Fundamentals of Ultrasound Guided Peripheral Regional Anesthesia Techniques

1. Fundamentals of Ultrasound
Guided Peripheral Regional
Anesthesia Techniques
Joseph McVicker, CRNA, MS

2. Retired Navy Nurse Corps
University South Alabama
Georgetown University East
Carolina University

3.  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

4.  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

6. “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?

7.  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

8.  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

9.  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

10.  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

11. Equipment Preparation

13.  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

14.  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

15. 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.

16.  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

17.  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)

18.  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

19.  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

20. Brachial Plexus Anatomy

21.  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

22.  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

23. Interscalene Block Technique

24. Interscalene Block Images

25. Supraclavicular Block Technique

26. Supraclavicular Block Images

27.  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

28.  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

29. Infraclavicular Block Technique

30. Infraclavicular Block Images

31. Infraclavicular Block Images

32.  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

33.  Picture to be added before presentation
Axillary Block Anatomy

34. Femoral Block Technique

35. Femoral Block Images

36.  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

37. Sciatic Nerve Block Technique

38. Sciatic Block Images

39. Popliteal Fossa Block

40.  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

41. ADDUCTOR CANAL
Vastus Medialis
FA
AC

42.  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

43. 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.

44. 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.

45. TAP Block Technique

46. TAP U/S Image

47.  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

48. References
Beaussier, 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/Enfo
rcementActivitiesbyFDA/WarningLettersandNoticeofViolationLetterstoPharmaceuticalC
ompanies/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.