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Usg r nerve block

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Usg r nerve block

  1. 1. WELCOME
  2. 2. USG GUIDED REGIONAL NERVE BLOCK Presented By. Maj Zahed & Maj Arif Department Of Anaesthesiology CMH DHAKA
  4. 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. 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. 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. 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. 8. SOME BASICS • HIGH frequency = great resolution but poor penetration • LOW frequency = poor resolution but great penetration
  10. 10. ULTRASOUND GUIDED APPROACH The short axis view is the preferred approach because it gives you a cross- sectional view of the nerve.
  11. 11. STERILITY
  12. 12. TECHNIQUE Ensure an ergonomic setup in anaesthetic room
  13. 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. 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. 15. TAP BLOCK
  19. 19. PEC BLOCK
  20. 20. PEC BLOCK
  21. 21. PEC I & PEC II
  22. 22. LOWER EXTREMITY • Sciatic nerve block • Femoral nerve block • Saphenous nerve block • Obturator nerve block • Ankle block
  23. 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. 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
  26. 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. 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. 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. 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. 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. 31. OBTURATOR NERVE BLOCK • Relief of painful adductor muscle contractions • Contractions of adduction of thigh duringTURBT • Additional analgesia after major knee surgery
  32. 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. 33. ANKLE BLOCK
  34. 34. UPPER EXTREMITY Brachial Plexus Block • Interscalene • Supraclavicular • Axillary
  35. 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
  36. 36. 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.
  37. 37. 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. 39. 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 .
  40. 40. USG VIEW
  41. 41. 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.
  42. 42. 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.
  43. 43. 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.
  44. 44. 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.
  45. 45. 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.
  46. 46. 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.
  47. 47. 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!