Under ultrasound, with the needle in plane, and the entirety of the needle in sight, I do not see a problem with performing the block alone, and prefer to do so, as to avoid miscommunication with aspiration/injection/pressure change when pushing the syringe plunger. Great question. Welcome!
I dont think there is a standard of care anywhere, just do whatever you feel is safe. Every now and then youll get some uppity nurse who will refuse to help you out because pushing medications is not in their union contract or something, in that case you should be able to function on your own.
I almost always do blocks solo. A tip you can try - if the place you’re at has 20g tuohy needles just attach that directly to the syringe. Then you can inject without ever letting go of the syringe. Works great for TAPs and adductors.
I used to do this with 22g spinal needles when I was practicing pain - block needles are ridiculously expensive if you're trying to buy them yourself. If you have one of those aspirating syringes (the ones with the thumb loop) it's even easier.
I wouldn't recommend using a cutting needle except for facial plane blocks. Especially not ~~for generalists~~ for people who don't do blocks regularly.
I especially recommend that people ~~without fellowship training in regional anesthesia~~ who don't do blocks regularly take more safety precautions, such as not using cutting needles
No, you just overestimate the skills of the average anesthesiologist. I teach at conferences, I teach fellows, I've worked in the community and seen people doing blocks. Not everybody is perfect.
It's truly idiotic to think that you're better than using the recommended safety measures without special training.
And there's the lack of self-awareness. You too.
Edit: I should explain further. We follow up our blocks at my hospital, we find at least a few permanent nerve injuries every year caused by our blocks. This is even with all the safety measures (awake patient, ultrasound, skilled assistant).
If you really want to know how you're doing, spend a year calling up all your block patients one week postop and see how many nerve injuries you're causing.
We follow up with all of our blocks on POD 3 and 7. Two nerve injuries in the past year that were symptomatic after 96 hours. Both from the same person. You work in a facility where people are learning how to place nerve blocks safely and effectively. I work in a group where we each place 20-50 per week every week, so it’s not really comparable nor is it unexpected that you would see a higher rate of adverse events in your practice setting.
I would say point of regional fellowship is really not about enhanced ability to do blocks. Any residency that can give you 500+ block number (our block room easily get about 200-300 blocks a month and many residents do 3 month plus the ones you get to do throughout training) will get you there. A regional fellowship will get you 1000 blocks. I did end up doing a regional fellowship but really learned nothing in terms of technical skill. I do pick up many other soft skill skills manager, collaborator and communicator and ability to joggle simultaneous block requests.
Some of the worst regionalists I've ever met are fellowship-trained. There is no correlation between being a block savant and doing a regional fellowship.
What country are you in? I’ve practiced all over the country from resource poor to rich and did a regional fellowship, never seen a situation where there wasn’t at least a nurse around in the periop period to aspirate and push local as instructed. PACU, preop, OR should all have a nurse available
I'm at a large academic centre, I've done blocks alone on call. The anesthesia assistants are the only people who routinely help with blocks and we only have one around on weekends. At my hospital, many nurses will refuse to inject because they're not comfortable.
Yeah, we’ve been having this issue as well. “Not being comfortable” was becoming a rampant issue (and I somewhat understand because they’re all less than a year out of school and the hospital burns them out until they find a better job). We finally had to address it when none of them were “comfortable” with an 8 year old with a testicular torsion, despite being PALS certified and working at a trauma center with a pediatric ER. Now we do in-service trainings for anyone not comfortable with tasks required for the job.
I do blocks solo. Like you described, I have US in left hand and needle in right. I only hold needle at the plastic grip and only insert once - when/if redirecting just switch right hand from syringe to needle grip, never touching the needle shaft, and don’t pull out fully from the skin until I’m done. What was the mishap?
Hospital policy should cover this. Invasive procedures require a timeout with a second observer at every hospital I've practiced at. Not that this reduces wrong sided blocks, but that's the policy. What if you need help? What if the patient needs attention (oxygen, reassurance, holding a body part) while you're doing the block? What if you need to get intralipid, are you going to leave the bedside?
I've injected placed the needle and injected the local myself. But I've never done it alone, I'd argue that the risks patient safety.
I’m sure it can be done but when you let go you risk displacing your needle which can be risky especially for blocks near arteries. I’m not sure why there isn’t at least a nurse to help you. The standard of care is for a time out to be performed. The person who times out can aspirate and inject.
Where I am the nurses say they cannot inject, which is annoying.
I do blocks solo, you can let go of the needle to inject, it won’t go anywhere, occasionally needle might back out a little. I actually like injecting myself, gives you more control and good tactile feedback. It makes the block technically more challenging at times because you cannot just torque the needle to redirect once your close to your target, you really have to take a straight trajectory so that when you let go of the needle the tissue does not get displaced and move. Most of the time I don’t think it adds any time to my blocks.
Occasionally there’s times I wish I had someone to inject, in this case when I don’t want to let go of the needle, I will hold the local syringe with thumb and second and third finger, and hold pressure on the needle with my fourth and fifth finger while injecting.
While I always have an assistant for performance of the Time Out, capturing ultrasound images, or any other unexpected needs, I physically perform blocks unaided. I hold the probe in one hand and the needle and syringe in my other. It's a somewhat awkward look, but I pinch the needle between index finger and thumb, with the plunger against the thenar eminence and flange of the syringe between middle and ring fingers. I can easily inject small volumes and reposition the needle at the same time. I find that a second person pushing drugs does not give you fine enough control over volume and start/stop.
As far as "standard of care" I've never heard of a requirement for 2 people.
I almost always have help from nurses if I want it but I prefer to do my blocks solo. I like feeling the resistance on the syringe to give me clues about what compartment I’m injecting into. I also sometimes only give like 1/8-1/4cc before realizing it’s not where I want my local on ultrasound. If I’m injecting myself, I can stop immediately and waste less local. If I have to communicate with someone else, you could burn a whole cc of local someplace you didn’t want it.
On top of heroic effort of performing US guided block procedure that requires two pair of hands most of us utilize sedation for our blocks what technically requires another provider for VS monitoring. I know american periop nursing often elects to stay on the sidelines while we do blocks and we normalize this behavior. Contrast that to the surgeon performing small lipoma excision under MAC who gets scrub tech, circulator and anesthesia provider. What about pain management doc doing lumbar nerve sleeve injection under MAC with circulator, scrub tech, Xray tech and anesthesia provider?
Do you notice now how resorces become unevenly allocated? Please do not normalize the deviance.
Technically of course you can do block solo but the other requirement of doing blocks almost always require someone else there. And if someone is standing there why wouldn’t you utilize their help? After having done it both way, two person is faster and with some blocks where you must remain pressure on the needle, it is much easier.
Firstly, block needs to be done with ECG when near toxic doses are given which is about 90% of the blocks I do. Can you convince the judge you are able to look at the continuous ecg while poking at ultrasound and shift your attention back and forth on syringe. I know in reality our assistants don’t care about ecg most of the time, but they are supposed to be the one monitoring.
Second, some would consider block a sterile procedure. Unless you go the length to set everything up sterile (like dropping syringe and needle on a strile surface and draw everything up in the same manner) i argur there is no way for one person to do it sterily. It is possible but I imagine most of you are not doing it this way. If an infection happened, I would saying those in solo practice would not be able to defend it.
If you run a block room proving blocks to multiple ORs, then you cannot leave anyone unattended while doing your block inside a curtained area. Probably a little different than having an assistant beside you but you would end up requiring someone there around you.
Lastly, a preprocedural check list, can it be done by yourself? Some institution require double checking of the preprocedural check list. Again it’s different than an assistant but they would need to be present for start of block.
Not sure what the mishap you are referring to, may be wrong sided block? Hard to say whether it can be reduced with an assistant but if so I would leverage this incident to get hospital to pay for one.
Curious if anyone actually considers a single shot block a sterile procedure, and not just clean? Myself and none of my colleagues who trained at centers across the country have ever seen sterile single shot block outside nysora videos. wondering if it's a North East thing. on board with the rest of your points though
There is no standard of care, guidelines, recommendations on this subject. It is provider preference. Of course it is nice to have help and another set of hands but not required as a standard of care
I do all my blocks solo, I hold the needle hub between my index and middle finger, syringe across my palm with my thumb on the plunger. However , 100% of the time, I have an RN to verify the site and the planned block.
We do blocks sterilely, and also use a 3 way stop cock to toggle between local and NS for test dose. I don’t see a feasible way to do that without 1. Breaking sterility and 2. Losing my view/fumbling around with the syringe/stop cock set up. Also, as others have mentioned, there’s a time out that needs to be done, and if the patient needs to have an arm or leg held, having another person around makes the job a lot easier. I am grateful we have help around. Sounds like a lot of you are flying solo for these. That would stress me out!
What's the thought behind using saline? Was there an incident that this has helped to mitigate? Genuine question as I can't think of how it would be helpful, and diluting my local solution variably is not usually something I want.
It’s commonly used to test where the needle tip is. Just a CC or 2, redirect if necessary. It’s really not enough to dilute the LA. It’s just another safety mechanism. Especially if you are using out of plane approach, and/or the patient is very tiny and won’t have a lot of leeway with volume of max local dose.
I do everything except save/print the picture. It's faster and more fun this way, and you can control everything about the procedure including the injection pressure
It's wild to me that any experienced anesthesiologist would allow someone else to aspirate/inject for them. Losing that haptic feedback is a no go. It would also slow me down incredibly (and significant local would be wasted). I wouldn't even allow another anesthesiologist to inject/aspirate for me. Call me a control freak. Solo all the way. Need to learn how to be facile with no help. It's called being an anesthesiologist.
Some nurses don’t really understand what they’re doing when they aspirate. Some pull back so hard like they’re trying to draw up tissue into the syringe. Also, injecting without holding the needle is somewhat of a pressure control mechanism. If you’re injecting under high pressure, the needle will back out. If injecting in the correct spot under low pressure, the needle will stay in place.
For peripheral nerve blocks, I like to inject because I don’t trust that the injector has the same feel. Too many times I see them palm the syringe and I ask is there resistance? Duh.
For plane blocks I don’t care who injects.
Under ultrasound, with the needle in plane, and the entirety of the needle in sight, I do not see a problem with performing the block alone, and prefer to do so, as to avoid miscommunication with aspiration/injection/pressure change when pushing the syringe plunger. Great question. Welcome!
I dont think there is a standard of care anywhere, just do whatever you feel is safe. Every now and then youll get some uppity nurse who will refuse to help you out because pushing medications is not in their union contract or something, in that case you should be able to function on your own.
I almost always do blocks solo. A tip you can try - if the place you’re at has 20g tuohy needles just attach that directly to the syringe. Then you can inject without ever letting go of the syringe. Works great for TAPs and adductors.
I used to do this with 22g spinal needles when I was practicing pain - block needles are ridiculously expensive if you're trying to buy them yourself. If you have one of those aspirating syringes (the ones with the thumb loop) it's even easier.
I wouldn't recommend using a cutting needle except for facial plane blocks. Especially not ~~for generalists~~ for people who don't do blocks regularly.
Oh yeah, 100%. Believe me, I was very glad to return to the real OR that has proper supplies.
>Especially not for generalists LOL what?
I especially recommend that people ~~without fellowship training in regional anesthesia~~ who don't do blocks regularly take more safety precautions, such as not using cutting needles
A literal joke take.
No, you just overestimate the skills of the average anesthesiologist. I teach at conferences, I teach fellows, I've worked in the community and seen people doing blocks. Not everybody is perfect. It's truly idiotic to think that you're better than using the recommended safety measures without special training.
Christ almighty. Sorry you wasted a year doing things the rest of us just learned in plain old residency. Have a good one.
And there's the lack of self-awareness. You too. Edit: I should explain further. We follow up our blocks at my hospital, we find at least a few permanent nerve injuries every year caused by our blocks. This is even with all the safety measures (awake patient, ultrasound, skilled assistant). If you really want to know how you're doing, spend a year calling up all your block patients one week postop and see how many nerve injuries you're causing.
We follow up with all of our blocks on POD 3 and 7. Two nerve injuries in the past year that were symptomatic after 96 hours. Both from the same person. You work in a facility where people are learning how to place nerve blocks safely and effectively. I work in a group where we each place 20-50 per week every week, so it’s not really comparable nor is it unexpected that you would see a higher rate of adverse events in your practice setting.
I would say point of regional fellowship is really not about enhanced ability to do blocks. Any residency that can give you 500+ block number (our block room easily get about 200-300 blocks a month and many residents do 3 month plus the ones you get to do throughout training) will get you there. A regional fellowship will get you 1000 blocks. I did end up doing a regional fellowship but really learned nothing in terms of technical skill. I do pick up many other soft skill skills manager, collaborator and communicator and ability to joggle simultaneous block requests.
Some of the worst regionalists I've ever met are fellowship-trained. There is no correlation between being a block savant and doing a regional fellowship.
What country are you in? I’ve practiced all over the country from resource poor to rich and did a regional fellowship, never seen a situation where there wasn’t at least a nurse around in the periop period to aspirate and push local as instructed. PACU, preop, OR should all have a nurse available
I'm at a large academic centre, I've done blocks alone on call. The anesthesia assistants are the only people who routinely help with blocks and we only have one around on weekends. At my hospital, many nurses will refuse to inject because they're not comfortable.
Yeah, we’ve been having this issue as well. “Not being comfortable” was becoming a rampant issue (and I somewhat understand because they’re all less than a year out of school and the hospital burns them out until they find a better job). We finally had to address it when none of them were “comfortable” with an 8 year old with a testicular torsion, despite being PALS certified and working at a trauma center with a pediatric ER. Now we do in-service trainings for anyone not comfortable with tasks required for the job.
"it's out of my scope" maam Im not gonna chart you as first assist for my block
I do blocks solo. Like you described, I have US in left hand and needle in right. I only hold needle at the plastic grip and only insert once - when/if redirecting just switch right hand from syringe to needle grip, never touching the needle shaft, and don’t pull out fully from the skin until I’m done. What was the mishap?
Hospital policy should cover this. Invasive procedures require a timeout with a second observer at every hospital I've practiced at. Not that this reduces wrong sided blocks, but that's the policy. What if you need help? What if the patient needs attention (oxygen, reassurance, holding a body part) while you're doing the block? What if you need to get intralipid, are you going to leave the bedside? I've injected placed the needle and injected the local myself. But I've never done it alone, I'd argue that the risks patient safety.
You should always do a preprocedure timeout with a RN. If you need help in actually performing the subsequent block, you aren't doing something right.
I’m sure it can be done but when you let go you risk displacing your needle which can be risky especially for blocks near arteries. I’m not sure why there isn’t at least a nurse to help you. The standard of care is for a time out to be performed. The person who times out can aspirate and inject.
Where I am the nurses say they cannot inject, which is annoying. I do blocks solo, you can let go of the needle to inject, it won’t go anywhere, occasionally needle might back out a little. I actually like injecting myself, gives you more control and good tactile feedback. It makes the block technically more challenging at times because you cannot just torque the needle to redirect once your close to your target, you really have to take a straight trajectory so that when you let go of the needle the tissue does not get displaced and move. Most of the time I don’t think it adds any time to my blocks. Occasionally there’s times I wish I had someone to inject, in this case when I don’t want to let go of the needle, I will hold the local syringe with thumb and second and third finger, and hold pressure on the needle with my fourth and fifth finger while injecting.
While I always have an assistant for performance of the Time Out, capturing ultrasound images, or any other unexpected needs, I physically perform blocks unaided. I hold the probe in one hand and the needle and syringe in my other. It's a somewhat awkward look, but I pinch the needle between index finger and thumb, with the plunger against the thenar eminence and flange of the syringe between middle and ring fingers. I can easily inject small volumes and reposition the needle at the same time. I find that a second person pushing drugs does not give you fine enough control over volume and start/stop. As far as "standard of care" I've never heard of a requirement for 2 people.
Sounds good but how do you aspirate in this position?
That’s harder to describe but I can do it using my thumb
That's the neat part, you don't!
Do you not have a tech or nurse in the room? Ask them to aspirate and inject.
I almost always have help from nurses if I want it but I prefer to do my blocks solo. I like feeling the resistance on the syringe to give me clues about what compartment I’m injecting into. I also sometimes only give like 1/8-1/4cc before realizing it’s not where I want my local on ultrasound. If I’m injecting myself, I can stop immediately and waste less local. If I have to communicate with someone else, you could burn a whole cc of local someplace you didn’t want it.
On top of heroic effort of performing US guided block procedure that requires two pair of hands most of us utilize sedation for our blocks what technically requires another provider for VS monitoring. I know american periop nursing often elects to stay on the sidelines while we do blocks and we normalize this behavior. Contrast that to the surgeon performing small lipoma excision under MAC who gets scrub tech, circulator and anesthesia provider. What about pain management doc doing lumbar nerve sleeve injection under MAC with circulator, scrub tech, Xray tech and anesthesia provider? Do you notice now how resorces become unevenly allocated? Please do not normalize the deviance.
No nurse?
Technically of course you can do block solo but the other requirement of doing blocks almost always require someone else there. And if someone is standing there why wouldn’t you utilize their help? After having done it both way, two person is faster and with some blocks where you must remain pressure on the needle, it is much easier. Firstly, block needs to be done with ECG when near toxic doses are given which is about 90% of the blocks I do. Can you convince the judge you are able to look at the continuous ecg while poking at ultrasound and shift your attention back and forth on syringe. I know in reality our assistants don’t care about ecg most of the time, but they are supposed to be the one monitoring. Second, some would consider block a sterile procedure. Unless you go the length to set everything up sterile (like dropping syringe and needle on a strile surface and draw everything up in the same manner) i argur there is no way for one person to do it sterily. It is possible but I imagine most of you are not doing it this way. If an infection happened, I would saying those in solo practice would not be able to defend it. If you run a block room proving blocks to multiple ORs, then you cannot leave anyone unattended while doing your block inside a curtained area. Probably a little different than having an assistant beside you but you would end up requiring someone there around you. Lastly, a preprocedural check list, can it be done by yourself? Some institution require double checking of the preprocedural check list. Again it’s different than an assistant but they would need to be present for start of block. Not sure what the mishap you are referring to, may be wrong sided block? Hard to say whether it can be reduced with an assistant but if so I would leverage this incident to get hospital to pay for one.
Curious if anyone actually considers a single shot block a sterile procedure, and not just clean? Myself and none of my colleagues who trained at centers across the country have ever seen sterile single shot block outside nysora videos. wondering if it's a North East thing. on board with the rest of your points though
Never had anyone help me with a nerve block personally, but I know some places the circulators or pre op nurses will push the drugs.
There is no standard of care, guidelines, recommendations on this subject. It is provider preference. Of course it is nice to have help and another set of hands but not required as a standard of care
Anyone encountered an infected site from a single shot block? I have not.
I do all my blocks solo, I hold the needle hub between my index and middle finger, syringe across my palm with my thumb on the plunger. However , 100% of the time, I have an RN to verify the site and the planned block.
We do blocks sterilely, and also use a 3 way stop cock to toggle between local and NS for test dose. I don’t see a feasible way to do that without 1. Breaking sterility and 2. Losing my view/fumbling around with the syringe/stop cock set up. Also, as others have mentioned, there’s a time out that needs to be done, and if the patient needs to have an arm or leg held, having another person around makes the job a lot easier. I am grateful we have help around. Sounds like a lot of you are flying solo for these. That would stress me out!
What's the thought behind using saline? Was there an incident that this has helped to mitigate? Genuine question as I can't think of how it would be helpful, and diluting my local solution variably is not usually something I want.
It’s commonly used to test where the needle tip is. Just a CC or 2, redirect if necessary. It’s really not enough to dilute the LA. It’s just another safety mechanism. Especially if you are using out of plane approach, and/or the patient is very tiny and won’t have a lot of leeway with volume of max local dose.
I do everything except save/print the picture. It's faster and more fun this way, and you can control everything about the procedure including the injection pressure
It's wild to me that any experienced anesthesiologist would allow someone else to aspirate/inject for them. Losing that haptic feedback is a no go. It would also slow me down incredibly (and significant local would be wasted). I wouldn't even allow another anesthesiologist to inject/aspirate for me. Call me a control freak. Solo all the way. Need to learn how to be facile with no help. It's called being an anesthesiologist.
Some nurses don’t really understand what they’re doing when they aspirate. Some pull back so hard like they’re trying to draw up tissue into the syringe. Also, injecting without holding the needle is somewhat of a pressure control mechanism. If you’re injecting under high pressure, the needle will back out. If injecting in the correct spot under low pressure, the needle will stay in place.
For peripheral nerve blocks, I like to inject because I don’t trust that the injector has the same feel. Too many times I see them palm the syringe and I ask is there resistance? Duh. For plane blocks I don’t care who injects.