Arteries through C5

 

 Over and over again, I am reaffirmed of the of the ‘everyday advantages’ of utilizing ultrasound for peripheral nerve blocks. [nonmember]…

 

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The position of my targets are clearly and quickly identified,  appropriate local anesthetic spread is confirmed or corrected and atypical anatomy is recognized. I see unexpected arteries and atypical nerve anatomy that cause me to alter my needle trajectory and target position all the time. The above video is  just one more example of the relatively common ‘problems waiting to happen’ that I encounter on a daily or weekly basis. Without ultrasound guidance, this could have easily turned in to a mess! If you are performing a few blocks with nerve-stimulation here and again to help some with post-operative pain, this kind of oddity will come across as the once in a while mysterious failed or partially functioning nerve block (or maybe the patient was just crazy or drug-seeking) or as an unexpected aspiration of blood, hematoma and aborted attempt. You come away with “Wow, that was weird. Blocks are SO unpredictable.”  You feel less inspired to expose yourself and your patients to the mysterious and unpredictable world of peripheral nerve blocks. With this scenario, I might agree; first do no harm, right?

     If you are doing lots of blocks with nerve-stimulation in an integrated block program, you soon recognize that the pace and performance expectation of ‘through put’ make for an unacceptable percentage of failure to achieve your goals. You certainly won’t be able to reliably depend on your blocks to allow you to alter or optimize downstream processes. That is, an arthroscopic shoulder case at the hospital that becomes a block failure can just be admitted/readmitted for pain control or just hurt more at home (Patients should expect pain after surgery, right?) . If you are banking on essentially 100% success because you have moved 23 hour observation shoulder cases to the surgery center, that 5 or 10% partial block/failure rate will be a real problem (as will the once in a while 15 or 20 minute block performance time).

     I realize that your current speed and accuracy with single injection blocks is probably superior and that changing to incorporate ultrasound will (initially) slow you down and possibly lead to less success. There are reliable approaches to transforming your practice to incorporate ultrasound that will ultimately lead to greater speed and success while minimizing the difficulty of transition that comes with change. When you are incorporating continuous nerve blocks, the reliability of the secondary block (that comes from the infusion through the catheter) with nerve-stimulation and ultrasound-guided block becomes even more pronounced. If this is where you are, the need to bite the bullet and learn to use ultrasound is far greater.

     Here are a few tips to aid in the transition to using ultrasound in your practice. First, continue doing what you usually do, but perform an ultrasound scan ahead of time. Just practice using the tool without the pressure to rely on it. Gain a confidence in recognizing typical sonoanatomy. If you happen to see an unexpected artery or nerve position, alter your nerve stimulation technique or abort if it is not possible with your usual technique. At the least, you may increase your success or have avoided a complication by this practice. At this stage, consider the path you would take if you were to use ultrasound while you are scanning.

     As you gain confidence, try the block with the probe in place but with the new angle/approach dictated by the ultrasound technique. You will want to select a patient with a favorable body habitus and an opportunity when you are not particularly strapped for time. Use nerve-stimulation as your primary technique. Either ignore the image completely, or let the ultrasound confirm your placement. If you traveled a distance that you thought should have been met with success, look at the image to see if that can show you which direction you should go with your next needle pass. Concentrate on using your nerve-stimulation skills to guide your maneuvers at this point. When you complete the block, scan the area again to see the ‘post-block’ image. Did your local go where you thought it would? Follow a length of the nerve to see the distance up and down that the local traveled. Would you have selected a different initial trajectory? All you have done to this point is selected a new trajectory for your nerve-stimulation technique.

Stay tuned for more helpful tips and tricks!

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