If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
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E-letters: Electronic letters published:
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Ultrasound model on the internet
- Mahamoud M gabal (12 June 2006)
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ultrasound regional anasethesia between lab. and clinical application
- Mahamoud M Gabal, Mahamoud M. Gabal (22 April 2006)
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Training in the use of ultrasound for regional techniques
- Amar Karmarkar, Swati Karmarkar (12 September 2005)
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Another advantage of ultrasound guidance in regional anaesthesia?
- John J Picard (15 January 2005)
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Reply to the letter by Gruber et al.
- Peter Marhofer (4 January 2005)
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Ultrasound assistance in regional anaesthesia
- Hannes Gruber (6 December 2004)
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Mahamoud M gabal, radiologist
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Dear Editor You readers can access on the internet my simple ultrasound model that will make it so easy to learn ultrasound skills. Please go on grsol2006@yahoo.com, and use my password =11223344 Thanks Conflict of Interest:us models |
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Mahamoud M Gabal, radiologist , Mahamoud M. Gabal
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I read with interest this work and all the letters to the journal. The prepheral nerves as I see with ultrasound are so easy to see even by 3.5 MHZ convex probes that it does not need much experience to learn. The largest branches can be traced from their orign nearly to their terminal parts. Second the needle introduction is so simple if we keep in mind that the probe is not a fixed bony part but we use it freely in several directions that show us a target nerve needed [like a spot light in the dark room searching for a target point. To help our recent members in this field we developed ultrasound models to make learning interesting. We will send it to your journal. Conflict of Interest:us models |
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Amar Karmarkar, specialist registrar anaesthesia, Swati Karmarkar
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Editor, We read with interest the article ‘Ultrasound guidance in regional anaesthesia’ by P. Marhofer, M.Greher, S.Kapral.(1) It took us many decades to evolve from giving open plexus blocks to using ultrasound. Before the advent of nerve stimulators, there was a phase where we used anatomical landmarks to give nerve or plexus blocks. In using anatomical landmarks, it is difficult to pass on the skills to the trainees because it depends on the expertise of the anaesthetist i.e. it is a subjective skill. In using nerve stimulators, it is difficult sometimes to get an accurate twitch. Sometimes the block fails to act in spite of getting the accurate twitch. The most important advantage of localising nerves using ultrasound is that once trained, the skills are transferable. Although the use of an ultrasound probe for peripheral blocks is a useful technique, the training remains scanty. There are not many courses designed to give hands on experience in giving regional blocks like trans- oesophageal echocardiography (TOE) courses for cardiac anaesthesia. Anaesthetists are becoming more acquainted with the use of ultrasound probe following the guidelines issued by NICE for insertion of central lines (2). However we need training in reading the ultrasound images i.e. identifying the nerves, which cannot be learnt in lecture theatres. Considering the advantages and recent advances in the ultrasound probe (3), there should be more training available in its use. A survey by the GAT committee on the study leave budget underlines the limited scope for attending national courses (4). Local courses should be made available and trainees should be encouraged to go on them. Training in identifying different structures on the ultrasound screen should also be organised from local radiology departments. A.Karmarkar, South Manchester University Hospitals. S.Karmarkar, North Manchester General Hospital. E mail: acarrom@yahoo.co.uk (1) Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005; 94(1): 7-17. (2) Final appraisal determination: Ultrasound locating devices for placing central venous catheters. NICE guidelines. Aug 2002. (3) Marhofer P, Willschke H, Greher M, Kapral S. New perspectives in regional anaesthesia: the use of ultrasound. Past, present, future. Canadian journal of anaesthesia June2005; 52 (supp 1). (4) Harries S, Nixon M. Group of anaesthetists in training: Study leave survey. 2001. www.aagbi.org/gat_studyleave.html. Conflict of Interest:None declared |
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John J Picard, Consultant Anaesthetist Charing Cross Hospital, London
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Marhofer et al. recently reviewed with enthusiasm the use of ultrasound in regional anaesthesia. They did not, however, mention a clinical conundrum which thwarts even the most avid proponent of nerve stimulation: how to block the nerves of a limb whose distal part is already amputated. If, for example, a patient’s leg has already been amputated below the knee, motor responses cannot guide sciatic blockade if further surgery is planned. Do the authors have experience of using ultrasound in this or analogous situations which otherwise drive the anaethetist toward the neuraxis or even general anaethesia? Conflict of Interest:None declared |
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Peter Marhofer
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In reply: We appreciate the letter from Gruber et al. about our recently published review article “Ultrasound guidance in regional anaesthesia” (1). Their main criticism describes the fact, that we prefer the performance of nerve blocks using a “transversal” technique, where the canula is introduced in a cross sectional direction in relation to the ultrasound probe. It is important to mention that we also perform the so-called “inline” technique, where the canula will be visualized in a longitudinal direction in relation to the probe. One example for this should be the supraclavicular brachial plexus block. Unfortunately the exact technique is not described in the paper above, which is due to the fact that the review article has been written about one year ago, and despite our study group has experience with ultrasonography in regional anaesthesia for over one decade, we always develop our techniques. In addition, we describe the psoas compartment block by using the “inline” technique, which is also published in a recent paper by Kirchmair et al. (2). Despite the advantage of a better ultrasonographic visibility of the canula when the inline technique is performed, we prefer for most of our blocks the transversal technique. One reason for this management of ultrasonographic guided blocks in the daily clinical practice is an approximately threefold shorter distance from the site of puncture to the nerves and therefore a better comfort for our patients with less pain during the block. In addition, in our mind the direct visualization of the tip of the canula in combination with other indirect signs of the needle position (e.g. movement of the tissues, dorsal shadow of the tip of the canula) allows an optimal placement of the canula in relation to the nerve structures. But the most important sign of a successful block is the distribution of local anaesthetic (“Not the tip of the needle, but the local anaesthetic blocks the nerve”). Gruber et al. are completely wrong with their opinion that the transverse technique is less exact compared with the longitudinal technique. Greher et al. impressively demonstrate this fact for specific indications in pain therapy (3,4). We agree with Gruber et al. that no image in our paper shows the relationship between nerves, needles and local anaesthetics, which shows the disadvantage of two-dimensional pictures, where three-dimensional (or even “four-dimensional” (5)) illustrations of the anatomical structures in relation to the canula and the local anaesthetics are necessary. We are aware about the problems of two-dimensional illustrations in publications, and therefore our figures should only illustrate the anatomy. In conclusion, ultrasonography in regional anaesthesia and pain medicine offers the advantage of excellent blocks with significant reduced amount of local anaesthetics. Our study group has the experience of several thousands of blocks in the daily clinical practice; most of them performed using the transversal technique. In our mind it is also a matter of personal experience which of the possible techniques is used for which block, but some considerations support the transversal technique for most of the indications. Peter Marhofer, MD Medical University of Vienna Department of Anaesthesia and Intensive Care Medicine Waehringer Guertel 18-20, A-1090 Vienna +43 1 40400 4107 (phone) +43 1 40400 4028 (fax) peter.marhofer@meduniwien.ac.at (email) www.sono-nerve.com (homepage) References 1. Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005;94:7-17. 2. Kirchmair L, Entner T, Kapral S, Mitterschiffthaler G. Ultrasound guidance for the psoas compartment block: an imaging study. Anesth Analg 2002;94:706-10; table of contents. 3. Greher M, Scharbert G, Kamolz LP et al. Ultrasound-guided lumbar facet nerve block: a sonoanatomic study of a new methodologic approach. Anesthesiology 2004;100:1242-8. 4. Greher M, Kirchmair L, Enna B et al. Ultrasound-guided lumbar facet nerve block: accuracy of a new technique confirmed by computed tomography. Anesthesiology 2004;101:1195-200. 5. Denny NM, Harrop-Griffiths W. Editorial I: Location, location, location! Ultrasound imaging in regional anaesthesia. Br J Anaesth 2005;94:1-3. Conflict of Interest:None declared |
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Hannes Gruber, Radiologist Innsbruck, Medical University, Dept. of Radiology I, AUSTRIA
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I read with interest the review of Marhofer, Greher and Kapral1 on the topic of peripheral nerve infiltration and regional anaesthetic block under ultrasound guidance. Here we learn that almost any regional nerve block may be performed under “direct visual control” avoiding unintended damage. We also learn about a needle guidance-technique (direction of the cannula perpendicular to the applicator orientation, Fig. 3) where only hypoechoic cross-section shadows of the puncture needle are visualized. Additionally the authors concede an indirect locating of the needle by watching the surrounding soft-tissue during needle movement. In my opinion, the authors misalign cannula and ultrasound-probe as the applicator should match the (intended)direction of puncture to watch the whole needle and the position of its tip in real-time. Thereby the target can also be watched continuously and unintended punctures are avoided. No image in the paper shows a “direct ultrasound visualization” of a puncture needle and a defined puncture. It must be stated that the authors´ topic is exhausting on “ultrasound assisted regional anaesthesia”- a technique defining the overall region of puncture with relative accuracy. Our peripheral neural injection technique2 shows that according orientations of applicator and needle (be it for a neural block or a therapeutic infiltration) allow a very defined puncture of even small neural structures. Therefore a success rate of nearly 100% and a lower consumption of local anaesthetics will be expected. Additionally, it will avoid unintended blocks. 1Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth. 2004 Jul 26; [Epub ahead of print]. 2Gruber H, Kovacs P, Peer S, Frischhut B, Bodner G. Sonographically guided phenol injection in painful stump neuroma. AJR Am J Roentgenol. 2004 Apr;182(4):952-4. Conflict of Interest:None declared |
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