ULTRASOUND
as flying a patient with an untreated pneumothorax at a height greater than 3,000 feet will aggravate the condition. PoC ultrasound scanning has an important role to play, enabling the presence or absence of a pneumothorax to be established, helping to avoid unnecessary invasive treatment being performed in conditions that are far from sterile.
The right tool for recovery Prior to the acquisition of a PoC ultrasound system, the paediatric retrievals service was dependent on whatever equipment the patient’s local hospital could provide. The referring hospitals differed considerably in size, from 1,000-bed regional centres to four-bed community nurse-led practices, and the variability in the ultrasound equipment offered – if any – made it very difficult to provide consistent treatment. The attending physician could be faced with anything from a complex, high-end obstetric ultrasound scanner that was extremely complicated to use, to an old-fashioned, first generation system from the early 1990s.
Having to use this unfamiliar, often
inappropriate equipment made central line placement in a baby or a young child quite a challenge. In the absence of an ultrasound scanner, the traditional landmark technique was used, but this can be a little ‘hit or miss’; using this method in small children without direct ultrasound guidance is far from ideal. Investing in a portable ultrasound system, SonoSite’s NanoMaxx, which is small, easy to clean, has a good battery life and is robust in all types of weather, was the solution. The system is a key asset for emergency transfers, providing the retrievals service with standardised, easy-to-use equipment. Physicians simply need to switch on and start scanning.
Benefits for both patient and hospital PoC ultrasound is also routinely used in paediatric theatres at the Royal Hospital for Sick Children, where orthopaedic and plastic surgeons are really keen for anaesthetists to carry out brachial plexus and similar nerve blocks, enabling good analgesia and allowing the children to mobilise more quickly and recover faster after their operations. In plastic surgery, there is an additional advantage for skin and muscle grafts; local anaesthetics are known to promote better blood flow and profusion after surgery, encouraging healing, which is a huge benefit. SonoSite’s S-Nerve system is ideal for needle guidance, offering the simplicity of operation needed to perform blocks in the theatre, together with excellent image quality. Good resolution of the nerves,
58 THE CLINICAL SERVICES JOURNAL
Accurate diagnosis is vital, particularly when a patient is to be transferred by air, as flying a patient with an untreated pneumothorax at a height greater than 3,000 feet will aggravate the condition.
such as those in the supra-clavicular plexus, can be obtained, enabling accurate catheter insertions in young children, which is essential for good analgesia. Before ultrasound was routinely adopted in the operating theatre, these blocks relied on a nerve stimulator technique to guide the needle.
In the past, the default pain relief option for children undergoing orthopaedic procedures has been either a morphine infusion, which generally makes them nauseous and does not always work effectively, or an epidural. While an epidural gives very good pain relief, it is a higher-risk procedure requiring increased post-operative care in a high dependency (HDU) or intensive care unit, which places significant demands on resources, as well as being a difficult environment for both the child and the parents to cope with. A more recent development is the use of nerve catheters, which allow targeted, effective analgesia to be provided at the operative site. Nerve catheters are generally inserted under light anaesthesia or sedation – a general anaesthetic can often be avoided – at the start of a procedure, using ultrasound guidance to ensure correct placement, and offer several benefits for the child, the parents and the hospital. Ultrasound guidance allows the nerve to be visualised, enabling the procedure to be
performed more rapidly and safely, with greater confidence. Infusing local anaesthetic from the outset removes the need for morphine, promoting clear-headed, rapid post-operative recovery. With the risk of nausea minimised, patients eat and drink normally and, without an epidural, can usually be cared for on the ward, avoiding the need for a critical care bed. Earlier mobilisation and initiation of post-operative physiotherapy may also be possible, promoting faster recovery. The ease of use and short boot-up times of the hospital’s various PoC instruments have popularised ultrasound throughout the hospital; everyone knows how to use the theatres’ system, and surgeons have started using it to insert surgical lines under general anaesthesia. But there is another, perhaps less obvious benefit of using ultrasound technology in a PoC setting. Junior medical colleagues and paramedics, once trained, are able to look at the screen and understand what it is that they are seeing, as are non-medically trained theatre colleagues. The procedure then becomes more of a team, rather than an individual, effort; it is somewhat akin to video laryngoscopy, where everyone in theatre can see what is going on. The entire team can follow the process, anticipating what needs to be done and, if there are difficulties, help with positioning or perhaps invoke other measures to try to improve the situation.
Summary
The use of ultrasound in the operating theatre, ICU and on patient retrievals has led to faster, more accurate insertions compared to the older placement techniques, which rely on the body’s morphology. Patient safety is enhanced as ultrasound allows the needle to be visualised, ensuring placement in the correct nerve or vein, giving total confidence that the procedure will definitely succeed. While some hospitals still recommend X-ray confirmation of correct placement, the hope is that as hospitals increasingly realise that PoC ultrasound is safer and quicker than X-ray, the latter will be superseded as a confirmatory checking procedure. With the technology continually improving, becoming more portable and offering better battery lifetime and storage options, it may well also become more commonplace in retrieval and emergency practice.
About the author
Dr Jon McCormack is a consultant in paediatric anaesthesia and intensive care retrieval at the Royal Hospital for Sick Children, Edinburgh.
APRIL 2015
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