surface anatomy and sonoanatomy for the occasional regional anesthesiologist

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  • Surface Anatomy and Sonoanatomy for the Occasional Regional Anesthesiologist

    @EMARIANOMDEdward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain MedicineStanford University School of MedicineChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System

    Surface Anatomy and Sonoanatomy

    Financial DisclosuresHalyard 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.

    Surface Anatomy and Sonoanatomy

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

    Surface Anatomy and Sonoanatomy

    Learning ObjectivesDefine optimal ultrasound transducer position for cross-sectional imaging of nervesApply surface anatomic landmark identification in ultrasound transducer applicationIdentify sonoanatomy of common peripheral nerves and surrounding structuresDiscuss tips and tricks to improve ultrasound images and block techniques

    Surface Anatomy and Sonoanatomy

    How Hard Can It Be?NYSORA.COM -

    Surface Anatomy and Sonoanatomy

    Lesson #1

    Surface Anatomy and Sonoanatomy

    Lesson #2Regional anesthesia is applied anatomy

    Surface Anatomy and Sonoanatomy

    History of Nerve LocalizationAnatomic landmarksFascial clicks or popsElectrical nerve stimulationSustained twitch at < 0.5 mA current suggests appropriate needle positionUltrasound

    Surface Anatomy and Sonoanatomy

    OverviewIntroduction to ultrasoundSurface anatomic landmarksRelevant gross anatomyTraditional nerve block techniquesSonoanatomy for nerve blocks

    Surface Anatomy and Sonoanatomy

    OverviewIntroduction to ultrasoundSurface anatomic landmarksRelevant gross anatomyTraditional nerve block techniquesSonoanatomy for nerve blocks

    Surface Anatomy and Sonoanatomy

    Basic SonoanatomyBlood vessels: hypo-echoic (dark)Muscles: hypo- > hyper-echoic (striations)Bone and fascia: hyper-echoic (white)Nerves: hypo-echoic

    Connective tissues are hyper-echoic (epineurium, perineurium)

    Surface Anatomy and Sonoanatomy

    A Closer Look at the NerveShort-Axis View

    Surface Anatomy and Sonoanatomy

    The A.R.T. of Target ImagingA lignmentR otationT ilt

    Surface Anatomy and Sonoanatomy

    Alignment: Where Do We Look?

    Surface Anatomy and Sonoanatomy

    Optimal Rotation

    Surface Anatomy and Sonoanatomy

    Optimal Rotation

    Surface Anatomy and Sonoanatomy

    Optimal Tilt

    Surface Anatomy and Sonoanatomy

    Optimal Tilt

    Surface Anatomy and Sonoanatomy

    OverviewIntroduction to ultrasoundSurface anatomic landmarksRelevant gross anatomyTraditional nerve block techniquesSonoanatomy for nerve blocks

    Surface Anatomy and Sonoanatomy

    Interscalene Block: How We Did It Needle inserted in IS groove at C6Antero-lateral approachNeedle angle 30-45Elicit motor response (deltoid, biceps, triceps, pectoralis)

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

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    Surface Anatomy and Sonoanatomy

    Interscalene AnatomyPosition: supine with head turned awaySCM clavicular headInterscalene groove posterior to SCM at cricoid level (C6)External jugular veinSubclavian artery

    SCM

    Surface Anatomy and Sonoanatomy

    Interscalene SonoanatomyTransverse Short-Axis ViewSCMASMMSMCTPBPMariano ER, et al. JUM 2010;29:329

    Surface Anatomy and Sonoanatomy

    Infraclavicular Block: How We Did ItInsertion 2 cm medial and 2 cm caudad to CPNeedle inserted plumb-bobAvg depth 4.241.49 cm in men, 4.011.29 cm in women

    Wilson JL, et al. A&A 1998;87:870

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    Surface Anatomy and Sonoanatomy

    Infraclavicular AnatomyPosition: supine with arm at side or abducted 90Palpate coracoid process below the claviclePlexus runs under coracoid process

    Surface Anatomy and Sonoanatomy

    Infraclavicular SonoanatomyTransverse Short-Axis ViewPMaPMiAAAVNNNMariano ER, et al. JUM 2009;28:1211

    Surface Anatomy and Sonoanatomy

    Femoral Nerve Block: How We Did ItNeedle insertion: lateral to artery at 45 angle aiming cephalad Feel 2 popsProper motor response = quad contraction

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

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    Surface Anatomy and Sonoanatomy

    Femoral AnatomyPosition: supine with roll under hipLeg straight Inguinal creaseFemoral arteryFemoral nerve is lateral to femoral artery

    Inguinal Crease

    Surface Anatomy and Sonoanatomy

    Femoral SonoanatomyTransverse Short-Axis ViewFAFLFIIliacusNMariano ER, et al. JUM 2009;28:1453

    Surface Anatomy and Sonoanatomy

    Adductor Canal AnatomyPosition: supine with thigh externally rotated and knee slightly flexedSubsartorial tunnel begins distal to the apex of the femoral triangleSaphenous nerve runs with superficial femoral artery

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

    Surface Anatomy and Sonoanatomy

    Adductor Canal UltrasoundTransducer placed along medial aspect of thigh distal to inguinal creaseShort-axis viewLandmarksSartorius muscleSaphenous (N)Femoral artery (A)

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

    Surface Anatomy and Sonoanatomy

    Popliteal Fossa Block: How We Did ItInsertion site: 8-10 cm cephalad to popliteal crease or at intertendinous junction4 needle angled 45 cephaladPlantar flexion or inversion preferred

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

    Surface Anatomy and Sonoanatomy

    Popliteal AnatomyPosition: prone with knee slightly flexedPopliteal creaseBiceps femoris laterallySemimembranosus and semitendinosus mediallyIntertendinous junction

    Biceps FemorisSemi-M/T

    Surface Anatomy and Sonoanatomy

    Popliteal SonoanatomyTransverse Short-Axis ViewFBFN

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

    Surface Anatomy and Sonoanatomy

    Transversus Abdominis Plane Anatomy

    Surface Anatomy and Sonoanatomy

    TAP SonoanatomyTransverse Short-Axis ViewEOIOTA

    Surface Anatomy and Sonoanatomy

    SummaryWe defined optimal ultrasound transducer position for cross-sectional imaging of nervesWe applied surface anatomic landmark identification in ultrasound transducer applicationWe identified sonoanatomy of common peripheral nerves and surrounding structuresWe discussed tips and tricks to improve ultrasound images and block techniques

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