surface anatomy and sonoanatomy for the occasional...
TRANSCRIPT
Surface Anatomy and Sonoanatomy for the Occasional
Regional Anesthesiologist
@EMARIANOMD
Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of MedicineChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System
Surface Anatomy and Sonoanatomy
Financial Disclosures
Halyard Health, B Braun – Unrestricted educational program funding paid to my institution
The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.
Surface Anatomy and Sonoanatomy
Learning Objectives
Define optimal ultrasound transducer position for cross-sectional imaging of nerves
Apply surface anatomic landmark identification in ultrasound transducer application
Identify sonoanatomy of common peripheral nerves and surrounding structures
Discuss tips and tricks to improve ultrasound images and block techniques
Surface Anatomy and Sonoanatomy
How Hard Can It Be?
NYSORA.COM -
Surface Anatomy and Sonoanatomy
Lesson #1
Surface Anatomy and Sonoanatomy
Lesson #2
Regional anesthesia is applied anatomy
Surface Anatomy and Sonoanatomy
History of Nerve Localization
Anatomic landmarks Fascial clicks or pops Electrical nerve
stimulation Sustained “twitch” at
< 0.5 mA current suggests appropriate needle position
Ultrasound
Surface Anatomy and Sonoanatomy
Overview
Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks
Surface Anatomy and Sonoanatomy
Overview
Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks
Surface Anatomy and Sonoanatomy
Basic Sonoanatomy
Blood vessels: hypo-echoic (dark)
Muscles: hypo- > hyper-echoic (striations)
Bone and fascia: hyper-echoic (white)
Nerves: hypo-echoic
Connective tissues are hyper-echoic (epineurium, perineurium)
Surface Anatomy and Sonoanatomy
A Closer Look at the Nerve
Short-Ax is View
Surface Anatomy and Sonoanatomy
The “A.R.T.” of Target Imaging
A lignment
R otation
T ilt
Surface Anatomy and Sonoanatomy
Alignment: Where Do We Look?
Surface Anatomy and Sonoanatomy
Optimal Rotation
Surface Anatomy and Sonoanatomy
Optimal Rotation
Surface Anatomy and Sonoanatomy
Optimal Tilt
Surface Anatomy and Sonoanatomy
Optimal Tilt
Surface Anatomy and Sonoanatomy
Overview
Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks
Surface Anatomy and Sonoanatomy
Interscalene Block: How We Did It
Needle inserted in IS groove at C6
Antero-lateral approach
Needle angle 30-45º Elicit motor response
(deltoid, biceps, triceps, pectoralis)
Borgeat A, et al. Anesth 2003:99:436
Surface Anatomy and Sonoanatomy
Interscalene Anatomy
Position: supine with head turned away
SCM clavicular head Interscalene groove
posterior to SCM at cricoid level (C6)
External jugular vein Subclavian artery
Subclavian Art
Cricoid
Surface Anatomy and Sonoanatomy
Interscalene Sonoanatomy
Transverse Short-Axis View
SCM
ASMMSM
CTP
BP
Mariano ER, et al. JUM 2010;29:329
Surface Anatomy and Sonoanatomy
Infraclavicular Block: How We Did It
Insertion 2 cm medial and 2 cm caudad to CP
Needle inserted plumb-bob
Avg depth 4.24±1.49 cm in men, 4.01±1.29 cm in womenWilson JL, et al. A&A 1998;87:870
Surface Anatomy and Sonoanatomy
Infraclavicular Anatomy
Position: supine with arm at side or abducted 90°
Palpate coracoid process below the clavicle
Plexus runs under coracoid process
Coracoid
Surface Anatomy and Sonoanatomy
Infraclavicular Sonoanatomy
Transverse Short-Axis View
PMa
PMi
AA AVNN
N
Mariano ER, et al. JUM 2009;28:1211
Surface Anatomy and Sonoanatomy
Femoral Nerve Block: How We Did It
Needle insertion: lateral to artery at 45° angle aiming cephalad
Feel 2 “pops” Proper motor
response = quad contraction
Ilfeld, BM, et al. Anesth 2008;108:703
Surface Anatomy and Sonoanatomy
Femoral Anatomy
Position: supine with roll under hip
Leg straight Inguinal crease Femoral artery Femoral nerve is
lateral to femoral artery
Surface Anatomy and Sonoanatomy
Femoral Sonoanatomy
Transverse Short-Axis View
FA
FL
FIIliacus
N
Mariano ER, et al. JUM 2009;28:1453
Surface Anatomy and Sonoanatomy
Adductor Canal Anatomy
Position: supine with thigh externally rotated and knee slightly flexed
Subsartorial tunnel begins distal to the apex of the femoral triangle
Saphenous nerve runs with superficial femoral artery
Horn JL, et al. RAPM 2009;34:486Manickam B, et al. RAPM 2009;34:578
Surface Anatomy and Sonoanatomy
Adductor Canal Ultrasound
Transducer placed along medial aspect of thigh distal to inguinal crease
Short-axis view Landmarks
Sartorius (S) muscle Saphenous (N) Femoral artery (A)
Mariano ER, et al. JUM 2014;33:1653
Sartorius
N A
Surface Anatomy and Sonoanatomy
Popliteal Fossa Block: How We Did It
Insertion site: 8-10 cm cephalad to popliteal crease or at intertendinous junction
4” needle angled 45° cephalad
Plantar flexion or inversion preferred
Hadzic A, et al. A&A 2002;94:1321
Surface Anatomy and Sonoanatomy
Popliteal Anatomy
Position: prone with knee slightly flexed
Popliteal crease Biceps femoris
laterally Semimembranosus
and semitendinosus medially
Intertendinous “junction”
Surface Anatomy and Sonoanatomy
Popliteal SonoanatomyTransverse Short-Axis View
F
BFN
Mariano ER, et al. RAPM 2009;34:480
Surface Anatomy and Sonoanatomy
Transversus Abdominis Plane Anatomy
Surface Anatomy and Sonoanatomy
TAP Sonoanatomy
Transverse Short-Axis View
EO
IO
TA
Surface Anatomy and Sonoanatomy
Summary
We defined optimal ultrasound transducer position for cross-sectional imaging of nerves
We applied surface anatomic landmark identification in ultrasound transducer application
We identified sonoanatomy of common peripheral nerves and surrounding structures
We discussed tips and tricks to improve ultrasound images and block techniques