Increasing consistency in upper limb UGRA
- 1. 1 Consistency in UGRA: Upper Limb Techniques Colin J.L. McCartney MBChB PhD FRCA FCARCSI FRCPC Head of Anaesthesia The Ottawa Hospital, Professor and Chair of Anaesthesia University of Ottawa, ON, Canada
- 2. Conflicts of Interest None
- 3. Summary: Consistency in UGRA 1. Start simple 2. Stay safe 3. Get trained 4. Use volume 5. Assess carefully and rescue if needed
- 4. 1. Start Simple Everything should be made as simple as possible, but not simpler Albert Einstein 4
- 6. R, SB 56 patients Axillary block US Perivascular or Transarterial technique 30mL 1.5% Lidocaine with epinephrine Block Onset time and Success
- 7. Diagram demo
- 8. Results
- 10. Diagram demo
- 12. Summary: Consistency in UGRA 1. Start simple 2. Stay safe 3. Get trained 4. Use volume 5. Assess carefully and rescue if needed
- 13. 2. Stay safe 13
- 14. Staying safe 1. Know your block 2. Know your ultrasound 3. Slow, incremental injection with frequent aspiration 4. Use a marker of IV injection 5. Use nerve stimulation and injection pressure 6. Sedate your patients adequately
- 15. Bad stuff happens to us all 15
- 16. Summary: Consistency in UGRA 1. Start simple 2. Stay safe 3. Get trained 4. Use volume (if needed) 5. Assess carefully and rescue if needed
- 18. Kathy Sierra: http://headrush.typepad.com/creating_passionate_users/2006/03/how_to_be_an_ex.html
- 19. J Shoulder Elbow Surgery 2007; 16 (Jul/Aug): 379-387
- 21. Simulation & Needle guides 20 2nd year anesthesia residents No US experience 2 groups: Gp1 Standard training; Gp2 1 hour training on low fidelity model Both gps started regional rotation Success/Failure of blocks assessed RAPM 2012
- 22. Simulation & Needle guides Success: Block performed within 15 minutes and suitable for surgery without rescue blocks
- 23. Simulation & Needle guides Conventional group 98 successful blocks, and the simulation group had 144 (51.3% vs 64%; P = 0.016). CUSUM: Conventional group 40% achieved proficiency, Simulation group, 80% proficiency (P = 0.0849)
- 24. Summary: Consistency in UGRA 1. Start simple 2. Stay safe 3. Get trained 4. Use volume (if needed) 5. Assess carefully and rescue if needed
- 25. 4. Use volume In the hands of experts very low volumes of local anesthetic can be used for successful BPB For some techniques (axillary, interscalene) Not for others (infraclavicular, supraclavicular) The proper dose of any drug is enough 25
- 29. RDBCT 40 patients USG ISB Posterior approach 5 vs 20 ml 0.5% ropivacaine Standard GA Primary endpoint: Phrenic block at 30 min Secondary: Postop pain, Oxygen saturation, spirometry BJA 2008
- 30. Can a low volume US-guided technique reduce common complications of ISB? Riazi S, Carmichael NM et al BJA 2008 20ml 20ml 5ml 5ml %=oxygen saturation on air in PACU
- 31. Can a low volume US-guided technique reduce common complications of ISB? Riazi S, Carmichael NM et al BJA 2008
- 36. Summary: Consistency in UGRA 1. Start simple 2. Stay safe 3. Get trained 4. Use volume (if needed) 5. Assess carefully and rescue if required
- 37. 5. Assess carefully and rescue if needed 37
- 38. Use a block room if possible Reduces anesthesia controlled time Allows time to perform blocks and allow onset before moving patient to OR Benefits for patient Allows teaching and research Costs: extra staff, space, equipment 38
- 39. Assess carefully Even experts have slow/failed blocks Push, pull, pinch, pinch Use rescue blocks if needed Dont be frightened of the dreaded swear words: Propofol and LMA Follow up with your patient Take responsibility for any adverse events 39
- 40. Rescue blocks: easy with US 40 RAPM 2007
- 41. Follow up with your patient
- 42. Summary: Consistency in UGRA 1. Start simple 2. Stay safe 3. Get trained 4. Use volume 5. Assess carefully and rescue if needed