In-plane ultrasound-guided needle insertion ALONG or ACROSS the visual axis hand positions

Comparison of ultrasound-guided internal jugular vein cannulation versus supraclavicular approach to brachiocephalic vein cannulation– A prospective, single-blind, randomised study

Background and Aims:

The internal jugular vein (IJV) is the most common site for central venous cannulation. Ultrasonography (USG)-guided brachiocephalic vein (BCV) cannulation has been described recently. The objective of this study was to compare the first attempt success rate, overall success rate and procedural ease between two techniques.

Methods:

This was a prospective, single-blinded, randomised clinical study. Patients were randomly allocated into two groups using computer generated random table. Group IJV included 55 patients of USG-guided out-of-plane approach to the right IJV cannulation and group BCV included 55 patients for USG-guided supraclavicular in-plane approach to right BCV cannulation. The success rate, number of redirections needed, vein and needle tip visualisation, cannulation time and complication rate were compared between the groups.

Results:

Demographic parameters were similar between the groups. Success rate of cannulation was 98.5% in IJV group and 100% in group BCV (P = 0.31). The first attempt success rate was 76.3% and 81.81% in IJV and BCV group, respectively (P = 0.42). IJV was collapsed in 14.5% cases and BCV was collapsed in 0.9% cases. The needle visualisation was better in BCV group (94.54%) compared to IJV (80%) (P = 0.02) group, which was statistically significant. The numbers of redirections of needle were more in IJV group. Thus the procedural ease was better with BCV than IJV.

Conclusion:

Supraclavicular USG-guided in-plane BCV cannulation is a good alternative to USG-guided out-of-plane IJV cannulation, because of good calibre of the vein and better needle visualisation in the BCV group.

Ergonomics in the anaesthetic workplace: Guideline from the Association of Anaesthetists

Ergonomics in relation to anaesthesia is the scientific study of the interaction between anaesthetists and their workspace environment in order to promote safety, performance and well-being. The foundation for avoiding pain or discomfort at work is to adopt and maintain a good posture, whether sitting or standing. Anaesthetists should aim to keep their posture as natural and neutral as possible. The successful practice of anaesthesia relies on optimisation of ergonomics and lack of attention to detail in this area is associated with impaired performance. The anaesthetic team should wear comfortable clothing, including appropriately-sized personal protective equipment where necessary. Temperature, humidity and light should be adequate at all times. The team should comply with infection prevention and control guidelines and monitoring as recommended by the Association of Anaesthetists. Any equipment or machinery that is mobile should be positioned where it is easy to view or reach without having to change the body or head position significantly when interacting with it. Patients who are supine should, whenever possible, be raised upwards to limit the need to lean towards them. Any item required during a procedure should be positioned on trays or trolleys that are close to the dominant hand. Pregnancy affects the requirements for standing, manually handling, applying force when operating equipment or moving machines and the period over which the individual might have to work without a break. Employers have a duty to make reasonable adjustments to accommodate disability in the workplace. Any member of staff with a physical impairment needs to be accommodated and this includes making provision for a wheelchair user who needs to enter the operating theatre and perform their work.

Ultrasound probe tilt impedes the needle-beam alignment during the ultrasound-guided procedures

The objective of this study was to identify the factors that complicate the needle visualization in ultrasound-guided in-plane needling procedures. Forty-nine residents were recruited and randomized to insert the simulated blood vessel with four different views including Neutral (the long axis of the probe along the visual axis and the ultrasonic beam vertical to the surface of gel phantom), 45°-rotation (45° angle between the long axis of probe and the operator’s visual axis), 45°-tilt (45° angle between the ultrasonic beam and the surface of gel phantom) and 45°-rotation plus 45°-tilt of probe. Number of needle redirections, insertion time, and needle visibility were documented and compared for each procedure. When the residents faced with 45°-tilt view, the needle redirections (2 vs 0) and insertion time increased significantly (39 vs 16) compared with that of the Neutral view. When faced with 45°-rotation plus 45°-tilt view, the residents’ performance decreased further as compared with that of the 45°-tilt view and the Neutral view. However, there was no performance difference between the Neutral view and 45°-rotation view. In conclusion, during ultrasound-guided in-plane procedures, tilting the ultrasound probe may increase the difficulty of needle-beam alignment.

Along or across the visual axis: a comparison of two ultrasound screen, needle and transducer orientation techniques

OBJECTIVE

To evaluate two transducer and needle handling methods, along the visual axis (AL) and across the visual axis (AC), in non-skilled and skilled clinicians.

STUDY DESIGN

Prospective randomized crossover study.

METHOD

A total of 26 students with no ultrasound locoregional anaesthesia experience (non-skilled group) and six clinicians experienced and familiar with ultrasound locoregional anaesthesia (skilled group) were enrolled. The non-skilled group was asked to perform two tasks: the first on a phantom and the second on canine cadavers, whilst the skilled group performed only the second task. The tasks consisted of guiding the tip of the needle to a target point (simulated nerve on the jelly phantom and sciatic nerve on the cadavers) using two different methods of needle handling-AL or AC. All operators performed each task three times for each method. The time to drive the needle to the target for the two methods was analysed with a paired Student t test, and the number of times the needle was not visualized on the screen between the groups was compared using an unpaired Student t test. Data are presented as mean ± standard deviation. Value of p < 0.05 was considered significant.

RESULTS

The AL method, compared with the AC method, resulted in shorter performance time in both skilled (9 ± 5 versus 20 ± 8 seconds for the second task) and non-skilled groups (9 ± 8 versus 17 ± 15 seconds for the first task and 18 ± 11 versus 32 ± 26 seconds for the second task).

CONCLUSION AND CLINICAL RELEVANCE

In both groups, the AL method significantly reduced the time to complete the task. Results from this study indicate that the AL method should be the preferred method for learning/teaching ultrasound-guided regional anaesthesia.

Analgesic Effectiveness of Ultrasound-Guided Pecs II Block in Central Venous Port Catheter Implantation

Background and Aim

In oncology patients, central venous port catheter (CVPC) implantation is generally preferred for venous route. However, in this procedure, postoperative pain is often observed. This study aimed to investigate the effectiveness of ultrasound-guided Pecs II block in the management of pain after CVPC placement.

Methods

One hundred and eighty-seven patients who underwent CVPC implantation between January 2017 and August 2018 were included in the study. Patients who underwent Pecs II block under ultrasound guidance were called as the Pecs group, and those who underwent local anesthesia (LA) were referred as the LA group. All procedural parameters were analyzed, including demographic characteristics of patients, visual analogue scores (VAS) at 2nd and 24th hours, and postoperative opioid, and non-steroidal anti-inflammatory drug (NSAID) consumption.

Results

The postoperative 2nd hour VAS scores were similar in both groups and were lower than the 24th hour VAS scores. VAS scores at the 24th hour in the Pecs group were significantly lower than the LA group (P = 0.001). While the number of fentanyl rescue doses administered in PACU was similar, the total NSAID consumption in the first 24 hours was higher in the LA group than in the Pecs group.

Conclusion

In CVPC placement, ultrasound-guided Pecs II block is a more reliable, easily applicable and longer-acting approach than LA infiltration for postoperative analgesia.

Development of a lateral ultrasound-guided approach for the proximal radial, ulnar, median and musculocutaneous (RUMM) nerve block in cats

OBJECTIVE

To describe a lateral ultrasound (US)-guided approach to the radial, ulnar, median and musculocutaneous (RUMM) nerves through a single proximal in-plane insertion in cats and to determine whether one or two injection points are required to successfully stain all the target nerves.

STUDY DESIGN

Prospective study.

ANIMALS

A total of eight client-owned healthy cats and 12 cat cadavers.

METHODS

In live cats, the US anatomy of the brachium, the landmarks and the site for needle accesses were determined. Then, 12 thawed feline cadavers were used to assess the spread of dye solution and nerve staining following the US-guided proximal-lateral-humeral RUMM injection using one and two injection points. Each cadaver was injected with 0.15 mL kg^-1 of a 0.25% new methylene blue solution in either a single injection aimed for the radial nerve of one limb (G1) or via two sites delivering 0.1 mL kg^-1 and 0.05 mL kg^-1 aimed for the radial and musculocutaneous nerves of the opposite limb, respectively (G2). Upon dissection, staining of the target nerves around their circumference for length of >1 cm was considered successful.

RESULTS

Sonoanatomy was consistent with anatomy upon dissection and target nerves were identified in all cadavers. Staining was 100% successful for the radial, median and ulnar nerves in both groups, and 41.7% and 100% for the musculocutaneous nerve in G1 and G2, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

This novel lateral US-guided approach for the proximal RUMM nerve block allowed a good identification of the nerves and related structures, and it provided a consistent muscular structure through which the needle could be easily guided. An injection performed in two aliquots (within the caudal and cranial compartments of the neurovascular sheath) appeared to be necessary to successfully stain all the target nerves.

Infraclavicular brachial plexus block in adults: a comprehensive review based on a unified nomenclature system

Over the last decade, considerable progress has been made regarding infraclavicular brachial plexus block (ICB) in adults, especially since the introduction of ultrasound guidance. The advancements in ICB have been attributed to the development of various approaches to improve the success rate and reduce complications. This has also necessitated a unified nomenclature system to facilitate comparison among different approaches. This review aimed to propose an anatomical nomenclature system by classifying ICB approaches into proximal and distal ones to aid future research and provide practice advisories according to recent updates. We also comprehensively discuss various aspects of this nomenclature system. Our review suggests that ultrasound-guided ICB should be categorized as an advanced technique that should be performed under supervision and dual guidance. For one-shot block, the conventional distal approach is still preferred but should be modified to follow ergonomic practice, with the arm in the proper position. For continuous ICB, the proximal approach is promising for reducing local anesthetic volume and increasing efficacy. Nevertheless, further studies are warranted in this direction. We provide practice advisories to maximize safety and minimize adverse events, and recommend designing future studies on ICB according to these findings based on the unified nomenclature system.

Ultrasound-guided truncal blocks: A new frontier in regional anaesthesia

The practice of regional anaesthesia is rapidly changing with the introduction of ultrasound into the working domain of the anaesthesiologist. New techniques are being pioneered. Among the recent techniques, notable are the truncal blocks, for example, the transversus abdominis plane block, rectus sheath block, hernia block and quadratus lumborum block in the abdomen and the pectoral nerves (Pecs) block 1 and 2, serratus anterior plane block and intercostal nerve block. This narrative review covers the brief anatomical discourse along with technical description of the ultrasound-guided truncal blocks.