Ultrasound Guided Regional Nerve Blocks

Transcription

1 Ultrasound Guided Regional Nerve Blocks

2 In the country of the blind the one eyed man is King -Deciderius Erasmus ( )

3 Objectives Benefits of Regional Anesthesia Benefits of US guidance Role of ultrasound in regional anesthesia Ultrasound Nerve Appearance Nerve Block Procedures with US Guidance

4 Regional Nerve Blocks Benefits Provide better post-op pain management Limit block to the body part undergoing surgery Reduced need for other analgesics (opioids) Decreased PONV Minimal side effects

5 Conventional Technique Define area to be blocked based on surface landmarks Insert stimulating catheter Confirm location with nerve stimulator watching for appropriate motor response Inject anesthetic

6 Conventional Nerve Block Procedures are performed without visual guidance

7 Role of Ultrasound Guidance See the target avoid the danger Visualize nerve and surrounding vascular/pleural structures Provides real time guidance Improves accuracy Observe anesthetic spread US guidance may prevent intraneural injury and improve block safety and effectiveness

8 Ultrasound Appearance Nerves can have 3 shapes: Round Oval Triangular Cervical Nerve Roots Peripheral Nerve

9 Ultrasound Appearance Cervical Roots Monofascicular appearance Dark Hypoechoic Peripheral Nerves Honeycomb appearance Hyperechoic Cervical Nerve Roots Peripheral Nerve

10 Needle Appearance Needle shaft

11 Ultrasound Appearance Identify adjacent vascular structures Easy to identify with Color Doppler

12 Nerve Pre/Post Injection

13 Nerve Pre/Post Injection Nerve

14 Nerve Pre/Post Injection Nerve

15 US Guided Nerve Blocks

16 US Guided Nerve Blocks Upper (Shoulder, Elbow or Hand Surgery) Brachial Plexus Interscalene Infraclavicular/Supraclavicular Axillary Lower Extremity Blocks (Knee, Foot or Ankle Surgery) Femoral Popliteal Sciatic

17 Upper Extremity 1 Axillary nerve 2 Musculocutaneous nerve 3 Radial nerve 4 Medial cutaneous nerve of the arm 5 Medial cutaneous nerve of the forearm 6 Median nerve 7 Ulnar nerve

18 Upper Extremity SC IS AX IF

19 Transducer Placement 1. Interscalene 2. Supraclavicular 3. Infraclavicular 4-5 Axillary Picture from Anesthesiology 2003;99:429-35

20 Interscalene Approach Used to visualize roots of the brachial plexus Brachial plexus nerve lies in-between the anterior and middle scalene muscles Appear round to oval hypoechoic structures

21 Brachial Plexus

22 Brachial Plexus

23

24 Brachial Plexus/Interscalene SCM MSM ASM

25 Nerve Pre/Post Injection

26 Nerve Pre/Post Injection

27 Supraclavicular Approach

28 Supraclavicular Approach Block brachial plexus at level of the nerve trunks or divisions Associated with high level of pneumothorax Not generally recommended for outpatients

29 Supraclavicular Approach

30 Supraclavicular Approach SCA

31 Supraclavicular Approach

32 Infraclavicular Approach Level of cords of brachial plexus arranged around axillary artery Lateral and medial cords like superficial to or at level of the subclavian artery Carries virtually no risk of pneumothorax 1 Reference 1- Prithvi Raj-P, Montgomery-S-J, Nettles-D, Jenkins-M-T. Infraclavicular brachial plexus block: A new approach. Anesth Analg 1973;52(6):

33 Brachial Plexus

34 Infraclavicular Approach

35

36 Infraclavicular/Axillary

37 Lower Extremity Nerve Blocks 1. Lateral femoral cutaneous nerve 2. Femoral nerve 3. Sciatic nerve 4. Obturator nerve Reference:

38 Femoral Nerve Lateral Femoral Cutaneous N.

39 Femoral

40

41 Femoral Artery

42 Femoral

43 Femoral

44 Identify Vessels with Color Doppler

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46 Nerve Pre-injection

47 Nerve Post-injection FA

48 Nerve Post-injection

49 Nerve Pre-injection FA FV

50 Nerve Pre-injection FA FV

51 Nerve Post-injection FA

52 Nerve Post-injection FA

53 Subgluteal Approach

54 Subgluteal Approach

55 Sciatic Nerve

56 Sciatic Nerve

57 Nerve Sciatic Nerve

58 Nerve Sciatic Nerve

59 Tibial/Popliteal

60 Tibial/Popliteal

61 Tibial/Popliteal

62 Tibial/Popliteal

63 Tibial/Popliteal

64 Tibial/Popliteal

65 Tibial/Popliteal

66 Summary Ultrasound guidance Shows exact nerve location Shows vital structures surrounding nerves Provides real-time guidance for needle advancement Improves accuracy Identifies local anesthetic spread Increase patient satisfaction

67 Regional Anesthestic Techniques have a failure rate of up to 20% because of incorrect needle and/or local anesthestic placement. Vincent Chan, 2004 A Practical Guide to Ultrasound Imaging For Peripheral Nerve Blocks

68 Questions?