Needle

How to: Femoral Nerve Block

Read more about How to: Femoral 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 femoral nerve block is used
for many different surgeries.
The femoral nerve block can be used for knee surgery,
hip surgery, femur surgery,
or even medial ankle surgery to get the saphenous nerve.
To perform the femoral nerve block,
there's a few key positioning tips.
We want to put the patient completely supine.
Many of our patients are larger and have larger abdomens,
so putting the patient supine allows us to get
high enough in the femoral region.
Also, if their adipose tissue hangs over the femoral region,
we want to put tape here and tape their abdomen away
out of the way, so you can put your probe
comfortably in the femoral region.
To do an ultrasound guided femoral nerve block,
we use a linear high frequency probe.
To start the femoral nerve block,
we usually put the probe right in the femoral crease.
On our screen now, we see several important features.
From medial to lateral, we see the Iliacus muscle,
we see the nerve sitting right on the Iliacus muscle,
and we also see the femoral artery,
and then to the right we see the femoral vein.
There are a few fascia coverings in this area
that are important.
The Facia Iliaca runs above the femoral nerve
and below the artery.
The Fascia Lata runs above all of this,
above the artery and vein as well.
Now for the femoral nerve, we want to see a hyperechoic
or bright nerve sitting on the Iliacus muscle.
The true femoral nerve is a wide, flat nerve
laying directly on the muscle.
If you inject above the Facia Iliaca,
this will create a barrier to your nerve
and allow a block that is not complete.
So as we move up and down the leg,
we're gonna see some key that will help you find
the femoral nerve in all patients.
More medially, you see the pulsating femoral artery,
and medial to that you see the femoral vein.
Here the vein collapses with pressure.
Now some keys to find the femoral nerve
in every patient are as follows.
If the probe is placed too cranially,
your femoral artery and vein and nerve
drop deep on the screen.
The femoral vein, artery, and nerve
are too deep, then you need to move the probe caudally.
If you probe is placed too distally,
that femoral artery is going to split
into two femoral arteries.
Here you can see a pulsating Profunda femoral deep
as well as a true femoral artery superficial.
Now I'm gonna put some color flow on that,
and you can see a pulsating artery deeper,
and a superficial femoral artery as well.
Now the vein is on the left,
represented in red in this picture.
As we move cranially, those two arteries come together.
When we look laterally from there,
the nerve has also come together from
many branches, forming one femoral nerve.
This way we can see the femoral nerve the best
when the artery also comes together as well.
Now our needle approach to the femoral nerve
is going to be from lateral to medial.
Typically, we use a 10-centimeter needle
because we use these in-plane approaches
to the femoral nerve.
I like to put my target on the further side of the screen
so I can see my needle coming in from the lateral side.
So I'll put my first injection lateral to the nerve
just above the Iliacus muscle
to ensure injection below the Fascia Iliaca
but not within the Iliacus muscle.
By using typical volume, such as 20 to 30 milliliters,
we'll get spread above the nerve
or below the nerve, without poking into
the nerve, and damaging the nerve.
In this femoral nerve block, you can see a single
injection needle being advanced lateral to the nerve
which is lying right on the Iliacus muscle.
You can see the pulsating femoral artery medially,
and the local anesthetic now spreading over
the wide, flat femoral nerve.
Our needle tracks in with the local anesthetic
so we can get local anesthetic spreading
all the way medial around the femoral nerve here.

Brightcove ID

5765925239001

https://youtube.com/watch?v=Z-O_EaAE_rg

Body

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

How to: Peripheral Arm Veins for Vascular Access

Read more about How to: Peripheral Arm Veins for Vascular Access

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An overview of ultrasound landmarks and scanning techniques used for peripheral arm vein access.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Media Library Tag

Subtitles

- Ultrasound can be a great adjunct
for peripheral vein access.
Normally, our nurses can get pretty good access
to the peripheral vein through standard palpations,
but sometimes the patient may have an edematous arm,
their arm may be obese,
you may not be able to feel an antecubital vein easily.
In addition, if the antecubital veins cannot be accessed,
we may want to access deeper veins of the arm,
those being the basilic and brachial veins.
Ultrasound provides great visualization
of all of those veins.
We're gonna go ahead and choose the linear array transducer.
This is going to allow high-frequency imaging
to give us really good image quality
for superficial structures.
Remember, these veins are superficial
so we're gonna to want to get as good image as possible.
I'm gonna go ahead and choose the exam type.
Once I've chosen this transducer,
I do have different exam types I can choose from.
I'm gonna use the Exam button
to choose the Venous preset,
hit Select.
I've already got some gel at the antecubital fossa.
I already have a tourniquet up.
So let me now take a look at his antecubital fossa
and see what veins we can identify.
Here we have the transducer marker here,
I'm gonna put it to the patient's right.
Again, it doesn't really matter when we do vascular access
if it's to the right or left,
as long as the target vein is in the center.
First thing I notice is
that I can probably decrease my Depth a little bit.
So I'm going to go ahead and do that.
I'm going to turn my Gain up a little bit.
And I notice here, right in the center of the screen,
is an an anechoic structure, that is easily collapsible.
And as you can see, with simple pressure with my hand,
this vessel easily collapses.
There's no pulsatile motion and it easily collapses.
It is also quite superficial.
If you look at the marks here
on the right hand of the screen,
this is a half centimeter mark,
this is a one centimeter mark.
This vein is only about four to five millimeters deep.
So it'd be very easy to access.
If I'm looking at the screen right now,
and I put the vein directly in the center,
that vein will be directly in the center
of the transducer below the skin.
If you can not find anything in the antecubital veins,
you may want to take a look at the deeper veins of the arm.
So now let's take a look at the brachial
and the basilic veins.
I'm gonna put a little gel, a little more medial
of the elbow, and a little bit more proximal.
I'm gonna scan transversely across the arm.
I see a large vein,
here in the center of the screen,
which is collapsible.
In fact, I see multiple veins.
You can put a pretty large catheter into here.
You can easily place a 14 or a 16 gauge catheter.
I will recommend you use a two inch catheter
in all of these cannulations.
If you use a standard angiocath, you will get a flashback.
But unfortunately, most likely the catheter will dislodge.
So this, this is a good vein here.
If you look around a little bit more laterally,
we can see other veins,
and we can see the artery as well.
Here in the center of the screen,
you see a pulsatile structure, which represents the artery.
If you're unsure, if it's a very small vessel,
is arterial venous, you can put the color flow on.
And we see classic color flow profile
of an arterial structure.
So we're now scanning just above the antecubital fossa,
a little bit medially.
We have a pretty good image here,
just above the antecubital fossa, a little bit medially.
And we see a few structures here I want to point out.
We can see an artery, here in the center.
Again, when I put a little compression on it,
you can see pulsatile flow.
Adjacent to that,
you can see a vessel which easily collapses.
This represents a venous structure,
which could be cannulated,
but it doesn't look like it's in a great location
because it sits right adjacent to the artery.
In addition, on the other side of it,
is a slightly hypoechoic structure.
This represents a nerve.
So if I was choosing a location for venous access,
I would not choose this vein,
given the proximity both to the artery and the nerve.

Brightcove ID

5508134285001

https://youtube.com/watch?v=Pga4SAD-J9U