lower extremity and trunk ultrasound guided blocks andrew biegner crna, faapm anesthesia staffing...

Lower Extremity and Trunk Ultrasound

Guided BlocksAndrew Biegner

CRNA, FAAPM

Anesthesia Staffing Consultants

Hillsdale Community Health Center

Hillsdale, MI

Lower Extremity Regional Anesthesia Blocks

Lumbar Plexus Psoas Compartment

Nerve Block

Sciatic Nerve Block

*Femoral Nerve Block *Saphenous nerve

Lateral Femoral Cutaneous Nerve Block

Fascia Iliaca Block

*Popliteal Fossa Block

Obturator Nerve Block

Ankle Block

Lumbar Plexus AnatomyGenitofemoral

Lower branch L1 and branch of L2

Obturator Anterior divisions of L2, L3 and L4

Femoral Large branches of the posterior divisions L2 and L3 Posterior division of L4

Lateral Femoral Cutaneous Small branches of the posterior division of L2 and L3

Femoral Nerve Block

Femoral Nerve Block

Produces anesthesia to the anterior portion Upper leg Medial calf

Results in inability Abduct the leg Extend the lower leg

Adjunct for postoperative pain relief

Femoral Nerve Block Indications

Surgical procedures of the anterior thigh

Complete or partial analgesia to: Painful conditions of the upper leg Femoral shaft and neck fractures Knee surgery

Femoral Nerve Anatomy

1. Inguinal ligament

3. Femoral vein

4. Femoral artery

5. Femoral nerve

10. Adductor longus muscle

Femoral U/S Nerve BlockPatient position

Supine or recumbent with groin exposed

Transducer location Placed axially between the inguinal crease to the

inguinal ligament

In-Plane approach

Needle size 100mm

LA volume 20 ml

Femoral Nerve Block Landmarks

Femoral Nerve Block* Landmarks

Femoral Nerve Block Complications

Intravascular injection

Hematoma

Direct nerve injury

Popliteal Fossa Nerve Block

Popliteal FossaDiamond-shaped area bounded

Provides innervation to distal lower extremity Except medial aspect of the leg

Saphenous nerve

Contains Posterior tibial nerve Common peroneal nerve Abundance of fat Connective tissue Popliteal vessels

Popliteal Fossa Nerve Block

Indications Foot and Ankle Surgery Improved tourniquet tolerance over

ankle block for foot surgery

For complete anesthesia / analgesia below the knee combine with Femoral nerve block or Saphenous nerve block

Popliteal Fossa U/S Nerve Block Patient position

Supine, prone or lateral decubitus

Transducer location Popliteal fossa crease

In-Plane approach

Needle size 50 mm

LA volume 20 ml

Popliteal Nerve Block: Anatomy External & Internal Landmarks

Popliteal Nerve Block: Anatomy

External & Internal Landmarks

Popliteal Fossa Ultrasound Nerve Block: Positioning

Prone Lateral

Popliteal Fossa Nerve Block Complications

Intravascular injection

Intraneural injection

Block failure

Saphenous Nerve Block

Saphenous Nerve Block Indications

Medial lower leg surgery

Ankle surgery Medial

Used with popliteal fossa block for complete anesthesia / anesthesia of lower leg

Saphenous U/S Nerve BlockPatient position

Supine with thigh and leg externally rotated

Transducer location Transverse

In-Plane approach

Needle size 50 mm

LA volume 10 ml

Saphenous Nerve Block Anatomy

Saphenous Nerve Block*

Blocks of the Trunk

TAP

Para vertebral

Intercostal

Rectus sheath block

Transversus Abdominus Plane Block (TAP)

Transversus Abdominus Plane Block (TAP) Indications

Lower abdominal procedures

Hysterectomy

C- section under GA

Abdominoplasty

Transversus Abdominus Plane Block (TAP)

Landmarks Triangle of Petit

Anteriorly External Oblique

Posteriorly Latissimus Dorsi

Inferiorly Illiac Crest

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Transversus Abdominus Plane Block

Patient position Supine

Transducer location Transverse between the margin of the 12th rib and superior iliac

spine

In-Plane approach

Needle size 100 mm

LA volume 20 - 30 ml bilaterally

Transversus Abdominus Plane Block

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Transversus Abdominus Plane Block

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Successful U/S Regional Anesthesia

Time management

Monitoring

Use 27g needle and pH adjusted local for skin wheels

Music....headphones for the patient

Use a Ultrasound machine

Successful U/S Regional Anesthesia

Needle selection

Small movements of the needle

Evaluate frequently and touch-up early

Identification of difficult landmarks

Successful U/S Regional Anesthesia

Use rabbits feet, rubbing stones, beads, and other totally ridiculous luck charms.

Questions / Comments

mnnavycrna@aol.com

C: 517-607-5969