Download - Joseph McVicker NCANA
![Page 1: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/1.jpg)
Fundamentals of Ultrasound Guided Peripheral Regional
Anesthesia Techniques
Joseph McVicker, CRNA, MS
![Page 2: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/2.jpg)
Retired Navy Nurse CorpsUniversity South AlabamaGeorgetown University East Carolina University
![Page 3: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/3.jpg)
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
![Page 4: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/4.jpg)
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
![Page 5: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/5.jpg)
![Page 6: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/6.jpg)
“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?
![Page 7: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/7.jpg)
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
![Page 8: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/8.jpg)
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
![Page 9: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/9.jpg)
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
![Page 10: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/10.jpg)
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
![Page 11: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/11.jpg)
Equipment Preparation
![Page 12: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/12.jpg)
![Page 13: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/13.jpg)
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
![Page 14: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/14.jpg)
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
![Page 15: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/15.jpg)
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.
![Page 16: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/16.jpg)
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
![Page 17: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/17.jpg)
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)
![Page 18: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/18.jpg)
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
![Page 19: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/19.jpg)
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
![Page 20: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/20.jpg)
Brachial Plexus Anatomy
![Page 21: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/21.jpg)
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
![Page 22: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/22.jpg)
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
![Page 23: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/23.jpg)
Interscalene Block Technique
![Page 24: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/24.jpg)
Interscalene Block Images
![Page 25: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/25.jpg)
Supraclavicular Block Technique
![Page 26: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/26.jpg)
Supraclavicular Block Images
![Page 27: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/27.jpg)
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
![Page 28: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/28.jpg)
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
![Page 29: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/29.jpg)
Infraclavicular Block Technique
![Page 30: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/30.jpg)
Infraclavicular Block Images
![Page 31: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/31.jpg)
Infraclavicular Block Images
![Page 32: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/32.jpg)
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
![Page 33: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/33.jpg)
Picture to be added before presentation
Axillary Block Anatomy
![Page 34: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/34.jpg)
Femoral Block Technique
![Page 35: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/35.jpg)
Femoral Block Images
![Page 36: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/36.jpg)
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
![Page 37: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/37.jpg)
Sciatic Nerve Block Technique
![Page 38: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/38.jpg)
Sciatic Block Images
![Page 39: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/39.jpg)
Popliteal Fossa Block
![Page 40: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/40.jpg)
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
![Page 41: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/41.jpg)
ADDUCTOR CANAL
Sartorius
Vastus Medialis
FAAC
![Page 42: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/42.jpg)
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
![Page 43: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/43.jpg)
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.
![Page 44: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/44.jpg)
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.
![Page 45: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/45.jpg)
TAP Block Technique
![Page 46: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/46.jpg)
TAP U/S Image
![Page 47: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/47.jpg)
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
![Page 48: Joseph McVicker NCANA](https://reader035.vdocuments.us/reader035/viewer/2022062823/58715ba71a28ab8e5b8b663d/html5/thumbnails/48.jpg)
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.