Ultrasound-Guided Nerve Blocks on DVD Version 2

T he DVD set Ultrasound-Guided Nerve Blocks on DVD for PC Version 2.0 by Alain Delbos is a 2-DVD QuickTime format set with interactive media designed to teach and develop techniques for ultrasound-guided nerve blocks. The first DVD is for upper extremity blocks, and the second DVD is for lower extremity blocks. As the format is DVD for PC, it seemed reasonable to investigate the accessibility of these discs by other routes to test whether the format would play in other devices. The discs will not play in a standard DVD player, nor will they play on a Mac computer (as expected, but there is a Mac version). Other home media players like the Xbox 360 and Sony PlayStation 3 had varied results. The Xbox recognized the disc but could not access the media. The PlayStation could read the media and play some of the video files, but did not play sound, and the media was not organized as it was intended to be presented to the user. On further review of this series, there appears to be a version 3.0 ($369.99 from publisher Lippincott, Williams & Wilkins, released in December 2012) with updated MEDLINE references which was not provided to this reviewer at the time of the review. It is noted that version 3.0 was released before version 2.0, and no indication as to why the editions are out of the expected order has been identified. The discs were loaded onto an older PC running the Vista operating system without difficulty, and the programs ran as intended. UPPER EXTREMITY DVD All anatomic modeling provided with the DVDs were exceptional and positionally entirely correct. As expected, all images were of textbook quality, which provides the user with the best possible learning experience. The DVD does not directly identify likely variances in anatomy or corrective measures to optimize images during the animations that describe the block. There is a section on “Principles and Physics of Ultrasound Imaging” that does delineate ultrasound techniques and ways to optimize imaging. This is a difficult area in which to translate an experience into words, but the DVD identifies basic techniques appropriate for individuals new to ultrasound to use with their imaging. Interscalene anatomy shown was classic textbook. This is a block with fairly wide variance in anatomy, and many practitioners have imaging techniques that assist in isolating the true plexus on ultrasound image. Explanation of these adjustments could have been a bit clearer, and discussion of advantages and disadvantages of delivering the block in certain distributions could have also been identified better. The supraclavicular video was confusing during redirection animations when the needle “shifted” in the space to place the needle to a secondary location. In actual practice, the needle will not carry itself over as the video may indicate. Withdrawal and reinsertion are the technically appropriate maneuvers to redirect the needle to an additional site of injection. All common and some less common selective nerve blocks are presented in the animation teaching section. Blocks included are interscalene, axillary, median nerve at elbow, radial nerve at elbow, supraclavicular, suprascapular, infraclavicular, median nerve at forearm, and ulnar nerve at forearm. LOWER EXTREMITY DVD As with the upper extremity, the anatomy pictures and descriptions are very good. The imaging for femoral nerve blocks was excellent as expected, but the DVD is limited in describing adjustments in ultrasound imaging when the picture isn’t quite as pristine. It is common for novice users to rotate the ultrasound probe into the inguinal crease, distorting the image, and there’s no comment for this correction in the instruction. For the sciatic blocks with the “out of plane” approach, the video does not describe adjustment of the ultrasound probe to follow the needle tip as this can be misleading if the angle of approach isn’t exact to the viewing depth. Ultrasound can be used for lumbar plexus blocks when more proximal access to femoral distribution is desired for surgeries like hip surgery. While many practitioners still perform this block in the standard “blind” technique with osseous contact, ultrasound can be used to identify depth and laterality to the transverse process segments. Understandably, the DVD cannot contain an infinite amount of information, but these would be notably helpful additions for completeness of instruction. Approaches in the animation teaching section included femoral, fascia iliaca, obturator, saphenous, lateral cutaneous nerve of thigh, sural, sciatic (transgluteal, subgluteal, anterior, and popliteal), superficial peroneal, deep peroneal, and tibial. SIMULATOR FOR BOTH The simulator will allow superficial and deep needle redirections without any advancement or withdrawal of the needle. It gives the misconception that if you are slightly or significantly off with angle of approach, all you have to do is adjust the angle outside the skin without any other needle movement. Additionally, the tactile experience of aligning the needle with the ultrasound probe is a particular item that no computer-based simulator can offer. It is a fair initial artificial experience to familiarize the new regionalist to the images and approaches, but is a world apart from true clinical practice. Overall, this is a decent resource for beginners to regional anesthesia and even for providers who consider themselves moderately good at performing basic blocks. For advanced regional anesthetists, however, the experience could strive a bit more to simulate realism for the execution of the blocks. The most substantial shortcoming this module suffers from is an inability to be cross-accessed from a PC or Mac machine. Many software bundles in 2014 use a uniform application common to Mac or PC, not an installed.exe or.dmg file. It has limited portability relative to many teaching tools in practice today. There aren’t many practitioners carrying around a laptop for reference or learning in modern operating rooms. Lastly, there isn’t any update capability apparent as with many other software options available in the current market and will likely become obsolete in 2 years based on the rapid rate of current teaching tool development. The SonoAccess App (free from the Apple App Store) recently updated for iPhone has many of the same teaching media as included in this program, though lacks a digital simulator. YouTube and Google can additionally provide a similar (and updated) teaching experience that does not carry a >$300 price tag. As with any resource, it is a tool that can be used to support knowledge and practice, but it is not to be considered a replacement to structured education and training of regional anesthesia under expert direction. Comparable resources for education include popular websites like NYSORA (http://www.nysora.com), ASRA (http://www.asra.com), and the Canadian Web site USRA (http://www.usra.ca/) which have instructional videos for placement of peripheral nerve blocks. Other media such as the Admir Hadzic’s Regional Anesthesia and Acute Pain Management are more inclusive texts but lack interactive media. Ultrasound-Guided Nerve Blocks on DVD Version 2: Upper & Lower Limbs Package for PC by Alain Delbos provides a limited experience that can outline fundamentals of regional anesthesia but regrettably isn’t a resource that can be accessed from anything other than a computer. The material presented in this DVD is a fair adjunct but not an entire compendium of knowledge. It provides a good introduction simulation but lacks the tactile experience learned from the hands-on experience of administering peripheral nerve blocks to patients.

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