Visualization of the needle when doing US guided nerve blocks

[ToKingdomCome]

I’m having trouble visualizing the needle when I use ultrasound to do PNB’s. Does anyone have any better tips in terms of getting a better view of my needle?

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[ucladoc2b]

I’m having trouble visualizing the needle when I use ultrasound to do PNB’s. Does anyone have any better tips in terms of getting a better view of my needle?

Small moves on the probe.

 

[nimbus]

1. Visualize the scanning plane in your mind (remember it’s about as thick as a credit card.) Keep the needle within that plane.

2. Insert the needle with the shallowest possible skin angle to keep the needle shaft as parallel as possible to the probe. You get stronger reflections if the needle shaft is parallel to the probe.

3. Plan before you puncture the skin. Make sure your target, your needle entry point, and your planned needle trajectory are all in plane.

 

[KENY1]

It's actually common not to see the needle at all times.
When I started I thought the textbooks were showing the reality when actually they were just showing the 'best view'.

Sent from my SM-F900U1 using Tapatalk

 

[deleted875186]

Honestly, I thjnk the way people get great pictures is by using one of the very echo genie needles. If I were able to use a Pajunk needle for every block, I’d be able to have a great view for even very steep angle blocks.

Sometimes the angle is too steep, or the tissue is just of a consistency (certain muscle layers) that the needle is not visualized all that well.

 

[nimbus]

Honestly, I thjnk the way people get great pictures is by using one of the very echo genie needles. If I were able to use a Pajunk needle for every block, I’d be able to have a great view for even very steep angle blocks.

Sometimes the angle is too steep, or the tissue is just of a consistency (certain muscle layers) that the needle is not visualized all that well.

That should have been my 4th point, use a Pajunk or a Tuohy.

 

[Ezekiel2517]

Move only one hand at a time, either the hand holding the probe or the hand holding the needle. Usually, if I can’t see the needle after I go in, I will make small movements with my probe hand to find the needle.

 

[caligas]

Learn to isolate probe movements to one variable at a time (sliding, rocking, rotating). Usually cutting off View of the needle tip is a rotation issue.

 

[vector2]

Hold the US probe toward the distal end and stabilize against the pt using the side of your hand / ring and little finger. Make sure left hand, right hand, and the screen are all in harmony before sticking. When you have a perfect anatomical picture, modify the needle position to match the picture, don’t move your US probe wildly to find the needle. If necessary, restick if it looks like your needle position is grossly off axis.

 

[Wolverines83]

line everything up...you, the needle, the patient, the ultrasound screen all in one straight line. You should only have to drop your eyes down to see your hands, then back up to see the screen. if you have to turn or tilt your head at all, that movement will make your hands move too (ever see a new driver look right and pull the steering wheel right?).

If you can't see your needle at all, stop everything and look down at the probe and the needle...are they lined up? probably not; your probe probably slowly slid off to the side because of all that slippery gel, no big deal. Move the probe back over the needle and line it up along the same axis as the needle under direct visualization and then look back at the screen. If you still can't see the needle you're only off by a fraction of a cm so slide right or left (very tiny movements) until the whole needle is visualized. If you see only a portion of the needle you have the probe rotated off axis to your needle (meaning you're not quite long axis, not quite short axis), rotate the probe until either you see all of the needle or none of the needle. If as you rotate you go from seeing a piece to seeing nothing it means you're now parallel to but to the side of the needle. Now you just need to slide the probe right or left to be over the needle and it'll be long axis again.

Basically, if your picture looks off, stop what you're going, look at your hands, make macro adjustments, look back at screen and make micro adjustments.

As one person said, try to have as shallow a needle angle as possible so it reflects more of the ultrasound beams back to the transducer. Even though you want the probe parallel to your needle, you want your beam to be perpendicular to the needle. That way more beams are reflected back to the probe. If it absolutely must be a steep angle (hey, big people need blocks too), try tilting the probe away from you (the end with the wire goes away from you so the probe is looking back at you) so that the ultrasound beam is as perpendicular to the needle as possible.

what vector said about resting your hand on the patient is great advice...do it for lines as well

Note: this advice assumes you haven't made some gross error in needle entry to begin with

 

[dchz]

Some good advice in here. After you've mastered the basics, remember:

-You need to anchor both hands to have fine motor control.

-You should only worry about the tip, "just the tip" as @SaltyDog would say it.

Lastly, a lot of people are afraid of moving the probe or getting out of the alignment. Once you've mastered doing the block in a 2D picture, remember this is a 3D structure. don't be afraid to sweep and fan around to understand the 3D structure you're looking at. Fanning and sweeping is also the key to finding the needle tip.

 

[deleted697535]

line everything up...you, the needle, the patient, the ultrasound screen all in one straight line. You should only have to drop your eyes down to see your hands, then back up to see the screen. if you have to turn or tilt your head at all, that movement will make your hands move too (ever see a new driver look right and pull the steering wheel right?).



Basically, if your picture looks off, stop what you're going, look at your hands, make macro adjustments, look back at screen and make micro adjustments.



what vector said about resting your hand on the patient is great advice...do it for lines as well

These 3 points plus loads of practice with a blue phantom (you can make one for 30cent) helped me.

Start just doing in plane technique only. And for heavens sake do it with the needle and USS pointing at the screen. For example for a left infraclav block, stand above the patients lefts shoulder and have the US's screen at his left hip. Never start with the needle and US's probe coming across your body at 90 degrees from you and the US's screen. That's hard and also insane if you ask me but so many of my colleagues do it and end up butchering the block. I cannot understand it. When you line everything up, and stabilise both hands, it's literally insanely easy to all your needle.


Id have some of my colleagues telling me you need new regional skills like using my left hand, or doing it at 90 degrees and I cannot understand why.

Even learning out of plane is a waste of time except maybe pop fossa. All the other blocks can be done in plane, easy, bang it out, move on...

 

[deleted162650]

Some good advice in here. After you've mastered the basics, remember:

-You need to anchor both hands to have fine motor control.

-You should only worry about the tip, "just the tip" as @SaltyDog would say it.

Lastly, a lot of people are afraid of moving the probe or getting out of the alignment. Once you've mastered doing the block in a 2D picture, remember this is a 3D structure. don't be afraid to sweep and fan around to understand the 3D structure you're looking at. Fanning and sweeping is also the key to finding the needle tip.

So to paraphrase your technique (if I may):

Anchor your hands.
Carefully insert until your tip is at the spot.
Fan and sweep.

I feel like I might know a liiiiiittle too much about you now.

 

[Monterosso]

To reiterate some of the above posts, often a main issue for early practitioners is "oblique-ing." As in the needle is obliqued to the probe, thus you only see a small cut of it rather than the entire needle.

With good technique, I feel you can, and should, keep the entire needle in view when using an in-plane approach (not "just the tip" of the needle). If you are seeing just the tip of the needle it means you are oblique-ing and there is a chance the cut of the needle you are seeing is not the actual tip but a midsection, thus risk of injury.

Some more nuanced techniques include in-toeing, meaning pushing the far part of the probe in and slightly lifting the near part, to better get the ultrasound beam perpendicular to the needle. Another similar move would be an ultrasound gel 'stand-off technique" to also obtain a more perpendicular angle.