USG Guided regional nerve block

1. WELCOME

2. USG GUIDED REGIONAL
NERVE BLOCK
Presented By.
Maj Zahed &
Maj Arif
Department Of Anaesthesiology
CMH DHAKA

3. INTRODUCTION

4. Both paresthesia and nerve stimulation
<0.5 mA are methods of low sensitivity (
37% and 75% respectively) for detecting
needle nerve contact when an insulated
needle is used for axillary block.

5. POTENTIAL ADVANTAGES
• Ultrasound guidance enhances visualization of the neural
target and its surrounding structures.
• Able to differentiate between vascular and non-vascular
structures.
• No ionising radiation
• Portability
• Accessibility
• Identify target nerve
White / hyperechoic is peri/epineurium
Black / hypoechoic is nerve tissue

6. POTENTIAL ADVANTAGES
• Identify surrounding structures e.g. blood
vessels,pleura, peritoneum
• Patients with neuropathy do not respond
normally to PNS
• Observe local anaesthetic distribution
• Assess catheter position

7. ADVANTAGES IN CHILDREN
• Under GA – warning signs of intravascular or
intraneural injection may be masked
• Smaller mass so nerves more superficial so
allowing higher frequencies to be used
• Less margin for error as vulnerable
structures such as pleura are closer to nerves.

8. SOME BASICS
• HIGH frequency =
great resolution but
poor penetration
• LOW frequency =
poor resolution but
great penetration

9. IN OR OUT PLANE APPROACH

10. ULTRASOUND GUIDED APPROACH
The short axis
view is the
preferred
approach
because it gives
you a cross-
sectional view of
the nerve.

11. STERILITY

12. TECHNIQUE
Ensure an ergonomic setup in anaesthetic room

13. TECHNIQUE
• Start deep, then work up (generally 4cm is adequate )
• Nerve should be viewed in middle depth of screen
• Orientate again
• Choose entry point
Out of Plane target in middle of screen
In Plane target on opposite side that needle enters to one
side of nerve- OOP approach 3/9 O’clock , IP approach 6/12
O’clock.
• PNS to confirm nerve
• Aspirate then inject 0.5ml LA / saline
• Assess spread

14. TAP(TRANSABDOMINIS PLANE BLOCK)
• Provides analgesia to the skin and muscles of the
antero-lateral abdominal wall and parietal
peritoneum. Does not block visceral pain
• Goal of the block is to place LA between the
internal oblique and transversus abdominis
muscle layers
• Used for patients undergoing lower abdominal
surgery; appendectomy, c-section,hernia repair,
abdominal hysterectomy and prostatectomy

15. TAP BLOCK

16. RECTUS ABDOMINIS BLOCK

17. SUBCOSTAL TAP BLOCK

18. TAP/SUBCOSTAL TAP/RECTUS BLOCK

19. PEC BLOCK

20. PEC BLOCK

21. PEC I & PEC II

22. LOWER EXTREMITY
• Sciatic nerve block
• Femoral nerve block
• Saphenous nerve block
• Obturator nerve block
• Ankle block

23. SCIATIC NERVE BLOCK
The sciatic nerve is a large nerve
that starts up high in the greater
sciatic foramen, deep to the
piriformis muscle that runs along
the posterior border of the leg.

24. SCIATIC NERVE BLOCK
Parasacral Transgluteal
Subgiuteal
Popliteal
Although there are
four locations one
can block the sciatic
nerve, the most
common place is in
the popliteal region.
Surgery on the knee, calf,
achilles tendon, foot, ankle.
Post operatively for
posterior knee pain
following surgery

25. POPLITEAL SCIATIC NERVE BLOCK

26. FEMORAL NERVE BLOCK
The femoral nerve is
the largest nerve of
the lumbar plexus.It is
made up of the
second through
fourth lumbar nerves.

27. FEMORAL NERVE BLOCK
Femoral Artery
Femoral Vein
Femoral
Nerve
Ultrasound to visualize exactly
where the artery is and move
lateral to the artery, it makes the
block more accurate especially
in larger patients.When using
ultrasound for this block it is
helpful to identify three
structures.The femoral vein is
the most medial of the three
structures, the femoral artery is
in the middle and the femoral
nerve is the most lateral

28. FEMORAL NERVE BLOCK
Major thigh surgery and
more importantly major
knee surgery are the
most common places of
femoral nerve blocks. For
inpatients the most
common use of a
femoral nerve block is
total knee replacements,
and for outpatients the
most common use is for
ACL reconstruction.

29. SAPHENOUS NERVE BLOCK
• The terminal sensory branch of the
femoral nerve is the saphenous nerve,
which innervates the medial calf and
ankle.
• Saphenous nerve block not only supports
medial ankle surgery, but it also can be
used for knee surgery as an alternative to
femoral nerve blocks.One of the most
common complaints that surgeons have
with femoral nerve blocks is the
weakening quadriceps side effect.So it can
replace a femoral nerve block with a
saphenous nerve block or adductor canal
nerve block, then it can be spare the
quadriceps side effects .

30. SAPHENOUS NERVE BLOCK
• Place the transducer on the
sartorius muscle, down in the
mid-thigh region. Look for the
femoral artery.
• Slightly below the sartorius
muscle and anterior to the
femoral artery is the saphenous
nerve.
• The saphenous block is a very
easy block to complete with
ultrasound because of the large
arterial landmark and the bright
white characteristics of the deep
border of the sartorius muscle.
saphenous nerve.

31. OBTURATOR NERVE BLOCK
• Relief of painful
adductor muscle
contractions
• Contractions of
adduction of thigh
duringTURBT
• Additional analgesia
after major knee
surgery

32. ANKLE BLOCK
• Provides surgical
anesthesia to the foot.
• Ankle block consists of
two deep nerves below
superficial facial (posterior
tibia and deep peronei)
and three superficial nerve
above the superficial facial
(sural, saphenous and
superficial peronei)

33. ANKLE BLOCK

34. UPPER EXTREMITY
Brachial Plexus Block
• Interscalene
• Supraclavicular
• Axillary

35. BRACHIAL PLEXUS ANATOMY
The brachial plexus extends from
C5 to T1; (C5, C6, C7, C8 and T1).
It innervates the shoulder and
arm.
The brachial plexus begins as
spinal nerve roots and continues
to the terminal branches that
supply the upper extremity.
Specifically, the anatomy
progresses from roots to trunks,
trunks to divisions, divisions to
cords (lateral, medial and
posterior cords) and finally to
terminal nerve branches

37. INTERSCALENE BLOCK
• The interscalene
block is the bread
and butter block for
shoulder surgery.
• The interscalene
nerve block
substantially covers
rotator cuff repairs,
total shoulder
replacements and
major upper
extremity trauma.

38. INTERSCALENE BLOCK
• This block targets higher at the roots of the
brachial plexus (C5, C6, +/- C7) in order to
reach the innervation of the shoulder.

39. INTERSCALENE LANDMARKS

40. INTERSCALENE BLOCK
LOCATING
• Scanning with ultrasound to locate the interscalene
plexus is a very easy two-step process.Look for the
“cluster of grapes sign,” where the trunks are next to
that subclavian artery.
• In a paintbrush stroke, move the transducer up the
neck in a simultaneous slide and tilt motion
• The shape of the brachial plexus narrowed into circles
on top of circles. This is referred to as the “stoplight
sign” representing the visualization of C5 and C6 .

41. USG VIEW

42. SUPRACLAVICULAR BLOCK
For upper extremity surgery,
excluding shoulder surgery,
which has been coined the
“spinal of the arm”.
The supraclavicular block
essentially numbs everything
from the proximal arm down to
the fingertips and gives the
capability of anesthetizing the
arm for both surgical and post-
operative pain control.

43. TARGET
• The supraclavicular
block starts high and
proximal on the patient.
• Technically the superior,
middle and inferior
trunks are targeting the
brachial plexus for this
block.

44. SUPRACLAVICULAR BLOCK
PATIENT POSITIONING
Position the patient resting
flat on their back with a
pillow and 30 or 40 degrees
elevated.Turn the patient’s
head up away and insert
the needle just above the
clavicle and posterior to the
transducer.

45. SUPRA CLAVICULAR BLOCK
IN PLANE TECHNIQUE
Turn the patient’s head
up away and insert the
needle just above the
clavicle and posterior to
the transducer.
This is an in-plane
technique that gives a
short axis view with a
wide linear array
ultrasound transducer.

46. AXILLARY BLOCK
• The axillary block is the most distal
brachial plexus block.
• It targets the terminal branches of
the brachial plexus.
• The axillary block can be used for
forearm, hand, or wrist surgery.
• It is useful for pulmonary patients
since it spares the phrenic nerve.
• It is also useful for morbidly obese
patients.

47. AXILLARY BLOCK
ULTRASOUND GUIDED APPROACH
Envision the axillary block
positioning like a clock face.
Consider the axillary artery the
clock and the
musculocutaneous, median,
ulnar and radial nerves as
targets aligned around the
clock face.

48. CONCLUSION
• Practice on yourselves and staff FIRST
• Start with simple (e.g. Saphenous and femoral)
block
• Always use a PNS until master on USG
• Use the highest frequency available for the depth
of target in tissues
• USG is only as good as the operator
• Remember it takes 3 years to train as a
radiographer!