332 procedural ultrasound ultrasound for procedure

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332 Procedural ultrasound Ultrasound for procedure guidance
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vein, and the proximal branch point of the greater saphenous vein, should help confirm the proper location for anesthetic administration. Some authors advocate the use of an out-of-plane (transverse) approach toward needle guidance for the femoral nerve block. As with other procedures, patient anatomy and operator comfort should determine the optimal approach It may be easier to visualize the interscalene nerve roots closer to the clavicle; once seen, trace them caudal for the block. Pitfalls With any peripheral nerve block, it is mandatory that anesthetic not be injected within the nerve. No pressure is required for these blocks, and they should not be painful. Pain and increased resistance to injection may be warning signs of intraneural injection. As with venous access ( Chapter 15 ), nerve blocks require significant hand– eye coordination. Position the patient, ultrasound machine, and operator in a comfortable position. The operator should be able to view the ultrasound image easily, and his or her hands should be in a position of comfort and stability. Aspiration prior to injection is wise with any procedure; this is even more important given the larger volumes of anesthetic employed for regional blocks (up to 20 or more mL for large nerves). Most importantly, motor blockade is common with regional nerve blocks; be sure to pad sensitive areas (such as the hip) to avoid injury or ulcer formation in the setting of a numb and immobilized extremity. Literature review A recent Cochrane review of 18 randomized controlled trials concluded that ultrasound-guided peripheral nerve blocks had success rates similar to those of other methods of nerve localization. However, ultrasound was shown to reduce complication rates and improve onset time. In addition, ultrasound may improve block quality [ 32 ]. Peripheral nerve blocks have been described in the anesthesia litera- ture, and a feasibility study of 22 forearm blocks performed by emer- gency physicians (EPs) demonstrated the efficacy of the technique [ 31 ]. The feasibility of EP-performed femoral nerve blocks was demon- strated in elderly patients with hip fracture. Reduced pain scores were noted in patients receiving the block [ 33 ]. Stone et al. compared supraclavicular brachial plexus blocks to procedural sedation in 12 patients with upper extremity injury [ 34 ]. The authors found decreased length of stay in the nerve block group, and no significant complications in either group. Procedural ultrasound 333 Ultrasound for procedure guidance
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References 1. Yang PC, Luh KT, Chang DB, et al. Value of sonography in determining the nature of pleural effusion: analysis of 320 cases. AJR Am J Roentgenol 1992; 159 : 29–33. 2. Weingardt JP, Guico RR, Nemcek AA, Li YP, Chiu ST. Ultrasound findings following failed, clinically directed thoracenteses. J Clin Ultra- sound 1994; 22 : 419–26.
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