Download - Surface anatomy and sonoanatomy for the occasional regional anesthesiologist

Surface Anatomy and Sonoanatomy for the Occasional

Regional Anesthesiologist

@EMARIANOMD@EMARIANOMD

Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain MedicineProfessor of Anesthesiology, Perioperative & Pain Medicine

Stanford University School of MedicineStanford University School of MedicineChief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System

Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy

Financial Disclosures Halyard Health, B Braun – Unrestricted

educational program funding paid to my institution

The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.


Disclaimer This presentation is intended for

educational purposes only and is not meant to be reproduced or redistributed for commercial purposes


Learning Objectives Define optimal ultrasound transducer

position for cross-sectional imaging of nerves Apply surface anatomic landmark

identification in ultrasound transducer application

Identify sonoanatomy of common peripheral nerves and surrounding structures

Discuss tips and tricks to improve ultrasound images and block techniques


How Hard Can It Be?

NYSORA.COM -


Lesson #1


Lesson #2

Regional anesthesia is Regional anesthesia is applied anatomyapplied anatomy


History of Nerve Localization

Anatomic landmarks Fascial clicks or

pops Electrical nerve

stimulation Sustained “twitch” at

< 0.5 mA current suggests appropriate needle position

Ultrasound


Overview Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks


Basic Sonoanatomy Blood vessels:

hypo-echoic (dark)

Muscles: hypo- > hyper-echoic (striations)

Bone and fascia: hyper-echoic (white)

Nerves: hypo-echoic Connective tissues are Connective tissues are

hyper-echoic (epineurium, hyper-echoic (epineurium, perineurium)perineurium)


A Closer Look at the Nerve

Short-Axis ViewShort-Axis View


The “A.R.T.” of Target Imaging

A lignmentR otationT ilt


Alignment: Where Do We Look?


Optimal Rotation


Optimal Tilt


Overview Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks


Interscalene Block: How We Did It Needle inserted in IS

groove at C6 Antero-lateral

approach Needle angle 30-45º Elicit motor response

(deltoid, biceps, triceps, pectoralis)

Borgeat A, et al. Anesth Borgeat A, et al. Anesth 2003:99:4362003:99:436


Interscalene Anatomy Position: supine with

head turned away SCM clavicular head Interscalene groove

posterior to SCM at cricoid level (C6)

External jugular vein Subclavian artery

SCM

SCM

Subclavian Subclavian ArtArt

CricoidCricoid


Interscalene SonoanatomyTransverse Short-Axis ViewTransverse Short-Axis View

SCM

ASM MS

M

CTP

BP

Mariano ER, et al. JUM Mariano ER, et al. JUM 2010;29:3292010;29:329


Infraclavicular Block: How We Did It

Insertion 2 cm medial and 2 cm caudad to CP

Needle inserted plumb-bob

Avg depth 4.24±1.49 cm in men, 4.01±1.29 cm in womenWilson JL, et al. A&A 1998;87:870Wilson JL, et al. A&A 1998;87:870


Infraclavicular Anatomy

Position: supine with arm at side or abducted 90

Palpate coracoid process below the clavicle

Plexus runs under coracoid process

CoracoiCoracoidd

ClavicleClavicle


Infraclavicular SonoanatomyTransverse Short-Axis ViewTransverse Short-Axis View

PMaPMi

AA AVNN

N



Femoral Nerve Block: How We Did It

Needle insertion: lateral to artery at 45° angle aiming cephalad

Feel 2 “pops” Proper motor

response = quad contraction

Ilfeld, BM, et al. Anesth 2008;108:703 Ilfeld, BM, et al. Anesth 2008;108:703


Femoral Anatomy

Position: supine with roll under hip

Leg straight Inguinal crease Femoral artery Femoral nerve is

lateral to femoral artery

Inguinal Crease

Inguinal Crease


Femoral Sonoanatomy

Transverse Short-Axis ViewTransverse Short-Axis View

FAFL

FIIliacus

N



Adductor Canal Anatomy

Position: supine with thigh externally rotated and knee slightly flexed

Subsartorial tunnel begins distal to the apex of the femoral triangle

Saphenous nerve runs with superficial femoral artery

Horn JL, et al. RAPM 2009;34:486Horn JL, et al. RAPM 2009;34:486Manickam B, et al. RAPM Manickam B, et al. RAPM 2009;34:5782009;34:578


Adductor Canal Ultrasound

Transducer placed along medial aspect of thigh distal to inguinal crease

Short-axis view Landmarks

Sartorius muscle Saphenous (N) Femoral artery (A)

Mariano ER, et al. JUM 2014;33:1653Mariano ER, et al. JUM 2014;33:1653

SartoriusN A


Popliteal Fossa Block: How We Did It

Insertion site: 8-10 cm cephalad to popliteal crease or at intertendinous junction

4” needle angled 45° cephalad

Plantar flexion or inversion preferred

Hadzic A, et al. A&A Hadzic A, et al. A&A 2002;94:13212002;94:1321


Popliteal Anatomy Position: prone with

knee slightly flexed Popliteal crease Biceps femoris

laterally Semimembranosus

and semitendinosus medially

Intertendinous “junction”

Bice

ps F

emor

isBi

ceps

Fem

oris Sem

i-M/T

Semi-M

/T


Popliteal SonoanatomyTransverse Short-Axis ViewTransverse Short-Axis View

F

BFN

Mariano ER, et al. RAPM Mariano ER, et al. RAPM 2009;34:4802009;34:480


Transversus Abdominis Plane Anatomy


TAP SonoanatomyTransverse Short-Axis ViewTransverse Short-Axis View

EOIO

TA


Summary We defined optimal ultrasound transducer

position for cross-sectional imaging of nerves We applied surface anatomic landmark

identification in ultrasound transducer application

We identified sonoanatomy of common peripheral nerves and surrounding structures

We discussed tips and tricks to improve ultrasound images and block techniques

Download - Surface anatomy and sonoanatomy for the occasional regional anesthesiologist

Top Related