US guided nerve blocks

[AKMD_1984]

so im having a difficult time seeing the needle under the ultrasound in plane.

was wondering if there are any specific tricks or techniques that can help me? i keep losing the view of the needle and then look down then look up on the ultrasound.
how much pressure do i gotta put on the probe?

http://www.bluephantom.com/details.aspx?pid=61

has anyone tried devices like these??? are they helpful?? should i buy one? (im allowed money for my yearly book expenditure).

i feel like we do so few of them (because the senior resident get priority) and when i do finally get them i am fudging them up.

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[ssmallz]

Practice practice practice....there's no other way around it. Everyone has different ways of doing it but here's a few tips

1) It's much easier to see the needle when it's more parallel to the probe and not perpendicular. Use as low an angle of attack as possible

2) shift your body so that you can look strait at the side of the transducer as if you were looking down the sight of a gun, then insert the needle in the middle of the transducer

3) When you lose the needle, and you can't find it by scanning, look down at the needle and try to imagine where the shaft is then realign the probe

 

[Idiopathic]

Practice practice practice....there's no other way around it. Everyone has different ways of doing it but here's a few tips

1) It's much easier to see the needle when it's more parallel to the probe and not perpendicular. Use as low an angle of attack as possible

2) shift your body so that you can look strait at the side of the transducer as if you were looking down the sight of a gun, then insert the needle in the middle of the transducer

3) When you lose the needle, and you can't find it by scanning, look down at the needle and try to imagine where the shaft is then realign the probe

great advice, exactly what i was going to say. the two biggest mistakes people make are two 1) not have a "birds-eye" view of the probe with proper needle alignment along that plane and 2) being afraid to slightly reorient their probe to "find" their needle, then readjust everything so that you are headed toward your target. remember, you can always find the nerve again...it doesnt move.

 

[narcusprince]

Saw this and had to give some major advice. Currently on an ambulatory surgery rotation and have done 5-6 blocks daily for the month mostly upper extremity single shot blocks. Here are some of the mistakes I have made.
Fatigue I am six four and in the beginning I was not pumping the bed height up enough to securely dock my hand which is holding the ultrasound probe. The probe hand should be resting on the patient in a comfortable orientation.
Find your view and dock that hand. Find the center of the ultrasound probe and use that as your entry point. Remember the ultrasound beam is the width of a credit card so you have to be in the center.
Third orientation ergonamics(not big for me because I grew up playing video games) but if your doing a R sided supraclavicular block your needle goes from R to L so make sure your orientation on the screen is R to L, also make sure the ultrasound machine is on the side away from the block.
Sonosite makes an gel simulator which I used all the time once I started it aided me in getting the needle in plane.
If your needle gets out of plane for God sake DO NOT ADVANCE the needle. Bad things can happen. Look down at the probe and make sure your needle is within the beam of the probe. Relax it takes time and practice. Everyday this month I have played with the ultrasound probe and the gel simulator and have gotten much better and feel confident I can do the base upper extremity blocks supraclaviculars, infraclavicualrs, and axillary blocks, and of course IS.
Good luck.

 

[Bertelman]

There are basically 2 axes you are manipulating with that probe to visualize the needle- learn how and when to manipulate those 2, and you will do well. As mentioned above, the more parallel the needle path to the probe (or perpendicular to the beam, however you want to describe it), the easier to visualize For me, that sometimes meant entering skin 1-2 cm behind the probe, instead of right up against it.

1st axis is pronation/supination, or "tilting" the probe. Do this if you cannot locate the needle at all on your screen.

2nd axis is rotation or "twisting" the probe. Try this if you see a small segment of the needle lighting up, but you are not capturing the full length of the needle to the tip. You've got the needle in view, but your US plane is not aligning with the needle plane.

Those are the 2 primary axes to adjust. Don't make the rookie mistake of moving the needle and probe at the same time.

You just need mucho practice. And try to keep the needle in plane from the very beginning. It sounds counterintuitive, but I've found that the less needle you have advanced, sometimes it is actually easier to locate and align the plane for final advancement.

I actually think it's fine advancing the needle a bit without visualizing it, if you think that may help. Just make sure you're not nestled up against an artery or something. Even if you are, just don't inject. I've never understood the admonitions to not move if you can't see the tip. People have been doing this for decades without seeing where the tip is.

 

[climbingak]

Just to add to the good advice above:
-Subtle pressure on one side of the probe or the other can help redirect the beam more perpedicular to the needle.
-entering away from the probe is key to make the beam more perpedicular.
-if you have a poor view of the end of your needle but its kind of there, inject a little. The sound wave travels better through liquid and it brightens up the picture.
-compression of the probe may help get a better picture in bigger people. otherwise I use medium to light pressure so that my needle is more maneuverable. If you are having trouble getting your needle above something, lighten up probe pressure.
-for deeper blocks (infraclav, sciatic), I use a 20g touhy needle. The rounded tip that points back toward the probe cathces the sound waves. Even if your needle isn't the brightest you still have a fairly bright echogenic tip (which is sometimes all that matters).

It gets better with practice.

 

[Bertelman]

Just to add to the good advice above:
-Subtle pressure on one side of the probe or the other can help redirect the beam more perpedicular to the needle.
-entering away from the probe is key to make the beam more perpedicular.
-if you have a poor view of the end of your needle but its kind of there, inject a little. The sound wave travels better through liquid and it brightens up the picture.
-compression of the probe may help get a better picture in bigger people. otherwise I use medium to light pressure so that my needle is more maneuverable. If you are having trouble getting your needle above something, lighten up probe pressure.
-for deeper blocks (infraclav, sciatic), I use a 20g touhy needle. The rounded tip that points back toward the probe cathces the sound waves. Even if your needle isn't the brightest you still have a fairly bright echogenic tip (which is sometimes all that matters).

It gets better with practice.

Generally good advice, but make sure all air bubbles have been removed from the syringe. The guy that loaded and injected for us in residency was not meticulous enough in doing this, and would invariably inject a dozen or so air bubbles with the first few cc's. Nothing kills an US interface like air bubbles. Never saw needle tip after that.

 

[Oggg]

There is a real learning curve at the beginning. Don't give up -- everyone says the same thing. Try not to succumb to the lure of echogenic needles or needle finding software. Save those for difficult blocks.

Get a head start on needle tracking by looking for your local needle on ultrasound. Then you know you have the right angle. If you can't see your local needle then you know you don't have the right angle to start.

 

[AKMD_1984]

thanks folks...is there any thing i can use to practise?!?!

like i practiced suturing using chicken and pig feet.

i feel like i have such limited time on the patient that i cant get over that hump of learning by trial and error and self diagnosing and correcting myself. the patient is awake and i get nervous and my attending doesnt want to teach me on teh spot because of this and i dont want to keep poking the patient.

its been a mess.

are there any cheap alternatives i can use to just practise on a model and just get a feel for it?

 

[RussianJoo]

Why don't you make the pt comfortable? Versed and Fentanyl will do the trick. Then the pt won't care if you poke him/her and you won't get nervous and your attending can teach you. Do you mind sharing where you're doing your residency? You can private message me if you wish. When I started out doing Axillary blocks it would take me like >20min to do them because I had trouble seeing my needle. The best is when your attending keeps telling you "show me the needle"... Like I am hiding it on purpose.

 

[Oggg]

Practice scanning real people. Then you will be fast at getting and keeping the right picture. Needle-probe coordination needs a lot of practice on real patients. Phantoms are too easy and don't offer much learning because the image is usually too good. Real patients are fat and curvaceous and they move and twitch. I think there was an article in RAPM about making a pork shoulder phantom from scratch

 

[deleted126335]

Anybody do their blocks sitting down? I am just a beginner at u/s regional and tall and have done a few blocks this way find it easier to get the needle parallel to the probe.

 

[desflurane]

Like everyone says its practice, practice, practice.

The ergonomics point is a great one. Get comfortable. You don't want to be stressed out and uncomfortable and in a rush when you are learning. Thats for us pp guys 🙂

There are two skills you need to learn. 1) US anatomy and 2) Manipulating a needle under US.

Practicing on a real patient is ideal because you learn both skills simultaneously. Since this isn't always possible because of the time crunch, I'd suggest separating the two skills as you are starting out.

First: Scan everyone you can. Your mom, wife, husband, co-residents, attendings, OR nurses, surgeons 🙂 anyone who will let you. Learn the US anatomy cold. It helps to know what you are looking at, so either an instructor or a good atlas should be with you. You already know the anatomy (or you should), so just understand the patterns as they appear under US.

Second: Practice needling. The phantoms are ok to start. It'll give you a sense of how narrow that beam really is. Practice with different size needles as well. Pork shoulders are good as well as they have tendons, muscle etc.

Both of these things can be done without the pressures of the OR schedule on your back. If you are in a program with a block room, the pressures shouldn't be there and if it is then they aren't doing it right.

 

[ssmallz]

Anybody do their blocks sitting down? I am just a beginner at u/s regional and tall and have done a few blocks this way find it easier to get the needle parallel to the probe.

I prefer to stand because I feel like I can make more subtle movements to fine tune my body position better. When doing blocks I always make sure the block site is about at the level of my sternum. This way I'm never bending over and I can rest my hands very comfortably on the pt to stabilize the probe and needle. Having a good base of support by resting your hands on your patient makes it less likely you will stray off course with your needle/probe. I also make sure the US is on the contralateral side to the block so that I can simply look up to see it without turning my head or moving my body. Even slight turns of your head and body can move the needle/probe and cause misalignment.

Another point to make is that you should line your body up so that you are almost perpendicular to the insertion site of your needle so you can line up your needle and probe like you would the sight on a gun. By keeping everything in a straight line you give yourself the best chance to hit your target.

 

[drccw]

I hate doing block sitting.. I can't get the ergonomics straight for some reason...

I jack the bed way up. I'm only 6 ft tall but I put the bed so that my hands are comfortable...

I scanned everything for a long long time... Long xlap? take out the US and scan the brachial plexus....

drccw

 

[fakin' the funk]

was wondering if there are any specific tricks or techniques that can help me? i keep losing the view of the needle and then look down then look up on the ultrasound.
how much pressure do i gotta put on the probe?

To specifically answer your question: a) it sounds like you're not "docking" your hand appropriately as another poster described, and b) you only need enough pressure to create an appropriate transducer-gel-skin interface.

My approach to keeping needle in plane is:
1) Rest the probe hand securely on the patient
2) Keep the probe and needle 90 degrees to each other
3) Probe-needle alignment has to be correct in all 3 axes (1 translational, 2 rotational) for the needle to be in the image properly. Slight adjustments go a long way. It's easy to slide laterally (translated) away from the needle and/or rotate the probe like a screwdriver so the long axis of the beam isn't aligned with the needle's long axis.

 

[epidural man]

so im having a difficult time seeing the needle under the ultrasound in plane.

was wondering if there are any specific tricks or techniques that can help me? i keep losing the view of the needle and then look down then look up on the ultrasound.
how much pressure do i gotta put on the probe?

http://www.bluephantom.com/details.aspx?pid=61

has anyone tried devices like these??? are they helpful?? should i buy one? (im allowed money for my yearly book expenditure).

i feel like we do so few of them (because the senior resident get priority) and when i do finally get them i am fudging them up.

Yes, the phantoms are VERY helpful.

I don't know how much they cost though.

I tell all the residents that start go spend A LOT of time messing with them. You can really get the mechanics of the hand holding the probe with the right amount of pressure (hardly any) and keeping the probe and needle aligned. However, do note that finding the needle on a phantom is 100% easier than in a person.

A ham, a shoulder, or chicken, or something like that also works well to practice - and I'm sure that is much cheaper.

I want to stress what others have also stressed. Angle is SO important. Anything over 30-40 deg is not going to show up, so do what you can to decrease the angle. This usually means entering the skin a lot farther away from the probe then you think. If the needle angle is steep, try heeling in the probe face so it and the needle are closer to parallel.

 

[Oggg]

Blue phantoms are really expensive. Great for residency where you have waves of noobs. After a few sticks I learned all I could from it though.

 

[Gern Blansten]

I think the ASRA journal had a recipe about a year ago for a build your own phantom. I'm not able to look it up right now, but it is out there as a letter to the editor I believe.

 

[sevoflurane]

Anybody do their blocks sitting down? I am just a beginner at u/s regional and tall and have done a few blocks this way find it easier to get the needle parallel to the probe.

Yes. I have a partner with L5-S2 spine/nerve issues. He always does his BP blocks in the supine position (I always do mine with the patient in the sitting position).... Cuz of his back, he also always sits... and his blocks always work. He's old school... doesn't even bother with an USD for BP blocks. I would imagine it would be just as easy with and USD machine. I have another partner that brings the patient in the room and puts them on the OR table with the patient in the supine position. He does USG blocks of the upper extremity from above the patients head as if you are getting ready to intubate. I'm sure you could use his technique sitting down. His success rate is also near 100%.

I still prefer the patient in the sitting position. I tend to think the gravity works in my favor in the sitting position...

 

[dhb]

I always do my blocks sitting down with the patient supine: takes to long to crank the bed up.
I also stand at the head for IS and supra-clav blocks

 

[Oggg]

+1 for sitting

I never have a good assistant, so I keep the ultrasound machine right in front of me so I can see the picture well and press/point-at buttons (as opposed to putting machine on opposite site

 

[sevoflurane]

so im having a difficult time seeing the needle under the ultrasound in plane.

was wondering if there are any specific tricks or techniques that can help me? i keep losing the view of the needle and then look down then look up on the ultrasound.
how much pressure do i gotta put on the probe?

http://www.bluephantom.com/details.aspx?pid=61

has anyone tried devices like these??? are they helpful?? should i buy one? (im allowed money for my yearly book expenditure).

i feel like we do so few of them (because the senior resident get priority) and when i do finally get them i am fudging them up.

You're all good buddy. You'll get there. Practice, practice, practice. Don't go for speed at first. Identify the nerve and try to get a doughnut that encases whatever nerve you are going for. Good suggestions above. Always good to add a little LA to see exactly where you are if you can't see the tip of the needle... sometimes you can reposition to get the nerve surrounded in a bath of LA.

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IMG_1951 by Crazyhorse75, on Flickr[/IMG]

Ain't she beautiful? 🙂

 

[sevoflurane]

I tell all the residents that start go spend A LOT of time messing with them. You can really get the mechanics of the hand holding the probe with the right amount of pressure (hardly any) and keeping the probe and needle aligned.

Great suggestion. Grab some other CA1's and practice on ea. other... especially for specific nerves... radial, median, ulnar, MC... etc...