Ultrasound Tip #3

There are a number of ways that you can gain assistance in recognizing the tip of your needle while advancing it. Some are cheap, and some are expensive. I’m certainly not going to say that you should abandon all of the mechanisms that allow you to recognize the needle tip that are available if your experience and skill are not at the appropriate point for this. I would like to challenge you, however, to aim at developing your skills over relying on every guide and assistance that’s out there. [nonmember]…

 

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 Once you have proven that, again and again, you can reliably identify the ‘snowman’ of the interscalene nerve block, do you always need to use a stimulating needle to confirm it? When you can consistently maintain needle-beam alignment, do you need to use an echogenic needle for a shallow block? When relatively perpendicular, even a non-echogenic 25 gauge needle lights up like crazy. What else does the echogenic needle do for you? Again, I can understand using one for a steep needle angle because the textured surface scatters sound back toward the probe.

     Do you need to upgrade to the latest ultrasound technology to angle the beam toward your steep needle descent? That is a useful tool if you have it, but your facility may or may not be up for that immediately. I’m all for safety (and efficiency and efficacy), but there is something to be said for developing quality technique and learning to interpret subtle ultrasound cues. The development of these skills can be hampered by relying too heavily on various ‘training wheels’. Sometimes you run across tips and tricks that you would not have if you used every aid in the book.

     One such trick,  I discovered a few years back using a regular epidural needle for TAP blocks. I still had not settled on the type of needle that I thought worked best. I certainly didn’t need a stimulating needle, and I didn’t want to open a whole tray for the few extra items that I needed, so I found a plain Tuohy needle and catheter set. I was using the bevel upside down to try to successfully scrape into the fascial layer to deposit my local, but I flipped it upward while ‘popping’ through the first two fascial planes to make them more notable. I used a relatively steep angle in order to pop through in a more pronounced fashion.

     With the relatively steep angle on my non-stimulating epidural Tuohy needle, I recognized that the needle tip was notably brighter than the rest of the needle. The steep angle caused much of the beam to reflect away from the probe, sometimes casting only a shadow when I was properly oriented. The tip was not only noticeable due to the altered appearance of the curve but by the fact that the curve caused it to have a more perpendicular  angle to the beam. I have utilized this little trick ever since.

There are lots of other minor observations out there like this that can help improve safety for your patients and give you hints to improve your success. Pay attention to these types of nuances to help sharpen your skills and keep yourself out of trouble.

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