surface anatomy and sonoanatomy for the occasional regional anesthesiologist
TRANSCRIPT
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.
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Disclaimer This presentation is intended for
educational purposes only and is not meant to be reproduced or redistributed for commercial purposes
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
How Hard Can It Be?
NYSORA.COM -
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Lesson #1
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Lesson #2
Regional anesthesia is Regional anesthesia is applied anatomyapplied anatomy
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Overview Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Overview Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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)
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
A Closer Look at the Nerve
Short-Axis ViewShort-Axis View
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
The “A.R.T.” of Target Imaging
A lignmentR otationT ilt
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Alignment: Where Do We Look?
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Optimal Rotation
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Optimal Rotation
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Optimal Tilt
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Optimal Tilt
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Overview Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Infraclavicular Anatomy
Position: supine with arm at side or abducted 90
Palpate coracoid process below the clavicle
Plexus runs under coracoid process
CoracoiCoracoidd
ClavicleClavicle
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Infraclavicular SonoanatomyTransverse Short-Axis ViewTransverse Short-Axis View
PMaPMi
AA AVNN
N
Mariano ER, et al. JUM Mariano ER, et al. JUM 2009;28:12112009;28:1211
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Femoral Sonoanatomy
Transverse Short-Axis ViewTransverse Short-Axis View
FAFL
FIIliacus
N
Mariano ER, et al. JUM Mariano ER, et al. JUM 2009;28:14532009;28:1453
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Transversus Abdominis Plane Anatomy
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
TAP SonoanatomyTransverse Short-Axis ViewTransverse Short-Axis View
EOIO
TA
Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
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