Ultrasound Guided Regional Anesthesia

1. Ultrasound Guided Regional Anesthesia Andrew Biegner CRNA, FAAPM Anesthesia Staffing Consultants Hillsdale Community Health Center Hillsdale, MI

2. Objectives • Discuss advantages and disadvantages to U/S guided regional anesthesia. • Describe basic theory and terminology of U/S technology. • Describe the anatomy of the upper and lower extremity. • Describe and discuss the performance and evaluation of upper and lower U/S guided regional anesthesia. • Discuss the application of U/S guided regional anesthesia in acute pain management.

3. Disclaimer I have no affiliations or disclaimers to declare.

4. My Contact Information mnnavycrna@aol.com C: 517-607-5969

5. Ultrasound Regional Anesthesia • Good judgment comes from experience, experience comes from bad judgment. • Mark Twain

6. U/S Regional Anesthesia Benefits • Accurate, quick completion of blocks • Quality blocks • Less reliance on external anatomy • Overcome challenges of obese patients • Overcome anatomical variability • Improved patient safety • Faster room turnover • Less trauma to patients • Develop more diverse skill set employability

7. U/S Regional Anesthesia Benefits • Alternative to GA • Physical attributes • Obesity • Airway • Pre-existing disease • Cardiac • Respiratory • Acute pain management • 20 hours of post-op pain relief • Single injection block • 72 – 96 hours of post-op pain relief • Continuous nerve catheter

8. Ultrasound in Anesthesia Practice • Changes in practice • Reliance on surface anatomy • Overcomes anatomical challenges • Appreciation for individual variations in anatomy • Direct visualization of nerves and vessels • Elimination of “hunt and peck” technique • Avoidance of dangerous areas • Appreciation of facial planes

9. Brachial Plexus • Supplies motor function to upper extremity • Supplies almost all sensory function to upper extremity • Caudad branches of the cervical plexus • Supplies posterior shoulder

10. Brachial Plexus • Upper extremity nerves • Nerve roots in close proximity to each other • Identifiable bony and vascular landmarks • Approachable at several levels • Multiple techniques

11. suprascapular C5 lateralsuperior C6 Muscut Axillary posterior C7 middle median C8 medial T1 radialinferior ulnar Branches Cords Divisions Trunks Roots a

13. Brachial Plexus Approaches • *Interscalene • Intersternocleidomastoid • *Supraclavicular • Infraclavicular • *Axillary • *MusculocutaneousNerve • Terminal nerves

14. Interscalene Approach

15. Interscalene Indications • Shoulder and clavicle procedures • Procedures proximal to the elbow • Inferior fibers frequently not anesthetized • T1 root • Ulnar nerve distribution

16. InterscaleneContraindications • Absolute • Contralateral recurrent laryngeal nerve palsy • Phrenic nerve palsy • Relative • Pre-existing nerve injury • Brachial plexus pathology

17. Distribution of IS Block Areas not shaded are not consistently anesthetized after IS block

18. Interscalene Anatomy 1. Carotid artery 2. SCM muscle 3. Phrenic nerve 4. External jugular vein 5. Anterior scalene muscle 6. Upper trunk of brachial plexus 12. Middle scalene muscle

19. suprascapular C5 lateralsuperior C6 Muscut Axillary posterior C7 middle median C8 medial T1 radialinferior ulnar Branches Cords Divisions Trunks Roots a

20. suprascapular C5 lateralsuperior C6 Muscut Axillary posterior C7 middle median C8 medial T1 radialinferior ulnar Branches Cords Divisions Trunks Roots a

21. Interscalene U/S Nerve Block • Patient position • Supine with head rotated toward the non-operative side • Lateral with block side up • Transducer location • At level of or below the cricoid cartilage • In-Plane approach • Needle size • 50 mm • LA volume • 20 ml

22. Interscalene Positioning Supine Lateral

23. Interscalene Anatomy Trans Middle Scalene Approach

24. Interscalene Ultrasound“Anchoring Landmark” • Subclavian artery and 1st rib • Anatomic structure • Fixed and reliable location • Consistent relationship

25. Probe Placement & Probe Orientation Subclavian View Interscalene Anatomy

26. Sliding or Moving Up the Plexus*

30. Needle: In-planeNerve: Short axis

31. Brachial Plexus and Needle*

32. Supraclavicular Approach

33. Supraclavicular Approach Indications Anesthesia to the entire upper extremity distal to the shoulder

34. Supraclavicular Approach Contraindications • Absolute • Contralateral recurrent laryngeal nerve palsy • Phrenic nerve palsy • Relative • Pre-existing nerve injury • Brachial plexus pathology

35. Supraclavicular Approach Positioning Supine Lateral

36. Supraclavicular U/S Nerve Block • Patient position • Supine with head rotated toward the non-operative side • Lateral with block side up • Transducer location • Coronal oblique position just anterior to the clavicle • In-Plane approach • Needle size • 50 mm • LA volume • 20 ml

37. Supraclavicular Anatomy External landmarks

40. Potential Points of Danger • Carotid Artery • Costocervical Trunk • Thyrocervical Trunk • Vertebral Artery • Dorsal and Suprascapluar Arteries • Transverse Cervical Artery • Subclavian Artery • Internal / External Jugular Veins • Intra-neural injections

41. Interscalene/ SupraclavicularSide Effects • Ipsilateral diaphragm paralysis • Nearly 100% incidence • Horner’s syndrome • LA spillage onto sympathetic chain • Ptosis • Miosis • Enophthalmus • Anhidrosis

42. Interscalene / Supraclavicular Complications • CNS toxicity • Pneumothorax • Recurrent laryngeal nerve block • Failed block • Intrathecal injection • Epidural injection • Intravascular injection • Vertebral artery • Carotid artery • Subclavian artery • Internal Jugular

43. Axillary Approach

44. Axillary Approach Indications • Procedures below the elbow • Safest and easiest approach • Patient must abduct arm

45. Axillary Contraindications • Absolute • Lymphangitis • Relative • Pre-existing nerve injury • Brachial plexus pathology

47. suprascapular C5 lateralsuperior C6 Muscut Axillary posterior C7 middle median C8 medial T1 radialinferior ulnar Branches Cords Divisions Trunks Roots a

48. Axillary Distribution of Anesthesia

49. Axillary Anatomy

50. Axillary Anatomy