Zero room for Error

[BLADEMDA]

http://m.youtube.com/#/watch?v=XTCwfTU6wgU&desktop_uri=/watch?v=XTCwfTU6wgU

Watch the video. Sonisite has this ad on prime time tv. I have made the switch to u/s for my nerve blocks and central lines. I even use the u/s more and more for arterial lines.

I was from the dinosaur age of nerve stimulator and landmark based lines/blocks. No more.
I have seen the benefits u/s offers and am now sold on its routine use especially for central line placement. I do utilize the static technique when the IJ is bigger than 10-12 mm in size because of my extensive experience; but, I prefer live u/s for teaching, any anticoagulants on board, previous carotid surgery, Small IJ, etc.

For nerve blocks I now use U/S for all my blocks and have expanded my routine blocks to include adductor canal, TAP, Subcostal TAP, supraclavicular, infraclavicular, Paravertebral, etc.

I now consider myself an advanced u/s user just a tad under expert. For those of you out there reluctant or hesitant to make the switch to u/s I urge you to take the leap. It is truly worth the effort and will only enhance your skills. The learning curve for u/s isn't as big as the learning curve for doing landmark based blocks. Those of you who are proficient in landmark based blocks can and should make the transition.

Advertisements like this to the general public should only enhance your desire to make the switch. Your patients will soon expect it.

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Members don't see this ad.

 

[BLADEMDA]

Visit http://www.sonosite.com/zero for more information about "Zero Room for Error".

When they realized there was a way to improve patient safety, they took action. Nothing was going to stop them from attaining zero iatrogenic pneumothorax complications. A brave step by a bold team now recognized by the Medicare HAC list. Inspired by the true story of hospital staff who believed even one medical error was too much to chance and a point-of-care ultrasound technology that would change their path of care forever.

 

[BLADEMDA]

Those healthcare professionals who are committed to providing their patients with the best level of care possible. Whether it is a nerve block or a steep angle injection, these forward-thinking doctors realize the advantages of SonoSite point-of-care visualization in guiding needles to improve care, increase efficiency, and decrease complications. Which results in faster onset of anesthesia, reduced used of drugs, and better outcomes. Congratulations on consistently hitting your mark.
What Our Customers Have to Say
“At this point, it would be hard to imagine a case in which I would perform a nerve block or central venous catheter placement without ultrasound. Any time one can see the needle and the target, whether it be nerves or blood vessels, it is going to contribute to greater safety and efficacy.”
- Gavin Martin, MB, ChB, FRCA, Associate Professor of Anesthesiology, Duke University Medical Center, Durham, North Carolina
“The ultrasound-guided technique allows us to use less analgesia, diminishes complications, and helps us avoid stimulating nerves that could cause additional pain or discomfort in the patient.”
- Paul Bigeleisen, MD, Clinical Associate, Professor of Anesthesiology, University of Rochester Medical Center (URMC), Rochester, New York
Ultrasound technology enables British anesthesiologists to efficiently and accurately place regional anesthesia, resulting in cost reductions for the hospital and a better patient experience.
To learn more about this program or any other SonoSite solution, please call 1.877.520.1649 or email us.
Ultrasound Visualization:
Anesthesiologists worldwide are using ultrasound visualization to improve patient safety, increase efficiency and decrease complications. SonoSite works closely with anesthesiologists to develop customized solutions that meet the rapidly expanding clinical requirements. Advanced needle visualization is just one example of our forward-thinking product enhancements. Advanced needle visualization makes the needle clearly distinguishable while maintaining striking image quality of the target and surrounding anatomy—especially at the steep angles needed on common procedures such as deep femoral blocks.
The implementation of ultrasound technology enables anesthesiologists to perform precision-based procedures and treatments, including nerve blocks, upper extremity blocks, neuraxial blocks, femoral nerve blocks, steep angle injections, paraspinal blocks, brachial plexus blocks, epidurals, and regional pain blocks, with increased efficiency. Because ultrasound technology enables an anesthesiologist to visualize the needle, injections can be administered more with a higher success rate than without ultrasound guidance. SonoSite Offers a Range of Customized Products That Provide:

Advanced imaging features for exceptional image quality with minimal key strokes
Fluid-resistant for easy cleaning and disinfection
Under 20 seconds from cold start to scanning
Custom use models for point of care applications
Built to exceed U.S. military specifications for durability
Industry leading 5-year warranty
Extensive training and education programs

Related Education Videos:
How to: Ultrasound Guided Infraclavicular Brachial Plexus Nerve Block
How to: Ultrasound Guided Supraclavicular Brachial Plexus Nerve Block

 

[leaverus]

did you learn on the job or did you take a workshop? what's the recommended workshop if there is one?

 

[excalibur]

The best workshop is

Internet/YouTube for sonoanatomy, probe position, technique
Using the ultrasound machine on yourself (save the femoral view)
Watching and Learning from the guru in your practice
Couple your ultrasound with a nerve stimulator
Review Netter's Anatomy textbook--Amazing how some of his cross section drawings are like the U/S pics

 

[BLADEMDA]

did you learn on the job or did you take a workshop? what's the recommended workshop if there is one?

I learned on the job and through the internet. I also took a workshop with Brandon Winchester of BlockJocks.com The best resource is doing the blocks with the Nerve Stimulator after watching the videos of blocks by Winchester or Auyong online (watch the videos at least ten times). Soon, you won't be using the nerve stimulator very much and your comfort level doing u/s will progress quickly. Then, you can start doing PVB, Subcostal TAP, etc. utilizing u/s and an assistant with ease.

 

[BLADEMDA]

 

[BLADEMDA]

Even with an Echogenic needle it is best if you start with the neddle 1-2 cm away from the edge of the probe. You get better images with a shallow angle even if using an echogenic needle

 

[BLADEMDA]

 

[leaverus]

ok, appreciate the responses. there really is no "guru" in my current practice and we do our blocks for post-op pain strictly in the OR prior to induction/neuraxial/whatever so there's really not much time for observation or practice; and i'm way too green compared to the other guys in the group to have any sway in changing this practice. still i'd like to keep up my skills whatever way i can.

 

[gasp]

Visit http://www.sonosite.com/zero for more information about "Zero Room for Error".

When they realized there was a way to improve patient safety, they took action. Nothing was going to stop them from attaining zero iatrogenic pneumothorax complications. A brave step by a bold team now recognized by the Medicare HAC list. Inspired by the true story of hospital staff who believed even one medical error was too much to chance and a point-of-care ultrasound technology that would change their path of care forever.

Is it just me or was that commercial cheesy? "are you ready to place the central line Dr?", "NO!, now we're ready". What a douche.

 

[MTGas2B]

Is that the sonosite commercial where the guys are claiming that ultrasound for subclavians should be standard of care? Maybe I'm a dinosaur already, but I can't buy into that one.

 

[DrN2O]

"Zero room for error"? Does that mean any complication is a cause for second guessing or woese? When do you ever say to a patient there's zero chance for xxx?

 

[cincincyreds]

So I've always used an ultrasound for central lines and blocks. One question I have is why would you do an infraclavicular block over a supraclavicular block? I've found really good success with the supraclavicular block for my hand procedures. I do realize the risk of a PTX, but with the ultrasound it is a very easy block to do.

 

[Gern Blansten]

So I've always used an ultrasound for central lines and blocks. One question I have is why would you do an infraclavicular block over a supraclavicular block? I've found really good success with the supraclavicular block for my hand procedures. I do realize the risk of a PTX, but with the ultrasound it is a very easy block to do.

when placing a catheter, it is better tolerated in the more lateral infraclavicular location, similar to a subclavian central line being better tolerated than an IJ central line. Less affected by neck movement and less likely to be dislodged. I believe there is a lower risk of PTX also, but the risk of PTX with a supraclav is small if you have experience and exercise appropriate caution.

 

[Oggg]

Use the infraclav nerve block view to image the axillary vein, then place your central line in that vein just before it dives under the clavicle to become subclavian vein. This avoids arterial sticks and ptx. Even our cardiac surgeons who have done millions of subclavian lines blind, they're always hitting the artery or doing multiple attempts. USG axillary-subclavian vein is tougher than USG IJ due to depth an reduced visibility, but sometimes you don't want a neck line. I've even rescued a few surgeons when they've flailed on subclavian access

 

[deleted126335]

Use the infraclav nerve block view to image the axillary vein, then place your central line in that vein just before it dives under the clavicle to become subclavian vein. This avoids arterial sticks and ptx. Even our cardiac surgeons who have done millions of subclavian lines blind, they're always hitting the artery or doing multiple attempts. USG axillary-subclavian vein is tougher than USG IJ due to depth an reduced visibility, but sometimes you don't want a neck line. I've even rescued a few surgeons when they've flailed on subclavian access

Awesome idea. Why didn't I think of that? How many have you done with this technique? Anybody else try this? What position do you put the arm on the side of the vein that you are trying to cannulate?

 

[BLADEMDA]

Use the infraclav nerve block view to image the axillary vein, then place your central line in that vein just before it dives under the clavicle to become subclavian vein. This avoids arterial sticks and ptx. Even our cardiac surgeons who have done millions of subclavian lines blind, they're always hitting the artery or doing multiple attempts. USG axillary-subclavian vein is tougher than USG IJ due to depth an reduced visibility, but sometimes you don't want a neck line. I've even rescued a few surgeons when they've flailed on subclavian access

http://m.youtube.com/watch?feature=related&v=Lnv7hfVaHsw

Is this your technique? Do you prefer the right or left side for this supraclavicular central line?

Or is this your technique?

http://m.youtube.com/watch?feature=related&v=IBmbc1ak5fY

 

[deleted162650]

Our regional guru is also a big proponent of U/S guided ax/subclavian central lines. He achieves the Infraclav view just as your would for a block using the small curvilinear c11 probe. He then rotates the probe 90 degrees and advances the needle in plane into the vein. He has also placed ax art lines in the same manner.

 

[BLADEMDA]

 

[BLADEMDA]

Our regional guru is also a big proponent of U/S guided ax/subclavian central lines. He achieves the Infraclav view just as your would for a block using the small curvilinear c11 probe. He then rotates the probe 90 degrees and advances the needle in plane into the vein. He has also placed ax art lines in the same manner.

Does he stick the needle lateral to medial (as I assume) for cental line placement? Also, the lung is only a few cm medial to the vein in this particular situation so extreme care is advised. Also, I find the vein is sometimes very small in some patients under 70kg. An Infraclavicular stick in the lateral location isn't reliably an easy central line access point.

Why not follow the vein down the from the neck and place the central line just above the clavicle?

 

[BobBarker]

The subclavian ultrasound guided central line view has been discussed on here a few times. There was an article in Critical Care over it a couple of years ago that I did a journal club on. I have done both blind and ultrasound guided subclavian lines. I greatly prefer the blind approach as the angle of the needle when accessing the axillary vein is at about 45 degrees right at the pleura.

 

[BLADEMDA]

The subclavian ultrasound guided central line view has been discussed on here a few times. There was an article in Critical Care over it a couple of years ago that I did a journal club on. I have done both blind and ultrasound guided subclavian lines. I greatly prefer the blind approach as the angle of the needle when accessing the axillary vein is at about 45 degrees right at the pleura.

What about the SUPRACLAVICULAR approach to the subclavian vein? Any experience with that technique?

Anyone done a few of these?

 

[BobBarker]

I have imaged the vein but never placed a line. I don't see why it would be difficult to do.

 

[reanimatore]

So I've always used an ultrasound for central lines and blocks. One question I have is why would you do an infraclavicular block over a supraclavicular block? I've found really good success with the supraclavicular block for my hand procedures. I do realize the risk of a PTX, but with the ultrasound it is a very easy block to do.

I think there are a several possible scenarios where it's optimal to be equally comfortable with the supraclavicular and infraclavicular blocks.

Remember, when performing a supraclavicular block you still run the risk of proximal/medial local anesthetic spread over the anterior scalene muscle, resulting in phrenic blockade. The incidence is lower with a supraclavicular block than with an interscalene, but it can still be significant if you're dealing with a pulmonary cripple. I have never seen nor heard of an infraclavicular block producing hemi-diaphragmatic paresis.

Also, as someone else alluded to, catheter retention seems to be greater in the infraclavicular location as you have the pectoralis major and minor muscles anchoring the proximal catheter.

Additionally, the supraclavicular area can be fairly vascular in some folks. In particular, I find that the transverse cervical artery can sometimes drape laterally over the brachial plexus in this view. It's nice to have another block handy that will allow you to avoid any vascular minefields.

Finally, another potential advantage of doing an infraclavicular block vs supraclav is being able to ensure that you have ample perineural spread of local anesthetic around the brachial plexus cord that innervates the area of the surgery (ie posterior cord covers radial/axillary distribution, medial covers ulnar/median, etc).

 

[reanimatore]

Our regional guru is also a big proponent of U/S guided ax/subclavian central lines. He achieves the Infraclav view just as your would for a block using the small curvilinear c11 probe. He then rotates the probe 90 degrees and advances the needle in plane into the vein. He has also placed ax art lines in the same manner.

Exactly, although this approach technically results in axillary vein cannulation.

When placing a line this way, I typically image the axillary vein in the usual infraclav view like you mentioned. I then scan as far lateral as I can while still maintaining a decent, ample diameter view of the vein, which gives you a better working space in relation to the pleura. I then rotate the probe from the short axis/cross-sectional view of the vessel into the long axis view, which allows for an in-plane, lateral to medial needle approach. This works very well for me, reducing the angle of entry and allowing me to simultaneously visualize the longitudinal vessel lumen/trajectory and the entire shaft/tip of the needle, while keeping me lateral to the pleura. Once you puncture the vein, you can also image the wire entering into the vessel lumen in the same view for confirmation.

If you're interested in this technique, try doing some quick vascular scanning the next time you're placing an infraclavicular block. It's not as tricky as I may be making it sound. The c11 probe can be very helpful for this approach as it provides deeper penetration and accommodates better visualization at a steeper approach if you're dealing with large patients.