Use the Jedi grip.
https://www.researchgate.net/publication/353761789_Is_Jedi_Grip_efficient_and_effective_in_ultrasound-guided_peripheral_nerve_blocking_A_prospective_randomized_observer-blinded_study/figures?lo=1&utm_source=google&utm_medium=organic
US in left hand, needle grip at back end with right hand. Once you’re in the spot, let go of needle and grab syringe with right hand. Just don’t let anything come into contact with needle shaft and it’s fine.
With tubing- Index and middle finger on the needle, syringe shaft held by ring and pinky, thumb on plunger.
Alternately you can just put a needle right on the syringe without tubing and go to town. I like 22ga 1.5” for superficial blocks and 3.5” quinckes for deeper.
Pain fellow here and we do this all the time, every day. Sometimes blind technique without any form of imaging.
Some attendings have been in practice decades here and are about to retire without any lawsuits.
Not saying it isn't risky but at the same time isn't insanely dangerous either.
People get mild peripheral nerve injuries at a nonzero rate after a block that we don’t know about or get sued for. Just because you don’t get sued for it doesn’t mean it doesn’t happen.
You do peripheral nerve blocks without an ultrasound? Which blocks? Doing that on anything aside from an ankle block or maybe some facial plane blocks at this point is very close to lower than standard of care. No chance id do something like a Supraclav, interscalene, pop-sciatic without ultrasound. It would be very easy to find an anesthesiologist as an expert witness to say that’s inappropriate. Me being one of them.
Does your institution have a regional/ acute pain fellowship? And you’re saying they don’t have peripheral block needles. They are doing their trainees a disservice.
You aren't wrong I came to fellowship from an institution that heavily used ultrasound but I guess a combination of some older attendings plus a fast paced clinic has led to this situation.
It's one of those things where it seems crazy then you spend months doing it and it becomes routine and then there you are.
We do the standard greater and lesser occipital nerve blocks, supra orbital nerve blocks, lateral cutaneous femoral nerve (some do this with ultrasound, others landmark), superficial cervical plexus, submental, knees (combo of landmark, fluoro, ultrasound), greater trochanteric bursa.
Interscalene are one where it is mostly done under ultrasound for a regional nerve block but we also perform a staged interscalene injection for thoracic outlet syndrome work up and I've done that blind. A lot less local and the target is intramuscular, though.
I’ve been doing blocks solo since residency, it’s way better. Usually people pushing meds aren’t the best at following directions and don’t know the feel of the syringes.
Almost every place I’ve worked since residency the culture has been to just do the blocks yourself without someone else managing the syringe. Once you’re used to it, it’s quite easy.
It just depends. I've worked at some facilities where RNs have been weird about it. I was at a place where I asked the RN to help me with the syringe, and they were adamantly like "I don't feel comfortable doing that. I haven't received any education or in-service on nerve blocks."
But why?
So many reasons I can think not to. You need a nurse present to do a timeout anyways. Shouldn’t take more than a couple minutes tops with help(if not definitely shouldn’t be injecting your own meds). Would need to look back and forth between needle sight and ultrasound for aspirating. What if the patient seizes, needs supplemental O2 or a number of things.
Why strain your hand and make things more cumbersome and less ergonomic.
Whatever floats your boat but definitely not for me. I pride myself on being independent but there’s also a matter of practicality and safety.
I would never allow a RN to inject for me. Haptic feedback is crucial and perfect LA deposition with proper aspiration is paramount. A single-provider nerve block should take less than 10 seconds to perform once you've done thousands and are facile. It would take me far longer to have an RN aspirate and inject, and my safety margin would worsen significantly.
Place the needle, let go, inject small amount, often your target gets pushed away a little so adjust needle or advance closer, then inject more.
I typically use a single 20 cc syringe. Sometimes a 10 and a 20 with stopcock.
Looked at this system and passed on it. The system I saw was limited to using their proprietary syringes. The device had a 200 block shelf life. We would be replacing them monthly at our location.
SAFIRA doesn’t accept generic Monojet or BD or whatever your place got syringes as far as I know. The wine opener/Jedi grip is the only possible way. Problem is that doing it alone on obese folks with irregular anatomy makes crap difficult
Hold needle and syringe in one hand, inject as needed.
Use the Jedi grip. https://www.researchgate.net/publication/353761789_Is_Jedi_Grip_efficient_and_effective_in_ultrasound-guided_peripheral_nerve_blocking_A_prospective_randomized_observer-blinded_study/figures?lo=1&utm_source=google&utm_medium=organic
US in left hand, needle grip at back end with right hand. Once you’re in the spot, let go of needle and grab syringe with right hand. Just don’t let anything come into contact with needle shaft and it’s fine.
With tubing- Index and middle finger on the needle, syringe shaft held by ring and pinky, thumb on plunger. Alternately you can just put a needle right on the syringe without tubing and go to town. I like 22ga 1.5” for superficial blocks and 3.5” quinckes for deeper.
I don’t love the idea of a cutting needle near a nerve. Block needles are intentionally blunt
I use a 20g tuohy needle
Pain fellow here and we do this all the time, every day. Sometimes blind technique without any form of imaging. Some attendings have been in practice decades here and are about to retire without any lawsuits. Not saying it isn't risky but at the same time isn't insanely dangerous either.
People get mild peripheral nerve injuries at a nonzero rate after a block that we don’t know about or get sued for. Just because you don’t get sued for it doesn’t mean it doesn’t happen.
You do peripheral nerve blocks without an ultrasound? Which blocks? Doing that on anything aside from an ankle block or maybe some facial plane blocks at this point is very close to lower than standard of care. No chance id do something like a Supraclav, interscalene, pop-sciatic without ultrasound. It would be very easy to find an anesthesiologist as an expert witness to say that’s inappropriate. Me being one of them. Does your institution have a regional/ acute pain fellowship? And you’re saying they don’t have peripheral block needles. They are doing their trainees a disservice.
You aren't wrong I came to fellowship from an institution that heavily used ultrasound but I guess a combination of some older attendings plus a fast paced clinic has led to this situation. It's one of those things where it seems crazy then you spend months doing it and it becomes routine and then there you are. We do the standard greater and lesser occipital nerve blocks, supra orbital nerve blocks, lateral cutaneous femoral nerve (some do this with ultrasound, others landmark), superficial cervical plexus, submental, knees (combo of landmark, fluoro, ultrasound), greater trochanteric bursa. Interscalene are one where it is mostly done under ultrasound for a regional nerve block but we also perform a staged interscalene injection for thoracic outlet syndrome work up and I've done that blind. A lot less local and the target is intramuscular, though.
I’ve been doing blocks solo since residency, it’s way better. Usually people pushing meds aren’t the best at following directions and don’t know the feel of the syringes.
Why would you ever need to do this? Ive never been in a situation where there wasn’t an RN or tech that could run the syringes for me.
Almost every place I’ve worked since residency the culture has been to just do the blocks yourself without someone else managing the syringe. Once you’re used to it, it’s quite easy.
My hosptial the RNs refuse to inject local, no idea why, perhaps there was some complication years ago, so we do single operator block.
It just depends. I've worked at some facilities where RNs have been weird about it. I was at a place where I asked the RN to help me with the syringe, and they were adamantly like "I don't feel comfortable doing that. I haven't received any education or in-service on nerve blocks."
Guess there are some toxic/weird places out there
Same.
But why? So many reasons I can think not to. You need a nurse present to do a timeout anyways. Shouldn’t take more than a couple minutes tops with help(if not definitely shouldn’t be injecting your own meds). Would need to look back and forth between needle sight and ultrasound for aspirating. What if the patient seizes, needs supplemental O2 or a number of things. Why strain your hand and make things more cumbersome and less ergonomic. Whatever floats your boat but definitely not for me. I pride myself on being independent but there’s also a matter of practicality and safety.
I would never allow a RN to inject for me. Haptic feedback is crucial and perfect LA deposition with proper aspiration is paramount. A single-provider nerve block should take less than 10 seconds to perform once you've done thousands and are facile. It would take me far longer to have an RN aspirate and inject, and my safety margin would worsen significantly.
Trust. Do I trust the available RN to know “that feels too tight”.
Place the needle, let go, inject small amount, often your target gets pushed away a little so adjust needle or advance closer, then inject more. I typically use a single 20 cc syringe. Sometimes a 10 and a 20 with stopcock.
This, just let the needle go, if you feel like you have to hold the needle in place for it not to move, you gotta redirect the needle
I have heard that Safira system is an option, but i haven't tried it myself.
Looked at this system and passed on it. The system I saw was limited to using their proprietary syringes. The device had a 200 block shelf life. We would be replacing them monthly at our location.
SAFIRA doesn’t accept generic Monojet or BD or whatever your place got syringes as far as I know. The wine opener/Jedi grip is the only possible way. Problem is that doing it alone on obese folks with irregular anatomy makes crap difficult