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Safety of needle insertion through the applied gel in Ultrasound guided regional anaesthesia- Is Normal saline an alternative-coupling medium?
- Baskar P Manickam (9 July 2009)
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Ultrasound Guided Central Neuraxial Blockade: a single person technique?
- Casey Curran, Santhanam Suresh, MD, FAAP (1 July 2009)
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Baskar P Manickam, Consultant Anaesthetist Darlington Memorial Hospital
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----------------------------------------------------------- ------------------------------------------- Ultrasound gels are commonly used for diagnostic scanning on patients. They are licensed for use on the skin only. It is harmless when applied on skin and use of sterile gel avoids the risk of infection. However, it is becoming increasingly common that interventional procedures are done under ultrasound guidance e.g peripheral nerve blocks. It is common practice to apply sterile gel on patient’s body to provide better US imaging quality before needle insertion. Often, the needle is inserted over the applied gel site to access the target nerves. However, there is no evidence to support the safety of such practice, considering the possibility of gel contact with nerve tissues. The real hazard of needle insertion over applied gel and possible penetration of gel into body cavities is not known. There are no reports so far of any adverse neurological sequelae due to chemical irritation from gel medium in ultrasound guided regional anaesthesia practice. The study published by Dr Karmakar and colleagues suggest avoidance of gel use for neuraxial imaging and real time needle guidance to access spinal/epidural space. They have recommended that saline should be used as the contact medium for such procedures to avoid risk of gel penetration into CSF space. However, there is no clear consensus on such practice and there are no studies done to evaluate the quality of imaging obtained with use of saline as a coupling medium. Saline as known from its physical properties is quickly evaporable and requires repeated application over the skin using a soaked swab. Moreover the quality of imaging obtained is not consistent when compared to gel. The deterioration of image quality during an interventonal procedure may be a significant disadvantage and increase the time for block performance. It also may expose the risk of unintentional damage to surrounding structures if the operator fails to notice the change in image quality. We recommend that a needle insertion point further away from the probe or removing the gel at the needle entry point, may avoid the risk of penetration of gel medium into body tissues. Furthur evaluation on the safety of gel penetration into body cavities is required and the quality of imaging of alternative coupling medium needs to be investigated for interventional procedures under ultrasound guidance. Conflict of Interest:None declared |
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Casey Curran, Research Assistant Department of Pediatric Anesthesiology, Children's Memorial Hospital, Chicago, USA, Santhanam Suresh, MD, FAAP
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We would like to commend Dr. Karmarkar and his colleagues for the excellent description of their approach to US-guided central neuraxial blockade. In our own experience we have performed many US-aided central neuraxial blockade in infants and children with the help of "a third hand". This novel approach with the use of the Episure™ needle may be the solution to our quest to utilize this technique in all epidural catheter placement. Will this technique be applicable to neonates and infants due to the pressure applied by the syringe? This technique may alter a clinician's approach to US-guided central neuraxial blockade in real-time. Further, single-operator real-time central neuraxial blockade comparing the use of loss of resistance technique to US-guided blockade with particular importance to time taken to perform the block and patient satisfaction should be carried out. Conflict of Interest:Sonosite Inc, Equipment support: Dr Suresh |
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