Femoral Artery

- The saphenous nerve block is useful for
medial knee surgery, medial leg surgery,
and medial ankle and foot surgery.
The saphenous nerve is a continuation
of the femoral nerve below the knee.
This is a good block to do in conjunction
with a popliteal sciatic nerve block to give you
complete anesthesia below the knee.
To perform the saphenous nerve block,
we typically use a linear probe.
The linear probe allows us to get
good resolution and reasonable penetration.
Typical settings for the saphenous nerve block
start between four and six centimeters total depth,
expecting the nerve to be between two and four centimeters.
Now the saphenous nerve is a small nerve,
and we may not see it in everybody.
In fact, most people we don't see it in.
The reason we do a saphenous nerve block
is that we don't take away any quadriceps muscles,
and so the patient will have no quadriceps muscle weakness.
To get a saphenous nerve, you may also do a femoral block,
but by doing a femoral block, you may
or you will take out all your quadriceps.
So this technique I'm going over is a great technique
for outpatient surgery, because their
quadriceps muscle strength will be intact.
This technique I'm using is useful in elderly
and obese patients because we're using muscle landmarks
rather than nerve or other small landmarks.
So we usually start about 10 centimeters above the knee.
Put the probe on the medial side of the leg.
We can abduct the leg a little bit
to give us better visualization here.
Now when we put the probe on here,
we like to start more anterior.
This gives us a view of the femur,
the hyperechoic stripe here, as well as the vastus medialis.
The vastus medialis can pretty much be found in everybody.
We're going to slide the probe posterior next.
The next muscle we'll come across is the sartorius muscle.
Now we see the vastus medialis muscle ending
and see the sartorius muscle in view now.
There are many anatomical differences in patient to patient.
The saphenous nerve can run anterior
to the sartorius muscle, posterior to the
sartorius muscle, and I've even seen it
piercing the sartorius muscle.
So the whole key is, is that we will put
our local anesthetic below the sartorius muscle
in order to get a good saphenous nerve block.
Most of the time we're doing a field type block
where we deposit the local behind the sartorius muscle,
and expect that that local will get to the nerve,
because these nerves can be difficult
to see in obese or elderly patients.
So now, our needle approach is
gonna be using a 10 centimeter needle.
This needle will be inserted a few centimeters
away from the probe in this angle.
We like to see the needle in a shallow plane
and then advance it deeper below the sartorius muscle.
This block can also be performed if the patient is prone,
imagine my needle coming from the other side.
Typical volumes used here are between
five and 20 milliliters of local anesthetic; if a good
nerve is seen, usually represented by a hyperechoic
structure, then I'll just place five milliliters.
Most patients, we do not see the individual
nerve here, and we will place 10 milliliters
as a type of field block in this area.
Here, our needle is advancing through the vastus medialis.
We try to position the tip of the needle
underneath the sartorius muscle,
which is located to the right of the screen.
You can see the hyperechoic areas,
some of which may represent the nerve.
Our needle is now directly below the sartorius muscle,
and you can see the local anesthetic
spreading below the sartorius muscle
to track to the saphenous nerve.

Brightcove ID

5508114742001

https://youtube.com/watch?v=E1tmS9Lv1bU

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block.

3D How To: Femoral Artery Catheter Insertion

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

/sites/default/files/CentralVenous_FemoralArtery_edu00502_thumbnail.jpg

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

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A linear array transducer
with a vascular exam type,
is used to perform an ultrasound guided insertion
of a femoral artery catheter via a transverse approach.
The patient is in a supine position,
with the operator at the right side.
The transducer is placed transversely,
just inferior to the inguinal crease,
with the orientation marker direction
to the patient's right at a 9 o'clock position.
The superficial femoral artery
is seen as a dark, anechoic, pulsatile, circular structure
in the mid-portion of the ultrasound image.
Deeper, and slightly to the right of the image,
the femoral vein will appear
as a dark, anechoic, elliptical shape
that is compressible with transducer pressure.
Adjust the transducer so it is centered
over the femoral artery, lateral to the vein.
Follow the needle entry by slowing sliding the transducer
in the direction of needle advancement.
The needle will appear as a small, bright 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 femoral artery.
The transducer should be moved slightly
proximally and distally to confirm that the needle tip
lies in the mid-portion of the artery.

Brightcove ID

5508128530001

https://youtube.com/watch?v=n7knHl9pSas

3D How To: Femoral Nerve Block

Read more about 3D How To: Femoral Nerve Block

/sites/default/files/Femoral_edu00499_thumbnail.jpg

3D animation demonstrating an ultrasound guided femoral nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

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: Femoral Vein Catheter Insertion

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

/sites/default/files/CentralVenous_FemoralVein_edu00503_thumbnail.jpg

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

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A linear array transducer
with a venous exam type is used to perform
an ultrasound guided insertion of a femoral vein catheter
via a transverse approach.
The patient is in a supine position
with the operator at the right side.
The transducer is placed transversely,
just inferior to the inguinal crease
with the orientation marker directed to the patient's right
at a 9 o'clock position.
The superficial femoral artery is seen as a dark
anechoic pulsatile circular structure
in the mid portion of the ultrasound image.
Deeper and slightly to the right of the image,
the femoral vein will appear as a
dark anechoic elliptical shape
that is compressible with transducer pressure.
Adjust the transducer so it is centered
over the femoral vein medial to the artery.
Follow the needle entry by slowly sliding the transducer
in the direction of needle advancement.
The needle will appear as a small bright dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory.
The needle is slowly advanced under
direct ultrasound visualization
until the tip is seen to indent
and then puncture the femoral vein.
The transducer should be moved slightly proximally
and distally to confirm that the needle tip
lies in the mid portion of the femoral vein.

Brightcove ID

5508120181001

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

3D How To: Saphenous Nerve Block

Read more about 3D How To: Saphenous Nerve Block

/sites/default/files/Saphenous_edu00504_thumbnail.jpg

3D animation demonstrating an ultrasound guided saphenous nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Media Library Tag

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided saphenous nerve block.
The target depth is approximately
one to three centimeters in an 80 kilogram adult.
The patient is positioned in a supine position
with the leg slightly abducted and externally rotated.
The transducer is placed in the middle of the thigh
in a transverse plane, with the orientation marker
directed to the patient's right.
The leg is scanned medially to laterally
to identify the superficial femoral artery,
which lies underneath the sartorius muscle.
The saphenous nerve can lie either
anterior or posterior to the artery.
The saphenous nerve may not be visible.
If it is, it will appear as a bright,
hyperechoic oval or triangular structure.
The needle is positioned one to two centimeters lateral
to the transducer, and advanced under the transducer.
Local anesthetic is injected incrementally,
superficial and deep to the artery
to complete the saphenous nerve block.

Brightcove ID

5508114714001

https://youtube.com/watch?v=54VG2GhJ3w4

Body

3D animation demonstrating an ultrasound guided saphenous nerve block.

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