don't know where you are going to practice.... and you MAY end up in a group that does not have access to an USD machine.

If you ONLY know how to do a block with USD, then you are handicapped.

You MUST learn how to do these blocks via a traditional landmark based approach.

This is coming from someone who uses USD daily.

Keep that in mind dudes....:rolleyes:
 
Good to see you converted

The femoral and sciatics are a piece of cake.

I think the femoral is actually often hard to visualize with US and sciatics can be challenging in the chubbies/fatties.

One truly great block by US is the supraclavicular: very easy to identify very dense plexus and good for procedures from the shoulder down. And it's not a block many people will dare do without u/s.
Did one yesterday for a radial head replacement: 10cc l-bupi + dexamethasone, this morning the patient had used 4mg of morphine from her PCA.
I'm pretty sure you can get the same result with 5cc of local. :thumbup:
 
I love the ultrasound, too. We have an Sonosite M-Turbo with the old L38 probe, and we got an HFL probe as a loaner but once we send it back, I just know my hospital is not going to want to pay for the new probe.

How is the Mindray? Are you using the M5? Someone posted about the new U-Blok system which is really cheap, but it looks like the images are crappy.

I'm a beginner at ultrasound and while it works on all my Medicare skinny old ladies, I've found that fat people and muscular people are a bit harder to ultrasound -- I think fat people have a ton of fat but their muscles and nerves are tiny, and the ratio throws me off. Muscular people just have bigger muscles, and I think that throws me off. I sometimes have to throw the needle in blindly, hope for a twitch, and then inject all the nerve-like structures in that vicinity.
 
I sometimes have to throw the needle in blindly, hope for a twitch, and then inject all the nerve-like structures in that vicinity.

This is not the way brother.

Start by putting the probe in the clavicular fossa. Look for the the ax artery, next to it you will find your honeycomb target. Now... keep it in the center of the screen and scan up and down the neck w/o loosing site of the the nerves... eventually they will stack up on top of ea. other. Change the angle of your probe beam in order to get the plexus into view if you are having trouble following the plexus as you scan up the neck.
 
Just one thing to keep in mind for those in residency....

You don't know where you are going to practice.... and you MAY end up in a group that does not have access to an USD machine.

If you ONLY know how to do a block with USD, then you are handicapped.

You MUST learn how to do these blocks via a traditional landmark based approach.

This is coming from someone who uses USD daily.

Keep that in mind dudes....:rolleyes:

Great advice. Thank you :thumbup:
 
I think fat people have a ton of fat but their muscles and nerves are tiny, and the ratio throws me off.

If they are walking around, their muscles are not tiny. As Carlos Pestana taught us, inside a walking fat person is a muscular, ripped physique cloaked in layers of adipose.

I can't speak as to nerve size, but my edumacated guess is that nerve sizes are conserved among people with similar lean habiti.
 
What are you cats using?

Sonosite M Turbo or S Nerve?

HFL 38x linear probe + C60 curved probe (for the sciatics and deep folkds)
OR
L25x linear + C60 curved?
 
Ultrasonix has a new machine coming out, with GPS guidance for the needle tip
Looks badass, but maybe technology overkill
 
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Great advice. Thank you :thumbup:

Yes, sevo gives good advice - for the anesthesiology individual in the current environment.

However, I do believe this advice will - or should be - soon outdated. The standard of care should be ultrasound!:eek:

It will be.

Older folks can keep fighting it (and me), but eventually it will be. Yes, if you are practicing in BFE US now or in a distant land, maybe you should know how to stim or landmark an IJ - but soon this will be below the standard of care. Done.

Fight it, you gray-hairs; you will loose over time.

Continue to learn Beck's triad - OR - learn how to put a probe on a patient's chest and identify pericardial effusion/PTX.

The gray-hairs or bleeding-heart "international medicine" types will continue to praise this 'Beck' and his pentad/triads; the rest of us will enjoy 'midnight vultures' and learn modern medicine. Use the GD ultrasound and join modern medicine.

For all you bleeding hearts: continue to learn sub-optimal medicine so you can save humanity in the third world. The rest of us will support the evolution of medicine in the US and other "first-world" countries and progress.

Paralyze the phrenic, if you want to hold on to tradition .

Or, grab an ultrasound/modern medicine and inject 5cc without complication.

Your choice.

HH
 
Yes, sevo gives good advice - for the anesthesiology individual in the current environment.

However, I do believe this advice will - or should be - soon outdated. The standard of care should be ultrasound!:eek:

It will be.

Older folks can keep fighting it (and me), but eventually it will be. Yes, if you are practicing in BFE US now or in a distant land, maybe you should know how to stim or landmark an IJ - but soon this will be below the standard of care. Done.

Fight it, you gray-hairs; you will loose over time.

Continue to learn Beck's triad - OR - learn how to put a probe on a patient's chest and identify pericardial effusion/PTX.

The gray-hairs or bleeding-heart "international medicine" types will continue to praise this 'Beck' and his pentad/triads; the rest of us will enjoy 'midnight vultures' and learn modern medicine. Use the GD ultrasound and join modern medicine.

For all you bleeding hearts: continue to learn sub-optimal medicine so you can save humanity in the third world. The rest of us will support the evolution of medicine in the US and other "first-world" countries and progress.

Paralyze the phrenic, if you want to hold on to tradition .

Or, grab an ultrasound/modern medicine and inject 5cc without complication.

Your choice.

HH

No one is disputing that US is better but what if your US breaks? What if you can't get a picture? Knowing how to use a stim is better than not knowing and while US should be and will be the standard of care, it's certainly important to know how to bail yourself out when things go wrong
 
hi jet , geat to hear that you are doing well , but why did you hire five great crna's instead of five great physicians?
fasto
 
Where's all this standard of care BS coming from?
All the experts agree that it will be impossible to prove superiority of one technique vs the other due to the low complication rate.
I'd rather have a rockstar that has done thousands of stim blocks take care of me than someone that has done a couple of dozen with u/s.

I love US for nerve blocks but the technique has it's pitfalls the main one being the temptation to multiply redirection with more potential for nerve trauma.
 
Where's all this standard of care BS coming from?
All the experts agree that it will be impossible to prove superiority of one technique vs the other due to the low complication rate.
I'd rather have a rockstar that has done thousands of stim blocks take care of me than someone that has done a couple of dozen with u/s.

I love US for nerve blocks but the technique has it's pitfalls the main one being the temptation to multiply redirection with more potential for nerve trauma.

Respectfully, you haven't heard what all the experts have to say. Many of the biggest in the field feel in will be the standard of care.
 
All the experts agree that it will be impossible to prove superiority of one technique vs the other due to the low complication rate.
I'd rather have a rockstar that has done thousands of stim blocks take care of me than someone that has done a couple of dozen with u/s.

I dunno what EXPERTS you are quoting, Dude.

I AM one of those ROKKSTAR stim block dudes you speak of.

With my diminutive ultrasound experience, and more importantly my intuition with a new technology I've tasted,

with all due respect,

You're wrong, man.

Ultrasound is gonna make This Rokkstar better.

No doubt in my mind.
 
hi jet , geat to hear that you are doing well , but why did you hire five great crna's instead of five great physicians?
fasto

Because he's not happy making 350k. He wants 500k so that means he has to hire CRNAs and sell out his field. :thumbdown:

I hope that extra 150k was worth it man
 
Jet, shhhhhhh... keep the secret to yourself. All of the oldtimers out there that refuse to embrace ultrasound give a lot of us the edge in job search. Almost every job, maybe every job, I looked at inquired about my regional and ultrasound skills.
 
I dunno what EXPERTS you are quoting, Dude.

I AM one of those ROKKSTAR stim block dudes you speak of.

With my diminutive ultrasound experience, and more importantly my intuition with a new technology I've tasted,

with all due respect,

You're wrong, man.

Ultrasound is gonna make This Rokkstar better.

No doubt in my mind.

Well you are getting me wrong i did not say u/s can't make you better.

Post block nerve damage is in the order of 1/10.000 with most injuries resolving in 6 months. To prove superiority thus standard of care you'll need to enroll hundred of thousands of patients in each arm of your study.
 
Everyone who does not do U/S always says their blocks are great with the stim.
Sure, our complication rates are miniscule either way, which is a testament to the field in general.
However, the consistency and reliability of my blocks with U/S (especially if I am dropping a perineural cath for a few days) will keep me from mucking around with the stim ever again.
In experience hands you can get an interscalene in <3 mins, not to mention forego the inelegance of multiple needle movements trying to dial down to 0.4mA.
 
I think I need more experience ultrasounding fat people. Maybe my problem is that when I change the depth, I am getting confused with the new dimensions. I think I might be subconsciously looking "~2cm-lateral to the IJ on the display" and it's a mental cheat that works for thin people. I think in fat people the dimensions are different and it's throwing me off. If the last fat guy I had had slightly bigger scalene muscles, than he had way way bigger amounts of adipose, and then when I increased the depth, it made his scalenes look smaller.

Sevo, I do use that technique you mentioned, but sometimes I have a hard time getting that good supraclav block picture -- I hope this is due to inexperience.

We have high volume shoulder scopes here, and all the old guys can whip out a nerve stim interscalene really really fast, so they're really ignoring the ultrasound. So I had to get really fast with nerve stim, which has been good for me. With all the setup time and documentation and prep and drape required for ultrasound, I have to BUST MY ASS to get the patient to sleep after the block in a similar amount of time, and I'm not sure it's worth it. Ultrasound is definitely awesome for all the other blocks though.

Question: how do you guys prep and drape for single shot blocks?
1. iodine, chlorhex, or alcohol swab
2. full body drape, sterile towels, or no drape
3. sterile gloves or regular gloves
4. sterile sleeve, sterile tegaderm directly on probe, sterile tegaderm on lube on probe, or "art-line style" (no prep, just put probe and non-sterile lube on probe and get picture, then use alcohol swab to wipe the entry site, then needle with non sterile gloves)
 
This thread further solidifies my desire to be an anesthesiologist. Damn my lack of patience..
 
Question: how do you guys prep and drape for single shot blocks?
1. iodine, chlorhex, or alcohol swab
2. full body drape, sterile towels, or no drape
3. sterile gloves or regular gloves
4. sterile sleeve, sterile tegaderm directly on probe, sterile tegaderm on lube on probe, or "art-line style" (no prep, just put probe and non-sterile lube on probe and get picture, then use alcohol swab to wipe the entry site, then needle with non sterile gloves)

1. chlorhexidine
2. no drape for block. sleeve and drape for catheter.
3. sterile gloves
4. tegaderm on probe. nonsterile gel inside tegaderm and also on pt.

anybody checking injection pressures?
 
I think I need more experience ultrasounding fat people. Sevo, I do use that technique you mentioned, but sometimes I have a hard time getting that good supraclav block picture -- I hope this is due to inexperience.

Push hard with the probe! The supraclavicular is one of the easier views to obtain. Sit them up about 30 degrees and make sure their head is turned away from you. I've seen people place a shoulder roll if it's difficult visualization but I haven't tried it.

I used this site during training for the cross-sectional cadaver anatomy. www.usra.ca
 
In our residency, it is difficult to learn pure landmark or stim techniques since the US is widely available and advocated by staff, and as there essentially no excuse not to use it since the complication and unsuccesful block rate is lower, our best bet is to identify landmarks prior and then confirm with US, and use nerve stim in conjuction with US. The reminder is that while residency is about learning, our patients are not our lab rats, and we are obligated to not provide them with a less safe means of anesthesia just so we can learn an older technique.

On that note, we don't do ANY interscalene blocks. For example, at our outpatient ambulatory surg center, all shoulder blocks are done pre-op "for post-op pain" in the patients day surg room (with family members sometimes present) with US guided, stim-assisted supraclavs. Surg then Gen LMA.

Which leads me to another question. I will get out of residency without ever doing an interscalene. Since US guided supraclav has good coverage for shoulders without as much risk as interscalene blocks, is there ever a private practice sitatuion (which utilizes US) where I'll ever use an interscalene block?
 
Because he's not happy making 350k. He wants 500k so that means he has to hire CRNAs and sell out his field. :thumbdown:

I hope that extra 150k was worth it man

I agree with the spirit of this post, but would do the same thing in his shoes. It's just a smart business decision. Jet's both a business-man, and a business, man.
 
On that note, we don't do ANY interscalene blocks. For example, at our outpatient ambulatory surg center, all shoulder blocks are done pre-op "for post-op pain" in the patients day surg room (with family members sometimes present) with US guided, stim-assisted supraclavs. Surg then Gen LMA.

Why no interscalenes?

Your post implied there was concern over increased complications with interscalenes vs supraclaviculars. Is this about the concern with phrenic blocks? Is this something catheter related?

Please explain.

Thanks, HH
 
....is there ever a private practice sitatuion (which utilizes US) where I'll ever use an interscalene block?

Yes... if your sonosite breaks down or you go to a group who doesn't use ultrasound.... or you only have one machine and 7 ortho rooms getting started at the same time.

It is to your advantage to learn how to do these under traditional landmark approach.
 
I'm new to PP and am wondering how you all do blocks solo? It seems like I need just one more hand! Is there a good way to do US guided blocks solo, or are you basically required to have a nurse or tech help you hold the probe or inject?
 
Personally, as being in training, I would like to learn to do these things blindly (did for some lines,) but confirm with ultrasound before going into the dangerous steps (injection, entering the vein.) Also to do things with ultrasound outright. Call me paranoid, but I like the idea of not being totally reliant on technology, because it can be taken away or not available.
 
I'm new to PP and am wondering how you all do blocks solo? It seems like I need just one more hand! Is there a good way to do US guided blocks solo, or are you basically required to have a nurse or tech help you hold the probe or inject?

You could have someone else inject or just let go of the needle. It shouldn't move out of position and I don't move the needle while injecting.
 
I guess letting go of the needle, as you suggest, may be the best option. My concern is with a superficial block (such as a supraclav in a skinny pt) it just may not hold its position.

I don't like the idea of letting someone untrained inject because they may not appropriately detect high resistance and intraneural injection.

I guess they could hold the probe, but I could see that being frustrating as well if they lose my view.

I remember seeing some needle holding device that attached to the US probe, but have never seen it in use. But I believe that only helps with obtaining in-plane views and probably does not securely hold the needle.
 
I don't think so. I would argue to never let go of the needle.

I often have the resident let go of the needle (it rarely moves or changes position) and spend the time getting the whole shaft in view. It's a great teaching tool, and a good practice. It always surprised the resident that letting go of the needle doesn't change the needle position - and getting them to believe it and do it is a challenge. It's a tuff pill for them to swallow - but rewarding.

Ultrasound is really great and so very rewarding to see the needle advance, and to see local anesthetic spread around structures. However, at times it is so very frustrating because the view you are suppose to get just doesn't happen. People's ultrasound physics (as the sound waves propogate through tissues) are sometimes such that things just aren't resolved well and you can't see crap.

I have been trying to increase my use in the pain clinic to cut down on fluoro exposure and I have been really pleased with some of the blocks. Cervical selective nerve root blocks really are best done using ultrasound. Stellate ganglion blocks work surprisingly well with a 1/5 of the amount of local as a traditional block done under xray. Piriformis injections are so rewarding and satisfying.

Also, we are doing deep cervical plexus blocks for awake carotids - and these are easy and work so very well. My next step is to try and block the mandibular nerve (to get the andle of the mandible numb for the jaw retractor during the surgery - this always seems to bother the patient). We currently are doing a blind intra-oral injection - but I think the ultrasound guided injection seems sexier. Anyone doing this?
 
I don't think so. I would argue to never let go of the needle.

An arm for the probe is a neat tool but a bit expensive:
2649428367_b896f8fc81.jpg


I often let go of the needle if it's truly in place it should not move. I've realized with ultrasound that often what happened with nerve stimulation was that you are stimulating trans-fascially so when you let go you loose the twitch.
This is imho the reason why with NS you get failures or blocks that take a long time to set since you're relying on diffusion.
With US i'm always entering the nerve sheath, the needle stay's put and i inject small amounts of local.
I'm down to 10cc for IS, SC, ax and sci pop nerves and i could go lower but that's splitting hairs.
 
The needle is the connection to your patient. IMHO.
 
Most u/s guided blocks are amenable to letting go of the needle. If you have half of the needle through the skin, the tip doesn't move much when you let go, and you are watching it under U/S to see if it does.

The biggest risk is displacement of the tip when you pick up the syringe and apply a different torque to the needle.

Of course I don't do a lot of blocks anymore, but in residency I would let go of the needle so I could get good real-time recordings of the injection.

- pod
 
The needle is the connection to your patient. IMHO.

I understand your reluctance. I learned it from Spencer Liu at HSS. It's a quasi-academic practice, MD-only (mostly) type place. They do their blocks in the room and sedation, so the block has to work. His blocks work. It's a safe and effective practice. Since you see the local spread, if you need to re-adjust you do, it's no big deal. You should try it.
 
Where's all this standard of care BS coming from?
All the experts agree that it will be impossible to prove superiority of one technique vs the other due to the low complication rate.
I'd rather have a rockstar that has done thousands of stim blocks take care of me than someone that has done a couple of dozen with u/s.

I love US for nerve blocks but the technique has it's pitfalls the main one being the temptation to multiply redirection with more potential for nerve trauma.

HAHAHAHAHAHAHAHA!

Dude.

Nerve-stimulating-peripheral-nerve-blockade is

BLIND.

There's, intrinsically, alotta

HUNTING. PROBING.

Peripheral nerve blockade via ultrasound is

LIVE.

I can see where I wanna go.

I GO THERE. I'm SEEING WHERE THE NEEDLE IS GOING. I POINT IT TO THE PROMISED LAND.

I can't do that with a nerve stimulator.

You can continue to kid yourself that nerve stimulation is commensurate with ultrasound, or you can

Admit the truth.

Philosophically speaking,

There Is Only One Truth.

In this instance, The Truth is

Ultrasound.
 
Nerve-stimulating-peripheral-nerve-blockade is

BLIND.

There's, intrinsically, alotta

HUNTING. PROBING.

This is true, I don't think anyone would deny that. Whether or not that extra poking around with a 22g blunt needle actually causes more complications is a different question altogether.

Let's be honest, complications from regional anesthesia are very rare. Intuitively it makes sense that with u/s those complications may be reduced, but lots of results in medicine don't line up with what we intuitively and logically expect.

It may be that it just doesn't matter what technique an experienced person uses.

It may be that u/s ultimately causes MORE complications than nerve stim techniques, because on the whole, the LA probably gets deposited closer to the nerves. Maybe that'll result in more neuropathy. We don't really know.

I think it's a little premature to declare u/s a new no-brainer standard of care.


All that said, I use u/s.
 
You can continue to kid yourself that nerve stimulation is commensurate with ultrasound, or you can

Admit the truth.

Philosophically speaking,

There Is Only One Truth.

In this instance, The Truth is

Ultrasound.

Dude i use US every day. I teach attendings, fellow residents US guided blocks.
Today i did an infraclav cath, femoral cath, hand block and an interscalene for a shoulder reduction in pre-op , by the time the lady got to the OR the shoulder was reduced the orthopod didn't even pull on it.

I love US but all the goodness doesn't cloud my judgement: there's actually no proof of superiority of the technique.

Btw Jet do you combine US with NS or are you going strait US?
 
An arm for the probe is a neat tool but a bit expensive:
2649428367_b896f8fc81.jpg

Am I the only one that thinks I can build something just as good for $100 worth of parts from home depot? We usually do our blocks alone or with a nurse that is just there to push more versed. I've been doing pre and post US images just for documentation but I'd love to be able to visualize my blocks.
 
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