UGRA is useful for upper limb b/c innervation of arm, shoulder, & lateral clavicular area is ______

This area is also amenable to UGRA b/c superficial location of brachial plexus, its branches, & surrounding structures allows __________.

UGRA is useful for upper limb b/c innervation of arm, shoulder, & lateral clavicular area is complex

This area is also amenable to UGRA b/c superficial location of brachial plexus, its branches, & surrounding structures allows high-quality US imaging

Interscalene approach

Between ___ mm

Must visualize needle to avoid insertion towards ___ ___

An advantage to the in-plane approach is that it maintains ________, however it requires greater ______.

An advantage to the out-of-plane approach is that it traverses _______; needle depth is ____, but ____ visualization is poorer.

Check on screen depth; for this block depth is usually ___cm

Between interscalene mm

Must visualize needle to avoid insertion towards cervical spine

An advantage to the in-plane approach is that it maintains view of needle throughout, however it requires greater distance to cover.

An advantage to the out-of-plane approach is that it traverses least distance to brachial plexus; needle depth is minimized, but needle visualization is poorer.

Check on screen depth; for this block depth is usually +/- 3 cm (fairly shallow)

Interscalene scanning technique

Pt position?

Nerve image?

Needle size?

Pt position: supine w/ head rotated toward nonoperative side

Nerve image: 3-4 hypoechoic circles located b/n scalenes

Needle size: 40-50mm (short)

Interscalene scanning technique

2 ways to ID structures:

1. Start ____ looking ___

-find __ & identify nerve _____ of BP

-trace bundle up neck until finding BP nerve roots in __ __

2. Start at ___ to locate CA & IJ

-move ______ to ASM & MSM

-idenitify BP nerve roots in __ ___

1. Start supraclavicularly looking caudally

-find SCA & identify nerve trunks of BP

-trace bundle up neck until finding BP nerve roots in interscalene groove

or

2. Start at C6 to locate CA & IJ

-move posteriorly to ASM & MSM

-idenitify BP nerve roots in interscalene groove

Clinical Pearls

Best view is often more ___ than traditional landmark approach, ie ...?

Tip of lateral end of sternocleidomastoid mm should be slightly ___ to superior neural structures in IS groove

What is a well-described variant of the BP nerve roots?

Best view is often more inferior than traditional landmark approach, ie more inferior than level of cricoid cartilage (you don't have to insert at C6, find the place of best visualization, either above or below C6 & do block there)

Tip of lateral end of sternocleidomastoid mm should be slightly posterior-lateral to superior neural structures in IS groove

1 or more nerve roots not in IS groove, but rather penetrating directly thru mm (AS or MS)

Supraclavicular approach

(above the ___)

Pt position?

Transducer location?

Nerve image?

Needle size?

(above the clavicle)

Pt position: supine w/ head rotated to nonoperative side

Transducer location: parallel to clavicle resting in the supraclavicular fossa

Nerve image: 3-6 hypoechoic circles located lateral & superior to SCA (main landmark)

Needle size: 40-50 mm

Which block is the 1st choice b/n shoulder & elbow?

"corner pocket"

bordered by 1st rib inferiorly, SCA medially, & BP superiorly

The supraclavicular approach provides excellent visualization d/t ______________

Do you use in-plane or out-of-plane technique?

d/t superficial location of BP & surrounding structures (SCA, pleura, 1st rib)

(infraclavicular block is deeper & not as easy to see)

either--same issues as w/ interscalene block

T/F:Supraclavicular block is the spinal of the arm & includes tourniquet coverage

Supraclavicular block could replace all blocks but ____

True

except interscalene block (doesn't reach high enough on shoulder)

1. grape-like cluster of 5-6 hypoechoic circles, which prolly represent divisions of BP

2. 3 hypoechoic circles likely represents trunks of BP

infraclavicular block

axillary block

Infraclavicular block

In-plane or out-of-plane?

Pt position?

Transducer location?

Nerve image? How are they distributed around art?

Needle size? Avg depth for block?

no evidence of difference in- or out-of-plane

position: supine w/ head toward nonoperative side, arm at pts side

transducer location: infraclavicular, perpendicular to clavicle along lateral segment in infraclavicular fossa

Nerve image: 3 hyperechoic circles typically distributed around axillary artery @ 3,6,9 o'clock

Needle size: 100mm (~4-6 cm deep)

In the infraclavicular block, pt can feel discomfort as the needle passes thru __ ___ & ___

Goal is to image AA 1-2 cm proximal to ____ process

Cords of BP are more ____ to visualize here than more proximally, secondary to ____ location

In the infraclavicular block, pt can feel discomfort as the needle passes thru pec major & minor

Goal is to image AA 1-2 cm proximal to coracoid process

Cords of BP are more difficult to visualize here than more proximally, secondary to deeper location

The infraclavicular block is reserved for pts w/ relative CI to supraclavicular block

 SCA pathology

localized infection

severe COPD 

Axillary approach

US has revolutionized ____ & ____ rates

What is key to success?

US has revolutionized performance & success rates

anatomical knowledge of both normal & variants

Axillary approach

it has become accepted that all 4 nerves should be blocked w/ _____ technique

What does this block provide anesthesia for?

it has become accepted that all 4 nerves should be blocked w/ multi-injection technique

hand/forearm sx & tourniquet pain

Axillary approach

Light pressure decreases likelihood of what?

Axillary approach

Using a clock as a reference, describe where the median, ulnar, & radial nerves are located

With LA injection, radial N often..?

Median typically 12 o'clock

Ulnar b/n 2-5 o'clock

Radial typically 4-9 o'clock

radial N often increases in visibility

Axillary approach

Pt position?

Transducer location?

Nerve image?

Needle size?

Position: supine w/ head rotated toward nonoperative side; pt arm abducted & externally rotated

transducer location: axillary crease formed by pec major & biceps mm, perpendicular to AA

Nerve image: variably located around AA

Needle size: 40-50 mm

Axillary approach Clinical Pearls

identify ___ & ___.

Median, ulnar & radial likely surround __ in _____ pattern, but there is sig. variance

Target nerves most imp to ___, as distortion after injection can ____ view

identify AA & AV 

Median, ulnar & radial likely surround AA in triangular pattern, but there is sig. variance

Target nerves most imp to sx, as distortion after injection can complicate view

Axillary approach Clinical Pearls

____ is useful as physiologic test of anatomical assumptions as nerves can be ...?

Ulnar N can be cm away from __ & next to an ___ rather than ___

There may be multiple ____ associated w/ axillary BP

Less artistic approach is ___ sign around __ if individual nerves are hard to ID

NS is useful as physiologic test of anatomical assumptions as nerves can be several cm away from AA

Ulnar N can be cm away from AA & next to an AV rather than AA

There may be multiple veins associated w/ axillary BP

Less artistic approach is donut sign around AA if individual nerves are hard to ID

In the lower limb, sonoanatomy is less ____

Complications typically arise from ...?

In the lower limb, sonoanatomy is less complex

Complications typically arise from extensive mm or fat

Femoral N block

Out-of-plane traverses ____ distance to FN

-needle depth is ____, but needle _____ is poor

 In-plane approach is ___ to ___

Potential ID difficulty d/t ...?

Out-of-plane traverses least distance to FN

-needle depth is minimized, but needle visualization is poor

In-plane approach is lateral to medial

Potential ID difficulty d/t FN position b/n iliopsoas mm & fascia

Femoral N block scanning technique

Moving too far caudally shows __ & ___

Too far cranially shows __, __ & __ moving deeper

How many layers of fascia do you go thru before injecting?

Moving too far caudally (distal) shows FA & PFA PFA=profunda femoris artery

Too far cranially shows FA, FV & FN moving deeper

2 layers--fascia lata & fascia iliaca; should feel "double pop"

Sciatic N block

Variety of techniques & approaches

Where do you inject?

What is the challenge w/ this area?

Anywhere along the course of sciatic N w/ good imaging

-gluteal region to popliteal fossa

challenge from high amts of surrounding mm & fat

Popliteal N block

For procedures below the knee, the ____ nerve is often blocked (____ or ____) in the popliteal fossa

Blockade of both ___ & ___ _____ nerves will target which area? Except?

For procedures below the knee, the sciatic nerve is often blocked (posteriorly or laterally) in the popliteal fossa

Blockade of both tibial & common peroneal nerves will target entire leg below knee

Except for area of skin supplied exclusively by saphenous N on anteromedial ankle & foot

Popliteal N block scanning technique

Where do you place the probe?

Find snowman of __, __, & ____

Scan proximally to find junction of __ & __

In crease behind knee

Find snowman of PA, PV, & nerves

Scan proximally to find junction of TN & PN

What are 4 of the most common complications in closed malpractice claims r/t CVC?

Which 2 had higher proportion of death than the other CVC injuries?

wire/catheter embolus

cardiac tamponade

carotid artery puncture/cannulation

hemothorax & pneumothorax

Death r/t:

cardiac tamponade

pneumothorax

Scarcity of peripheral sites

Large-bore venous catheter needed for rapid admin of fluid, blood products, vasopressors, etc

Need for PA catheter or transvenous pacemaker

Need for continuous CVP

SCV & IJV access in severe coagulopathy

Local infection over intended site

Why are SCV & IJV cannulation CI in severe coagulopathy?

What is preferred site in this case?

SCV & IJV in severe coagulopathy poses risk d/t:

SCV--noncompressible nature 

IJV--risk of accidental carotid puncture

FV preferred

Inability of pt to tolerate positioning

Lack of pt cooperation

Morbid obesity of pt? (w/ US this might not be CI b/c easier to visualize vessels)

6 mechanical CI to CVC

Contralateral ___ or ____
Inability of pt to tolerate ___ pneumothorax

Venous ___ or ___ injury

____ ventilator settings

Trauma pts w/ ___ ___ ___ in place

Presence of _____or_______in FV cannulation

Contralateral pneumothorax or hemothorax (don't want to have both lungs compromised)
Inability of pt to tolerate ipsilateral pneumothorax

Venous thrombosis or vessel injury

High-pressure ventilator settings

Trauma pts w/ cervical spine collars in place

Presence of Greenfield or IVC filter in FV cannulation

How do you position pt for CVC placement of IJ or SC? FV?

What about your position?

IJ or SC--slight trendelenburg w/ head in neutral position or maximally rotated 30 degrees

FV--neutral position

Maintain proper body ergonomics & alignment as w/ UGRA

CVC placement technique w/ US

After vein ID, center vein on screen. Then inject lido at anticipated path of needle. Puncture skin with thin-walled percutaneous entry needle.

Do not focus on US monitor until...? Why?

So, when do you direct visual focus to US monitor?

What if you don't see needle?

not until needle has entered skin

can lead to inadvertent needle sticks

Visual focus directed to US monitor after needle entered skin

If not needle not directly visualized, look for tenting of each tissue plane

In short-axis, scan back & forth w/ probe over needle to locate needle tip

CVC placement technique w/ US (direct)

When can you set aside US transducer?

What is an alternative to this?

What does this allow?

What does this view minimize?

After needle punctures vessel & produces blood return, US transducer may be set aside & remainder of procedure completed w/ out US guidance

or

Assistant can capture vessel image in longitudinal plane

This allows visualization of guidewire as it is threaded into vessel.

This view minimizes risk of puncture of posterior vessel wall

T/F: After US guided placement of CVC, it is not necessary for CXR

False!!

postprocedural CXR is necessary to confirm placement & evaluate for complications (ie pneumo)

In short-axis technique of US guided CVC placement, vessel is centered under ____.

Needle is inserted at ___ degree angle using _____ as a reference point.

In short-axis technique of US guided CVC placement, vessel is centered under transducer

Needle is inserted at 45 degree angle using midpoint of the transducer as a reference point.

In long-axis technique of US guided CVC placement, what is visualized?

Needle is inserted at a __ degree angle along axis of ___

greatest anterior-posterior diameter of target vessel

Needle is inserted at a 30 degree angle along axis of transducer