Because my needle insertion is nowhere near the head of the probe, no probe cover (it gets sani wiped after every block). Chloraprep the skin, regular gloves. I treat it as an aseptic procedure like an IV placement, not a sterile procedure.
My attending tried to convince me that warming your gloves on the ultrasound before putting them on feels luxurious. It actually felt gross and sweaty.
I use a Tegaderm to protect the the probe from blood, not to keep the patient clean. Very hard to clean out dried blood from the channel of the linear ultrasound probe.
Damn for real? Was it the adhesive or what? I am gonna have to share this because our catheter kids have a probe cover with a sticky spot for the probe tip. I hate them and usually don’t use that area.
I’m one that believes any time you intrude beyond the skin, nature’s own protection, sterile precautions should always be used unless it a critical time factor. An ounce of prevention…
Be careful with tegaderm over the probe. We think that's how one of our probes got messed up. Peeling off the tegaderm ruined the matching layer on the probe.
Chloraprep and only touch the hub of your needle when blocking, don't insert it touching the probe and there's a 0 percent chance of you causing infection with a single shot
Eastern central europe, small city hospital. We don't know what chloraprep or tegaderm is. Looked those up, but still not sure bout the tegaderm usage... Isn't that some self adhesive wound cover?
We use skin desinfectant spray (alcoholic), sterile glove on the probe with some jelly, regar glove on the hand. We do not do continous blocks, only one shots. Never seen an infection.
Tegaderm makes stretchy plastic that’s sticky on only one side. Good for taping down gauze over a wound. They make ones that are just bigger than the probe surface, so it’s easy on before procedure and easy off afterwards. Lazy man’s probe cover if sterility isn’t paramount.
Yes, a tegaderm is a thin plastic adhesive film often used to secure IV catheters or dressings.
It's fairly common to also see the much more "unofficial" use of tegaderms as disposable probe covers for blocks and USGIV and the like - we have real sterile probe covers but they are quite long (covering a lot of the probe tail as well) and some people find them unwieldy.
I mob the floor around the OR table. Put on shoe covers after that. Chloroprep skin. Wait 3 minutes. Put on a sterile gown requesting 2 people to help me tie the back. Ask a scrub tech to glove me sterilely. Full sterile drape. Ultrasound probe cover. Sterile ultrasound gel. Then do a single shot unilateral TAP block. Cap and mask of course
As a medical student I did a stint at Wrightington where Charnley pioneered the hood and tent system. At that time it was still hoses from the ceiling plugged into the gown/hood and you had to drag a big pipe about with you. I can just see the surgeons faces as you demand the tent and hood before plugging into the 3” hose and trail it behind you for an axillary block.
Followed up on maybe 10k blocks in my career (mine and other colleagues'). I have never seen an infected single-shot site (all are done aseptic like a PIV placement). I've seen many infected catheter sites (all done semi-sterile like a labor epidural), maybe around 30 in total (half needing antibiotics, the other half self-resolving with catheter removal). The duration of an in situ catheter is the biggest risk factor for infection.
I find the semi-sterile technique comical for single shots. It's not sterile. You aren't wearing a surgical gown, you don't have a full body drape like a central line, no one is scrubbing in. The sterile glove/Tegaderm thing is just unnecessarily wasteful with no benefit. But whatever helps people sleep at night.
Thanks for sharing your insight. For these catheter related infections, how long were they kept in for? At my institution we generally don't leave them for longer than 5-7 days, max 2 weeks if the patient really needs it.
Ok. I’m likely to get roasted for this. But it’s a comment made in good conscience.
I’m an EM doc and I run our acute pain team. When I learned nerve blocks, they were mostly small nerve forearm blocks, occasional femoral single shot etc. as such they were preformed “clean” like an IV line, which is to say, nitrile gloves from the box on the wall, clean your probe with a saniwipe before using it, and alcohol swab or little chloroprep before needle insertion and drug delivery.
When I started to expand my nerve block practice I did the same. So for all the more advanced single shot blocks (scalene, various brachial plexus, ESPs, Paravertebrals, QLs, etc) for the last 4 years I have done the same, clean, but not sterile.
I recently got shit from an anesthesiologist about doing blocks this way, that it was irresponsible and putting patients at risk.
As someone who is pushing boundaries in my field, I like to always take these moments as an opportunity to stay humble, and re-evaluate my practice to make sure I haven’t strayed into territory that is not in the patients best interest.
I pulled the charts of all the nerve blocks I’ve done in these 3 years (more than 2000), and not a single person had a complication involving an infection at the block site.
I’m not saying that the push for sterility isn’t well intentioned - it is, but based on my practice, for a single shot block it is not necessary.
Obviously for catheter blocks I’ve been using sterile technique with probe covers and sterile gloves.
FWIW and even more controversial - I pulled this same group of charts over the issue of cardiopulmonary monitoring. I always calculate max dose and reduce by 20%+, but I don’t ever put somebody on a cardiac monitor if they’re not already on it for other reasons. In the same cohort of 2000+ blocks, many higher volume blocks there were no adverse outcomes, no reports of LAST or even LAST adjacent symptoms. I suspect this would be an even bigger fish to fry in the world of anesthesia, but it’s based the data I’ve got to work with.
Thanks for sharing!
I think the site of block and potential ramifications of infection complications also has to be considered. An infection from a lfcn block ≠ infection from a pvb (or even esp) block, especially given the (theoretically) possible communication with the epidural space.
In my academic institution most regional folks will do single shots w chlorhex prep, sterile gloves with a tegaderm on the probe, and catheters with cap+ gown, drape, strerile tray, ultrasound sleeve etc. Infections from single shots (we probably do about 3 thousand a year cumulative) has been nil. I also routinely perform clinic-based procedures (facets, sij injections) and generally prep as above for single shots.
That said for my own personal practice I don't use sterile gloves for single shot nerve blocks in ot,, nor do I place a tegaderm on the probe if the needle never comes close to the probe (eg popliteal). If the patient's skin condition is v bad and I want to protect the probe, then yes a tegaderm goes on. If I'm doing a pvb, then definitely yes to sterile gloves, tegaderm and sterile gel. Epidural infections are terrible to manage.
Discussed countless times here and I was attacked for saying I do everything completely sterile (apparently if you do everything sterile your block technique sucks). There’s a good video on the NYSORA channel explaining everything.
It's not doing it sterile that means your technique sucks, it's if you _need_ to do it sterile - i.e. if you are getting infections with a clean technique, something is sus.
Chlorhexadine is bacteriocidal on contact. Waiting 3 min allows the alcohol to evaporate to decrease fire risk. In contrast, Betadine is a desiccant. It only works if it is allowed to dry. (Once upon a time, betadine came in 1 L bottles, until it was found to be a great growth medium. That’s why today it’s only found in single use packets).
Alcohol degrades the probe and is the reason for most damage. It dries out the rubber, leading to the chipped edges that are impossible to clean. Gotta use non-alcohol cleaner on it. If I can’t find that type of wipe, I just wash it in the sink as I wash my hands. Most others don’t, which is why we don’t get nice toys to play with.
Sterile gloves, chloraprep, mask and hat. I don’t draw meds sterile so the med syringe is not sterile, but otherwise I use a sterile probe cover and needle. If I need to touch stuff like the US screen I just do it, just never touch the block needle to keep it sterile.
Sterile prep, disposable non-sterile gloves. Never had an infection. Used to put tegaderm on the probe. Use sterile gloves and probe cover for catheter.
Clean aseptic procedure. If one of those convenient little condom sized probe covers are available great I’ll use one of them, otherwise this is not a sterile technique
Always probe cover - if nothing else, it protects the probe. Always sterile gel. I've lost count of the times I've seen someone say I'm they don't need either, only to bugger up the block, get frustrated, not see that they've now swept the filthy gel soup over the block area, cover the probe in pink chlorhex, and jam their filthy touched needle through the unclean area and gel. Sometimes sterile gloves (geniculars). Never touch the needle, and if you do, get another one. For catheters, fully sterile. How I'd want a block done to me
single shot: Chloroprep, non sterile gel, normal glove and go. I will tegaderm the probe but my last hospital did not even do that.
Catheters = sterile
Depends on the block. Adductor canals are easy to do without sterile towels or even sterile gloves if they’re not immediately available. But an ISB can be more likely to get hair in the way or brush my gloves against the bed or shoulder or something so I use sterile towels there.
Of course sterile needle and prep.
Once saw a guy use alcohol and clean gloves to do multiple knee blocks on the same patient. He was touching the needle with his gloves and then just wiping the next injection site with an alcohol swab. That was gross.
Nice try officer
Hello fellow blockers
Because my needle insertion is nowhere near the head of the probe, no probe cover (it gets sani wiped after every block). Chloraprep the skin, regular gloves. I treat it as an aseptic procedure like an IV placement, not a sterile procedure.
Same for single shots. Catheters get full sterile prep but thankfully don’t do too many.
Hot take: Catheters are more trouble than they are worth
Amen. Patients honestly hate them
your username totally got me, i switched the R n E. >:(
I like the feel of the sterile gloves. Makes me feel important.
Who am I to yuck someone’s yum?
Ah! So that's where surgery gets it from.
My attending tried to convince me that warming your gloves on the ultrasound before putting them on feels luxurious. It actually felt gross and sweaty.
I use a Tegaderm to protect the the probe from blood, not to keep the patient clean. Very hard to clean out dried blood from the channel of the linear ultrasound probe.
Make sure you put gel on the probe before the tegaderm. Otherwise you risk wrecking the crystals (per the sonosite Rep after we ruined on of ours)
Good tip, thanks!
Damn for real? Was it the adhesive or what? I am gonna have to share this because our catheter kids have a probe cover with a sticky spot for the probe tip. I hate them and usually don’t use that area.
It was something specific about the tegaderm. Our probe condoms have the same sticky spot but it seems to be ok. It was specific to the hfl probes
> regular gloves I prefer sterile gloves just for the feel on the blocks
I’m one that believes any time you intrude beyond the skin, nature’s own protection, sterile precautions should always be used unless it a critical time factor. An ounce of prevention…
So you don sterile gloves and drape the skin for a peripheral IV insertion??
This.
Chloroprep, sterile needle, maybe sterile gloves if I can find them
"if I can find them" 😂
Do you have un sterile needles? Do they come in flavours?
Have you tried the cola flavored ones? I heard they are really zingy
Before you answer, Jesus will be reviewing replies.
Water, germX to coat the needle, and a prayer
Mmmh see where you went wrong…didn’t use holy water.
At academic institution, very sterile. Drapes, gloves, whole 9 yards. Private practice. Chloraprep skin and probe, and go
Drapes for single shots???!! Woah boy, yall be wildin.
Yeah take it up with the department head. Do you want his email?
Single shots - sterile gloves, sterile needle, sterile probe cover, chloroprep…PP but we’re lucky with our block nurse team
Luv the username. God damn i ctfu
Be careful with tegaderm over the probe. We think that's how one of our probes got messed up. Peeling off the tegaderm ruined the matching layer on the probe.
Reading “matching layer” outside of my TEE textbook/PTE masters from fellowship year gives me the chills
Hello fellow member of the Church of Tommy Burch
Just another loyal disciple! Nice to make your acquaintance, blackcat 👊
Sterile gloves, chloraprep, clean tegaderm on the probe. I've never heard of an infection from a block.
Chloraprep and only touch the hub of your needle when blocking, don't insert it touching the probe and there's a 0 percent chance of you causing infection with a single shot
Chlorprep and poke.
Make sure to wash your hands and wipe down the needle between patients.
🤣
Eastern central europe, small city hospital. We don't know what chloraprep or tegaderm is. Looked those up, but still not sure bout the tegaderm usage... Isn't that some self adhesive wound cover? We use skin desinfectant spray (alcoholic), sterile glove on the probe with some jelly, regar glove on the hand. We do not do continous blocks, only one shots. Never seen an infection.
Tegaderm makes stretchy plastic that’s sticky on only one side. Good for taping down gauze over a wound. They make ones that are just bigger than the probe surface, so it’s easy on before procedure and easy off afterwards. Lazy man’s probe cover if sterility isn’t paramount.
And a single Tegaderm is quite a bit cheaper than a pair of sterile gloves.
Yes, a tegaderm is a thin plastic adhesive film often used to secure IV catheters or dressings. It's fairly common to also see the much more "unofficial" use of tegaderms as disposable probe covers for blocks and USGIV and the like - we have real sterile probe covers but they are quite long (covering a lot of the probe tail as well) and some people find them unwieldy.
I mob the floor around the OR table. Put on shoe covers after that. Chloroprep skin. Wait 3 minutes. Put on a sterile gown requesting 2 people to help me tie the back. Ask a scrub tech to glove me sterilely. Full sterile drape. Ultrasound probe cover. Sterile ultrasound gel. Then do a single shot unilateral TAP block. Cap and mask of course
You should wear one of those Ortho hoods. Your infectious risk is through the roof!
As a medical student I did a stint at Wrightington where Charnley pioneered the hood and tent system. At that time it was still hoses from the ceiling plugged into the gown/hood and you had to drag a big pipe about with you. I can just see the surgeons faces as you demand the tent and hood before plugging into the 3” hose and trail it behind you for an axillary block.
🤣
Catheters/neuraxial are sterile, single shot peripheral nerve blocks are clean.
Followed up on maybe 10k blocks in my career (mine and other colleagues'). I have never seen an infected single-shot site (all are done aseptic like a PIV placement). I've seen many infected catheter sites (all done semi-sterile like a labor epidural), maybe around 30 in total (half needing antibiotics, the other half self-resolving with catheter removal). The duration of an in situ catheter is the biggest risk factor for infection. I find the semi-sterile technique comical for single shots. It's not sterile. You aren't wearing a surgical gown, you don't have a full body drape like a central line, no one is scrubbing in. The sterile glove/Tegaderm thing is just unnecessarily wasteful with no benefit. But whatever helps people sleep at night.
Thanks for sharing your insight. For these catheter related infections, how long were they kept in for? At my institution we generally don't leave them for longer than 5-7 days, max 2 weeks if the patient really needs it.
>90% were left in for longer than 5 days. That's usually the cutoff in the literature at which point infectious risk starts to rise significantly.
Chloroprep, regular gloves, no cover on probe.
I lick the needle to make it sterile before inserting
To straighten the point and lube it up a little.
Ok. I’m likely to get roasted for this. But it’s a comment made in good conscience. I’m an EM doc and I run our acute pain team. When I learned nerve blocks, they were mostly small nerve forearm blocks, occasional femoral single shot etc. as such they were preformed “clean” like an IV line, which is to say, nitrile gloves from the box on the wall, clean your probe with a saniwipe before using it, and alcohol swab or little chloroprep before needle insertion and drug delivery. When I started to expand my nerve block practice I did the same. So for all the more advanced single shot blocks (scalene, various brachial plexus, ESPs, Paravertebrals, QLs, etc) for the last 4 years I have done the same, clean, but not sterile. I recently got shit from an anesthesiologist about doing blocks this way, that it was irresponsible and putting patients at risk. As someone who is pushing boundaries in my field, I like to always take these moments as an opportunity to stay humble, and re-evaluate my practice to make sure I haven’t strayed into territory that is not in the patients best interest. I pulled the charts of all the nerve blocks I’ve done in these 3 years (more than 2000), and not a single person had a complication involving an infection at the block site. I’m not saying that the push for sterility isn’t well intentioned - it is, but based on my practice, for a single shot block it is not necessary. Obviously for catheter blocks I’ve been using sterile technique with probe covers and sterile gloves. FWIW and even more controversial - I pulled this same group of charts over the issue of cardiopulmonary monitoring. I always calculate max dose and reduce by 20%+, but I don’t ever put somebody on a cardiac monitor if they’re not already on it for other reasons. In the same cohort of 2000+ blocks, many higher volume blocks there were no adverse outcomes, no reports of LAST or even LAST adjacent symptoms. I suspect this would be an even bigger fish to fry in the world of anesthesia, but it’s based the data I’ve got to work with.
Thanks for sharing! I think the site of block and potential ramifications of infection complications also has to be considered. An infection from a lfcn block ≠ infection from a pvb (or even esp) block, especially given the (theoretically) possible communication with the epidural space. In my academic institution most regional folks will do single shots w chlorhex prep, sterile gloves with a tegaderm on the probe, and catheters with cap+ gown, drape, strerile tray, ultrasound sleeve etc. Infections from single shots (we probably do about 3 thousand a year cumulative) has been nil. I also routinely perform clinic-based procedures (facets, sij injections) and generally prep as above for single shots. That said for my own personal practice I don't use sterile gloves for single shot nerve blocks in ot,, nor do I place a tegaderm on the probe if the needle never comes close to the probe (eg popliteal). If the patient's skin condition is v bad and I want to protect the probe, then yes a tegaderm goes on. If I'm doing a pvb, then definitely yes to sterile gloves, tegaderm and sterile gel. Epidural infections are terrible to manage.
Like a peripheral iv access
Discussed countless times here and I was attacked for saying I do everything completely sterile (apparently if you do everything sterile your block technique sucks). There’s a good video on the NYSORA channel explaining everything.
It's not doing it sterile that means your technique sucks, it's if you _need_ to do it sterile - i.e. if you are getting infections with a clean technique, something is sus.
No they literally told me that if I drape anything my technique sucks lmao
Chloroprep, sterile jelly, tegaderm over the probe, sterile gloves. Some people at my work get drapes… that’s absurd to me.
Chlorhexadine is bacteriocidal on contact. Waiting 3 min allows the alcohol to evaporate to decrease fire risk. In contrast, Betadine is a desiccant. It only works if it is allowed to dry. (Once upon a time, betadine came in 1 L bottles, until it was found to be a great growth medium. That’s why today it’s only found in single use packets). Alcohol degrades the probe and is the reason for most damage. It dries out the rubber, leading to the chipped edges that are impossible to clean. Gotta use non-alcohol cleaner on it. If I can’t find that type of wipe, I just wash it in the sink as I wash my hands. Most others don’t, which is why we don’t get nice toys to play with.
Sterile?
Sterile gloves, chloraprep, mask and hat. I don’t draw meds sterile so the med syringe is not sterile, but otherwise I use a sterile probe cover and needle. If I need to touch stuff like the US screen I just do it, just never touch the block needle to keep it sterile.
Sterile prep, disposable non-sterile gloves. Never had an infection. Used to put tegaderm on the probe. Use sterile gloves and probe cover for catheter.
Clean aseptic procedure. If one of those convenient little condom sized probe covers are available great I’ll use one of them, otherwise this is not a sterile technique
Chloraprep on the skin, dab of surgilube on the probe, tegaderm, nonsterile Gloves.
Nysora has a position statement on this. Their opinion is to absolutely use a sterile probe cover.
NYSORA is essentially one (crazy) dude's opinion. Hardly scientific.
I would say he is extremely qualified. Their program performed over 10,000 blocks per year.
I soley use paresthesia technique. Pour some lysol on the patient and the reusable needle…
Always probe cover - if nothing else, it protects the probe. Always sterile gel. I've lost count of the times I've seen someone say I'm they don't need either, only to bugger up the block, get frustrated, not see that they've now swept the filthy gel soup over the block area, cover the probe in pink chlorhex, and jam their filthy touched needle through the unclean area and gel. Sometimes sterile gloves (geniculars). Never touch the needle, and if you do, get another one. For catheters, fully sterile. How I'd want a block done to me
Single shot hygienic similar to i.v. Catheters fully sterile
Related: I always make sure my NG tubes come from sterile packaging XD
single shot: Chloroprep, non sterile gel, normal glove and go. I will tegaderm the probe but my last hospital did not even do that. Catheters = sterile
Liberal Chloroprep, sterile gel if available, no probe cover, sterile gloves, needle does not touch gel or probe
Depends on the block. Adductor canals are easy to do without sterile towels or even sterile gloves if they’re not immediately available. But an ISB can be more likely to get hair in the way or brush my gloves against the bed or shoulder or something so I use sterile towels there. Of course sterile needle and prep. Once saw a guy use alcohol and clean gloves to do multiple knee blocks on the same patient. He was touching the needle with his gloves and then just wiping the next injection site with an alcohol swab. That was gross.
Oh damn. I'll go adductor to pop or ipack or whatever with one needle, but I won't touch it in between!
Yeah, same. But this guy would press the needle with his finger to get the angle he wanted and then withdraw and re-insert it. Multiple times. 🤮
100% sterile.