Popliteal Vein

- So, it's actually quite easy to do
an ultrasound examination in the E.D.
to determine if a patient has deep vein thrombosis,
and this is a well established practice of ultrasound.
We're gonna do a modified version of that
for the E.D. exam though.
To set up for this examination you want to tilt
the gurney, so that you're in a reverse trandelenburg.
So this encourages venous extension in the leg,
so it's easier to visualize the veins with ultrasound.
We're going to use a linear transducer for this examination,
and the views that we do for this exam
will just be in a transverse orientation only.
So when you're setting up for this examination
make sure the orientation marker again is to the right.
For this examination technique we're gonna use
a compression technique where we just
slightly compress the vein with some downward motion.
When you set up the exam on the system,
just select the exam key,
then from your menu select the venous exam type,
and hit select.
When you do this you're optimizing the system,
so it's automatically configured
for your best resolution of the veins.
We're gonna use a little bit of ultrasound gel,
and we're gonna assess two areas.
The femoral area and the popliteal area.
I'm gonna start with the femoral area.
We're going to place the ultrasound transducer
at the inguinal crease...
in a transverse view.
When I do this, immediately below the transducer and the
ultrasound image I'm going to see two anechoic structures.
The one that's gonna be more
medial is the common femoral vein.
The one that's more lateral is the common femoral artery.
The way I can landmark this is by looking for
the junction with the saphenous vein,
or the long saphenous vein.
And we see this emptying into the
anterior aspect of the common femoral vein.
And in this image we actually see the
venous valves separating
the long saphenous and common femoral veins.
So at this point what I do, is I just
use my compression technique.
So I just push with the transducer down until I see
both walls of the vein coapt or touch and meet each other.
If I get a complete coapt like this
I know there's nothing between those two walls,
so there's no venous thrombosis in the vein.
So again, just compress down until
you see those two walls meet completely.
You'll see that the artery does not compress,
and is pulsatile beside the vein.
Now that you've identified your landmarks,
you wanna do a thorough evaluation of that area.
So again placing the transducer at the inguinal crease,
we're going to compress the area of the common femoral vein.
We wanna move a few centimeters proximal to this,
so superiorly on the body,
and we'll start a compression technique.
Making sure that those walls collapse completely,
and we just work through this area
compressing every centimeter.
We see our common femoral vein and saphen junction here,
and we can continue compressing
just a few centimeters below this.
On the ultrasound we've seen the division to
superficial femoral artery and profunda artery.
Just lateral to the vein,
and then we should see the vein divide to
femoral vein and profunda vein.
Again, compressing all the way down,
until you see this junction.
From here I'm going to move down to the popliteal region.
Just move the system down towards the knee,
and we're going to actually go behind the knee.
Putting the transducer into the popliteal fossa.
Once you've identified the popliteal artery and vein,
mid-popliteal fossa level,
you wanna evaluate above and below this area
to make sure you evaluate all those areas
for deep vein thrombosis.
So we're going to start mid-level,
and just work our way superiorly in the leg.
To the superior aspect of the popliteal fossa.
Compressing all the way.
We go up a few centimeters,
and then we start to move down the leg
compressing into the inferior aspect of the popliteal fossa.
Again making sure that those vein walls
actually touch and meet each other,
so we know that there's no deep vein thrombosis
that's fresh which would be h-ai-p-oe-c-u-g.
Could be difficult to see if we did not
do this compression technique.
Those are the two steps for assessing the leg
for deep vein thrombosis.
It's just these two evaluation points.
But just make sure that you evaluate each area thoroughly,
and you do your compression technique completely.

Brightcove ID

5508114175001

https://youtube.com/watch?v=FHerMNhCR54

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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Sciatic-Popliteal Nerve

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Clinical Specialties

Anesthesiology (Regional)

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Popliteal Nerve1

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Clinical Specialties

Anesthesiology (Regional)

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Popliteal Nerve

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Anesthesiology (Regional)

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Popliteal Nerve Bifurcation1

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Anesthesiology (Regional)

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Popliteal Nerve Bifurcation

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Anesthesiology (Regional)

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3D How To: Popliteal Sciatic Nerve Block

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3D animation demonstrating an ultrasound guided Popliteal nerve block.

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How To Videos

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform ultrasound guided
popliteal nerve block.
The target depth is approximately 2 to 4 centimeters
in an 80 kilogram adult.
The patient is positioned in a lateral decubitus position
with the hip and knee slightly flexed.
The transducer is placed transversely
on the popliteal skin crease with the orientation
marker directed laterally.
The transducer should be moved medially and laterally
to identify the dark round pulsatile popliteal artery.
The compressible poplital vein can be seen superior
to the popliteal artery.
The tibial nerve lies superficial to the popliteal vein
and appears as a bright hyperechoic oval structure.
The transducer should be slowly translated
up the posterior thigh to identify the point
where the peroneal and tibial nerves join.
The ideal point for needle insertion is at or just below
the split of the tibial and peroneal nerves.
The needles is advanced using an in-plane technique.
The needle is positioned 1 to 2 centimeters lateral
to the transducer and advanced under the transducer.
The initial end point for the needle is immediately
beside the tibial nerve.
Local anesthetic should be principally injected
around the tibial nerve, as it is responsible
for the majority of the innervation of the foot.

Brightcove ID

5764118112001

https://youtube.com/watch?v=9c1A-87maFE

Body

3D animation demonstrating an ultrasound guided Popliteal nerve block.

3D How To: Deep Vein Thrombosis Exam

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3D animation demonstrating a Deep Vein Thrombosis ultrasound exam

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Lower Extremity

Deep Venous Thrombosis

Three-Point Compression

Patency

Mid Thigh

Superficial Femoral Vein

Common Femoral Vein

Subtitles

- [Voiceover] A linear array transducer
with a venus exam type is used to perform
a lower extremity, deep vein thrombosis ultrasound exam.
At least three evaluation sites are necessary.
Common femoral vein, at the saphenofemoral junction,
confluence of the proximal deep femoral vein,
and the superficial femoral vein,
and the popliteal vein.
The patient is in a supine position
with the leg in slight external rotation and flexion.
Place the transducer in a transverse position
with the orientation marker to the patient's right side,
at the level of the inguinal ligament.
The three structures of the femoral triangle are visualized.
The common femoral artery, common femoral vein,
and greater saphenous vein.
The common femoral artery is round and pulsatile,
and the common femoral vein is thin-walled,
oval in shape and collapsible with compression.
The greater saphenous vein confluence
is observed at the anterior aspect
of the common femoral vein.
With the transducer perpendicular to the skin,
apply gentle downward compression
until the vein collapses
and the anterior and posterior walls completely touch.
Slide the transducer distally to the level
of the confluence of
the superficial femoral and proximal deep femoral veins.
Repeat the compression technique,
demonstrating complete collapse of the veins.
Move the transducer to the popliteal fossa.
From this approach, the popliteal vein
will appear anterior to the popliteal artery.
Repeat the compression technique.

Brightcove ID

5508123491001

https://youtube.com/watch?v=khD3dnxEt2o

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