Abstract
Dear Editor:
There can be no denying the fact that of all the radiological imaging methods available, ultrasound is the most economical and least harmful method known. Besides using the ultrasound for diagnostic purposes, it also has been used for various interventions. Interventions being performed from a palliative care point of view include pleural taps, ascitic taps, and nerve blocks. Most of the nerve blocks that are required to be placed in cases of abdominal malignancies can be successfully performed using bedside ultrasound imaging. However, classically such nerve blocks have been placed using CT scan and C-arm guidance.1–7 There are various benefits that ultrasound provides over CT scan and C-arm guidance. 8
From a clinician's point of view there are advantages of using bedside ultrasound. Namely, these include zero radiation exposure to both patient and doctor; ease of performing nerve blocks at the bedside; and provision of real-time imaging that helps a clinician to visualize the needle movement, accurately position the needle, and target drug delivery. 8 Moreover, injection of a radiocontrast dye is required when one uses CT scan or C-arm guidance to perform nerve blocks. This dye if injected intravascularly can lead to a dye reaction 9 if the patient is sensitive to it. Moreover, the cost of dye adds to the patient's economic burden. Dye reaction as well as the cost of dye gets by-passed when ultrasound is used.
As already mentioned, when using an ultrasound these blocks can be placed at the patient's bedside. This results in the patient being more comfortable. The patient does not have to be in an prone position; instead, the patient is in a comfortable supine position. The patient gets to see familiar faces in the ward, and so feels more at ease. Fear of going to an operation theater (OT) also is not there.
Because an OT is not necessary, time required for OT preparation and shifting the patient to the OT is all saved, resulting in a greater number of patients getting treatment per day. Fewer employees are required because of these reasons, resulting in financial savings for the health care setups. Moreover, because OT settings are not required, we also can give a diagnostic block as well the neurolytic block on the same day, making these blocks daycare procedures. When using OT settings these blocks require hospital admission for at least one day. Hence, patients don't have to miss out on their day's work (because no admission is required).
The equipment cost of ultrasound is much lower compared with CT scan or C-arm when the costs of building and maintaining an OT are considered. The cost of running an ultrasound also is much lower compared with CT scan and C-arm. Ultrasound also gives the option of mobility unlike the other two modalities.
Highly skilled technicians are not required for operating the ultrasound machine. Besides the operator (i.e., clinician) only one more person is required to run the ultrasound machine. That person can be trained easily. Ultrasound also results in a reduced economic burden on part of health care setups.
Because OT setup is not required, it becomes easier and more economical to build a setup where nerve blocks can be placed using an ultrasound machine. This would result in more widespread availability of such setups throughout a country, even at village levels. Hence, the provision span of specialized palliative care could be increased immensely. This also would lead to a reduction in patient load on tertiary-level health care providers.
Many authors have even pioneered the use of bedside ultrasound for blocks such as hypogastric plexus block with good results. 8 Usually, the diagnostic block and neurolytic blocks are given on consecutive days. However, the diagnostic block can be given during a morning session and if everything remains all right the neurolytic block can be administered on the same day after one to two hours. This can result in placement of these nerve blocks being outpatient procedures. There have been published studies that have omitted the use of the diagnostic block prior to the neurolytic block and have observed that sensitivity of the diagnostic block is high but specificity is not high. 10
However, having said all that it must be borne in mind that use of ultrasound has its own problems. The operator needs to receive a proper training in the use of ultrasound, handling of probes, and the knowledge of nerve blocks. Despite fulfilling the above conditions a radiologist may be required at times, which may not be possible at all locations. Even the quality of imaging in an ultrasound machine is dependent on the machine model and make and is not universal. Moreover, the probes of an ultrasound machine are very fragile and expensive. They require a high level of care.
From the above discussion it becomes clear that the ultrasound holds immense potential in specialized palliative care for clinicians and health care setups as well as for patients. Use of an ultrasound will provide benefits to everyone with the least chance of complications.11,12,13