Injection

3D How To: Saphenous Nerve Block

Read more about 3D How To: Saphenous Nerve Block

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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.

3D How To: Supraclavicular Nerve Block

Read more about 3D How To: Supraclavicular Nerve Block

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3D animation demonstrating an ultrasound guided Supraclavicular 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
supraclavicular regional 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 neck exposed on the operative side.
The patient's head is rotated 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 at an acute angle
with the orientation marker directed
to the patient's right at a ten o'clock position
with the transducer aimed into the thorax.
The subclavian artery is seen as a round pulsal tile
structure superior to the bright reflection
of the first rib.
The plura is seen as a bright hyperechoic reflection
deep two, or at the same depth as the first rib.
The nerves of the brachial plexus are posterior
or superior to the subclavian artery.
The nerve trunks appear as hypoechoic dark circles
within the bright hyperechoic fascia of the brachial plexus.
Colored doppler imaging may be used
to identify smaller arterial branches
running through the brachial plexus
or lying in the path of needle advancement.
The needle is positioned one to two centimeters
lateral to the transducer, and advanced
using an in plane technique.
The initial end point of the needle
is just posterior to the artery
immediately above the first rib.
It is important to distinguish the plura
from the first rib to avoid a pneumothorax.
The local anesthetic is injected
incrementally close to the nerves.
The needle can be redirected towards
the upper trunks of the brachial plexus
if the spread of local anesthetic is not deemed adequate.

Brightcove ID

5750031878001

https://youtube.com/watch?v=9vW1uo7mKDc

Body

3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

How to: Stellate Ganglion Block

Read more about How to: Stellate Ganglion Block

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This videos discusses some of the scanning techniques involved when performing a stellate ganglion nerve block under ultrasound guidance.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- Today I'm going to demonstrate the stellate ganglion block
performed under ultrasound guidance.
Traditionally this block was performed blindly,
without the use of any imaging modality.
Currently thoracoscopy is a preferred method,
however utilizing ultrasound such as this M Turbo system
utilizing the HFL 50 linear probe,
this can be done with less radiation
and avoidance of vascular structures
that might not otherwise be seen
under thoracoscopic guidance.
The C6 transverse process, Chassaignac's tubercle,
immediately inferior is the C7 body
and transverse process.
The probe is placed in a transverse orientation,
clearly identifying and avoiding the vertebral artery.
And the needle coming in contact with
the C7 transverse process.
To perform this particular block,
the following equipment is necessary.
The chlorhexidine prep,
one percent buffered lidocaine
with a one and one half inch 27 gauge needle,
a 25 gauge three and one half inch spinal needle,
a 10 cc syringe that will contain seven ccs
of one percent lidocaine with epinephrine,
or quarter percent bupivacaine with epinephrine.
The procedure is performed with the patient
in the supine position, with the chin up
and the following anatomic structures are identified.
The thyroid cartilage, the cricoid cartilage, and then,
the finger is placed in the groove next to the trachea,
and pressure applied until a bony protuberance is felt.
This is Chassaignac's tubercle or
the transverse process of C6.
Currently, the use of thoracoscopy
indicates use at the C7 level.
The reason for this is to provide
better sympathetic blockade while avoiding some
of the common side effects such as Horner's syndrome,
as well as recurrent pharyngeal nerve paralysis.
In this case, the HFL 50 probe will be utilized.
It provides a very high definition, high resolution view
of the subcutaneous structures.
Gel is placed at the formerly marked C6 level.
And the HFL 50 probe is placed on the skin
in a transverse arrangement.
The initial view is of the cricoid cartilage,
and then the probe is moved slightly cephalad
and then rotated slightly outward.
At this point the thyroid as well as the carotid artery
and Chassaignac's tubercle are clearly visible
as the hump located immediately in the center of the screen.
Since this is the C6 tubercle,
we will move slightly interior until it flattens out
and this becomes the C7 transverse process.
It's important to note at this point to utilize
the color flow Doppler which will indicate
vascular structures such as perforating thyroidal arteries
that are not to be violated,
as well as the carotid artery,
and the vertebral artery more laterally.
The structure of interest is the longus colli muscle.
At this point, local anesthetic
one percent lidocaine buffer is injected,
and a 25 gauge three and a half inch needle
is advanced through this track to contact the oss at C7.
The needle is backed off slightly and then the injection
of local anesthetic, preferably epinephrine
containing one percent lidocaine,
six to seven ccs is gently and slowly injected.
At this point, the probe is removed, the skin wiped
and cleaned, and if needed, a band aid placed
over the small puncture site.
This successfully concludes a stellate ganglion block
performed under ultrasound guidance.

Brightcove ID

5508120224001

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

How to: Piriformis Injection

Read more about How to: Piriformis Injection

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This videos discusses some of the scanning techniques involved while performing a piriformis injection.

Clinical Specialties

Media Library Type

Media Library Tag

Nerve Entrapment Neuropathy

Subtitles

- Today I'm going to demonstrate the piriformis injection.
Piriformis injection under ultrasound guidance is useful
in diagnostic maneuvers,
specifically for patients
that may have sciatic-like symptoms
as the sciatic nerve passes close to the piriformis muscle.
In piriformis syndrome
the piriformis muscle is hypertrophied
and can mimic sciatic symptoms
caused by lumbar herniated disks.
If this has been excluded,
this particular procedure can be done
under ultrasonographic guidance.
The patient is placed in the prone position
with a pillow underneath to provide bolster.
The side in question is identified and prepped
in this particular fashion.
The gluteus is exposed.
For facilitation of visualization
I utilize the Sonosite M Turbo
with the musculoskeletal setting to help enhance
the muscular fibers of the piriformis muscle,
the gluteus minimus and maximus,
and the curvilinear shape facilitates entry of the needle
into the targeted site.
To perform this particular block
the following equipment is necessary.
Chlorhexidine for sterile technique,
local anesthetic syringe containing 1% buffered lidocaine,
and then a syringe containing five cc of bupivicaine 1/2%
mixed with five cc of 1% lidocaine,
and then 40 to 80 milligrams of triamcinolone kenalog,
which is a particulate steroid.
A 3-1/2-inch 25-gauge spinal needle
will also be utilized for the procedure.
There will be sterile four by fours
necessary to clean the area at the conclusion
and a simple BAND-AID will suffice to cover the wound.
Copious amounts of gel are required
for this particular procedure.
The middle portion of the gluteus is identified
and then in a transverse or left-to-right positioning
the probe is placed in contact with the skin.
The leg in question can be mobilized
in a abduction-adduction maneuver
demonstrating motion of the piriformis muscle
as it inserts out towards the greater trochanter
and towards the ischium centrally.
Clearly in the middle of the screen
you can also identify the sciatic nerve
as it passes very close
to the fibers of the piriformis muscle.
A central point is identified,
making sure to stay away from the investing fascia
around the sciatic nerve.
The skin is marked and then 1% local anesthetic is injected
directly in short axis view
and then a 25-gauge 3-1/2-inch needle
is passed through this anesthetized track
and approximately six cc of local anesthetic
containing bupivicaine and lidocaine in a one to one mixture
with a small amount of steroid if desired can be injected.
- [Voiceover] This is a short axis view
and the curvilinear probe is applied
in the transverse orientation.
The leg is being adducted and abducted
to show the muscle moving.
The sciatic nerve is clearly visible
in the substance of the muscle.
It is the band-like hyperechoic structure.
The injectate is the hypoechoic structure
that grows within the substance of the muscle.
- The probe is withdrawn,
the area wiped with a four by four,
and then a BAND-AID placed over the wound.
This is the successful completion
of a piriformis injection under ultrasonographic guidance.

Brightcove ID

5508136045001

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

How to: Cervical Spine Injection

Read more about How to: Cervical Spine Injection

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This videos discusses some of the scanning techniques involved while performing the cervical spine injection.

Clinical Specialties

Physical Med & Rehab

Media Library Type

How To Videos

Subtitles

- Today I will perform an anatomic demonstration
of the cervical spine utilizing
the M-Turbo Ultrasound System,
utilizing the C60 curvilinear probe.
The point of this exercise is to demonstrate
the anatomic considerations when performing
cervical epidural steroid injections
and cervical facet injections.
Typical patients may have have a variance in their anatomy
and the traditional approaches utilizing
loss of resistance techniques for
cervical epidural steroids can present come challenges.
The purpose of utilizing the ultrasound system
for an anatomic survey is that the patient,
who normally has a cervical epidural steroid injection
performed under fluoroscopic technique
may occasionally encounter false losses of resistance.
Utilizing this particular tool as a sounding device
may perhaps improve the accuracy of injection.
The way this is performed is utilizing again the C60 probe,
setting the depth to approximately 9.2 centimeters,
remembering that the average depth to the epidural space
is appx six centimeters.
The nerve setting will also be used
to highlight any neural structures that may be of interest.
On the patient, initially, I like to mark
utilizing a Sharpie, the C7 spinous process.
This is the most easily palpable spinous process,
and this is facilitated with the patient
in the prone position, a bolster under the thorax,
and the head slightly flexed.
I place a copious amount of gel
across the patient's C7 spinous process,
and then utilizing the probe in the transverse,
that is the left-to-right positioning,
I place contact on the skin, and clearly visible
is the patient's C7 spinous process.
In this particular view you can also see the lamina,
and the transverse processes of T1 just below.
And in the center of the screen,
under the shadow of the spinous process is a white line.
This white line, and I will highlight it here,
demonstrates the actual location of the epidural space.
So looking off to the right of the screen,
we can see that the depth is approximately
five centimeters in this particular patient.
Other potential views include
the cranial carotid orientation, or sagittal plane
of the probe, and placed along the neck,
and slightly off midline,
again now can be seen newer structures.
In this particular case the facet joint line
is very clearly indicated at these locations.
The actual location for a medial branch block
would be on these superior surfaces.
On the lateral mass.
If the probe is then rotated further out,
and a more oblique view obtained,
the actual foramen of the nerve roots
can thus be discerned.
And as we move further cephalad,
it is possible to view the vertebral artery pulsations.
And this obviously is a structure
that would want to be avoided at all costs.
This concludes the successful anatomical survey
utilizing ultrasonography of the cervical spine.

Brightcove ID

5508121212001

https://youtube.com/watch?v=qlLfe5CE454

How to: Caudal Epidural Steroid Injection

Read more about How to: Caudal Epidural Steroid Injection

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This video discusses some of the scanning techniques involved when performing a caudal epidural steroid injection under ultrasound guidance.

Clinical Specialties

Media Library Type

Media Library Tag

Lumboscral Root Compression

Sciatica

Lumbar Spinal Canal Stenosis

Caudal Approach

Epideral Space

Subtitles

- Today I'm going to demonstrate a
caudal epidural steroid injection.
This is a variation on the technique
of a lumbar epidural steroid injection.
With the probe in this location we can see
the following anatomic structures.
The coccyx, the sacrococcygeal ligament,
and the sacral cornua.
This indicates the entry at the sacral hiatus.
The needle is placed thusly, performing the block.
Indications for this procedure include
patients with lumbar spinal stenosis,
lumbar radiculopathy, and any other cause
of radiating and low back leg pain.
In this particular case, the caudal epidural
steroid approach is utilized to reduce the need for
loss of resistance syringes, fluoroscope radiation
exposure to the patient, and removal
of the need for ionic contrast.
The same benefit can be achieved utilizing ultrasound.
In this particular case I'm going to be using a Sonosite
C60 probe because of its curvilinear shape
which will facilitate viewing of the sacral anatomy.
This is key for the demonstration of the relevant anatomy
and ultimate placement of the needle
for successful completion of the procedure.
The settings are set for 5.6 centimeter depth.
Obviously this is patient specific.
A larger patient may require a deeper depth.
The other setting is the musculoskeletal setting
or the MSK setting.
This provides the best bony enhancement,
and as we'll see we'll need to be
passing a needle between two bony plates,
and this setting facilitates the best view of this.
In order to facilitate placement of the patient
for the procedure, it is necessary to have
the patient in the prone position as seen here.
This is a typical position that would normally
be used for a lumbar epidural steroid approach.
One key difference, however, is the need to
move the gluteal folds so that access
to the sacral hiatus, which is the
key target, is facilitated.
In this particular case you can see that the gluteal folds
have been taped down and away in
a caudal fashion to the patient.
We now have a clean access point
within the two gluteal folds.
In order to facilitate a proper block,
the following equipment is required.
A chlorhexidine prep for sterile technique,
a local anesthetic syringe with a 27 gauge
one and a half inch needle for local anesthetic placement
preferably one percent bicarbonated
lidocaine, buffered lidocaine.
A syringe containing the epidural steroid mix
which is composed of one percent, one CC lidocaine,
six CCs of bacteriostatic saline,
and then 40 to 80 milligrams of triamcinolone kenalog
which is a particulate steroid.
The needle utilized to enter the space
is a three and a half inch spinal needle.
For the conclusion of the procedure
it will be necessary to have
sterile four by four for cleanup
and then a simple Band-Aid will suffice
to cover the entry site.
Placement of a copious amount of gel
for coupling, aqueous coupling is important
to enhance resolution on the screen.
And then contact is made in the midline.
Because there's anatomic variation in the midline,
physiologically, a sagittal view
and then gently rocking the probe
in the oblique direction can help find the spinous processes
of the sacral space, and then
the probe is moved caudally and very clearly
the sacral hiatus comes into view.
There is a superior plate and an inferior plate
and in between them is the sacral hiatus.
I'll demonstrate where that access point is.
The needle is angled thusly.
At this point, I would utilize
the local anesthetic to perform a local anesthetic track
down to this level.
Removing that, I would then place
the three and a half inch 25 gauge spinal needle
along with the same anesthetized track
and then once between the two plates,
I would attach my local anesthetic and steroids mix.
- [Voiceover] The needle is visible
as this view is in the long axis.
The sacral plate is clearly visible,
diving anterior and cephelad.
Once the injectate enters the canal,
the colored doppler shows the fluid perturbation
confined within the sacral epidural space,
indicating a successful injection
without need for contrast or X-ray.
- Once the injectate is done and the image is recorded
as necessary for the medical record,
the probe is removed.
The needles are removed.
The area is cleaned, and then place
a Band-Aid over the wound.
And thus this concludes a successfully placed
caudal epidural steroid injection.

Brightcove ID

5508128556001

https://youtube.com/watch?v=yD6L4aSbSZA

How To Perform An Interscalene Nerve Block

Read more about How To Perform An Interscalene Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an interscalene brachial plexus nerve block.

Media Library Type

How To Videos

Subtitles

- The interscalene block is used
for shoulder surgery and clavicle surgery.
So, to start the interscalene block,
proper positioning is very important.
The best way to get to the interscalene block
is to have the patient sitting up
about 30 or 45 degrees.
Next, we turn the patients head away
from the shoulder to the opposite side.
This gives us a lot of room to put the probe
and have our hands come from the posterior side.
The proper approach to the interscalene block
is to have the needle approach from the posterior side.
This avoids the phrenic nerve and allows us
to not injure the phrenic nerve with our needle approach.
So, for the interscalene block,
we usually use a high frequency linear probe.
The high frequency linear probe is best
for structures that are superficial.
Usually, in the interscalene groove,
the interscalene nerves or the roots
of the brachial plexus lie very shallow.
Usually, two centimeters or less
even in large patients.
So, to start, I usually set my ultrasound depth
to approximately three centimeters
in an average sized patient.
I also set the frequency to general setting
or resolution setting, in skinnier patients.
To get to the interscalene groove
the best place to start is in the supraclavicular region.
The reason we start in the supraclavicular region
is that it allows us to use
a vascular structure to find the nerves.
So, when I start, I put the probe on
just posterior to the clavicle
aiming straight down the body.
In this area we will see a pulsating artery
sitting on the first rib,
as well as some pleura, possibly.
Posterior to the pulsating subclavian artery
are your nerves.
Your nerves in this setting are hyperechoic, or bright,
and have many fascicles, or dark circles, within 'em.
These are the nerves that are gonna become
the roots of the brachial plexus
as we trace backwards up the neck.
Now, to find the interscalene groove
we take our pulsating artery,
look for the nerves posterior,
and we're gonna slide the probe back up the neck.
The probe slides up the neck as well as tilts
as we move the probe up the neck.
Here, we are moving up the neck
following the upper trunk, this most superior nerve,
as we go up the neck those nerves will become
more dark and larger fascicles, or dark circles.
Now, we are up at the interscalene groove.
The interscalene groove is found by identifying
the anterior scalene muscle,
anterior here is to the left of the screen
and the middle scalene muscle
posterior to the right of the screen.
The nerves are hypoechoic, or dark, surrounded by
hyperechoic, or bright, fascial covering.
Here, we are looking at the C5 and C6 nerve roots
in the interscalene groove.
If I slide the probe anterior,
we get a carotid artery
with a internal jugular vein on top of it.
The sternocleidomastoid is above these structures.
As I slide posterior, we have out anterior scalene,
our interscalene groove,
and posterior is our middle scalene.
Here is a very good picture
of the nerve roots here and they are
sandwiched between the anterior scalene on the left
and the middle scalene on the right.
So, now, we are looking specifically
at the C5 and C6 nerve roots.
Our needle approach comes from posterior.
Usually, I start the needle
approximately one centimeter away from the probe.
In this image we see the interscalene groove
with the C5, C6 nerve roots.
The needle is passing through the middle scalene muscle.
You'll see an injection on the posterior side
of the brachial plexus.
The needle will be then moved
underneath the C6 nerve root.
An injection will be given now.
You can see the local anesthetic spreading
on the anterior side of the brachial plexus,
between the brachial plexus and the anterior scalene muscle.
And the needle is positioned below the C6 nerve roots.
I usually deposit about
20 to 30 milliliters of local anesthetic.
Some people use less to avoid
paralysis of the phrenic nerve, temporarily,
from the local anesthetic.

Brightcove ID

5508105692001

https://youtube.com/watch?v=0Cboqf1Qnhc

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an interscalene brachial plexus nerve block.

How to: Infraclavicular Brachial Plexus Nerve Block

Read more about How to: Infraclavicular Brachial Plexus 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)

Media Library Type

How To Videos

Subtitles

- The infraclavicular block is used for surgery
below the mid-humerus.
Any surgery of the elbow, forearm, wrist or hand
can be performed under a properly executed
infraclavicular block.
Many people use curvilinear, low-frequency
or mid-frequency probe to do the infraclavicular block.
With proper positioning
you can do a infraclavicular block
with a basic linear probe.
I'm gonna demonstrate the infraclavicular block
with a basic linear probe
because most people have a linear probe
in their ultrasound repertoire.
Proper positioning for
the infraclavicular block is important.
We usually keep the patient supine
for infraclavicular block.
We also move the patient completely to the other side
of the bed of the site to be blocked.
Abduction of the arm moves the clavicle down
and out of the way of your needle.
If the arm is down by the side
our needle approach is gonna bump into the clavicle.
Usual depth settings
for infraclavicular block in a normal patient
usually range between four to six centimeters total depth.
Ultrasound probe positioning in the infraclavicular region
is done in the parasagittal plane below the clavicle.
I will orient the probe
so the left side of the screen is caudal
and the right side of the screen is cranial.
This makes sense because if I bring
the needle from the cranial side on the screen
it will also come from the right side.
The first thing we see here
is the pectoralis major
and we also will see a pectoralis minor
if I move slightly lateral.
Here we now have identified both the axillary vein
and the axillary artery.
The vein is found more caudal than the artery.
The artery is found cranial.
Around the artery we now identify our nerves.
The nerves at this level
are the cords of the brachial plexus.
Traditionally the medial cord is described as being
approximately seven to ten o'clock
on the artery in this picture.
The posterior cord is described around
six o'clock on the artery
and the lateral cord is described between three
and six o'clock on this picture.
It's difficult to see individual nerves
because this is a deep block.
So the important thing is to surround the artery
with local anesthetic.
Now if we move more medially
we see some lung on the bottom left side of the screen here.
Lateral approaches to the infraclavicular block are safer
because the more lateral you are
the less likely you are to enter the lung with your needle.
Typically we use about 20 to 30 milliliters
of local anesthetic for infraclavicular block.
Our first injection of the artery
will be below the artery.
Some studies have described a single injection
resulting in a complete brachial plexus block
by depositing our entire local anesthetic below the artery.
Usually I do my first injection below the artery
and look at the spread.
If the spread is adequate I'll stop there.
If I need to position the needle in other places
I'll go either to the lateral cord
or approximately three o'clock
and then lastly at the medial cord
which would be about ten o'clock on the artery.
Complete spread of local anesthetic around the artery
will result in a good brachial plexus block.
In this image of the infraclavicular block
we see the local anesthetic being injected
cranial to the axillary artery.
Superficial we see the pectoralis major.
The pectoralis minor's not very visible on this picture.
Deep to the artery we see the subscapularis.
The needle has now injected on the cranial side
and is being advanced deep to the artery.
And you can see the injection there below the artery
getting local anesthetic around the posterior cord.
We continued to advance the needle
so it injects around the medial cord
on the more caudal side of the artery.

Brightcove ID

5508104662001

https://youtube.com/watch?v=1xTsXuiUNiw

Body

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

How to: Axillary Nerve Block

Read more about How to: Axillary 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)

Media Library Type

How To Videos

Subtitles

- Axillary nerve blocks are used for surgery,
usually below the elbow.
If properly executed, axillary nerve block
can be performed by identifying individual nerves
or just in depositing local anesthetic
below the artery and above the axillary artery.
Axillary nerve blocks under ultrasound
can improve safety because you can view
many of the small arteries and veins in the axilla,
and avoid intravascular injection.
To properly position for the axillary nerve block,
we have moved our patient to the opposite side of the bed,
and we will now abduct the arm 90 degrees.
For the axillary nerve block,
we usually use a linear probe.
Usually axillary nerve blocks are very shallow,
so I've put my initial depth setting
to about two and a half to three centimeters.
Usually, I also set the frequency settings
to general or resolution for the axillary nerve block.
To do a properly executed axillary nerve block,
identification of the artery and vein is important.
If you find the artery,
injection below and above the axillary artery
usually results in a good nerve block.
We initially place the probe in the axilla,
and identify a pulsating artery in the axilla.
This is your axillary artery.
Now, as you can see, the pulsating artery,
there is no vein in my initial picture.
This is because the vein is collapsed
with light pressure of the probe.
It is very important to identify the axillary vein,
so you do not inject into the axillary vein.
As I let up some pressure,
you can now see the axillary vein
superficial to my pulsating artery.
Other structures visualized in this shot
include the biceps and coracobrachialis
on the right side of the screen,
and either the latissimus dorsi,
or the triceps, on the left side of the screen,
depending on what level I am at.
Our needle approach to the axillary block
is always cranial to caudal in this direction.
The reason we come cranial to caudal
is for two reasons:
the axillary vein, as you see on the picture,
usually lies caudal,
and we do not wanna puncture the axillary vein
with a needle approach from the caudal side.
Also, it's much cleaner to go through the deltoid
or the biceps, rather than the axilla.
My initial needle insertion point
will direct the needle below the artery.
If you inject below the artery,
local anesthetic can spread backwards
along the latissimus dorsi, or triceps muscle,
to get to the radial and ulnar nerves.
Here, we can see the needle,
advancing through the biceps muscle.
Our first injection is gonna be below the artery,
and you can see the needle advancing to that area.
You can see the axillary artery, and the axillary vein.
The radial nerve is located deep to the axillary artery.
The ulnar nerve is located between the artery and vein,
and the median nerve is located at nine o'clock
on the axillary artery.
Now we see the needle being advanced above the artery.
You can see the local anesthetic has already been injected
deep to the artery,
and now the median nerve is sitting on top of the artery,
at twelve o'clock.
The needle is now pushing the artery down
and injecting local anesthetic all around the artery
and the median nerve.
We then advance the needle towards the ulnar nerve,
which is now directly in front of the needle.
Our goal is to get local anesthetic
around the ulnar nerve here.
Total volume injected appears to be large,
but it is only 20 milliliters so far.
Now the ulnar nerve is visible,
floating in the local anesthetic,
in the median on top of the artery.
Next, I would like to identify the musculocutaneous nerve.
The musculocutaneous nerve is the fourth nerve
of a properly executed axillary block.
I find the musculocutaneous nerve by moving slightly distal
along the arm.
I also wanna increase the depth,
and look for a hyperechoic nerve
within the biceps or coracobrachialis muscle.
Traditionally, the musculocutaneous nerve
can be oval or triangular.
The musculocutaneous nerve is one of the brightest,
or most hyperechoic nerves in the body,
and it's easily blocked with local anesthetic
in the realm of three to five milliliters.
Here we see a hyperechoic musculocutaneous nerve
surrounded by a hyperechoic fascia.
Our needle is being advanced to the lateral portion.
The local anesthetic is now being injected
below the musculocutaneous nerve,
and now above the musculocutaneous nerve,
to give complete surrounding of that nerve.
The needle is being advanced to the biceps muscle.
You can see the pulsatile axillary artery medial as well.

Brightcove ID

5765651694001

https://youtube.com/watch?v=rG7PXuXrqbU

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

How To Perform A Supraclavicular Nerve Block

Read more about How To Perform A Supraclavicular Nerve Block

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The Sonosite SII ultrasound machine supports regional anesthetic techniques used during supraclavicular blocks – serving as an alternative or adjunct to general anesthesia needed for postoperative pain control for upper extremity surgeries (mid-humerus through the hand). Anesthesiologist Dr. David Auyong MD of Seattle, Washington here reviews scanning techniques and sonographic landmarks for the ultrasound guided nerve block. Dr. Auyong highlights patient position, the type of transducer used, the needle position and injection technique. The ability to image the plexus, rib, pleura, and subclavian artery increases safety due to improved monitoring of anatomy and needle placement.

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- The supraclavicular block is used
for surgery below the shoulder.
A proper supraclavicular block will effectively block
the elbow, forearm, wrist and hand.
The reason we use supraclavicular blocks
is because the nerves are located very tightly together
and our needle movements can usually get
all the brachial plexus with minimal movements
of the needle.
The supraclavicular block has made a resurgence
since using ultrasound.
The reason is we are able to visualize
some important structures, such as the first rib
the subclavian artery and the pleura.
To start a supraclavicular block,
it's very important to position the patient properly.
The way we position patients for the supraclavicular block,
is to move the pillow all the way over to the side,
so our hands have plenty of room
to come from the posterior side of the patient.
We also turn the patient's head away
from the site to be blocked.
Then we elevate the head of the bed
30 to 45 degrees.
And that gives us the ability to have
our hands in a comfortable position while we do the block.
We use a high frequency linear probe
for the supraclavicular block.
Our nerves should be found half a centimeter
to two centimeters below the skin.
I have oriented the probe so the left side
of the screen is anterior
and the right side of the screen is posterior.
In this setting we now see a bright white strip
going across the screen
with a pulsating subclavian artery
sitting on this bright white stripe.
This stripe can be either first rib
or it can be pleura.
Your needle tip should never be below this stripe.
We call the area below this stripe the no fly zone.
On the screen we now see from left to right
the anterior scaling on the left,
the pulsating subclavian artery,
the most important place to make sure
you have local anesthetic is between
the pulsating subclavian artery and the first rib.
This is because the inferior trunk lies in this area.
And some people have difficulty
with the supraclavicular block
because area is ulnar sparing.
Usually I do two injections for this supraclavicular block.
I put one injection down in the corner
between the pulsating artery and the first rib
and then I put a second injection up higher
by the superior trunk.
My needle position for the supraclavicular block
comes posterior to anterior
and starts about a centimeter away from the probe.
If I start a centimeter or more away from the probe
my needle angel will be flat
and it will be visualized better on the ultrasound machine.
It's very important to have my needle
completely in plane with the ultrasound probe
so it will be visualized during it's entire length.
Give some injection of local anesthetic.
Usually about one to two milliliters
to see the spread of the local anesthetic
on the ultrasound screen.
Injections below the nerves will push
the rest of the brachial plexus more shallow
making the rest of the block easier.
I usually inject about 20 to 30 millimeters
of local anesthetic in the supraclavicular region.
This example of a supraclavicular injection.
The first injection is lateral to the nerves.
Our needle is barely visible because it is at a steep angle.
As the needle is flattened out we will see it better.
You can see the pulsating subclavian artery
sitting on the first rib.
And you can even see pleura out more laterally.
As the injection is put into the pocket between
the artery and the first rib,
notice the artery is even lifted off
the first rib during this injection.
Now you can see the needle much better,
because it is at a flat needle angle.
You can see the nerve just posterior to the artery
and the hypoechoic local anesthetic spreading
below the nerves.

Brightcove ID

5750036243001

https://youtube.com/watch?v=YOOoNT27Irg

Body

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