Hyperechoic

M-Turbo: Popliteal Nerve Block with Needle

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M-Turbo: Popliteal nerve block with Needle.

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Anesthesiology (Regional)

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M-Turbo: Popliteal nerve block with Needle.

How To Perform A Popliteal Nerve Block

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A popliteal sciatic nerve block done with the Sonosite SII ultrasound machine is a clinically valuable technique that results in anesthesia of the calf, tibia, fibula, ankle, and foot. Anesthesiologist Dr. David Auyong MD of Seattle, Washington here reviews scanning techniques and sonographic landmarks for the procedure, discussing important structures, techniques to visualize the popliteal vein, types of probe used, and needle/injection choices. The Sonosite II allows precise placement of local anesthetic, much reducing patient discomfort, providing superior visualization of the nerve and the needle during block placement.

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- The Popliteal Sciatic Nerve Block
is a good block to do for the sciatic nerve
because this is where the sciatic nerve
is found most shallow.
This block can be performed for post year knee pain
after knee surgery, as well as, calf, foot
and ankle surgery.
This is the main nerve that supplies the lower leg.
I find a lateral position gives you good control
of the patients airways if you sedate them
as well as good ergo-dynamics to do the block.
Here we have our patient positioned laterally
with a pillow between the legs for comfort.
To do the Popliteal Sciatic Nerve Block
we use a linear probe.
The linear probe allows us to see structures well
in the shallow plane,
but gives us a wide field of view
to see our needle approaching the nerve.
To perform the Politeal Sciatic Nerve Block
we put the probe directly in the back of the knee.
Placement of the probe in the back of the knee
reveals a structure of the nerve, the vein, the artery.
I call this structure, the snowman in the back of the knee.
You have three circles on top of each other.
The upper most circle represented by the tibial
component of the sciatic nerve.
The middle structure represented by the vein
and the deep structure represented by the popliteal artery.
If we put color Doppler on the screen
we are able to see the pulsating artery
in this area.
Sometimes it's difficult to see the popliteal vein
because this is a low-flow state,
such as we see here.
To visualize the popliteal vein better
we can squeeze the back of the calf,
increasing venous flow through the popliteal vein,
such as this.
There we can see increased venous flow
through the popliteal vein represented better
by color Doppler.
Now, as I mentioned, this is only the tibial component
of the sciatic nerve.
We wanna get the nerve where it comes together
and has both components, the peroneal
and the tibial component.
As we scan up the leg, here we now see
the peroneal component laterally,
the tibial component medially,
the popliteal vein and popliteal artery.
On the medial side we see the semitendinosus
and semimembranosus muscles.
On the lateral side we see
the biceps femoris, long and short heads.
As we keep going up the leg
the tibial and peroneal components join into one nerve.
Sometimes we block the nerve at this level
where the two components are joining.
This allows us to get both components
with a single injection at the nerve.
My needle approach for these blocks
are gonna be from lateral to medial.
What I typically do is measure the depth
of the sciatic nerve in this setting.
Here the sciatic nerve is approximately
one-and-a-half to two centimeters deep to the probe.
So if I measure one-and-a-half to two centimeters deep,
my needle is gonna come in completely perpendicular
and have a very bright view of the needle
and needle shaft as it advances to the nerve.
Now, I typically like to inject deep to the nerve
as well as superficial to the nerve
in order to get complete surrounding
of the popliteal sciatic nerve
for the most rapid onset for this block.
Typical volumes used are 20 to 30 milliliters
of local anesthetic.
This block takes some time to onset
and studies have shown even with complete surrounding
of the nerve, it takes up to 30 minutes
for the nerve block to onset in most patients.
Here we see the popliteal sciatic nerve
surrounded by the biceps femoris laterally
and the semitendinosis/semimembranosis medially.
Our needle is advanced directly above the nerve
and the local anesthetic is injected,
pushing the nerve deeper.
We then withdraw the needle
and readvance the needle again close to the nerve
so we can get local anesthetic spreading
to the medial side of the nerve,
which is more of the tibial component.
Now you can visualize both the peroneal and tibial component
with a local anesthetic completely surrounding the nerves.

Brightcove ID

5508136021001

https://youtube.com/watch?v=X0wqmWXEcTg

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How To Perform A Saphenous Nerve Block

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

Clinical Specialties

Anesthesiology (Regional)

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Subtitles

- 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

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

How to: Subgluteal Sciatic Nerve Block

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

Clinical Specialties

Anesthesiology (Regional)

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How To Videos

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- The Sciatic Nerve Block can be used for surgery of the
leg, knee, foot and ankle.
To do the Sciatic Nerve Block,
you can block it at the Popliteal region
or you can block it higher.
Some benefits of blocking it higher
are to be above the tourniquet,
so you don't have to worry so much about nerve ischemia.
You may also get the Posterior Femoral Cutaneous nerve
of the thigh, which comes off very high on the Sciatic nerve
and it's also medial to the Sciatic nerve, as well high up.
This way, you can cover any kind of pain of incision
in the upper thigh area.
To position patients for Subgluteal Sciatic Nerve Block,
we position the patient lateral.
This way, the patient is comfortable,
they can be well-sedated and you can place a probe
on the posterior side of the leg and advance the needle
from lateral to medial.
The probe we use for a Sciatic Nerve Block
is a curvilinear low-frequency probe.
The reason we use this probe is because
it penetrates deeper and this is useful in larger patients.
So some of the landmarks we use
for the Subgluteal Sciatic Nerve Block
are the Greater Trochanter laterally,
the Ischial Tuberosity medially, and
directly in between these two is where we place the probe
The initial view we see is the Greater Trochanter
on the left side of the screen.
On the right side of the screen,
we see the Ischial Tuberosity.
There is a large muscle, the Gluteus Maximus
at the superficial level of the screen.
Underneath the Gluteus Maximus is a hyperechoic nerve,
the Sciatic Nerve.
Between the two bony landmarks is the Quadratus Femoris.
So on this level, the nerve is sandwiched between
the Gluteus Maximus and the Quadratus Femoris.
The nerve here can appear wide, flat or triangular.
It is not a circular structure like some people imagine.
Needle approaches for the Sciatic Nerve Block,
whether is be here, at the Mid-Femoral region,
or higher up at the Subgluteal region,
are performed from a lateral-to-medial approach.
The lateral-to-medial approach usually starts
three to four centimeters away from the probe in this angle.
Now, higher up we'll use the same needle approach.
We can see the triangular Sciatic Nerve here,
and we'll start the needle angle about here.
Now you typically put my nerve
on the distal side of the screen from where my needle
is entering, in order to see the needle better
and travelling across the screen to the nerve.
Typical volumes are 20 to 30 milliliters
of local anesthetic.
Because this nerve is so deep in some people,
some anesthesiologists like to approach this nerve
from an Out-of-Plane needle angle.
And Out-of-Plane needle angle would be in this direction
into the Sciatic Nerve.
Other people like to turn this probe in a longitudinal
direction and see the nerve in long axis.
So here we are turning the probe in the long axis
and following that nerve in the longitudinal pattern here.
So now we see the Sciatic Nerve going down the leg.
The needle approach in this orientation would be in
this angle in plane of the ultrasound beam
down to the Sciatic nerve.
- (Dr. Auyong) Here you can see the Greater Trochanter
on the left side of the screen, the Ischial Tuberosity
on the right side of the screen, the Gluteus Maximus
superficial and a 21 gauge needle
advancing to the Sciatic Nerve.
The Sciatic Nerve is below the Gluteus Maximus
and above the Quadratus Femoris.
Our needle is advancing above the Sciatic Nerve
to attempt to get local anesthetic to spread
to the medial side of the nerve.
Which would be more likely to get the larger
Tibial component, as well as the posterior femoral
cutaneous nerve of the thigh.
Now you can see the nerve, which very hyperechoic,
below the local anesthetic.

Brightcove ID

5508120191001

https://youtube.com/watch?v=IL4qqETpb0k

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

How To Perform A TAP Block With Ultrasound

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

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- The ilioinguinal and iliohypogastric nerve block,
is used for inguinal hernia repair,
and lower abdominal surgery.
This block is a field block,
where we put the local anesthestic within the plane,
between the transversis abdominis,
and the internal oblique muscle.
In order to find these landmarks,
we should position the patient properly,
we have the patient completely supine,
expose the iliac crest here
and the costal margin superiorly.
We use a linear probe for these blocks,
with a frequency of five to 10,
and have the frequency set
in the general or penetration mode.
Our initial probe placement is gonna be
just above the iliac crest.
I usually place the probe in this direction,
so we can see both the iliac crest caudally there,
and if I move slightly cranially,
you can see the three muscles of the abdominal wall.
Going from superior to inferior,
the first layer is Adipose Tissue,
the second layer is External Oblique,
the third layer is the Internal Oblique.
Now in some large patients, it's difficult to tell layers,
because their Adipose Tissue is quite significant.
So, a good clue is that, the Internal Oblique muscle layer
is going to be the thickest muscle layer.
Just as we see here.
The thin layer and the fourth layer down,
is a Transversus Abdominus muscle.
Below that is Bowel.
So that's very imporant to note,
that we are getting very close to Bowel,
and good needle visualization
is important for doing this block.
To actually do the block, I do turn my probe 90 degrees,
keeping those those planes on the picture.
And I still see the External Oblique, Internal Oblique,
and Transversus Abdominus deep.
My needle approach, is gonna be from anterior to posterior,
in this angle.
It's important to start several centimeters away
from the probe for this block, in order to see
the needle well.
If you start too close to the probe, such as here,
you'll have a sharper needle angle,
and you will not visualize your needle as well.
Flat needle angles, far away from the probe,
will allow you to visualize your needle.
Now I like to advance my needle in a shallow plane,
to view it first, and then advance it a little bit deeper.
I'm going to deposit local anesthetic
between 10 and 20 milliliters,
between the two deepest muscle layers,
the Internal Oblique, and the Transversus Abdominus.
In this image we can see the three layers of
the abdominal wall.
The External Oblique, the Internal Oblique
and the Transversus Abdominus.
Below the Transversus Abdominus is Bowel,
and you can see that moving.
So we wanna be very careful
not to advance our needle too deep.
Our goal is to inject between the Internal Oblique
and the Transversus Abdominus,
so we will carefully position our needle tip there,
and inject our local anesthetic.
For higher surgeries, you may want to perform
the same block higher.
Higher up, it's the same block,
using the same muscle planes, just given a different name.
Some people call this the Transversus Abdominus Plane Block,
or TAP Block.
Here now, we have moved just below the costal margin,
slightly cranially.
I will use the same needle position and advance it,
cranial to caudalal in this direction.
By moving higher up, we hope to get spread
a few dermatomes higher, potentially up to T7
with larger volumes.
The volumes I usually inject here are
10 to 20 milliliters on one side.
For bilateral blocks, for midline surgeries,
I'll stay on the same side, and just move my hands
over in this direction.
So I don't need to switch the machine to the other side.
I'll just lean over the patient,
get the same three muscle layers, and advance the needle
like this, in the middle of the probe,
just like previously.

Brightcove ID

5508104674001

https://youtube.com/watch?v=6E3ynIn6Ud4

Body

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