CUTTING EDGE Ultrasound-guided blocks are considered state of the art.

Regional anesthesia equipment has undergone a significant overhaul in the last decade. Transitioning from the stimulation era to the ultrasound era has left many practitioners behind. Many are stubbornly holding onto the thought that stimulation techniques are just as safe and adequate as ultrasound-guided technology. But that's just simply not the case.

In the hands of a trained practitioner, ultrasound technology allows for direct 2-dimensional, 3-dimensional and even 4-dimensional visualization of the anatomical structure and landmarks used in regional anesthesia, not only for peripheral nerve blocks, but also for spinal-epidural placement. This direct visualization reduces needle passes, inadvertent intravascular punctures and injections, and intraneural injuries, while decreasing anesthetic volumes and increasing block success. Here's a look at what you need to do ultrasound-guided blocks efficiently.

• Get training. Anesthesia providers should seek out advanced training. Ultrasound regional courses are now available throughout the country with CEU credits at very reasonable pricing. Courses are short and very helpful, often only 2 days. If possible, attend a cadaver course. These types of courses offer hands-on needling, which allows for the best ultrasound education.
• Appoint a block nurse. A block nurse can be crucial to the successful placement of perineural catheters. Block RNs are nurses with advanced training in ACLS, PALS and BLS, who can provide conscious sedation and have advanced training assisting specifically in ultrasound-guided regional anesthesia techniques. You can train block nurses on the job or have them enroll in a formal short course.
• Educate patients. We often fail to educate patients about nerve blocks, particularly patients that receive continuous catheters. Preprinted educational materials and 24-hour phone access are important for patients returning home with continuous catheters. At discharge, give patients and their caregivers detailed instructions regarding the care, complications and risks of their continuous catheters.
• Designate a block bay/room. Ultrasound-guided regional techniques are safest when performed in a designated space with access to all the appropriate equipment and emergency supplies. Adequate work space, lighting, monitoring and privacy allow for more efficient, safe and successful blocks. Blocks may not be limited to the block area, so it's important that your equipment be portable.

INFORMED DECISION
Pros and Cons of Ultrasound Guidance

Pros	Cons
Direct visualization of anatomic structure	Deep structures difficult to visualize
Decreased procedure time	Additional dexterity and visual training required
Increased block success	Cost of ultrasound devices
Decreased anesthetic volumes	Portability of devices
Decreased vascular punctures	Decreased access to devices
Decreased needle passes	Dearth of highly trained practitioners

• Ultrasound machine. Purchasing the correct machine will depend on your resources and the type of blocks you perform. Ultrasound machines range from $5,000 for refurbished models to more than $100,000 for 3D models. Most important is that you choose the equipment that can accomplish the blocks you plan on performing. Picture quality is essential in the success and safety of your blocks. Multiple probe options are available for most machines and understanding their use is essential. For example, a higher frequency probe will give you a much better quality image but tissue penetration depth will be limited often to 2 to 4cm. On the other hand, a lower frequency probe will give you much better tissue penetration but limit your image quality. Before you purchase your machine, consider the portability of the device, image storage and transfer, Doppler and color flow options are all considerations.
• Nerve block cart. Your block cart should be spacious and portable. Carts should have a locking mechanism and be well-marked. Stock a wide variety of local anesthetics, block needles, syringes, Chloraprep, continuous and single-shot trays, catheters and gloves. Designate one drawer for emergency equipment if the cart is to be portable and used away from the primary anesthetizing location. This should include the intralipid rescue kit. Portable carts should also include emergency medications: epinephrine, atropine, ephedrine, phenylephrine, midazolam, succinylcholine, propofol or barbiturates.
• Nerve block needles. A wide variety of nerve block needles is available. Needles are designed based on their length, gauge, echogenicity, bevel and insulation qualities. Many of the new needles focus on the ability to enhance their visualization with the use of ultrasound; etching on the outer diameter of the needle enhances their echogenicity. Echogenicity is the ability to reflect the ultrasound waves back to the transducer, enhancing visibility.

Much of the choice in needle selection is up to the clinician. Shorter bevel needles, which create less risk of neural injury, are most frequently used. Gauge and length of needles are mostly dependent upon the type of block you're performing and the individual patient. Insulated needles allow for the use of stimulation at the very distal tip of the device. Stimulation techniques in conjunction with ultrasound guidance have proven to be very helpful with difficult blocks. Dual guidance is particularly helpful in the early training phases of ultrasound guidance. Stimulation is used as a positive reinforcement during ultrasound training. Specialized Toughy needles of multiple length and gauge are also used for the placement of continuous peripheral nerve block catheters. Toughy needles, often 17 gauge and 18 gauge, let the catheter pass through the needles. Recent introduction of catheter-over-the-needle devices allow for more efficient catheter placement and less leaking at the puncture site.

PRECISION PLACEMENT Ultrasound lets you place blocks by looking at the screen, not the patient's skin.

• Nerve stimulator. There's still a role for nerve stimulation. At times it's the default choice, such as when ultrasound visualization is difficult or impossible. Most newer models address resistance regarding output. The ability to adjust frequency, milliamps and pulse width are standard features.
• Continuous catheter trays. Customized nerve block and catheter trays contain all of the sterile supplies you'll need to place the block or peripheral catheter. Items such as sterile clear drapes, Chloraprep, Toughy needles, catheters, adhesives, syringes, local anesthetic for skin and test dose, labels, sterile probe covers and ultrasound gel can be included. Customized trays can be economical and time-efficient versus individual supply collection. You can add catheter-securing devices to your kit.
• Elastomeric pumps. These non-mechanical balloon pumps infuse local anesthetics based on the stretch of the balloon mechanism generated by filling the balloon reservoir. Reliability of infusion rates has become increasingly consistent with these pumps. The anesthesia provider decides the local anesthetic concentration and volume, as well as the length of time the catheter is to stay in place. Most pumps are filled to volumes of around 400ml and last 2 to 3 days. Pumps may be adjustable or fixed-rate. Most pumps are disposable and are discarded at the time of catheter removal. The portable pump doesn't interfere with the ambulation of the patient. Removing the catheter and pump is so simple that the patient or caregiver can usually do so.
• Monitoring. Monitor all patients undergoing ultrasound-guided regional anesthesia. Follow the same guidelines for sedation and general anesthesia in the block area as in the operating arena, including ASA monitoring guidelines for sedation. An adequate source of oxygen and the ability to provide positive pressure ventilation are standards of care. Keep bag valve masks and all age-appropriate intubation and ventilation supplies immediately available. Monitor and document continuous pulse oximetry, EKG and non-invasive BP, as well as respiration and cognitive status. Monitor patients for a minimum of 30 to 45 minutes after block placement for local anesthetic toxicity. Trained nurses must continuously attend patients throughout this time. Have a crash cart anywhere blocks are performed.
• Lipid rescue kit. Although the intravascular injection of local anesthetic is very uncommon, when it does occur, it is a life-threatening event. Intralipids are a must at the bedside. Keep 2 500cc bags of 20% intralipids at the bedside in a very visible kit. Educate staff on its use. Perform mock intravascular injections every 6 months.

Ahead of the curve
Proper preparation and education can change the level and quality of care you provide at your facility. With the face of health care changing daily and the increasing expectations on us by both patients and payors, separating yourself from the competition is critical. Patient satisfaction and quality care indicators will soon drive your reimbursement. Ultrasound technology can help you move forward, be ahead of those changes and more than meet all of your patients' and clients' regional pain expectations.