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An improvised indigenous technique for nerve


stimulation‑assisted peripheral nerve blocks
Anuj Jain, Surendra Singh A b s t r a c t
Department of Anesthesiology,
Sanjay Gandhi Postgraduate Regional anesthesia is one of the most satisfying expertise in anesthesia. Nerve
Institute of Medical Sciences, stimulation guided peripheral nerve blocks greatly enhance the success rate of
Lucknow, Uttar Pradesh, India block. Often the nerve stimulation needle becomes a limiting factor due to cost and
unavailablity. We have proposed a simple innovation to create a nerve stimulation needle
Address for correspondence: at the point of care that would overcome the limitation associated with commercially
Dr. Anuj Jain, available needle for nerve stimulation .This innovation may prove instrumental in training
Department of Anesthesiology, of anesthesia residents at no extracost to the patient.
Sanjay Gandhi Postgraduate Institute
of Medical Sciences, Lucknow,
Uttar Pradesh, India Key words: Nerve stimulation needle, peripheral nerve blocks, regional anesthesia
E‑mail: anuj.jain.mln@gmail.com

are seldom performed. Although the problem associated


INtroduction
with USG‑guided PNBs cannot be resolved without
adequate funds, we suggest a unique innovation as far as
Regional anesthesia (RA) is one of the most challenging
NSG blocks are concerned. The aim of this innovation
and satisfying modalities in the branch of anesthesia.
is to increase the expertise among the anesthesia
Somehow, the scope of RA has been limited to central
residents in placing PNBs, which would drastically
neuraxial blockade, with most of the centers not practising improve the efficiency of day care facilities in developing
peripheral nerve blocks (PNBs) due to some reason or the countries.
other. The chief reason for deferring PNBs is the high
failure rates associated with the procedure.
Description
Efforts are on to revive the modality of PNBs by using
guided techniques like nerve stimulation‑guided (NSG) A nerve stimulator is a machine that produces a DC
and ultra sonography (USG)‑guided nerve blocks and, output that can be regulated. It has two electrodes, i.e. one
at times, combining both these techniques. Although the positive electrode and one negative electrode. The negative
guided nerve block techniques increase the success rate electrode is connected to the nerve stimulator needle
and the positive electrode is attached to a skin electrode
many folds, there are drawbacks associated with guided
placed along the route of the nerve to be blocked. When
techniques as well. USG is most of the times not available
the needle is inserted into the skin and as it approaches
owing to its cost and, if available, the learning curve with
the proximity of the nerve, muscle twitches are seen,
USG is long. NSG blocks have different problems. The as the current starts to flow along the nerve from the
stimulator needle becomes the limiting factor as it is active electrode to the passive electrode along the nerve,
costly and hence usually not available in hospital stocks. thereby stimulating the nerve. The intensity of current
Because of its higher cost per procedure and usual is gradually reduced to a target of 0.3–0.4 mA, at which
unavailability of nerve stimulator needle, NSG blocks muscle twitches are visible. This indicates that the tip of
the needle is very close to the nerve and that the local
Access this article online
anesthetic solution can be injected.
Quick Response Code:
Website:
www.saudija.org Improvised Needle

DOI: Our improvised needle is a modified 20 swg intravenous


10.4103/1658-354X.101241 (iv) cannula. An iv cannula has four parts, i.e. a metallic
stylet with a luer chamber, a polyvinyl chloride cannula, a

Saudi Journal of Anaesthesia Vol. 6, Issue 3, July-September 2012


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Jain and Singh: An improvised nerve stimulation needle


Page | 316
flashback chamber and a luer lock cap [Figure 1]. The iv Step 4: The nerve stimulator electrode is adjusted so that
cannulae can be converted into a nerve stimulator needle it touches the stylet in the luer chamber.
in four simple steps [Figure 2].
In this way, the improvised nerve stimulator needle is ready
Step 1: The diaphragm of the flashback chamber is to be used. This improvised needle can be used to locate
perforated using a 14G hypodermic needle. the nerve in the usual manner as described earlier. Once
Step 2: The negative electrode is inserted through the the nerve has been localised, the stylet can be removed to
perforated diaphragm of the flash back chamber [Figure 3]. leave the catheter in situ for drug injection or the flashback
Step 3: The flashback chamber is attached to the luer chamber detached and injection of drug made through
chamber [Figure 4]. the stylet.

Figure 1: Diagram showing various parts of an intravenous cannulae Figure 2: Flashback chamber of an intravenous cannulae

Figure 3: Negative electrode of the nerve stimulator inserted through


the flashback chamber Figure 4: Final assembly of the nerve stimulator needle

Table 1: The average depth from the skin at which the nerve is encountered
Name of the nerve block Depth of the nerve plexus from the skin Length of the nerve stimulator needle recommended
Upper limb blocks
Interscalene 2–2.5 cm# 25 mm
Supraclavicular 2–3 cm# 50 mm
Infraclavicular 2.5–4 cm# 50 mm
Axillary 3–4 cm# 50 mm
Lower limb blocks
Femoral 3–4 cm# 50 mm
Posterior popliteal approach 2–2.5 cm# 25 mm
Length of the 20G cannula is approximately 45 mm. Derived from Peripheral Nerve Blocks. A Colour Atlas 2nd Edition Edited By Jacquese Chelly. #Depth indicated are for the
Caucasian population of average built

Vol. 6, Issue 3, July-September 2012 Saudi Journal of Anaesthesia


[Downloaded free from http://www.saudija.org on Friday, September 30, 2016, IP: 106.221.149.208]

Jain and Singh: An improvised nerve stimulation needle


Page | 317
We have used this improvised needle in placing upper factor and availability of nerve stimulator needles may not
extremity blocks and lower extremity blocks in normal‑built be a limiting factor in popularising PNBs in the developed
patients [Table 1] with almost 100% success. This needle’s countries, but they definitely matter for the developing
length may not be adequate in placing lower extremity countries.
blocks in obese patients.

Therefore, a procedure as simple as making a hole in the How to cite this article: Jain A, Singh S. An improvised indigenous
flash back chamber of an iv cannula can help popularize technique for nerve stimulation-assisted peripheral nerve blocks.
Saudi J Anaesth 2012;6:315-7.
the technique of nerve‑stimulated guided PNBs at no
Source of Support: Nil, Conflict of Interest: None declared.
extra cost of the costly nerve stimulator needle. The cost

Saudi Journal of Anaesthesia Vol. 6, Issue 3, July-September 2012

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