Anesthesiology (Regional)

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- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided, interscalene nerve block.
The target depth is approximately one to three centimeters
in an 80-kilogram adult.
The patient is positioned in a 45-degree reclining position
with a pillow under their head
and the head turned toward the contralateral side.
The examination begins by finding
the supraclavicular region of the brachial plexus
as a landmark technique.
The transducer is placed posterior
to the midpoint of the clavicle
with the orientation marker
directed to the patient's right at a three-o'clock position.
The subclavian artery is seen
as a round, pulsatile structure
superior to the bright reflection of the first rib.
The pleura is seen as a bright, hyperechoic reflection
deep to or at the same depth as the first rib.
The nerves of the brachial plexus are posterior or superior
to the subclavian artery.
The nerves appear as hypoechoic dark circles
within the bright hyperechoic fascia
surrounding the brachial plexus.
To identify the interscalene region of the brachial plexus,
slowly slide the transducer up the neck.
The interscalene muscles will frame the nerves
within the interscalene groove.
The nerves will change in shape
from a grape-like cluster in the supraclavicular region
to a chain-link appearance in the interscalene groove.
The C5 and C6 nerve roots appear as three circles.
The hypoechoic pulsatile carotid artery
will appear medial to the anterior scalene muscle.
The needle can be advanced
using an in-plane or out-of-plane technique.
For an in-plane technique,
the needle is positioned one to two centimeters
lateral to the transducer and advanced under the transducer
until the tip is just posterior to or between
the C5 and C6 nerve roots.
The local anesthetic is injected incrementally
close to the nerve roots.
The needle can be redirected
if the spread of local anesthetic is not deemed adequate.
It is not necessary to have local anesthetic
anterior and posterior to the nerve roots.
Posterior spread only of local anesthetic is effective.

Brightcove ID

5508123555001

https://youtube.com/watch?v=wAABZF1aSO8

3D How To: Infraclavicular Nerve Block

Read more about 3D How To: Infraclavicular Nerve Block

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3D animation demonstrating an ultrasound guided infraclavicular nerve block.

Clinical Specialties

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Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided, infraclavicular regional nerve block.
The target depth is approximately three to four centmeters
in an 80 kilogram adult.
The patient is positioned supine
with the arm abducted 90 degrees
and the elbow bent 90 degrees
to move the clavicle posterior,
and permit a shallow angle of needle insertion.
The patient's head should be rotated
toward the contralateral side.
The transducer is placed on the chest in a paramedian plane,
inferior to the midpoint of the clavicle
with the orientation marker directed to the patient's head.
The axillary artery is seen as
a dark, round pulsatile structure with a hyperechoic wall
inferior to the pectoralis major and minor muscles.
The axillary vein lies beside the axillary artery
and collapses with compression.
The nerve cords appear as hyperechoic circles
with a honeycomb appearance
within the bright hyperechoic fascia of the brachial plexus.
The transducer is slowly moved in a lateral direction,
following the course of the axillary artery.
The nerves will split into a lateral,
medial, and posterior cord.
The optimum position of the transducer
for the infraclavicular nerve block
is as lateral as possible.
The needle is positioned two centimeters cephalad
to the transducer and advanced using an in-plane technique.
The needle path is directed over the clavicle
and through the pectoral muscles.
The initial endpoint for the needle is
immediately posterior to the midpoint of the artery.
The spread of local anesthetic should be observed.
Supplemental injections can be made anterior to the artery
to deposit local anesthetic
around the lateral and medial cords if required.

Brightcove ID

5745561363001

https://youtube.com/watch?v=8xRDVLKb5BY

3D How To: Ultrasound Guided TAP Block

Read more about 3D How To: Ultrasound Guided TAP Block

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3D animation demonstrating an ultrasound guided Ilioinguinal and Iliohypogastric nerve blocks.

Clinical Specialties

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Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound guided ilioinguinal
and iliohypogastric nerve block.
The target depth is approximately three centimeters
in an 80 kilogram adult.
The patient is positioned in a supine position.
The transducer is placed over the bony prominence
of the anterior superior iliac spine
with the orientation marker directed to the patient's right.
The transducer is rotated slightly counterclockwise
so one side rests on the anterior superior iliac spine
and the other side points at the umbilicus.
The medial side of the transducer is slowly swept superiorly
and inferiorly while maintaining the bony iliac crest
in the lateral part of the ultrasound image.
The structures of the anterior abdominal wall
should be identified from superficial to deep,
including adipose tissue, external oblique muscle,
internal oblique muscle,
and the transversus abdominis muscle.
A fourth muscle, the iliacus, may occasionally
be visualized underneath the transversus abdominis.
The nerves are located between the internal oblique
and the transversus abdominis muscle layers.
They may appear only as hyperechoic thickness
between these two muscles or as dark hypoechoic
oval structures with the bright hyperechoic covering.
The nerves are very closely related to the iliac crest.
The needle is advanced using an in-plane
or out-of-plane technique.
If using an in-plane technique,
the needle is positioned one to two centimeters
medial to the transducer and advanced under the transducer.
The end point for the needle is
between internal oblique and transversus abdominis.
The local anesthetic is injected incrementally
close to the nerves.

Brightcove ID

5508136009001

https://youtube.com/watch?v=uurxBFRT_EE

3D How To: Gluteal Sciatic Nerve Block

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3D animation demonstrating an ultrasound guided Gluteal Sciatic nerve block.

Clinical Specialties

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Subtitles

- [Voiceover] A curved array transducer
with a nerve exam type is used to perform
a ultrasound guided sciatic nerve block.
The target depth is approximately four to six centimeters
in an 80 kilogram adult.
The patient is positioned in a lateral decubitus position
with the hip and knee flexed.
The transducer is placed between the greater trochanter
and the ischial tuberosity in a transverse position
just proximal to the gluteal fold
with the orientation marker directed laterally.
The bony landmarks will appear
as bright hyperechoic crescents with posterior shadowing.
There are several layers of tissue
between the bony landmarks, which should be identified
from superficial to deep, including adipose tissue,
the gluteus maximus muscle and quadratus femoris muscle.
The sciatic nerve lies deep to the gluteus maximus
and superficial to the quadratus femoris muscle.
It appears as a bright hyperechoic oval
or triangular shaped density.
The transducer should be moved slightly cranially
or caudally from the initial position
by slightly rocking the transducer
so the beam is perpendicular to the nerve
for the best echo reflection if it is difficult to identify.
When the transducer is moved distally in the thigh,
the sciatic nerve becomes more oval in shape
and is found more superficially between the biceps femoris
and abductor magnus muscles.
The needle is advanced using an in plane technique.
The needle is positioned one to two centimeters lateral
to the transducer and advanced slowly under the transducer.
The initial end point for the needle
is just lateral and deep to the nerve.
The local anesthetic is injected incrementally
close to the nerve.
For a successful block, a spread of locals
should be observed around the medial side
or tibial component of the nerve.

Brightcove ID

5508134308001

https://youtube.com/watch?v=xvAY_bu_S7A

3D How To: Femoral Nerve Block

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3D animation demonstrating an ultrasound guided femoral nerve block.

Clinical Specialties

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Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided femoral nerve block.
The target depth is approximately one to three centimeters
in an 80 kilogram adult.
The patient is placed in a supine position.
The transducer is placed just superior
to the inguinal skin crease
with the orientation marker directed to the patient's right.
The common femoral artery is seen
as a round, pulsatile structure.
The transducer should be moved laterally
one to two centimeters to identify the femoral nerve.
The nerve lies deep to the fascia iliaca
and appears as an oblong, bright hyperechoic structure
lying on the iliacus muscle.
It may contain dark hyperechoic circles
that represent the nerve fascicles.
The nerve always lies deep to the fascia iliaca
and should not be confused
with the bright hyperechoic tissue lying above the fascia,
which is lymphatic tissue.
The needle is advanced using an in-plane technique.
The needle is positioned one to two centimeters lateral
to the transducer and advanced under the transducer.
The initial end point for the needle
is just lateral to the nerve and deep to the fascia iliaca.
The local anesthetic is injected incrementally,
close to the nerve.
For a successful block, a spread of local
should be observed behind the femoral artery.
If local anesthetic is identified anterior to the artery,
then the needle is superficial to the fascia iliaca
and the needle needs to be repositioned deeper.

Brightcove ID

5508117977001

https://youtube.com/watch?v=pCkjioc-EmQ

3D How To: Subclavian Vein Catheter Insertion

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3D animation demonstrating an ultrasound guided insertion of a Subclavian Vein Catheter.

Applications

Clinical Specialties

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Subtitles

- [Voiceover] A linear array transducer
with a venous exam type, is used to perform
an ultrasound guided insertion of a subclavian
vein catheter via an transverse approach.
The patient is in a supine position
with the head neutral.
The operator should stand to the patient's right side.
The transducer is placed transversely
just inferior to the mid portion of the clavicle,
with the orientation marker directed
to the patient's head at a 12 o'clock position.
The hyperechoic clavicle can be seen
in the superior portion of the ultrasound image.
The vein is dark, and anechoic,
just inferior and deep to the clavicle.
The transducer should be slowly moved one to two inches
toward the shoulder, with the face of the transducer
staying below the clavicle to obtain the best view
of the subclavian or axillary vein.
It is important to note that the lung lies directly
posterior to the vessel.
So, posterior wall puncture of the axillary vein
should be avoided.
Adjust the transducer so it is centered over the vein.
Follow the needle entry by slowly sliding the transducer
in the direction of needle advancement.
The needle will appear as a small, bright, hyperechoic dot.
When the needle tip appears, the transducer
should be advanced a short distance distally
to follow the tip of the needle trajectory,
and stay in advance of the needle entry.
The needle is slowly advanced
under direct ultrasound visualization
until the tip is seen to puncture the subclavian vein.
The probe should be moved slightly proximally and distally
to confirm that the needle tip lies
in the mid portion of the vein.

Brightcove ID

5508120188001

https://youtube.com/watch?v=IBmbc1ak5fY

3D How To: IJV Catheter Insertion (Transverse)

Read more about 3D How To: IJV Catheter Insertion (Transverse)

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3D animation demonstrating an ultrasound guided insertion of an internal jugular catheter (transverse).

Applications

Clinical Specialties

Media Library Type

Subtitles

- [Voiceover] A linear array transducer
with a venous exam type
is used to perform an ultrasound-guided insertion
of an internal jugular catheter via a transverse approach.
The patient is in a supine position
with the head slightly turned
toward the contralateral side.
The operator is positioned at the head of the bed.
The transducer is placed transversely
just below the apex
of the sternocleidomastoid muscle triangle,
with the orientation marker directed to the patient's left
at a 9:00 position.
The most superficial structure
identified in the ultrasound image
is the sternocleidomastoid muscle.
Deeper to this, the internal jugular vein
will appear as a dark anechoic elliptical shape,
and is compressible with transducer pressure.
The artery will be circular and pulsatile.
The thyroid gland lies medial to these structures,
and has a light gray echo signature.
Adjust the transducer so it is centered
over the internal jugular vein.
Follow the needle entry by slowly sliding the transducer
in the direction of needle advancement.
The needle will appear as a small bright hyperechoic dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory,
and stay in advance of the needle entry.
The needle is slowly advanced
under direct ultrasound visualization
until the tip is seen to indent,
and then puncture the internal jugular vein.
The transducer should be moved
slightly proximally and distally
to confirm that the needle tip lies
in the mid-portion of the jugular vein.

Brightcove ID

5742626540001

https://youtube.com/watch?v=eesN9rGoXFM

3D How To: IJV Catheter Insertion (Long)

Read more about 3D How To: IJV Catheter Insertion (Long)

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3D animation demonstrating an ultrasound guided insertion of an Internal Jugular Catheter (Longitudinal).

Applications

Clinical Specialties

Media Library Type

Subtitles

Brightcove ID

5508120188001

https://youtube.com/watch?v=IBmbc1ak5fY

3D How To: Femoral Vein Catheter Insertion

Read more about 3D How To: Femoral Vein Catheter Insertion

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3D animation demonstrating an ultrasound guided insertion of a Femoral Vein Catheter.

Applications

Clinical Specialties

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