Is interscalene block without ultrasound a violation of the standard of care?
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- Опубліковано 21 гру 2023
- Watch the video as we navigate a challenging situation in the operating room: performing an interscalene block for shoulder surgery without an ultrasound machine. Our day began with the usual routine, but things took an unexpected turn when all our ultrasound devices were in use, and time was ticking. Watch as we switch gears and use a nerve stimulator for the block, guiding a fellow who's never done it without ultrasound. The tension mounts: can we safely and successfully administer the block with just a nerve stimulator? Experience the nerve-wracking 30 seconds it took to administer the block and the surprising results we discovered once we finally got our hands on an ultrasound machine.
We leave you with some thought-provoking questions:
1. Was it a violation of the standard of care to perform this block without ultrasound?
2. Would you consider a nerve stimulator block if an ultrasound wasn't available?
3. In an ultrasound-dominated era, is it still crucial to teach nerve stimulator techniques?
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Everything depends on skills and experience of anesthesiologist. I am semiretired and have done hundreds of interscalene (actually supraclavicular) blocks with stimulator. Success rate - 100% in last 4 years. No significant complications so far. Never incountered clinically significant paralysis of diaphragm. I made a rule for myself never insert needle more than approx. 1/2 inch. Always start injection at low pressure and 1 ml volume and wait few seconds. Never inject if feel higher resistance. But everything is a result of extensive experience and hand feeling. I was lucky for not having any complications in a process of developing that feelings. So, I think that young anesthesiologists trained with ultrasound technique should stick with that, while for older guys like me, stimulator is safer and preferable.
Having done interscalene and supraclavicular blocks without nerve stimulation and without ultrasound by paresthesia alone from 1980 until my retirement in 2020 I can state unequivocally that it can be done with safely and efficiency comparable to that of ultrasound. During that time I had one pneumothorax with supraclavicular block in a patient with a history of a broken clavicle and one intraneural injection with interscalene. The intraneural injection was my own foolish error in technique early in my career before the advent of pressure measuring devices to detect resistance to injection. I believe the pneumo was because of landmarks distorted by the distorted clavicle. I also became proficient in ultrasound technique. I went to paresthesia alone in the 80s when nerve stimulation equipment was clumsy and unreliable. After paresthesia technique was perfected in my hands nerve stimulation offered no advantage and was significantly more uncomfortable for the patient.
Paresthesia and even nerve stimulation guided techniques are now lost arts in almost all US environments. They are therefore no longer defensible. The relevant comparison studies are no longer even possible. There is no longer a sufficient number of skilled individuals who can defend it. The Lone Ranger was an imaginary, fictional character. I do not believe medicine can be ethically practiced alone without the understanding, support, concurrence and comaraderie of one's peers. Every additional person who is even potentially part of a medical decision moves the process away from idiosyncrasy and towards the objective end of the therapeutic spectrum. One should be neither the first, the last, nor the only practitioner to use a technique. Thanks for posing this important question.
Absolutely agree with you. I think, as anything else in anesthesia and surgery, a lot depends on experience and skills of particular practitioner. New generation should stick with US techniques, while older anesthesiologists are safer and better with their skills.
Thanks a lot for sharing the extraordinary video. All anesthesiologists should know the alternative way to overcome adverse situations. So they should be taught the blocks without any machine aslo as landmark and paraesthesia techniques which we have done earlier. Hope to see more like this video.
100% agreed!
Everything depends on your resources and is a balance of risks/benefits.
Any "standard" will be relevant to the context in which it is believed to be applied.
I'm old enough to have done blocks with a nerve stim, now I do them with both ultrasound and nerve stim and based on the current evidence I don't inject if I get a twitch at a level years ago we would have been told wasn't close enough to inject.
I once saw a consultant when I was a trainee do an axilary block purely by landmarks and tactile feel on the end of a needle, around the artery (successfully).
Working in a resource poor setting I'd do one with a nerve stimulator, if it was a life threatening siutation I'd potentially do one anyway (but strugling to think of a life threatening situation where a block would be necessary)
Alot of the skills we used to have though have been degraded due to loss of use or subtleties that aren't necesarily obvious with other techniques which raises the risks of doing things that were once but no longer are routine.
Informed patient consent in that they understand the reasoning and the risks/benefits of the procedure and agree to it in that context is the main component (followed by documentation to satsifsy any lawyer).
Great reply. Ineed, who looks at the neck veins, or listens to the heart sounds any longer to detect a gallop or a valve issue - everyone gets an ultrasound. With nerve blocks - however the ultrasound is most prevalent tool to guide regional blocks - the organized societies have not adopted ant standards - so nerve stimulator-guided nerve blocks are not a violation of the standards, unless the local institution makes up their own standards whereby the Ultrasound is standard locally. Greetings
@@DRBLUESNYC haha, Interestingly - I always listen to heart sounds when preassessing a patient.
Mainly it's to develop raport with the patient and convince them I'm a proper doctor, however I can can tell you a story of when it saved me (or more accurately my patient).
The main thing in practice (at least in my country) is the risk and the benefit to the patient, both must be estimated and the patient must consent competently.
excellent and instructive video Dr. Hajik thanks!!!
Very happy to hear that!
We should be able to do that not only when all equipment is avoiable, but also in "war situations". Perhaps this blockade is not so important for an anaesthesiologist because he/she can always do a general anesthesia but it id crucial to do central vein cannulation without ultrasound.
Another great reply! aGREED!
Central line wise I fully agree. I’m luckily old enough to have performed many central lines (jugular and subclavian) without ultrasound and young enough to have also had great teachers for the ultrasound guided approach!
As i am practicing in small city of Gujrat India since last 43 years.We trained giving blocks only by paraesthesia and landmark guided.In 2000 PNS came in our practice then comes USG. Anesthetist who is practicing as freelancer can not afford to buy USG as well there is PNDT act in india which prevents you to move your USG machine.I strongly suggest that every Anesthesiologist should know PNS guided blocks
Thank you for your valuable input. It is regrettable that many medical workers encounter various obstacles in their work, but we must continue striving to find solutions to them. Thanks once again.
AMAZING VIDEO, however, i think that pernorming a Pns guided block nowdays is only justified if you dońt have any ultrasound at all, or as we saw in the video, as a Way of teaching Under supervision. In other circumstances, i Think that waiting for the ultrasound is the better option for the patient .
The fact that there are so few comments here highlight the fact that almost all practitioners today would simply insist that the wait for the ultrasound was justified by patient safety considerations. Only a handful of practitioners in this country have maintained the skills to do interscalene or supraclavicular blocks without ultrasound. It is notable that even in this example ultrasound was ultimately used to confirm spread. Had a clinical endpoint not been achieved without ultrasound I can only suppose that the anesthesiologists would have proceeded by general anesthesia alone or waited for ultrasound.
The task of teaching all anesthesiologists the alternative of non ultrasound guided upper extremity block is now, I believe, impractical if not impossible. We lack the most important resources: teachers with sufficient skill and experience to teach it in a setting that would tolerate the delay and inconsistency of the teaching. Additionally we would require motivated students.I maintained my non ultrasound upper extremity skills until retirement in 2020. This was only possible because I developed them in a favorable high volume environment in the 80s and practiced and taught them consistently thereafter. Without these resources I strongly believe this is now a nearly lost art in the United States. It could be rediscovered and resuscitated only at great cost and with help from active experience practitioners from outside the country.
I think it was appropriate (ethical and reasonable) given the expertise present and the prime patient anatomy on display.
Time saved on block was likely lost with additional physician documentation though lol
As long as Ultrasound is NOT a formal standard in the practicing institution - you are not violating anything. And the blocks with NS vs Ultrasound are only slightly - possibly less efficient/safe
In India, all anesthesiologists are masters in pns guided blocks ,and USG is a royalty lol
Nothing wrong with that! Greetings from the rotten-spoiled part of the world! ;)
Exactly
Not true. Now a days even govt Hospitals ve ultrasound in India. Depends on which state you are working
I am using ultrasound and nerve stimulator, sometimes no ultrasound machine available good to go ahead with nerve stimulation method..
Great - thank you for sharing!
The spread of local anaesthetic was more in the muscle plane i think. In muscle but in proximity to brachial plexus
Greetings
This is coming from a person who had only given nerve blocks by ultrasound guidance. I think one point favours use of nerve stimulator at least in conjunction with ultrasound if not alone and that is risk of intraneural injection. Somehow I feel we may misjudge needle tip position by ultrasound alone and injure a nerve. Stimulator adds to safety.
Also one of the senior consultants during my junior residency days was more comfortable with nerve stimulator and with barely any adverse events.
One thing that concerns me is some patients may become anxious on experiencing twitching. Mild sedation with 1mg midazolam and 5 mg ketamine would help with that
I believe trainees should be exposed to non ultrasound techniques- there will be situations where ultrasound machine will be unavailable- it shouldn’t hamper the anaesthesiologist to continue performing blocks.
os cara é nutella viu
Would you do ultrasound without nerve stimulator available?
Not as a routine. The two tools provide different, complimentary information. With ultrasound, NS is used as a monitoring tool for safety - usually not as a localization tool.
Here we regularly and routinely use ultrasound only for all blocks. Hardly anyone uses the simulator since hi res ultrasound is available... Unfortunately I was hardly trained to even use one, although I'm still a resident
Both
If the patient got any complications and takes you to the court, God help you
Agree. Safe technique in the most experienced hands BUT those hands are fast disappearing and increasingly unavailable for expert witness defense.
Disagree. Ultrasound has not been formally established as “standard of practice”. Therefore - you would not be violating any standards by not using it. Greetings!
I think mastering the nerve stimulator is an essential skill to have along with Ultrasound. But blind blocks should not be used.
Nerve stimulator-guided block can not be labelled as “blind”.
@@nysoravideo True. I did that for years before US guidance. I then combined both to start until I mastered both and then now I simply use US guidance. Thanks for all your help along the way!
@@TheFlyrodder68 Great. Thank you for replying great discussion!
Ok to skip u/s in resource poor environment. Legally suspect to improve OR throughput where machines exist even w/wait.
of course not !!!!!!
We do it blindly by landmark technique.
Any anatomical variations can not be seen through the skin without ultrasound. The risk of phrenic nerve block is much higher. We should not promote those kinds of blocks. Ultrasound should be the standard.
And further more the needle trajectory is straightly towards the neuraforamen. In case of catheter positioning there is a high risk of catheter migration into the spinal canal. Letal situations are described in the literature for such cases.
As anything else, it depends on skills of particular practitioner. Older generation got their skills by doing hundreds if not thousands of blocks using stimulator technique. In their hands this technique is actually safer and more comfortable to patients. It would be ridiculous to waist their skills.