US Injections—controlling the probe, needle, syringe

[au bon pain]

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Anybody have a setup they like for ultrasound-guided injections that allows them to control the proble, needle, and syringe?

I currently do a mix of “let it go” and “bedforth” grip but am trying to settle on one way to increase speed. Maybe there’s a better way?

‘Let Go’ technique in ultrasound guided Regional Anaesthesia | Journal of Anaesthesia & Critical Care Case Reports

Vol 5 | Issue 3 | Sep-Dec 2019 | page: 7-9 | Shiv Kumar Singh, Tuhin Mistry Authors: Shiv Kumar Singh [1], Tuhin Mistry [2] Address of Correspondence 1 Department of Anaesthesiology, Royal Liverpool University Hospitals, Liverpool, United Kingdom. 2 Department of Anaesthesiology, All India...

jaccr.com

What’s everyones technique and why do you like it?

 

[lobelsteve]

Paging Oreos...
Dr. Oreos on the blue phone.

Since we have world's foremost US mSK expert on the forum......

 

[pinstriped1992]

Anybody have a setup they like for ultrasound-guided injections that allows them to control the proble, needle, and syringe?

I currently do a mix of “let it go” and “bedforth” grip but am trying to settle on one way to increase speed. Maybe there’s a better way?

‘Let Go’ technique in ultrasound guided Regional Anaesthesia | Journal of Anaesthesia & Critical Care Case Reports

Vol 5 | Issue 3 | Sep-Dec 2019 | page: 7-9 | Shiv Kumar Singh, Tuhin Mistry Authors: Shiv Kumar Singh [1], Tuhin Mistry [2] Address of Correspondence 1 Department of Anaesthesiology, Royal Liverpool University Hospitals, Liverpool, United Kingdom. 2 Department of Anaesthesiology, All India...

jaccr.com

What’s everyones technique and why do you like it?

I'm sure this depends on what kind of procedure you're doing. I do all my procedures solo without an MA. Always have left hand on probe and right hand on syringe with 4th and 5th fingers acting as stabilizer on the body. Only time I drop the probe is to switch out the syringe in the case of an aspiration or switching from anesthetic only to my injectate syringe. Once I have the new syringe on, I reposition to probe to make sure my needle is still at my target and then I continue my injection under ultrasound guidance. I'm never advancing/injecting without the probe looking at the needle tip. This method eliminates the need for extension tubing for everything I do.

 

[Orin]

I've had reps talk to me about this but I just let the needle go and inject if I'm ever lucky enough to be solo in the hospital

SAFIRA™

SAFIRA™: SAFer Injection for Regional Anaesthesia Creates a single operator procedure Engineered safety solution to control injection pressure threshold Reduces chances of nerve injury Improves patient safety Current Regional Anaesthesia process: Current regional anaesthesia...

www.ltrmedical.com

 

[RaceCanyon]

Uh, am I weird? I just hold the syringe like I am about to inject at all times. I drive that way and once I am in place I inject. No tubing needed.

 

[DoYouEvenLiftBro]

I do let go unless stellate, those I have an assistant on the syringe

 

[BobBarker]

Uh, am I weird? I just hold the syringe like I am about to inject at all times. I drive that way and once I am in place I inject. No tubing needed.

I think they are using the designed US block needles that come with tubing. I use a 20g Tuohy and do it like you.

 

[au bon pain]

Uh, am I weird? I just hold the syringe like I am about to inject at all times. I drive that way and once I am in place I inject. No tubing needed.

I’ve certainly done it that way before. But in general I find there’s less needle/pressure control unless most of the needle is buried.

 

[FSQT]

Hold the syringe. I never use tubing for anything. I think that's a weird regional anesthesiology thing. Slower procedures are more painful procedures. Tubing might make sense for a block using 20-30mL. I do a TAP or ESP maybe a couple times a year so I don't bother with the tubing.

Stabilize. There's lots of ways to do this, and I adapt to the patient, procedure, and setting. For instance, you can rest your elbow on the patient's body or a mayo stand next to you. Sometimes I'll just stabilize by pressing my volar forearm against my rib cage. Can also stabilize keeping digit 4 and 5 in contact with the patient.

Optimize your ergonomics. Aim down the barrel of the rifle: Your eyes, the needle (rear sights), the probe (front sights), and the screen (target down range) should all be lined up. If you're having to look "back-and-forth" from needle to screen, then your setup was bad.

 

[Orin]

I’ve certainly done it that way before. But in general I find there’s less needle/pressure control unless most of the needle is buried.

My hands can do that with a loaded 5 mL syringe, but anything smaller/bigger it gets too difficult

 

[oreosandsake]

Paging Oreos...
Dr. Oreos on the blue phone.

Since we have world's foremost US mSK expert on the forum......

whoever is the foremost msk expert needs to chime in but that's def not me.

I've never seen anyone use those techniques in the paper. they look useful to do for high volume regional blocks where you want to be able to grip a 10 ml syringe... and maybe squeeze it all through extension tubing. if the syringe plus needle length is too unweidly, why not just place the needle and then attach the syringe afterwards?

the needle should not move a ton. what I've seen as someone who has taught hundreds of US cadaver courses is that it is easier to advance the needle in plane once you get it. Trying to find it again after you've moved away the probe is difficult for a lot of people. but it is very feasible.

ex: if im doing a TAP block in someone with a lot of girth, i numb the skin and then advance my spinal needle to the depth. get close to where I need to be and then pull the stylet and attach my 10ml syringe. get to the last few mm and inject. with enough practice you also learn to be efficient and SAFE with out of plane so you dont need to use so much needle to reach your targets.

 

[au bon pain]

whoever is the foremost msk expert needs to chime in but that's def not me.

I've never seen anyone use those techniques in the paper. they look useful to do for high volume regional blocks where you want to be able to grip a 10 ml syringe... and maybe squeeze it all through extension tubing. if the syringe plus needle length is too unweidly, why not just place the needle and then attach the syringe afterwards?

the needle should not move a ton. what I've seen as someone who has taught hundreds of US cadaver courses is that it is easier to advance the needle in plane once you get it. Trying to find it again after you've moved away the probe is difficult for a lot of people. but it is very feasible.

ex: if im doing a TAP block in someone with a lot of girth, i numb the skin and then advance my spinal needle to the depth. get close to where I need to be and then pull the stylet and attach my 10ml syringe. get to the last few mm and inject. with enough practice you also learn to be efficient and SAFE with out of plane so you dont need to use so much needle to reach your targets.

So it sounds like you arrive near your destination and then attached the syringe to the needle and go—is that right?
Would you mind clarifying the last part of the bolded above, especially “you don’t need to use so much needle to reach your target.” Do you mean you pick the shortest needle that should get you to your target based on a scout US image? Or something else?

 

[interjectionreflection]

whoever is the foremost msk expert needs to chime in but that's def not me.

I've never seen anyone use those techniques in the paper. they look useful to do for high volume regional blocks where you want to be able to grip a 10 ml syringe... and maybe squeeze it all through extension tubing. if the syringe plus needle length is too unweidly, why not just place the needle and then attach the syringe afterwards?

the needle should not move a ton. what I've seen as someone who has taught hundreds of US cadaver courses is that it is easier to advance the needle in plane once you get it. Trying to find it again after you've moved away the probe is difficult for a lot of people. but it is very feasible.

ex: if im doing a TAP block in someone with a lot of girth, i numb the skin and then advance my spinal needle to the depth. get close to where I need to be and then pull the stylet and attach my 10ml syringe. get to the last few mm and inject. with enough practice you also learn to be efficient and SAFE with out of plane so you dont need to use so much needle to reach your targets.

Do you prefer out of plane to in plane? I'm sure it varies with type of injection but generally speaking

 

[oreosandsake]

Do you prefer out of plane to in plane? I'm sure it varies with type of injection but generally speaking

in plane is always more reliable and safer
OOP is great for really superificial targets or things that don't really need perfect precision (safety margin) or if it becomes the safest approach to avoid sensitive structures. you can also find things in a classic view and come oblique to the probe (OOP but diagonal) I do a lot of SIJ injections like this so that I can still get the trajectory towards to joint without having to pull out a spinal needle. yes, you can get a lot of SIJ with a 1.5in 25G

 

[oreosandsake]

So it sounds like you arrive near your destination and then attached the syringe to the needle and go—is that right?
Would you mind clarifying the last part of the bolded above, especially “you don’t need to use so much needle to reach your target.” Do you mean you pick the shortest needle that should get you to your target based on a scout US image? Or something else?

yes, arrive at your target and attach syringe if spinal needle and 10 ml syringe

yes, scout image.

 

[lobelsteve]

in plane is always more reliable and safer
OOP is great for really superificial targets or things that don't really need perfect precision (safety margin) or if it becomes the safest approach to avoid sensitive structures. you can also find things in a classic view and come oblique to the probe (OOP but diagonal) I do a lot of SIJ injections like this so that I can still get the trajectory towards to joint without having to pull out a spinal needle. yes, you can get a lot of SIJ with a 1.5in 25G

Not in Georgia.
Biscuit poisoning.

 

[CB1Antagonist]

I am a fellowship trained pain doc who graduated in 2007, with zero exposure to ultrasound. Does anyone have advice on a mentorship or course to learn hands on ultrasound guided nerve blocks and MSK injections?

 

[nvrsumr]

Nysora and YouTube videos talk me alot

 

[Ducttape]

i have done an injection in the SI region using ultrasound.


i billed it as a trigger point after insurance denied the SI injection.

 

[pinstriped1992]

I am a fellowship trained pain doc who graduated in 2007, with zero exposure to ultrasound. Does anyone have advice on a mentorship or course to learn hands on ultrasound guided nerve blocks and MSK injections?

For diagnostic US can't beat these PDFs - Subcommittee Ultrasound - European Society of Musculoskeletal Radiology
For diagnostic and procedural videos these are oldies but goodies, extremely thorough and cover a lot of what is covered in PM&R residencies -