Increased Needle Visibility in Ultrasound-Guided Percutaneous Liver Biopsy by an Echogenic Sheath: A Proof of Concept Study in a Human Cadaver

Purpose For the safety and success of an ultrasound-guided percutaneous liver biopsy, needle visibility and needle tip identification are critical. The aim of this pilot study was to evaluate the influence of an innovative echogenic sheath placed over a standard biopsy needle on needle visibility in ultrasound imaging. Materials and methods Ultrasound videos of three sheaths with different coating characteristics (echogenicity) and one conventional liver biopsy needle were recorded at two angles (30° and 60°) and two depths (5 and 10 cm) in a human cadaver. The videos were blinded for needle type and presented to five independent radiologists who used Likert-scale scoring to rank each video for six characteristics on needle visibility. In addition, a phantom model was used to acquire standardized images for quantitative evaluation of the ultrasound visibility. Comparative statistical analysis consisted of a one-way ANOVA. Results The three prototype sheaths were ranked higher than the control needle at 60° with 5 cm depth, with an equal performance for the other conditions. The radiologists expressed more confidence in taking a biopsy with the echogenic sheaths than with the control needle, with 1 Likert score difference at 30°. Contrast analysis in the phantom model showed a statistically significant effect of a sheath (p = 0.004) on echogenic intensity. Conclusion This pilot study suggests that the use of an echogenic sheath may increase needle visibility, particularly for trajectories requiring steeper insertion angles. To investigate the superiority of the echogenic sheath over conventional needles, a clinical study is necessary.

Ultrasound probe tilt impedes the needle-beam alignment during the ultrasound-guided procedures

The objective of this study was to identify the factors that complicate the needle visualization in ultrasound-guided in-plane needling procedures. Forty-nine residents were recruited and randomized to insert the simulated blood vessel with four different views including Neutral (the long axis of the probe along the visual axis and the ultrasonic beam vertical to the surface of gel phantom), 45°-rotation (45° angle between the long axis of probe and the operator’s visual axis), 45°-tilt (45° angle between the ultrasonic beam and the surface of gel phantom) and 45°-rotation plus 45°-tilt of probe. Number of needle redirections, insertion time, and needle visibility were documented and compared for each procedure. When the residents faced with 45°-tilt view, the needle redirections (2 vs 0) and insertion time increased significantly (39 vs 16) compared with that of the Neutral view. When faced with 45°-rotation plus 45°-tilt view, the residents’ performance decreased further as compared with that of the 45°-tilt view and the Neutral view. However, there was no performance difference between the Neutral view and 45°-rotation view. In conclusion, during ultrasound-guided in-plane procedures, tilting the ultrasound probe may increase the difficulty of needle-beam alignment.

Localization Accuracy of Ultrasound-Actuated Needle with Color Doppler Imaging

An ultrasonic needle-actuating device for tissue biopsy and regional anaesthesia offers enhanced needle visibility with color Doppler imaging. However, its specific performance is not yet fully determined. This work investigated the influence on needle visibility of the insertion angle and drive voltage, as well as determined the accuracy and agreement of needle tip localization by comparing color Doppler measurements with paired photographic and B-mode ultrasound measurements. Needle tip accuracy measurements in a gelatin phantom gave a regression trend, where the slope of trend is 0.8808; coefficient of determination (R2) is 0.8877; bias is −0.50 mm; and the 95% limits of agreement are from −1.31 to 0.31 mm when comparing color Doppler with photographic measurements. When comparing the color Doppler with B-mode ultrasound measurements, the slope of the regression trend is 1.0179; R2 is 0.9651; bias is −0.16 mm; and the 95% limits of agreement are from −1.935 to 1.605 mm. The results demonstrate the accuracy of this technique and its potential for application to biopsy and ultrasound guided regional anaesthesia.

A Quantification System of Needle Visibility in B-mode Ultrasound with Linear and Curved Transducer

Apart from its usefulness in interventional procedure, ultrasound-guided needle insertion has also crucial problem in terms of needle visibility. The inconsistency of needle visibility is needed to be quantified to evaluate the significance of possible technical factors, e.g., imaging strategies, needle type, and needle-transducer relative position. Needle visibility quantification is important as an initial step before further investigation about fundamental physics behind it and further development of needle visibility enhancement. 20G, 150 mm spinal needle inserted in degassed water phantom is imaged with B-mode Flex Focus 800 BK-Medical using 12 MHz linear transducer and 6 MHz curved transducer. The insertion angles are varied between 15°-70°. The quantified visibility representing each needle position are combined into a comprehensive visibility map covering the whole insertion area. It is also evaluated based on insertion length. The results suggest that both linear and curved transducer, for all insertion angles, the distributions of needle visibility have similar pattern and they are not affected by the insertion length. Practically, this applied method of visibility quantification can be used as specific reference and to predict the distribution of needle visibility limited by the specification of needle and ultrasound system, i.e., range of transducer’s frequency and needle’s size.

Use of Echogenic Needles for Ultrasound-guided Transversus-Abdominis-Plane Block: Better Visibility Transforming into Better Postoperative Analgesia

Introduction: Ultrasound (USG)-guided Transversus-Abdominis-Plane (TAP) block is recommended due to its safety and reliability. Echogenic needles provide better needle visibility and might result in better postoperative analgesia after USG-guided TAP block. Aim: To compare visibilty and block-characteristics (including postoperative analgesia) of echogenic vs. non echogenic needle for USG-guided TAP block. Materials and Methods: This randomised double-blind study was carried out at King George’s Medical University, Lucknow over a period of one year (November 2018 to October 2019). Seventy patients undergoing abdominal surgeries were enrolled and randomly allocated to one of two groups Group-E (echogenic) and Group-NE (non echogenic). Bilateral TAP block was performed postoperatively in all the patients and 20 mL of 0.25% Bupivacaine was deposited on each side. In Group-E, echogenic needle was used and in Group-NE, non echogenic needle was used for TAP block. Research assistant documented the start and finish time of the block procedure, number of attempts and redirections based on predetermined criteria. Visibility of needle tip and shaft were graded on a 3-point scale based on recorded and de-identified video-clips. Total procedure-time, number of needle redirections and skin punctures, incidence of vascular punctures, Visual Analogue Scale (VAS) scores and rescue analgesia requirement were also noted. Statistical analysis was done using SPSS Version 21.0. Results: Needle visibility on USG was significantly better in Group-E than Group-NE (χ2=57.24, p<0.001). Mean time to reach the TAP plane (t=-16.89, p<0.001) and total procedure time (t=-15.76, p<0.001) were also significantly lesser in Group-E. Mean number of needle redirections (t=-11.21, p<0.001), mean number of skin punctures (t=-2.12, p=0.038) and postoperative VAS scores throughout the study were found to be significantly lesser in group-E as compared to group-NE. Postoperative analgesia required in 24 hour was lesser in group-E and time of first rescue analgesia required was earlier in group-NE (p<0.001). Patients in both the groups were haemodynamically stable throughout the study. Conclusion: Use of echogenic needle for USG-guided TAP block provides much better needle-visibility resulting in better block-performance. It also provided better analgesia in our study as evident by lesser VAS-scores and lesser requirement of rescue analgesia postoperatively. So, use of echogenic needle should be advocated in all the patients undergoing USG-guided TAP blocks provided there are no financial constraints.

Retroclavicular vs Infraclavicular block for brachial plexus anesthesia: a multi-centric randomized trial

Background The coracoid approach is a simple method to perform ultrasound-guided brachial plexus regional anesthesia (RA) but its simplicity is counterbalanced by a difficult needle visualization. We hypothesized that the retroclavicular (RCB) approach is not longer to perform when compared to the coracoid (ICB) approach, and improves needle visualization. Methods This randomized, controlled, non-inferiority trial conducted in two hospitals, included patients undergoing distal upper limb surgery. Patients were randomly assigned to a brachial plexus block (ICB or RCB). The primary outcome was performance time (sum of visualization and needling time), and was analyzed with a non-inferiority test of averages. Depth of sensory and motor blockade, surgical success, total anesthesia time, needle visualization, number of needle passes and complications were also evaluated. Subgroup analysis restricted to patients with higher body mass index was completed. Results We included 109 patients between September 2016 and May 2017. Mean RCB performance time was 4.8 ± 2.0 min while ICB was 5.2 ± 2.3 min (p = 0.06) with a 95% CI reaching up to 5.8% longer. RCB conferred an ultrasound-needle angle closer to 0° and significantly improved needle visibility after the clavicle was cleared and before local anesthetic administration. No differences were found in the secondary outcomes. Similar results were found in the subgroup analysis. Conclusion RCB approach for brachial plexus anesthesia was similar to ICB approach in terms of time performance. Needle visibility, which represent an important clinical variable, was superior and angle between needle and ultrasound probe was close to 0° in the RCB group. Clinical trial registration ClinicalTrials.gov (NCT02913625), registered 26 September 2016.

Retroclavicular vs Infraclavicular block For Brachial Plexus Anesthesia: A Multi-Centric Randomized Trial

Background: The coracoid approach is a simple method to perform ultrasound-guided brachial plexus regional anesthesia (RA) but its simplicity is counterbalanced by a difficult needle visualization. We hypothesized that the retroclavicular (RCB) approach is not longer to perform when compared to the coracoid (ICB) approach, and improves needle visualization. Methods: This randomized, controlled, non-inferiority trial conducted in two hospitals, included patients undergoing distal upper limb surgery. Patients were randomly assigned to a brachial plexus block (ICB or RCB). The primary outcome was performance time (sum of visualization and needling time), and was analyzed with a non-inferiority test of averages. Depth of sensory and motor blockade, surgical success, total anesthesia time, needle visualization, number of needle passes and complications were also evaluated. Subgroup analysis restricted to patients with higher body mass index was completed. Results: We included 109 patients between September 2016 and May 2017. Mean RCB performance time was 4.8 ± 2.0 min while ICB was 5.2 ± 2.3 min (p=0.06) with a 95% CI reaching up to 5.8% longer. RCB conferred an ultrasound-needle angle closer to 0° and significantly improved needle visibility after the clavicle was cleared and before local anesthetic administration. No differences were found in the secondary outcomes. Similar results were found in the subgroup analysis. Conclusion: RCB approach for brachial plexus anesthesia was similar to ICB approach in terms of time performance. Needle visibility, which represent an important clinical variable, was superior and angle between needle and ultrasound probe was close to 0° in the RCB group. Clinical Trial Registration: ClinicalTrials.gov (NCT02913625), registered 26 September 2016.

Retroclavicular vs Infraclavicular block For Brachial Plexus Anesthesia: A Multi-Centric Randomized Trial

Background: The coracoid approach is a simple method to perform ultrasound-guided brachial plexus regional anesthesia (RA) but its simplicity is counterbalanced by a difficult needle visualization. We hypothesized that the retroclavicular (RCB) approach is not longer to perform when compared to the coracoid (ICB) approach, and improves needle visualization. Methods: This randomized, controlled, non-inferiority trial conducted in two hospitals, included patients undergoing distal upper limb surgery. Patients were randomly assigned to a brachial plexus block (ICB or RCB). The primary outcome was performance time (sum of visualization and needling time), and was analyzed with a non-inferiority test of averages. Depth of sensory and motor blockade, surgical success, total anesthesia time, needle visualization, number of needle passes and complications were also evaluated. Subgroup analysis restricted to patients with higher body mass index was completed. Results: We included 109 patients between September 2016 and May 2017. Mean RCB performance time was 4.8 ± 2.0 min while ICB was 5.2 ± 2.3 min (p=0.06) with a 95% CI reaching up to 5.8% longer. RCB conferred an ultrasound-needle angle closer to 0° and significantly improved needle visibility after the clavicle was cleared and before local anesthetic administration. No differences were found in the secondary outcomes. Similar results were found in the subgroup analysis. Conclusion: RCB approach for brachial plexus anesthesia was similar to ICB approach in terms of time performance. Needle visibility, which represent an important clinical variable, was superior and angle between needle and ultrasound probe was close to 0° in the RCB group. Clinical Trial Registration: ClinicalTrials.gov (NCT02913625), registered 26 September 2016.