Our Practice

The newest US scanners offer Wi-Fi-based, secured, encrypted data transfer, but this feature rarely has been incorporated in the daily clinical practice of most anesthesiologists. It allows for a safe, easy, and simultaneous transfer of US data of the nerve block procedure to the patient’s electronic medical record in real time.

In our practice, we use a Sonosite X-Porte US scanner (Fujifilm Sonosite, Inc, Bothell, WA), which exclusively belongs to our department of anesthesiology and is used only for anesthetic procedures. It is connected to a Symbol LS 2208 barcode scanner (Zebra Technologies Corporation, Lincolnshire, IL) (Figure 1). The US scanners are connected to a secured Wi-Fi network at the hospital governed by the Central Denmark Region. The Wi-Fi network is made accessible on the US scanners by a medical technician manually logging the server address into the US scanner. The medical technician assigns the US scanners manually with an application entity title (AET).

Figure 1. Sonosite X-Porte US scanner with a Zebra Technologies Barcode scanner.

We have changed the default setting on the X-Porte US scanner so that “Patient Data” is the opening screen when the US system is turned on (Figure 2). Scanning the barcode on the patient’s ID wristband transfers the patient’s ID (social security number) to the X-Porte US scanner in real time, labeling all the consecutive US scans with the patient ID until the exam is ended (Figure 3). We enter a code for the performed procedure in the Patient Data window (Figure 4). Editing and labeling procedure codes can be done on the X-Porte US scanner as desired. This method is fast, and the risk of a patient ID mix-up is nearly nonexistent. The X-Porte US scanner has been set up to record 60-second (maximum) video clips retrospectively, making recording of the entire nerve block procedure easy. However, any default choice of retrospective vs prospective and length of recording is possible.

Figure 2. Sonosite X-Porte US scanner, default setting when starting the US scanner.

Figure 3. Scanning the patient ID with a Zebra Technologies Barcode scanner.

Figure 4. Sonosite X-Porte US Scanner. Entering a code for the performed procedure in the 'Patient Data' window.

To make a recording, do the following.

1. Pull out the needle after completion of the nerve block injection.
2. Press the “Save Video Clip” button. The last 60 seconds of the nerve block procedure is recorded (Figure 5).
3. Press the “End Exam” button. The images or video clips are stored on the US scanner in a Dicom Format (Digital Imaging and Communications in Medicine). The images or video clips are transferred in real-time with WPA2- (Wi-Fi Protected Access) and AES- (Advanced Encryption Standard) certified data encryption to a secure server in Impax (AGFA Healthcare, Mortsel, Belgium) and filed according to the AET from the US scanner.
   

Figure 5. Sonosite X-Porte US scanner. After ending the nerve block procedure, the video clip is saved and transferred to the radiology image archive, by clicking “Save Video Clip and End Exam.”

The Impax database, which is the radiology image archiving and communication system most often used in Denmark, is connected to our electronic medical record (MidtEPJ, Systematic, Columna, Clinical Information System, Aarhus, Denmark), in which we document the nerve block and anesthetic procedures.

The anesthetic procedures are filed in Impax according to the patient social security number and date for performing the US procedure. If the procedure is labeled with a procedure code, it can be readily distinguished from other procedures filed in Impax.

Other Tips and Tricks

If your US scanner cannot connect with a barcode scanner or your hospital does not use barcodes on patient ID wristbands, two other methods can be used to transfer a patient ID to the US scanner. The anesthesiologist can enter the patient ID manually on the US scanner (Figure 2); however, this is time consuming and risky should the wrong patient ID be entered. The second way is to make a daily US work list in a booking system. An example is Carestream Ris version 10.1.10 Build 60 (Carestream Health, Rochester, NY). Compared with the first method, this is time consuming and cumbersome. Patients must be manually booked in the system, and this work list must be transferred to the US scanner again by using an AET address. Before carrying out the nerve block procedure, the anesthesiologist will have to find the patient on the work list on the US scanner. Again, this carries a possible risk of a wrong patient ID match if the anesthesiologist selects an incorrect name from the work list.

Discussion

Trainees in anesthesiology can learn regional anesthesia in many different ways. With our new way of securing US data in the electronic medical record, trainees can study the nerve block techniques of senior consultants. By keeping every nerve block procedure in secure databases, systematic and constructive feedback can be given using actual patient imaging. If the trainee experiences a block failure, the procedure can be reviewed with a mentor to see if the nerve block was performed according to best practices. Our method also makes the process of publishing US images and video clips associated with research data feasible so that US data may be accessible to readers when publishing online. It also facilitates publishing new nerve block techniques as US images or video clips, which can be made accessible to readers.   

Our method also may be helpful for quality improvement. Neurologic injury after nerve block procedures is uncommon.² When patients experience nerve damage during the perioperative period, it can be caused by a wide variety of factors. After reviewing a video clip, our method may assist in determining whether a nerve injury is related to a block procedure.

By using our preferred Wi-Fi-based method, data can be quickly, easily, and safely recorded, transferred, and secured. A medical technician can set up all new US machines to capture nerve block scans in less than one hour, which includes changing default settings, connecting to the Wi-Fi, assigning an AET, and connecting to a radiology image archive. We hope to encourage more institutions to start using this method to save US images and video clips on every performed nerve block.

Christian Jessen, MD, is a consultant anesthetist and PhD fellow in the Department of Anesthesiology and Intensive Care Medicine, H-Hip, Horsens Regional Hospital, Horsens, Denmark and in the Department of Clinical Medicine at Aarhus University in Aarhus, Denmark.

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Kjartan E. Hannig, MD, is a consultant anesthetist in the department of Anesthesiology at Kolding Hospital in Kolding, Denmark.

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Uday K. Soni, MD, consultant anesthetist in the Department of Anesthesiology and Intensive Care Medicine, Horsens Regional Hospital, Horsens, Denmark.

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Thomas F. Bendtsen MD, is a professor and consultant anesthetist, PhD in the Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark and Department of Clinical Medicine, Aarhus University, Aarhus Denmark.

References

1. Regulation (EU) 2016/679 of The European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation) (2016). Official Journal of the European Union. 2016. https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A02016R0679-20160504.
2. Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007;104(4):965-74. https://doi.org/10.1213/01.ane.0000258740.17193.ec