A Quick Guide: Ultrasound Guided Nerve Blocks
Vol 2 | Issue 1 | January-June 2021 | Page 02-03 | Vrushali Ponde, Kapil Gupta, Neha Singh
DOI: 10.13107/ijra.2021.v02i01.016
Authors: Vrushali Ponde [1], Kapil Gupta [2], Neha Singh [3]
[1] National President and Ex founder secretary, Academy of Regional Anaesthesia, India.
[2] Department of Anaesthesia, V.M.M.C & Safdarjung Hospital, New Delhi, India.
[3] Department of Anaesthesia, AIIMS, Bhubaneshwar, Odisha, India.
Address of Correspondence
Dr. Vrushali Ponde,
National President and Ex founder secretary, Academy of Regional Anaesthesia, India.
E-mail: vrushaliponde@gmail.com
Ultrasound Machine and Image Acquisition Scanning Preparation
1. Obtain written informed consent for the block- AORA Written Consent Form
2. Re-examine the patient before administering the block
3. Checklist ticked before the block –(anaesthesiologist and nurse to be present)
AORA Checklist
– Ensure we have correct patient/block and marked site/side of block
– Check Documents and Equipment before initiating the procedure
– I.V cannula secured before performing the block
-Minimum ASA standard monitoring (pulse oxymeter, NIBP, ECG) started
4. Ergonomics- Ultrasound machine should be in direct line of sight of the anaesthesiologist performing the block
5. Selection of Pre-Set in certain machines to better visualize that structure (eg: Nerves/ Musculoskeletal/Vascular)
6. Probe selection – High frequency probe (13-6 MHz) for superficial nerves/structures and Low frequency probe (5-2 MHz) for deeper nerves/structures and neuraxial blocks
7. Tegaderm, Cling Wrap or Camera Cover wrapped around the probe for sterility
8. Oxygen administration via ventimask /nasal prongs
9. I.V. sedation like Midazolam /Fentanyl I.V. before initiating the block, but after finishing timeout/checklist
10. Maintenance of strict asepsis during the block procedure- AORA Sterility Precautions
11. Skin infiltration with 1% Lignocaine 1 min before inserting the needle; at the site of needle entry
12. Probe holding: Pen holding method is preferable for most blocks
13. At end of procedure- probe should be cleaned with Soap and water
Image Optimisation
The following movements of the probe can be utilized for optimization of image:
Transducer Movements:
1. Sliding
2. Tilting
3. Rocking
4. Rotation
5. Compression
Needle Approaches
In Plane- Whole length of the needle is visualized
Out of Plane- Only needle tip is visualized
Clinical Pearls
1. Optimize the image by setting the appropriate focus, depth and gain
2. Focus the target in centre of the screen
3. Ensure that the skin sterilizing solution has dried, before inserting the needle for block, as contact of sterilizing solution with the nerve can lead to nerve injury (neuropraxia /neurotemesis /axonotemesis)
4. Incremental injection of Local Anaesthetic in 2-3 ml aliquots after repeated aspiration
5. Stop administration of perineural drug, if the patient complains of pain during injection; as it can be a feature of intraneural injection of drug and lead to nerve injury
6. When using peripheral nerve stimulator, never inject the drug, if muscle contraction occurs at current less than 0.3 MA; as it can be a feature of intraneural (intrafascicular) administration of drug and cause nerve injury
7. Scan with the Colour Doppler while doing Brachial Plexus Block (especially Interscalene and Infraclavicular blocks); to avoid inadvertent intravascular injection
These practical tips decrease the potential complications, making ultrasound guided regional anaesthesia a safer technique. Acquisition of a better image improves the success rate of the block.
From the protocols and guidelines committee of AORA
Dr. Kapil Gupta
Professor, Anesthesiology,
V.M.M.C & Safdarjung Hospital, New Delhi, India.
Dr. Neha Singh
Additional Professor, Anesthesiology,
AIIMS, Bhubaneshwar, Odisha, India.
| How to Cite this Article: Ponde V, Gupta K, Singh N | A Quick Guide: Ultrasound-Guided Nerve Blocks | International Journal of Regional Anaesthesia | January-April 2021; 2(1): 02-03. |
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all das nicht … Anders als die konventionellen wachsen die Bio-Weihnachtsbäume in Mischkulturen. Stattdessen halten oft Schafe die Pflanzen zwischen den Bäumen kurz.
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Bio-Anbauverbände, erst recht dem EU-Biosiegel, dem Biokreis-Siegel,
dem Bioland-Siegel, dem Demeter-Siegel und dem Siegel von Naturland.
Das macht sie weniger anfällig für Schädlinge und die Flächen werden wie bei Bio üblich nicht
mit Herbiziden bespritzt. Kunstdünger und chemisch-synthetische
Pestizide sind hier ausgeschlossen. Speziell bei
Naturland-Weihnachtsbäumen wurden die Richtlinien für die ökologische Waldnutzung
von Naturland bei den Umweltverbänden Robin Wood,
Greenpeace und BUND erarbeitet. Zu den Bio-Kriterien gehört der Verzicht
auf Kahlschlag, Pestizide, Düngungen und Entwässerungsmaßnahmen. Nachhaltige Weihnachtsbäume kommen auch aus FSC-zertifizierten Wäldern.
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Auf Platz sieben der meist gesuchen Tattoo Motive landen mit je 4.400 Suchanfragen pro Monat Katzen, Drachen und Wikinger.
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Tiere wie Eulen und Schmetterlinge sowie Blumen und Traumfänger
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Diese Motive werden monatlich rund 12.100 Mal in die
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Sind solche Belege es gibt kein oder gehen sie verloren, kann als Ersatz ein Eigenbeleg erstellt
werden. Zumeist werden Eigenbelege vom Unternehmer selbst oder von leitenden Angestellten ausgestellt, die hierzu bevollmächtigt sind.
Eigenbelege dienen vor dem Finanzamt als Ersatz für Rechnungen oder Quittungen. Hierbei gilt jedoch grundsätzlich jeden Beleg aufzubewahren und zeitnah
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können nicht zu finden oder vernichtet worden sein.
Schließlich hinterlässt kein Dieb eine Quittung.
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