Joseph McVicker NCANA

Fundamentals of Ultrasound Guided Peripheral Regional

Anesthesia Techniques

Joseph McVicker, CRNA, MS

Retired Navy Nurse CorpsUniversity South AlabamaGeorgetown University East Carolina University

I have not been reimbursed nor received benefits from any company or individual other than the NCANA for this presentation.

Technology and images presented in this presentation are not an endorsements for a specific company or product. There are for illustrative and demonstration purposes only.

Conflict of Interest

List the benefits of U/S guidance for peripheral regional anesthesia.

Discuss commonly used machine controls and methods to improve ultrasound imaging to obtain optimal view.

Identify the images of peripheral nerves, nerve plexuses, and adjacent anatomy for common upper and lower extremity nerve blocks.

Objectives

“Inadequate pain relief after surgery may delay surgical recovery, decrease patient satisfaction, increase length of stay, raise risk of hospital readmissions and increase overall healthcare costs” (Patacsil et al, 2016).

Why PNBs?

Peripheral Nerve Blocks play an important role in anesthesia and analgesia for ambulatory surgery.

Either obviates need for GA or decrease anesthetic requirement.

Faster Discharge; more quickly “Street Fit”.

Part of multimodal approach to pain management and decrease need for intraoperative and post operative opiates.

Less PONV. Less postoperative pain.

PNB’s

Traditional approaches rely on strong knowledge of anatomy and physical assessment.

Require motor stimulation and movement. (Pain?) Potential for intravascular injection (can’t see). Adjacent structure injury. Nerve stimulators with insulated needles provide

evidence of proximity at time of injection. Higher incidence of failure than U/S guided.

Usual practice not to move needle after injection started (risk injury to nerve, movement to intravascular).

Traditional PNB Techniques

Visualize surrounding structures Validate external landmarks

Not a substitute for knowledge of anatomy Real time needle guidance!

Avoid injury to adjacent structures “Steering Needle”

Visualize other structures to provide local anesthesia prior to placing block needle (Fascia tough and painful with blunt needle.)

More accurate inject local anesthetic can see tissue displacement and see spread of local.

Benefits of Ultrasound Techniques

U/S machines are smaller and more portable. Less Expensive than larger and more

cumbersome ancestors. Quality of modern software provides

improved imaging. Familiarization with the machine and controls

will improve quality and outcomes.

Ultrasound Machines

Equipment Preparation

Pt. Identifiers. Informed Consent for regional anesthesia

(Correct Site). Mark/Initial Block location on the patient.

When positioning patient possible to get wrong side errors. Propose adding a block band to the extremity to ensure site being blocked is on the same extremity.

Procedural Time Out/ Facility Protocol. Include the patient. Sedate after the time out!

Informed Consent

Linear array transducers scan a plane through the body that can be viewed as a Real-time, two-dimensional image on the screen. (Patients are 3D).

Doppler used to identify pulsatile fluid filled structures. Commonly superimposed on B-mode image.

2D or B(Brightness)-mode

Depth Control

Depth: Depth controls the distance over which the B-Mode images the anatomy.

To visualize deeper structures, increase the depth.

If there is a large part of the display which is unused at the bottom, decrease the depth.

B-Mode Gain increases or decreases the amount of echo information displayed in an image.

It may brighten or darken the image if sufficient echo information is generated.

B-Mode Gain

Increases the number of focal zones or moves the focal zone(s) so that you can tighten up the beam for a specific area.

A graphic caret corresponding to the focal zone position(s) appears on the right edge of the image on the Logiq e U/S machine.

Focus (Logiq e)

Doppler Mode: Identifies vascular structures.

Differentiate between arterial and venous structures.

The use in this application is solely to facilitate location of adjacent neuronal structures and avoidance of vascular injury.

Doppler Mode

Hyperechoic: Bones, Fascia & Tendons Hypoechoic: Muscle, Fat, Small Veins and

Arteries Anechoic: Large Arteries and Veins Variable: Nerves above Clavicle-Hypoechoic,

Below Clavicle-Hyperechoic Anisotropy: Non-perpendicular angulation skews

the return of the waves returning to the transducer

Echogenicity

Brachial Plexus Anatomy

Most beneficial PNB for outpatient shoulder surgery (Lin, Choi, Hadzic, 2013).

Primary anesthetic with MAC or Adjunct to GA.

Duke Surgery Center primarily ISB catheter/MAC.

NHCL/NHCCP Single Shot ISB/GA

Interscalene Nerve Block

Block at level of Nerve Trunks. U/S probe placed where palpate in classic

technique “Scanning” the neck above clavicle helps with

anatomy Hypoechoic (above the clavicle) Deep to the posterior margin of the SCM Between anterior and middle scalene muscles Classic “Stop Light” appearance at this level

Interscalene Nerve Block

Interscalene Block Technique

Interscalene Block Images

Supraclavicular Block Technique

Supraclavicular Block Images

Block at the level of the Cords Cords are adjacent to the axillary artery at this

level Lateral, posterior and medial Nerves more dense at this level, longer latency Decreased incidence of PTX and vascular injury No need to supplement the musculocutaneous

as with the axillary

Infraclavicular Block

Parasagittal plane below clavicle medial to corachoid

Hyperechoic cords? Not always, sometimes Hypoechoic.

Goal to approach from cephalad to posterior aspect of the axillary artery to proximity of the posterior cord. Increased success in this approach for single injection.

Infraclavicular Block

Infraclavicular Block Technique

Infraclavicular Block Images

Infraclavicular Block Images

Medial aspect of upper arm, for surgery below the elbow.

Musculocutaneous has left the sheath at this level

Like other brachial plexus blocks need a tourniquet ring if not providing significant sedation or general anesthesia.

Very shallow.

Axillary Nerve Block

Picture to be added before presentation

Axillary Block Anatomy

Femoral Block Technique

Femoral Block Images

Large Hyperechoic nerve. Primarily blocked for procedures knee and

long bones of the lower extremity. Can be accessed at popliteal fossa ankle

procedures.

Sciatic Nerve Block

Sciatic Nerve Block Technique

Sciatic Block Images

Popliteal Fossa Block

Block in the medial thigh. In conjunction with sciatic nerve block for lower

extremity surgery (further discuss Sciatic approach)

Primarily Sensory and provides superficial medial anesthesia below the knee.

Contents: FA/FV, Saph. N., Nerve to Vastus Medialis, Medial Cutaneous, Post Br. Obturator.

Preserves the Quadricep Strangth & Balance

Adductor Canal

ADDUCTOR CANAL

Sartorius

Vastus Medialis

FAAC

Infiltration within the posterior capsule of the knee

Ultrasound guided Infiltration technique 15 – 20 ml local between artery and femur under

ultrasound guidance Uses for ACL*, TKA, etc. Will demonstrate during hands on.

* not beneficial patellar graft is harvested.

iPACK Nerve Block

Transversus Abdominis Plane Block

Provides anesthesia for T10-L1 nerves. No relief for surgery above the umbilicus.

Somatic innervation to the lower anterior abdominal wall by nerves in the fascial plane between the TA and IOM.

No visceral component. Provides relief for Hysterectomy,

Hernia, Lap Procedures. May be used diagnostically for chronic

pain.

TAP Block Technique Patient positioned supine. Can be done under general anesthesia. Arms Abducted. Costal Margin, Iliac Crest, Axillary line. Needle direction medial to lateral. In plane technique. Distinct Needle

“Pop”. NS test injection. 20-30 ml local anesthesia per side.

TAP Block Technique

TAP U/S Image

Liposome Injection of Bupivacaine. Extended Release.

December 14, 2016 FDA approval for TAP Block use. Rescinded warning letter for off label

advertising. Dosing for TAP. One 20ml vial diluted to 40-

60 ml. No more Local after administration of TAP for

72 Hours.

Exparel/ TAP

ReferencesBeaussier, M., Sciard, D., & Sautet, A. (2016). New modalities of pain treatment after outpatient orthopaedic surgery. Orthopaedics & Traumatology, Surgery & Research : OTSR, 102(1 Suppl), S121-4. doi:10.1016/j.otsr.2015.05.011 [doi]

Buckenmaier, C., & Bleckner, L. (2009). In Redding J. (Ed.), Military advanced regional anesthesia and analgesia, handbook (First ed.). Washington, DC: Office of the Surgeon General at TMM Publications.

Food and Drug Administration. (2015). Removal of warning letter; TAP block approval. Retrieved from http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/EnforcementActivitiesbyFDA/WarningLettersandNoticeofViolationLetterstoPharmaceuticalCompanies/UCM477250.pdf

Lin, E., Choi, J., & Hadzic, A. (2013). Peripheral nerve blocks for outpatient surgery: Evidence-based indications. Current Opinion in Anaesthesiology, 26(4), 467-474. doi:10.1097/ACO.0b013e328362baa4 [doi]

Patacsil, J. A., McAuliffe, M. S., Feyh, L. S., & Sigmon, L. L. (2016). Local anesthetic adjuvants providing the longest duration of analgesia for single-injection peripheral nerve blocks in orthopedic surgery: A literature review. American Association of Nurse Anesthetists Journal, 84(2), 95.