S.Giovanni- Addolorata Hospital
Personal data: born in Rieti, Italy, 1th August 1957 Citizenship: Italian, Home address: via Comotti, 35, 02100 Rieti, Italy, Email:
Education:1977-1983 M.D. Medicine and Surgery Degree, graduated with honors La Sapienza School of Medicine, University of Rome, Italy, 1984 – 1986 Anesthesiology and Intensive Care Residency , specialist diploma with honors School of Anesthesiology and Intensive Care, University Hospital Policlinico Umberto 1°, La Sapienza University, Rome, Italy, 2004- 2005 Master in Acupuncture, University La Sapienza, Roma, School Of Medicine
Postgraduate Training in Regional Anesthesia: November 2004 preceptorship on advanced regional anesthesia techniques in orthopedic surgery, Rehabilitations-Krankenhaus (Rehabilitation Hospital),Ulm, Germany (prof Mehrkens): March-April -1992 visiting doctor on regional anesthesia techniques, Virginia Mason Clinic and Hospital, Seattle, USA , 1990 15 days preceptorship program on Obstetric Anesthesia and Analgesia, Hospital Herriot, Lion, France; 1984-1985 six months preceptorship program on Regional Anesthesia, Hospital Medical School, Santo Spirito Hospital, Rome.
Current position and appointments : Consultant Anesthesiologist, Dept. of Anesthesia and Intensive Care, S. Giovanni–Addolorata Hospital , Rome, appointed referent for Ultrasound Guided Regional Anesthesia in Clinical Practice and Research
Previous positions appointments: 2000 - 2006 Orthopedic Anesthesia Supervisor with special appointment on introduction and development of regional anestesia techniques in clinical practice, Dept Anesthesia and Intensive Care , Rieti General Hospital; 2006 to 2009 Referent on Ultrasound guided nerve blockade clinical and scientific projects, Anesthesia Dept, CTO Trauma and Orthopedic Hospital, Rome; 2009-2010 Appointed Expert on Ultrasound in Regional Anesthesia Program, Dept. of Anesthesia and Perioperative Care, Parini Regional Hospital, Aosta, Italy
Pubblications on the topic of regional anesthesia and US guided nerve blockade 15 Abstracts and Scientific Papers presented at ASRA – ESRA Congresses 3 scientific papers on Regional Anesthesia published on peer reviewed journals: latest: Femoral nerve-artery relation in patients with proximal femur fractures, Journal of Clinical Anesthesia (2013), C.A. Lobo. C.M.Pinheiro, M.G.Rodrigues, M.A.Fondi
Conferences: Invited Lecturer at several national and International Congresses in the last 10 years on the topic of Regional Anesthesia and US guided peripheral nerve blocks
Teaching: Over 30 Scientific Directorship- Lecturship- Tutorship in Courses and Workshops on regional anesthesia and US guided nerve blockade
Honors and Awards: Finalist at the Ultrasound Innovation Award Contest, ISURA 2010 Course, Toronto. Canada; Designed anesthetist to perform regional anesthesia on the Holy Father Pope Ratzinger (ultrasound guided axillary brachial plexus blockade) at Aosta Parini Hospital , 17th july 2009.
Society Membership ASRA, ESRA, SIAARTI
Associate editor International Journal of Perioperative Ultrasound and Applied Technologies
Interview with the expert
1- What do you think about the current situation of ultrasound guided regional
anesthesia in Italy? Are you working with wireless, 3D, electromagnetic tracking?
As in the rest of the world, also in Italy the ultrasound guidance for regional anesthesia is expanding quickly as the availability of ultrasound machine in the anesthesia departments is growing. In every anesthesia department it is usual to have a small number of colleagues very interested in the clinical practice of US guided procedures while many others use ultrasound only occasionally and still prefere ENS as primary guidance for nerve blockade. The issue seems to be related to the relatively steep learning curve associated with US proficiency and the the need to attend preceptorship programs. As a regular US training course coordinator a see a huge demand for high quality handson training and workshops.
I had occasions to try out new US technologies but in the every day clinical practice I only work with traditional 2D imaging and colordoppler: mastering the 2D imaging provides the operator with all the essential key points of an US guided precedure and with the best image resolution. The 3D imaging has the potential to provide the operator with many moresimultaneous useful informations compared to 2D imaging, but image quality and resolution may result not ideal, as not ideal for real time needling is the slow imaging refresh. So at the moment 3D US seems to me a research tool with the potential of interesting clinical applications. The electromagnetic tracking is certainly useful in controlling a precise and safe needle navigation to the target, and is a helpful technology for operators of every skill level, but mostly for beginners and intermediate that are allowed to visualize the needle at any depth and angle of insonation. I rather would love to work with a wireless probe system for even more freedom in probe manipulation.
2- How do you feel about the degree of difficulty of the ultrasound techniques for peripheral nerves blocks ? Do you think it is really hard for begginers? Maybe not with the new tools?
We need to consider the 2 arms of an US guided procedure:1) the “left” “probe” arm, namely image acquisition and sonomorfology understanding: the ability to scan and acquire a good US image of a given anatomical region is something generally quickly learned; the ecotomographic image understanding, on the other hand, takes a slightly longer time, as it comes from the study of the correspondent anatomical or m.r.i. cross sectional imaging. Generally speaking the “left arm” basic skills can be acquired with a minimal committment, perseverance and exercise. Much more difficult is to reach good proficiency in 2) the “rigth”, “needle” arm of the procedure, namely navigating the needle to the target in plane or out of plane under ultrasound guidance, enhancing needle visibility and control, needle hydrolocation and fascial plane and nerve hydrodissection concepts, understanding right and wrong local anesthetic spread and so on. As good skills in
controlling the needle are among the hardest to be achieved, here the novel electromagnetic tracking systems can really make easier the needling work.
3- Please, share a good trick in your ultrasound technique with us...
Yes, I’m happy to share with you 2 tricks that you will see have much to deal with this month subject of the new ultrasound technologies. In fact , while using the regular 2D imaging, theese tricks provide extra informations obtained simply through dinamic manipulation of the probe.
Trick 1. Heel/toe angling of the transducer along its long axis for better visibility of aneedle inserted in plane at a steep angle with the US beam.
In Fig 1 A the needle is inserted in line with an angle to the ultrasound beam. We know that the steeper this angle the less visible the needle will be, specially the needle tip, due to the reflections of ultrasounds away from the probe . So angling hill/toe the probe to make the ultrasound beam more perpendicular to the needle result in a consistent increase in its visibility.
Trick 2. With the nerve imaged in a transverse view, after injection of local anesthetic around the nerve, the sliding of the probe cranial or/ and distal to the site of injection allows to observe and evaluate the longitudinal extent and amount of local anesthetic in multiple sequential 2D images (same concept of 3D volume imaging).
Comments a recent paper about New technologic trends
Choquet O, Abbal B, Capdevila X.
Curr Opin Anaesthesiol. 2013 Aug 13
In this modern times we realize how important is to follow closely the quick development of the anesthesia related technologies. Conventional sonography has recently entered our specialty, transforming radically the approach to regional anesthesia and needle guidance. However the practice of ultrasound guidance is associated to a steep learning curve that may represent an obstacle to a more widespread diffusion. Now substantial new developments of ultrasound technology are already available. Can these technologic developments illustrated in the reference article make ultrasound imaging even more user-friendly? The answer, seems to me: yes, with a few remarks. The electromagnetic tracking systems actually help performance of safe and accurate sono-assisted procedures. They provide a real-time display of the needle using sensors in both needle and transducer so that the relative spatial position of target, probe and needle tip are displayed on the screen. With in- plane techniques, orientation bars on the monitor facilitates needle alignment and tracking. For out- of- plane navigation, the system extrapolates the point where the needle will intersect the beam based on needle trajectory. In my opinion the major advantage of these systems is to facilitate the out-of-plane needle approach to target. Not many recognize that out of plane needling proves to be very useful and flexible, but the technique is demanding as it is associated to several issues as poor needle tip visibility, tip versus shaft recognition, and no information about needle trajectory (that is why this approach is not much popular). For the in plane approach the advantage seems to me less, as the needle visibility is satisfactory. However for deep blocks or for targets close to sensible structures to be avoided, the electromagnetic tracking is valuable not only for beginners but also for confirmed operators. If the navigation systems do help the needle guidance , namely the most difficult and stressful part of a ultrasound guided procedure, in the other hand it does not exempt the sonographer from good sononatomy understanding and sensible assessment of local anesthetic spread. Regarding 3D US imaging, this modality deserves attention but is still under development and at the moment do not seems immediately ready to come in the everyday clinical practice. As expected, given the increased magnitude of information the system has to process, both the spatial resolution and frame rate generated by the 3D systems tend to be low compared with 2-dimensional sonography. Although recent improvements have resulted in faster volume acquisition, less bulky and lighter probes, at present my feeling is that 3D is just an interesting research tool for regional anesthesia imaging. Doubtless we can appreciate the importance to evaluate a dynamic 3 dimensional imaging of the heart and its chambers, and the precision of 3D volumetric data quantitative measurements in the echocardiography setting. The question is if we really need such a big amount of volume data to evaluate the spread of few milliliters of local anesthetic.