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https://www.youtube.com/watch?v=0BR8YoFOMEU
Transcript

- All right, well thank you everyone for coming.

My name is Chris Pennell.

I'll be moderating today's webinar.

Today's webinar is SonoSite Behind the Scan webinar titled

The Power of SonoSite Systems

for Ultrasound Guided at Regional Nerve Blocks.

Before we begin, I have just a few things to cover.

All attendees are muted.

We'll be conducting a q and a session at the

end of the presentation.

However, we're currently broadcasting this webinar on

multiple platforms

and in order to ask questions,

you must be on the main zoom stream.

If you're on the zoom stream,

you can type your questions into the q

and a box in the toolbar located at the

bottom or the site of your screen.

Feel free to enter them throughout the presentation

and we'll get to them once the main presentation is over.

Now this webinar will be recorded

and archived for future reference on our webinars page.

Here with us today we have Dr. David Ayung. Dr.

Ayung is the medical director

of the Lindeman Ambulatory Surgery Center

and section head of Orthopedic Orthopedic Anesthesiology at

Virginia Mason Franciscan Health in Seattle, Washington.

His research focuses on improving patient outcomes

with regional anesthesia.

He's the co-author of the popular textbook,

ultrasound Guided Regional Anesthesia.

Dr. Ayung, thanks so much for being here

and let's get the presentation started.

- Thank you Chris. Great to be here

and talking about the new Sono site st,

or recently released Sono Site st.

This is a ultrasound that has a unique form factor

but still with the unrivaled image quality

of the sono site line.

So if you look at a sono site like this, it is ready

to go out of the box.

You turn it on and you are ready

to image it has all the features that you're used to,

but rarely do you have

to push much more than setting the depth

and adjusting the gain.

Like most sono site images, this is fully optimized

and almost ready to do any block as soon

as you turn your system on.

I haven't touched a single thing here

and to image this first block a tap block,

I generally just change the depth and maybe the gain,

otherwise the image is ready to use as soon

as you turn it on here.

Let's start by going right to the abdomen

and imaging the transversus abdominis plane.

To find this, I typically find the

rectus abdominis anteriorly.

Here you can see a beautiful rectus abdominis muscle below

that, some of the peristalsis of the abdomen.

Below that, as I move laterally, you can see the muscles

of the lateral abdominal wall, the external oblique,

internal oblique, and the transverses abdominis.

At this level, the image quality is so good.

You can see blood vessels between those

muscles in the fascia planes, as well as some

of the nerves in the fascia planes as well.

To give you idea how good this quality is, even

with a high frequency linear transducer, I'm able

to move all the way posterior

and see the next muscle in the similar plane,

the quadratus lumborum muscle.

You can see the striations of that muscle

with great image even allowing you to do

that without even changing your transducer.

Now, to give you an idea how easy this machine is to use

and to get a great image, we'll go right from the tap plane

and move up to the brachial plexus level A block

that's likely much shallower.

Here we'll use the same transducers.

I haven't touched the single setting

and I'll put it right on the patient.

So now we're imaging the supraclavicular view

and we can see I maybe need to change depth

with this touch screen.

I can move this image

and change the depth by moving the depth button over here.

I can also use the arrows

to change the depth shallower and deeper.

Also, I may need to change the gain. To change the gain.

All I'm gonna use is this slider button here

to make it brighter and darker.

Also, I'm able to change the time gain compensation

or the tcs.

This allows me to change the brightness of the bottom

half of the screen, the middle part of the screen

or the top part of the screen,

or even use the slider to move up and down

and change any part of the image brighter or darker.

Here I'll make the near field a little bit darker

and I think that gives me a uniform appearance

of my entire image.

Next, we'll go and scan the brachial plexus

and moving up to the inner scaling level.

Here you can see the brachial plexus to the right

of the artery sitting on the first rib.

As I move up, we'll trace those nerves up

to the inner scaling level.

At the inner scaling level, I'm able

to see three distinct circles, the C five

and the two sles of the C six nerve roots.

The C seven nerve root a little bit deeper is

also very clear.

Now these are images

and structures that you may see in many ultrasound machines,

but additional imaging allows me to see

the cervical plexus in this image as well.

If I move up a little bit, I see beautiful imaging

of the C four nerve root

and the C3 nerve root shallow to the anterior

and middle scaling,

but deep to the sternal collateral mastoid

and these kind of nerves we weren't able to see

with ultrasounds that aren't at this level of quality.

Moving down, we can also image a beautiful dorsal scapular

nerve root in the middle scaling muscle.

As I move the ultrasound probe cranial

and coddle, you can see the dorsal scapular nerve move

away and towards the brachial plexus.

This type of imaging allows me to have confidence

as I move my needle through the middle scaling muscle

that I can avoid structures I don't want to hit,

but put my needle onto structures that I want

to be very close to and inject my local anesthetic.

Now we've moved to the sono site lx.

The Sono Site LX is your full system ready to do everything

that you'd expect in our world of anesthesia.

For example, you could do transthoracic echo.

You of course could do the nerve blocks

and vascular access with linear transducers,

you have your curvy linear transducer

to do gastric ultrasound or deeper nerve blocks as well.

The LX is also able

to support transesophageal echo if you need

that in your department as well.

So let's look at some gastric ultrasound since

that's something that has increased interest since the

introduction of the diet medications

that slow gastric emptying.

So here I'll change from one transducer the linear

that I was scanning prior to the curvilinear transducer.

Here we have the preset abdomen and I'll select that

and move to the curvilinear transducer.

Also with the LX we're able

to introduce a new technology called voice assist

With voice assist.

You have a microphone on your ultrasound

and instead of pushing buttons on the ultrasound to change

most of the things we want to change,

the parameters are able to be adjusted with just your voice,

even in loud, noisy environments like a hospital bay

in a busy pre-op or postoperative area.

So here it is toggled with a single button voice assist on.

So I'll turn the voice assist on by saying activate voice.

You'll notice on the left side

of the ultrasound image I have all the parameters

that I can change just with my voice first.

Some basic things like reduced depth

and you can see the depth is reduced.

The other thing, it looks a bit dark, so I can say brighter,

brighter, brighter.

And now we can see many of the structures

underneath the stomach.

So to go over some of the structures I see on the screen,

I see my liver On the left side, I can see the

stomach, which appears generally full

with a starry appearance, which is a sign

of generally being recent food ingestion.

So in this patient I would say I'm probably gonna wait

to do anesthesia.

So to go back to voice assist, I'll say activate voice.

Other things I can do, if I want to document this,

I can say freeze.

I can say image

save unfreeze.

If I wanna see some of the vascular structure in the

underneath the stomach, I can turn color on here,

you can see the color.

Now I can say color off.

So now you can see with a very nice voice command, I'm able

to adjust most of the parameters I need

to without having assistant or reaching across the bed.

If I have sterile hands, I can get to everything I need

to just with my voice.

Next I wanna show that you can get great images

with the cardiac transducer and do a transthoracic echo.

So we'll use a low frequency phased away transducer,

two button pushes,

and I'm ready to scan with this transducer.

So voice assist also works with this. So I'll turn this on.

So now I've found a

per sternal long axis image of the heart.

It looks a bit dark to me. I'll say activate voice.

Brighter, brighter, reduce depth.

Now you can see this per sternal long axis

view of the heart.

I'll change the transducer orientation

and I can see a nice short axis view

of the heart reduce depth.

So you can see you can get a great

transthoracic echo very easily with the sono cyte lx.

Now let's move on to a live question

and answer session where I can answer any

questions that you might have.

- All right, thank you so much - Dr. A Young, we have Dr.

A Young here with us as well.

I'll ask him to go ahead and start his video

and we can get to the q and a session now.

So once again, we're currently broadcasting on multiple

platforms, but we can only take questions if you're on our

main zoom broadcast, the q

and a box should be available at the bottom

or the side of your screen to get those in.

And it looks like we do have a few in here already.

Dr I Young, when is the best time

to use a cervical plexus block?

- Oh, thanks Chris.

Yeah, I think cervical plexus block is something

that we don't talk a lot in the world

of regional anesthesia,

but I've really found it useful clinically.

Probably the two places that I use it most are

for awake carotid surgery essentially,

or sleep carotid surgery for postoperative pain.

But if you have a surgeon

that does awake carotid endarterectomies, those,

those really are great.

I can remember one time we had a BMI patient over 40,

had a first year resident, had an inpatient surgeon

and I said, Hey, just give us a second.

We're gonna give you the best, you know, awake

carotid field that you'll ever have.

And she put this in my, my first year resident,

large patient, and the,

the surgeon couldn't stop talking about how good

of a cervical plexus block

and then a result in surgical field she had.

So I think that was one that really hit home

that an ultrasound guided cervical plexus block on top

of anything will be much better than even just a

field block or a landmark guided cervical plexus block.

If you saw that video, essentially the,

the block is putting local anesthetic in that plane

between the sternal cla mastoid

and the scaling muscles that you're used to seeing

with an inner scaling block.

And we drop off about five 10 mils at the

most in that plane.

I do warn you that the, the fascia overlying those

scaling muscles does go around the entire neck.

So if you put large volumes, you have the risk

of doing a bilateral phrenic nerve paralysis.

So keep your volumes low.

Those are small nerves they block easily with five mils,

not, definitely not more than 10 for

that cervical plexus block.

The other place I use cervical plexus blocks I think is a

great place, is clavicle fractures.

You know, I think when you look at clavicle innervation,

people have all kinds of debates whether you do

different blocks where the clavicle is fractured.

For me, in you, you know, I live in Seattle,

we have all kinds of people falling off bikes,

breaking their clavicles.

For me it's really hard to say, oh,

this person specifically clavicle vac

switches from one nerve to the ano.

Another here for me,

I pretty much always do a cervical plexus block

for most clavicle fractures

and then add in a inner scaling block

and I do catheters on the inner scaling level

and then a single shot cervical plexus for most.

So again,

those are the two places I use cervical plexus blocks mainly

for awake carotid surgeries and then clavicle fractures.

- Excellent. All right.

Looks like the next question is,

is gastric ultrasound clinically useful

to make a call on NPO status and will it hold up legally?

- That's a very interesting question, Chris.

I think most of us know gastric ultrasound.

It, it hasn't been around that long.

You know, pretty much every conference you go

to people are learning and teaching about POCUS

and all kinds of different ways.

We are learning to image as anesthesiologists

and in other fields as well.

But specifically for us, you know,

there becomes a a great legal risk of aspiration

and should we be proceeding on any case?

And now that we have the GLP one diabetic

and diet type medications used more

and more we get to a point where we go,

should we be imaging essentially almost everybody on

these medications?

I think I, I hold in most regard the statement put out

by A A SA about almost a year ago,

I think it was mid-year 2023, where they suggest

how you should hold the GLP one medications

for at least a week.

And if not,

or any, any issues then consider,

I think they consider if you have the expertise using

gastric ultrasound.

So I think that is something that, you know,

as it was worded because it is a SA

that it's not a strong statement saying we all should use

it, but those of us that have some expertise in it,

it it can be used to assess gastric volume.

And I think there's more and more papers out coming out

to say it is something both just in a supine position

or if you're able to turn your patient lateral,

that you are able to make assessments

with some experience about the gastric volume

and whether somebody has a stomach full

of any kind of content.

So I do find it something

that I have been leaning on more.

I have found patients with residual gastric volumes

and I've found patients

that I'm worried about that are empty.

Does it change my clinical practice a few times?

It actually has.

I think it can definitely, if it's empty, you go, boy,

that really decreases my anxiety about getting this patient

off to sleep and putting a breathing tube in.

Generally I still err on putting a breathing tube in if they

don't say meet gastric or NPO status

or if they are on these kind of new medications

that slow gastric emptying,

but at least I'm not as anxious putting

that breathing tube in.

Most of the time though, if there is any concern about full

stomach, I'm still doing a rapid sequence induction.

Although I, I, I find it nice to know

that I don't see anything in the stomach at that time.

Like I tell most of my trainees,

if you are just scanning those patients,

you're concerned about whether they are on these medications

or on obese

or coming in for trauma, I,

I find it not something

that is easy in every patient scanning

for gastric volume.

So it's something that we should be doing like say first

case of the day when maybe you show up a little bit early

and have some time to scan that first patient just

to get used to identifying that stomach

and assessing that gastric volume.

Look at some normal patients

before you're called upon

to figure out a questionable patient.

- Excellent. All right, looks like our next question is when

of you found a TTE useful in clinical practice?

- Well if, if you don't know me,

I'm not a cardiac anesthesiologist so you know, my,

my knowledge of say TEE at baseline is you know,

at pretty much a resident level

and residency was just a few years ago.

A you know me, so reaching

for a transthoracic probe is something that I have been,

you know, exploring since I was a resident

because obviously I've been very interested in ultrasound

but it's not something I use daily, weekly,

or I would say even monthly going to transthoracic echo.

But when I do need it, I have found things like effusions,

decreased function

and probably most commonly is decreased volume status.

So when I find that

a tachycardic hypotensive patient, I think

that is usually when it is the most useful to say,

should I just start pressors inotropes or give more volume?

And I think that is probably as strong

as the clinical decisions I make with the transthoracic

transthoracic echo.

Something else that I find it may not be as optimal

as when you see people teaching it.

When you see people teaching it like just came back from a

national conference and they had the patient

and they're returning the patient on the side,

you know when you have a patient hypotensive in the recovery

room or even intraoperatively, we can't always position

that patient perfectly to get the perfect views,

but I really find that even just standard views

that like a parasternal long

and short axis, pretty much what I showed just a bit ago,

we can find a lot of those questions like if someone

has an effusion, if they have low volume hypo hypovolemia

or just decreased function.

So some of those basic questions I have found useful

and I typically use a transthoracic echo

probably once a month

or slightly less when I reach for that transthoracic echo

outside of teaching just

to actually answer a clinical question.

- Alright, next question is why not just do a rectus

sheath block instead of a tap block?

- Yeah, I find a lot of abdominal blocks, there are a lot

of choices these days

and when you're looking at which one you want to do,

if you wanna find I think the easiest block

to do multi-level coverage with a single injection,

I really think that tiche like the whoever asked

that question, I think is a beautiful block to do

for multi-level coverage and simplicity.

I often find that rectus sheath is slightly

shallower if you saw that rectus abdominis muscle.

If you don't know the rectus sheath block,

it's just an injection generally on the lateral part

of the deep fascia essentially

underneath the muscle without piercing that fascia

and injecting the slight lateral edge of that

and putting in some volume.

And what we have found, not just me but papers

and research have found

that it does provide multi-level coverage

'cause it can spread cephalad caught at with a decent volume

of say 20 mils.

And so I think the rectus sheath,

if you have a midline incision ends up a nice block,

especially if you have the upper abdominal incisions

because those upper abdominal incisions are quite difficult

with the tap block 'cause you have

to be right along the rib cage so

that rectus sheath block becomes a really nice block

where it is not useful is anything not midline

because you start to get more lateral cutaneous nerves

that come off those intercostal nerves more laterally.

And so if you're only injecting erectus sheath block,

you have a risk of missing those lateral cutaneous nerves.

So that's where a tap block may be preferred.

I think a tap block, they've both been around a while,

but I think if you're looking at ultrasound blocks,

I think the tap block was one of the earlier blocks

to be introduced and so that where, that's

where it got it's popularity.

Although the rec toif block, I think more

and more people are gravitating back towards that.

It was a block described even without ultrasound.

And if you do have that midline incision,

that rectus sheet block is a nice block

to have in your armamentarium.

- All right, moving a little bit upwards.

The next question is,

I'm interested in the dorsal scapular nerve.

Is there any benefit to just blocking that nerve alone?

- Oh that's a, that's a good question.

I mean, me and my, one of my fellows,

boy it's almost been a decade ago, wrote up a case report

of doing a block on the dorsal scapular nerve

for a patient with scapular surgery.

This patient had a scapular surgery where they detached some

of the muscles and reattached

for a scapular type pathology.

And so we've also done it for scapular fractures,

which are pretty rare, at least in my hospital.

We're not a huge trauma center

but we've done blocks for scapular fractures as well.

And I think one of the, if you read the case report

that I wrote, it is something that we figured out

provided a decent amount of analgesia

'cause we weren't sure at the time whether dorsal

scapular block would cover this.

So we just did a single shot block.

This was a young woman

and she did great for you know, roughly

that single shot duration somewhere between 12 and 18 hours.

And then we came and saw her the next day

and she's like, oh it's really hurting now.

Can you repeat the block?

So we repeated the block,

put in a continuous nerve block just on

that dorsal scapular nerve, hooked it up to an infusion, ran

that infusion I believe about four mils an hour

of 0.2 ropivacaine and sent that patient home.

She did great at home with that infusion.

So I think

because we did that single shot block, it wore off,

she got pain again, we replaced it with great effect

with a continuous infusion.

That was a good, good evidence for me that

that dorsal scapular provides a significant amount

of innervation to that scap scapula.

So if you do have any kind of scapular pathology,

you can target that dorsal scapular nerve within

that middle scaling muscle

and really spare a lot of the rest of the brachial plexus

so the patient doesn't have hand arm weakness during

that recovery period.

- Alright, next question that came in is

how do you cover the upper T six to T eight levels?

- How do I cover the upper T six to T eight levels?

My favorite block

for upper thoracic surgery right now is the ESP block.

I think if you look at

in a training program

where I'm not holding the needle all the time,

I think the ESP block gives a nice, we can do this block

and pretty much everyone, no matter what their BMI,

I can do it with trainees and I can do it quickly.

So I mean those kind of three main

qualities of the ESP block are what I really like

about the ESP block.

Now I've done a lot of blocks in my life,

so if I'm holding the needle

and let's say you have a T seven eight rib fractures,

I actually go a little bit deeper

and try to get down to the pair

of vertebral level in my hands.

Now if you look at the ESP evidence,

and this could be a whole lecture,

maybe we'll have another webinar on that,

but doing a slightly deeper than a classic ESP block,

we call it an inter transfer process block.

I think there's more and more evidence suggesting

by going a little bit deeper we cover those nerves

and get a little better analgesia

by going slightly deeper than just a posterior,

or sorry, just the anterior fascia

of the erector spina plane muscle.

So if you can imagine your transverse processes

and your erector spina muscle, if you know,

I think the classic was just

to inject either right on the transverse process.

I think more and more evidence suggests both in cadavers

and a few in in actual patients suggest going a little bit

deeper and getting

between those transverse processes you get a little bit

deeper perhaps through some additional fasas

and ligaments and we can then get a little better effect.

So that, that was a long-winded answer.

I think day to day I typically do ESP blocks maybe slightly

deeper than a ES classic ESP and go into transverse process

and then if I have a very specific rib that I need

to block, then I'm going

and trying to get down to the paravertebral level.

- Alright. And kind of staying up there,

what is your go-to block for shoulder surgery?

Do you usually use inner scaling superior trunk

or supraclavicular supraclavicular or something else?

- Something else? Great. That's actually where the majority

of my research has been in the last few years.

And so I think what the, the question's great

because essentially

what the research has shown is you can do any

of those from a analgesic standpoint.

You can pretty much do any inner scaling superior trunk

supraclavicular and that's for anesthesia.

You could pretty much do any of those for anesthesia,

for analgesia you can even add in a

a selective anterior suprascapular block

and that will essentially create non-inferior analgesia

across the entire spectrum of the brachial plexus.

All those blocks that I just mentioned.

So essentially in summary for analgesia,

you can pretty much do any block

above the clavicle if you position your needle right

and get the same quality of pain relief

after either rotator cuff surgery

or shoulder replacement.

So definitely smaller surgeries

and that should create the same kind

of block.

So, so what is my go-to

because you know the other part

of this is always phrenic paralysis

and your ability to decrease phrenic paralysis.

We essentially are getting away more

and more from inner scaling blocks

and just drifting down a little bit, getting down to

that superior trunk instead

of the three circles drifting down to

where those circles become a kind of oval,

more horizontal oval And that is kind of the superior trunk.

That same basic anatomy holds true.

If you get down to the supraclavicular level, you don't have

to go in that corner pocket

that's been traditionally described at the supraclavicular

level between the artery and the rib.

You can still inject that superior trunk

that lays up high along the nerves.

So just a s portion of that

supraclavicular nerve level.

And if you target that superior area even more on the

lateral side, you're gonna be closer

to the shoulder innervation.

So you can save even more phrenic paralysis

by going slightly lateral

and high on the supraclavicular level.

And that is another one of my go-to areas

for shoulder surgery.

I really try to get down lower

and definitely not do an inner scaling block when I start

getting to BMI over 35

and definitely over 40 I'm getting down

to a supra clavicular block more often.

And if you have that smaller transducer,

the vascular

or the 25 millimeter transducer, I like to get down

and even do selective anterior suprascapular nerve blocks

targeting that suprascapular nerve.

And that has been shown to save the most lung function,

especially when you get down to lower volumes like five 10

and definitely 15 mils at the most targeting that.

So I think the research in the last five

to 10 years really has shown we don't need

to do inner scaling blocks as a standard

for most shoulder surgeries.

And the lower we go on the brachial plexus,

the better we save lung function.

- Excellent. Alright,

next question is if we need more x perl volume,

have you diluted more than company recommendations

- If you need more X perl volume?

I I, our hospital does not carry xprl

but I think from a dilute standpoint I think you would be

fine diluting if you're trying to get more volume.

I think I would dilute, I think the recommendations are

with bupivocaine only, so dilute your local anesthetic

with BUPIVOCAINE only

and I think creating that more dilute volume,

whether you're using EXPAREL or

or any other local anesthetic, a lot

of our plane blocks we're trying to create a larger volume

to create more spread

and I guess I could talk about that too And,

and one of my tips for plane blocks, whether it's tap blocks

or ESP blocks,

is I generally don't just put my local anesthetic in one

place and this probably even is more important for xprl

'cause it doesn't seem to traverse tissue quite as well.

So don't be afraid to move your needle while you inject.

I think in plain blocks those vascular areas are

smaller or the vascular arteries are smaller.

So I think you have less chance of pun puncturing

and injecting into them.

So I do advance

and inject if you're worried about that,

you could consider inject advancing your needle first

and injecting on the way back.

But I think a lot of just plain

plane blocks are generally taught

as put your needle one spot and inject.

But I think one technique that I use to really increase

where that local anesthetic goes is not rely on simple

diffusion of any local anesthetic but use your needle

and move it so I don't just inject one spot on the tap

plane, I don't inject one spot on ESP, go ahead

and move your needle

and try to to spread that local anesthetic

around more so that that time

that local anesthetic is working doesn't have

to wait for diffusion.

And there's a great MRI study

that showed diffusion takes up to six hours.

So if your local anesthetic less 24 hours

or less, then you definitely don't want to wait six hours

for it to reach peak spread.

- Right. It looks like we don't have any more

questions coming in.

Let's see. Yeah, looks like we've gotten

through all of those.

So Dr. A young, thank you so much for joining us today.

We really appreciate your presentation

and you sticking around for the q and a.

Really great information here.

Thank everybody else for joining us

for this webinar as well.

We'll be announcing some more webinars soon,

so keep an eye on sono site.com/behind the scan webinar

for more details on those.

Dr. Ayung, we really appreciate you sharing your expertise

with everybody today and thank you so much for joining us.

- Thank you Chris, and thanks for everyone that joined us.

- Thanks. We'll see you at the next webinar.

Watch David Auyong, MD as he demonstrates the new Sonosite Voice Assist application for hands-free system control using Sonosite LX. He also shows how Sonosite ST offers amazing image clarity to perform procedures such as Ultrasound-Guided TAP and interscalene blocks. In addition, see how gastric content can be clearly seen when properly scanning a patient's stomach prior to surgery with Sonosite ST.

What You'll Learn

  • Voice Assist hands-free system control, reducing the need to reach over the bedside to push buttons
  • Sonosite ST ease-of-use and imaging capabilities
  • TAP block and brachial plexus sonographic anatomy
  • Gastric imaging on a patient with a full stomach
David Auyong
Presenter: David Auyong, MD
Position: Medical Director of the Lindeman Ambulatory Surgery Center Section Head of Orthopedic Anesthesiology at Virginia Mason Franciscan Health

Dr. Auyong's research focuses on improving patient outcomes with regional anesthesia. He has co-authored a popular textbook, Ultrasound Guided Regional Anesthesia, now in its second edition. Aside from his academic work, Dr. Auyong is often recognized by his Fujifilm Sonosite videos on YouTube describing ultrasound guided regional anesthesia approaches to many different nerve blocks.

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This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.