Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices

courtesy of AHRQ
The AHRQ recently published an update to its landmark 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (AHRQ Evidence Report No. 43). The updated 2013 report analyzed a growing body of patient safety research to determine the level of evidence regarding the outcomes, as well as implementation, adoption, and the context in which safety strategies have been used.  After analyzing 41 patient safety practices, an international panel of patient safety experts identified 22 safety practices which were deemed ready for adoption and ten were selected as “strongly encouraged” for adoption based on the strength and quality of evidence. Number nine on that list was “Use of real-time ultrasound for central line placement.”

For a list of all  22 patient safety strategies discussed in the new report and information on an Annals of Internal Medicine supplement that features several articles on selected patient safety strategies, go to

Gulfcoast Ultrasound Institute offers several options for Ultrasound Guided Vascular Access training:

Ultrasound-Guided Vascular Access: In-Plane Approach


Ultrasound-Guided Vascular Access: In-Plane Approach

Needle Placement In-Plane
Figure 1: Needle placement in-plane with beam

The transducer is held stationary with the non-dominant hand while advancing the needle using the dominant hand.

The in-plane or long access approach is the technique used to allow visualization of the entire needle when performing ultrasound-guided vascular access.

In-Plane Approach
Figure 2: In-plane approach

The transducer is positioned in a long axis over the selected vein.  The vessel is visualized straight across the screen.  The needle is placed at the center of the transducer in-line with the ultrasound beam and the trajectory of the vessel with the bevel up.

Ultrasound Image of the Needle
Figure 3: Ultrasound Image demonstrating needle (yellow arrow)

To learn more about ultrasound-guided procedures, check out ultrasound-guided training courses from Gulfcoast Ultrasound Institute.

Figure 2: Adapted from Chapter 19, Emergency Ultrasound Ed. 2, James Mateer MD, editor”


Word of the Day: Ultrasound-Guided Regional Anesthesia: In Plane-Needle Approach

Ultrasound-Guided Regional Anesthesia:  In Plane-Needle Approach

Needle placement in-plane with transducer - Images courtesy of John Antonakakis, MD
Ultrasound-Guided Regional Anesthesia: Needle placement in-plane with transducer/sound beam

The in plane or long axis needle approach is the technique used to allow visualization of the needle shaft and tip when performing ultrasound-guided regional anesthesia procedures.

The transducer is positioned over the selected nerve(s).  The needle is placed at the center of the transducer in-line with the ultrasound beam and the trajectory of the nerve bundle.

The transducer is held stationary with the non-dominant hand while advancing the needle using the dominant hand.

The needle shaft and tip are seen as a bright echogenic line.  The nerves are indicated by the yellow arrows.

To learn more about Ultrasound-Guided Anesthesia in plane-needle approach, and how to identify it during ultrasound-guided regional anesthesia and nerve block ultrasound courses, check out upcoming ultrasound-guided courses and products at Gulfcoast Ultrasound Institute.

Needle shaft and tip - Images courtesy of John Antonakakis, MD
Ultrasound-Guided Regional Anesthesia: Needle shaft and tip (red arrow), nerves indicated by yellow arrows.








Images courtesy of John Antonakakis, MD



Ultrasound-Guided Regional Anesthesia

by Bret P. Nelson, MD, RDMS, FACEP

Ultrasound-guided regional anesthesia (UGRA) is an emerging application of point-of-care sonography. Once solely the purview of anesthesiologists, other specialists are now realizing the benefits of these procedures and gaining competency in their performance.

Two recent review articles summarize key blocks nicely:

  • De Buck F, Devroe S, Missant C, Van de Velde M. Regional anesthesia outside the operating room: indications and techniques. Curr Opin Anaesthesiol. 2012 Aug;25(4):501-7 (PMID: 22673788)
  • Antonakakis JG, Ting PH, Sites B. Ultrasound-guided regional anesthesia for peripheral nerve blocks: an evidence-based outcome review.Anesthesiol Clin. 2011 Jun;29(2):179-91. (PMID: 21620337)

Ultrasound-Guided Regional Anesthesia Landmark approach

Traditionally, the only method for performing procedures was using anatomic landmarks. For example a femoral nerve block would be performed by first locating the femoral crease and then palpating the pulse of the femoral artery. The needle would be inserted lateral to the femoral artery.

Nerve Stimulator approach

Use of the nerve stimulator increased success rates and the ability to perform more difficult blocks. When using a nerve stimulator the needle is still attached to a syringe of anesthetic solution. However it is also attached to a nerve stimulator which creates a mild (typically less than 0.5 mA) current. Position of the needle tip is confirmed by muscle twitch. For example, quadriceps muscle twitch when performing a femoral nerve block.

In the past decade many providers have moved from nerve stimulation to ultrasound guidance, in part due to data studies such as this one:

  • Abrahams MS, Aziz MF, Fu RF. et al. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth 2009 Mar;102(3): 408-417 (PMID: 19174373)

Ultrasound guidance

Most recently ultrasound guidance has become the method of choice for many clinicians performing regional nerve blocks. It can be used alone or in combination with nerve stimulation. In the video below the femoral artery is seen pulsating to the screen right; to the screen left a growing anechoic space represents anesthetic being infiltrated around the femoral nerve. Note that in this video the operator is using a nerve stimulator in addition to ultrasound guidance.

Common Blocks

There are a number of nerve blocks commonly employed in acute care and operative settings. Many are reviewed on NYSORA’s website. Here are a few to consider if you are new to the technique:

  • Femoral nerve block: Helpful for femur, knee, thigh injuries
  • Forearm block: helpful for hand injuries
  • Interscalene brachial plexus block: helpful for shoulder, humerus, elbow injuries

For further information regarding nerve blocks please check out the resources listed in this post, as well as the anesthesiologists, emergency physicians, pain management and/or sports medicine physicians at your local institution. To learn more about Ultrasound-Guided Regional Anesthesia, check out the upcoming courses by Gulfcoast Ultrasound Institute.