|LETTERS TO EDITOR
|Year : 2018 | Volume
| Issue : 7 | Page : 565-566
In the plane, but not in plane: Mind the gap in the transversus abdominis plane
Bikram Kishore Behera, Satyajeet Misra
Department of Anaesthesiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||11-Jul-2018|
Dr. Satyajeet Misra
Department of Anaesthesiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Behera BK, Misra S. In the plane, but not in plane: Mind the gap in the transversus abdominis plane. Indian J Anaesth 2018;62:565-6
Ultrasound-guided nerve blocks are widely accepted as the standard of care in the provision of post-operative pain relief as they allow for needle visualisation during the entire procedure and minimise the risk of complications. In resource-limited countries, stylets of intravenous (IV) cannulae are commonly used as they are 1/10–1/15th the cost of ultrasound needles and yet adequately reflect ultrasound so as to allow stylet visualisation during the performance of the block.
Some IV cannula manufacturers provide an additional hole in the body of the stylet, just proximal to the distal opening so as to allow for quick flash of blood in the catheter allowing for its earlier detection in the vein. We wish to highlight the fallacy of using such stylets for ultrasound-guided nerve blocks. A 9-year-old boy was posted for elective laparoscopic splenectomy under general anaesthesia. Transversus abdominis plane (TAP) block was planned for post-operative analgesia in this patient under ultrasound guidance.
After induction of anaesthesia, under sterile precautions, the TAP plane was identified with the vascular probe (HFL 38x/13-6 MHz) of SonoSite ultrasound machine (Fujifilm SonoSite Inc., Bothell, WA, USA). The stylet of a 20 G IV cannula (Polyflon™, Polymed medical devices, India; website-www.polymedicure.com) was used for performing the block. The tip of the stylet was clearly identified in the TAP plane [Figure 1]a. However, when the local anaesthetic drug was administered, it was found to be dispersing into the muscle plane [Figure 1]b and [Video 1]. On withdrawal and inspection, it was found that the stylet was provided with an additional proximal hole for quick flash technology and though the stylet tip was in the correct plane, the drug was eluting through this proximal hole [Figure 1]c. The TAP block was then re-attempted with a standard IV cannula stylet, and this time, the local anaesthetic drug was correctly delivered in the plane [Figure 1]d and [Video 2].
|Figure 1: (a) The tip of the stylet is seen indenting the TAP plane (arrow). (b) Although the stylet tip indents the TAP plane, drug deposition is observed proximal to the tip (arrow head) and occurs in the internal oblique muscle plane. (c) Withdrawal and inspection of the stylet reveals a proximal hole in the body of the stylet (black arrow). (d) Use of a standard IV cannula stylet without proximal hole results in correct drug deposition in the TAP plane leading to separation of the plane (arrows) and the stylet is also visualised (arrow head). TAP – Transversus abdominis plane, IV – Intravenous|
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This case highlights the importance of pre-checking stylets, spinal needles or long hypodermic needles that may be used for performing ultrasound-guided nerve blocks by simply flushing these hypodermic needles with saline.
Consent for reporting this observation was obtained from the parents of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hopkins PM. Ultrasound guidance as a gold standard in regional anaesthesia. Br J Anaesth 2007;98:299-301.