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11 December
2015
Ultrasound Guided Regional

Anesthesia
BY
HOSSAM HELMY ZAHEI ELDEEN
M.B.B.CH, FACULTY OF MEDICINE, ZAGAZIG UNIVERSITY
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Acknowledgment
Before all, I am thankful and grateful to GOD the kind and merciful for helping me throughout
this work.
I would like to express my profound gratitude to Prof. Dr. Ahmed Mohamed Salama El Naggar,
Professor of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University for his most
valuable advices and support all through the whole work and for dedicating much of his precious
time to accomplish this work.
I am also grateful to Prof. Dr. Kamelia Ahmed Abaza, Professor of Anesthesia and Intensive
Care, Faculty of Medicine, Zagazig University for her unique effort, considerable help, assistance
and knowledge she offered me throughout the performance of this work.
My special thanks and deep obligation to Dr. Mohamed Aly Zeidan, Lecturer of Anesthesia and
Intensive Care, Faculty of Medicine, Zagazig University for his continuous encouragement and
supervision and kind care.
Ultrasound Guided Regional Anesthesia 11 December
2015
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Introduction
Ultrasound guidance has become popular for performance of regional

anesthesia and analgesia due to multiple reasons such as dissatisfaction with success
rates of traditional block techniques, hastens block performance and onset of block
(Marhofer and Chan, 2007).
The ideal in the practice of regional anesthesia would be the ability to deliver
precisely to the target nerve exactly the right dose of local anesthetic without carrying
any risk of damage to the nerve or its related structures. This goal can be mostly
achieved under sonographic visualization which provides real time imaging guidance
allowing for purposeful needle movement and proper adjustment in the direction and
depth (Greher et al., 2002).

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Aim Of Work
Updated reviews are studied to show the

different advantages of ultrasound in regional
anesthesia over blind techniques.

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Review
 Anatomy of Upper and Lower Limb Nerves and Trunk Nerve Plexuses.
 Pharmacology of local Anesthetics.
 Physics of the Ultrasound.
 Upper Extremity Nerve Blocks.
 Lower Extremity Nerve Blocks.
 Techniques of thoracic and abdominal nerve blocks.
 Complications of regional anesthesia.

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PROF. DR. AHMED MOHAMED
SALAMA EL NAGGAR
PROFESSOR OF ANESTHESIA AND INTENSIVE
CARE FACULTY OF MEDICINE, ZAGAZIG
UNIVERSITY.
PROF. DR. KAMELIA AHMED ABAZA
Supervised By PROFESSOR OF ANESTHESIA AND INTENSIVE
UNIVERSITY.
DR. MOHAMED ALY ZEIDAN
LECTURER OF ANESTHESIA AND INTENSIVE
UNIVERSITY.

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PROF. DR. AHMED MOHAMED
SALAMA EL NAGGAR
UNIVERSITY.
PROF. DR. AHMED ABD-EL-HAKIM
BALATA
Committee Board PROFESSOR OF ANESTHESIA AND INTENSIVE
UNIVERSITY.
PROF. DR. THANAA MOHAMED AL-
NOMANI
CARE FACULTY OF MEDICINE, TANTA
UNIVERSITY.
2015
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HUMAN NERVES ANATOMY
Upper Limb Nerves Lower Limb Nerves Trunk Nerve Plexuses

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 Supraclavicular Branches
 The Nerve to the Rhomboids (C5).
 The Nerve to Serratus Anterior (C5–
7).
 The Suprascapular Nerve (C5, 6).
 The Nerve to Subclavius (C5, 6).
BRACHIAL PLEXUS

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 Lateral Cord Branches

 The Lateral Pectoral Nerve (C5–7).
 The Musculocutaneous Nerve (C5–7).
BRACHIAL PLEXUS

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 Medial Cord Branches 12
 The Medial Pectoral Nerve (C8, T1).
 The Medial Cutaneous Nerve of the
Arm (C8, T1).
 The Medial Cutaneous Nerve of the
Forearm (C8, T1).
 The Ulnar Nerve (C7, 8, T1).
 The Median Nerve (C5–8, T1).
BRACHIAL PLEXUS

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 Posterior Cord Branches 13
 The Upper and Lower Subscapular
Nerves (C5, 6).
 The Nerve to Latissimus Dorsi (C6–8).
 The Axillary (Circumflex) Nerve (C5, 6).
 The Radial Nerve (C5–8, T1).
BRACHIAL PLEXUS

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 Iliohypogastric (L1).
 Ilio-inguinal (L1). 14
 Genitofemoral (L1, 2).
 Dorsal divisions:
 Lateral cutaneous nerve of thigh (L2, 3).
 Femoral nerve (L2–4).
 Ventral divisions:
 Obturator nerve (L2–4).
 Accessory obturator nerve (L3, 4).
 Muscular branches to:
 Psoas major.
 Psoas minor.
 Iliacus.
 Quadratus lumborum.
LUMBAR PLEXUS
Branches

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 Sciatic Nerve.
 Tibial Nerve.
SACRAL AND COCCYGEAL PLEXUSES

Branches

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 Celiac plexus and splanchnic 16
nerves.
 Paravertebral space.
 Intercostal nerves.
 Ganglion impar (ganglion of
Walther).
 Superior hypogastric plexus.
 Transversus abdominis innervation.
Thoracic and Abdominal Nerves

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LOCAL ANESTHETICS PHARMACOLOGY
Molecular Mechanism Pharmacodynamics Pharmacokinetics

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 Amides 18
 Bupivacaine (Marcaine) &
levobupivacaine.
 Etidocaine (Duranest).
 Lidocaine (Xylocaine).
 Mepivacaine (Carbocaine).
 Prilocaine (Citanest).
 Ropivacaine.
Molecular Mechanisms of Local Anesthetics

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 Amines 19
 Chloroprocaine (Nesacaine).
 Cocaine.
 Procaine.
 Tetracaine (Pontocaine).
Molecular Mechanisms of Local Anesthetics

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 Chemical Properties in Relation to 20
Potency.
 Chemical Properties in Relation to Onset
and Duration of Action.
 Sensitivity to Blockade.
 Local Anesthetics Affinity.
 Local Anesthetic Efficacy.
 Clinical Applications:
 Vasoconstrictive Drugs.
 Alkalinization of Local Anesthetic
Solution.
 Alpha2 (α2) Adrenergic Agonists.
 Other Adjuvant Drugs.
Pharmacodynamics of Local Anesthetics

2015
 Systemic Absorption. 21
 Distribution.
 Elimination.
 Clinical Application:
 The ability to predict the peak
plasma level (Cmax) after the
agents are administered, thereby
avoiding the administration of toxic
doses.
Pharmacokinetics of Local Anesthetics

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Physics of the Ultrasound
The Nature of Generation and US Characteristics of Performing Ultrasound-

Ultrasound Detection of US Waves Needles for Nerve Block Guided Nerve Block

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 The Sound Spectrum. 23
 Propagation of US:
 Transfer of Energy.
 Pressure Waves.
 Longitudinal Propagation.
 Simple Wave Parameters.
The Ultrasound Nature

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 The Piezoelectric Phenomenon. 24
 Production and Detection of US.
 US Transducers:
 The Crystal Element.
 Electrical Connections.
 Backing Material.
 Acoustic Insulator.
 Transducer Housing.
Generation and Detection of US Waves

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 The following criteria should be 25
known about the needle used in
the nerve block:
 The echogenicity of the needle.
 The image quality of the needle
with different US machines.
 The impact of different insertion
angles on the image quality.
US Characteristics of Needles for Nerve Block

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 Technique. 26
 Type of Needle.
 Type of Transducer.
 Scanning.
 Sonoanatomy.
 Needle Insertion.
 Local Anesthetics and Volume.
Performing Ultrasound Guided Nerve Block

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Upper Extremity Nerve Blocks
Axillary Block Suprascapular Block Supraclavicular Block Interscalene Block

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Upper Extremity Nerve Blocks
Elbow and Forearm

Infraclavicular Block Mid Humeral Block Block Wrist Block

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 The best suited for anesthesia and 29
analgesia of the upper extremity
distal to the elbow, (Marhofer et al.,
2010).
 The probe is placed transversely to
the humerus and the needle is
advanced in plane from lateral
(superior) to medial (inferior), (Sites
and Spence, 2007).
 it is possible to inject about 5 mL of
local anesthetic solution per nerve,
usually requiring a total volume of
20-30 Ml, (Sites and Spence, 2007).
Axillary Block

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 It is frequently performed for 30
different shoulder pain conditions
and for perioperative and
postoperative pain control after
shoulder surgery, (Siegenthaler et al.,
2012).
 A 21-gauge, 50-mm b-bevel needle is
inserted along the longitudinal axis
of the ultrasound beam, (Dominic
Harmon et al., 2007).
 Levobupivacaine 0.5% (4 mLs) and
triamcinalone (80 mgs) mixture is
injected, (Dominic Harmon et al.,
2007).
Suprascapular Block

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 Anesthesia and/or analgesia for 31
any procedure on the upper
extremity distal to the shoulder,
(Jeon and Kim, 2010).
 The needle is advanced in plane,
from lateral to medial, (Franco,
2010).
Supraclavicular Block

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 The interscalene block provides 32
adequate analgesia that can last for a
period of up to 6–12 h. A catheter
can be left in place for continuous
analgesia, (Tsui and Suresh, 2010).
 There are two approaches for the
needle insertion, anterior approach
(medio-lateral) and posterior
approach (Cervical paravertebral,
latero-medial), (Sites and Spence,
2007).
 With the needle under direct
visualization, the injection is
performed in the proximity of C6 root
, (Neal et al., 2009).
Interscalene Block

2015
 It is particularly useful for placing a 33
catheter in the posterior cord for major
reconstructive procedures of the upper
extremities, (Capdevila et al., 2008).
 For both proximal and distal approaches
the needle is usually preferred to be in
plane technique from lateral to medial
(Superior to inferior), (Franco, 2010).
 A complete and rapid onset of nerve block
is achieved when the local anaesthetic is
injected posterolateral to the axillary
artery, (Neal et al., 2009).
Infraclavicular Block

2015
 It is used to anesthetize each nerve 34
separately, possibly using local
anesthetic with different durations
of action, (Capdevila et al., 2008).
 The needle is inserted using an in
plane approach, (Bhatia, 2011).
 Injection of 10 mL of local
anesthetic at each nerve location,
(Capdevila et al., 2008).
Mid Humeral Block

2015
 It is used to provide anesthesia and 35
analgesia for hand and forearm surgery,
(Russon et al., 2010).
 For radial nerve block, the needle is
inserted in an in-plane approach from the
lateral side of the transducer, (Brennan et
al., 2011).
 For the median nerve block, the approach
in the forearm can involve either the in-
plane or out-of-plane technique, (Neal et
al., 2009).
 Injection of 10 mL of local anesthetic at
each nerve location , (Bhatia, 2011).
Elbow and Forearm Block

2015
 A wrist block is most commonly used for 36
carpal tunnel and hand and finger surgery,
(Soeding and Eizenberg, 2009).
 For the median nerve block, the needle is
inserted from the radial side of the probe
and in an in-plane approach, (Russon et
al., 2010).
 For ulnar nerve block, the needle is
inserted from the radial side of the probe
and in an in-plane approach, (Marhofer et
al., 2010).
 Injection of 5 ml of local anesthetics per
each nerve usually achieves the desired
block, (Soeding and Eizenberg, 2009).
Wrist Block

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Lower Extremity Nerve Blocks
Femoral Nerve Block Sciatic Nerve Block Obturator nerve block

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Lower Extremity Nerve Blocks
Saphenous Nerve Block Ankle Block

2015
 Femoral nerve block can be used to 39
provide peri-operative analgesia for
femoral neck fractures or total hip
arthroplasty, (Murray et al., 2010).
 The in plane approach is also commonly
used for femoral nerve block by aligning
the block needle with the ultrasound
beam, (Bhatia, 2011).
 In the out of plane approach, insert a
needle perpendicular to the transducer
and the ultrasound beam, (Bhatia, 2011).
 Usually we use no more than 20 mL of
local anesthetic solution and as little as 10
mL in some occasions, (Franco, 2010).
Femoral Nerve Block

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 Most surgical procedures of the foot 40
and ankle, as well as in knee surgery
in combination with femoral nerve
block, (Suresh et al., 2010).
 It can be performed by gluteal
(transgluteal), popliteal, proximal
thigh (mid-femoral) or subgluteal
approach.
 For anesthesia 1.5% mepivacaine plus
1:400,000 epinephrine provides 3-4
hr. of anesthesia. For longer duration
0.5% ropivacaine can be used. For
analgesia 0.2% ropivacaine is
appropriate, (Franco, 2010).
Sciatic Nerve Block

2015
 It is rarely performed alone. It is 41
more often combined with femoral,
lateral femoral and/or sciatic
blocks, (Franco, 2010).
 Out of plane technique from distal
to proximal is the best approach,
(Franco, 2010).
 Inject 5-10 mL of local anesthetic in
each of the 2 intermuscular fascial
planes, (Bhatia, 2011).
Obturator Nerve Block

2015
 It's often coupled with popliteal block for 42
foot and ankle surgery, (Sites and Spence,
2007).
 For in plane approach, insert a needle
parallel to and in line with the transducer
and the ultrasound beam, (Bhatia, 2011).
 The out-of-plane approach is also
commonly used for saphenous nerve
block, (Bhatia, 2011).
 If the saphenous nerve is visualized (a
predominantly hyperechoic structure),
inject 5-10 mL of local anesthetic around
the nerve, (Bhatia, 2011).
Saphenous Nerve Block

2015
 Terminal branches of the sciatic nerve in 43
the ankle region are, (Bhatia, 2011):
 Tibial nerve.
 Superficial peroneal nerve.
 Deep peroneal nerve.
 Sural nerve.
 Local anesthetic injection can be
extremely painful or even impossible in
foot injuries with extensive and diffuse
cutaneous and subcutaneous trauma or
foreign body impaction, (Chin et al., 2011).
 Usually 5-8 mL of local anesthetic is
injected, (Bhatia, 2011).
Ankle Block

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Thoracic and abdominal nerve blocks
Transversus Ilioinguinal / Lumbar Paravertebral

abdominis plane Iliohypogastric (Psoas Compartment) Thoracic
(TAP) block Nerve Block Block Paravertebral Block

2015
 This block is indicated for any lower 45
abdominal surgery including
appendectomy, hernia repair, caesarean
section, abdominal hysterectomy and
prostatectomy, (Karim Mukhtar, 2009).
 A needle is inserted in-plane with the
transducer, in an anterior-posterior
direction, (Bhatia, 2011).
 A total of 20-30 mL of local anesthetic
(e.g., ropivacaine 0.5 to 0.75%) is injected
into this plane on each side. The maximum
recommended dose of local anesthetic (3
mg/kg of ropivacaine, (Bhatia, 2011).
Transversus abdominis plane (TAP) block

2015
 Blockade of the ilioinguinal and 46
iliohypogastric nerves is indicated
for analgesia following inguinal
hernia repair, (Bhatia, 2011).
 Insert a needle parallel to and in
line with the transducer and the
ultrasound beam , (Bhatia, 2011).
 A total of 10-20 ml of local
anesthetic is injected into this
plane, (Bhatia, 2011).
Ilioinguinal / Iliohypogastric Nerve Block

2015
 It is a reliable method for anesthesia 47
and analgesia of hip, and the anterior
aspects of the inner and outer thigh
as far as the knee, (Murray et al.,
2010).
 A needle is aligned out-of-plane to
the probe placed in the transverse
plane. The longitudinal plane is used
to verify the needle placement close
to the plexus, (Capdevila et al., 2008).
 20-30 mL of local anesthetic for
surgical anesthesia or postoperative
analgesia, (Bhatia, 2011).
Lumbar Paravertebral (Psoas Compartment) Block

2015
 Single paravertebral blocks primarily 48
have been used for patients
undergoing breast surgery with and
without axillary dissection, inguinal
and umbilical hernia repair, and
thoracotomy and video assisted
thoracic surgery, (Kevin et al., 2012).
 In the classic approach, the needle is
advanced in plane and medially ,
(Kevin et al., 2012).
 15-20 mL of local anesthetic is
injected slowly in small increments
into the thoracic paravertebral space
), (Bhatia, 2011).
Thoracic Paravertebral Block (PVB)

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Complications of regional anesthesia
Complications
Complications Related to
Related to Local Complications Application
Anesthetics Related to US Waves Techniques

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Complications of regional anesthesia
Hypotensive /
Infection Bradycardiac Events

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 Central Nervous System (CNS) Toxicity. 51
 Cardiovascular Toxicity (CVS) of Local
Anesthetics.
 Direct Chemical Exposure to Local
Anesthetics:
 Intraneuronal Injections.
 Intravascular Injection.
 Subarachnoid or Epidural Injection.
 Cervical Sympathetic Chain.
 Recurrent Laryngeal Nerve.
 Phrenic Nerve.
 Myotoxicity of Local Anesthetics.
 Allergic Reactions to Local Anesthetics.
Complications Related to Local Anesthetics

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 Recognition (Signs of severe 52
toxicity).
 Immediate management.
 Treatment:
 In circulatory arrest.
 Without circulatory arrest.
 Follow-up.
Treatment of Systemic Toxicity of Local Anesthetics

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 Immediately: 53
 Give an initial intravenous bolus
injection of 20% lipid emulsion 100
ml over 1 min.
 Start an intravenous infusion of 20%
lipid emulsion at 1000 ml/h.
 After 5 min:
 Give a maximum of two repeat
boluses of 100 ml.
 Continue infusion at same rate but
double rate to 2000 ml/h if indicated
at any time.
 Do not exceed a maximum
cumulative dose of 840 ml., (Cave et
al., 2010).
An approximate dose regimen for a 70-Kg patient

2015
 The potential biological 54
consequences of the irradiation of
tissues with US will depend on the
total amount of energy deposited
per unit mass of tissue, (Stoylen,
2010).
 The use of equipment with
unnecessarily high output
intensities or any unnecessary
prolongation of exposure
durations, can be and should be
avoided, (Brown, 2009).
Complications Related to US Waves

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 Mechanical Trauma to the Nerve.

 Mechanical Trauma to the Pleura.
 Mechanical Trauma to the Vessels.
Complications Related to Application Techniques

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 Risk factors for catheter- related 56
inflammation include:
 Intensive care unit admission.
 Catheter duration of more than 48
hours.
 Male sex.
 The absence of prophylactic
antibiotic at the time of insertion.
 Operator experience, (Neal et al.,
2009).
Infection

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 Possible aetiologies of HBE included 57
β1-agonist effects of exogenous
epinephrine and activation of the
Bezold-Jarisch reflex.
 This reflex occurs when the
combination of decreased venous
return and heightened sympathetic
tone leads to forceful contraction of
a near empty left ventricle, with
consequent parasympathetically
mediated arterial vasodilation and
bradycardia, (Neal et al., 2009).
Hypotensive / Bradycardiac Events (HBE)

2015
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Summary
In this essay we threw light on application of ultrasound in blockage of the brachial plexus by
four techniques which are interscalene, supraclavicular, infraclavicular and axillary brachial plexus
block.
Lower extremity nerve blocks are becoming an excellent anesthetic choice for lower extremity
surgery, a number of highly efficacious peripheral nerve block techniques can be used to
provide excellent surgical anesthesia and good postoperative analgesia in patients undergoing
wide variety of surgical procedures.
Nerve block for thoracic and abdominal regions can be used in surgical anesthesia and also as
postoperative analgesia as in cases of thoracic operations to enhance return of respiratory
functions after thoracic and upper abdominal surgeries by preventing pain and also by
decreasing the doses of postoperative opioids used to control pain.

2015

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Ultrasound Guided Regional

Ultrasound guidance has become popular for performance of regional

Ultrasound Guided Regional Anesthesia 11 December

Updated reviews are studied to show the

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Upper Limb Nerves Lower Limb Nerves Trunk Nerve Plexuses

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

 Lateral Cord Branches

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

SACRAL AND COCCYGEAL PLEXUSES

Ultrasound Guided Regional Anesthesia 11 December

Thoracic and Abdominal Nerves

Ultrasound Guided Regional Anesthesia 11 December

Molecular Mechanism Pharmacodynamics Pharmacokinetics

Ultrasound Guided Regional Anesthesia 11 December

Molecular Mechanisms of Local Anesthetics

Ultrasound Guided Regional Anesthesia 11 December

Molecular Mechanisms of Local Anesthetics

Ultrasound Guided Regional Anesthesia 11 December

Pharmacodynamics of Local Anesthetics

Ultrasound Guided Regional Anesthesia 11 December

Pharmacokinetics of Local Anesthetics

Ultrasound Guided Regional Anesthesia 11 December

The Nature of Generation and US Characteristics of Performing Ultrasound-

Ultrasound Guided Regional Anesthesia 11 December

The Ultrasound Nature

Ultrasound Guided Regional Anesthesia 11 December

Generation and Detection of US Waves

Ultrasound Guided Regional Anesthesia 11 December

US Characteristics of Needles for Nerve Block

Ultrasound Guided Regional Anesthesia 11 December

Performing Ultrasound Guided Nerve Block

Ultrasound Guided Regional Anesthesia 11 December

Axillary Block Suprascapular Block Supraclavicular Block Interscalene Block

Ultrasound Guided Regional Anesthesia 11 December

Elbow and Forearm

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Mid Humeral Block

Ultrasound Guided Regional Anesthesia 11 December

Elbow and Forearm Block

Ultrasound Guided Regional Anesthesia 11 December

Ultrasound Guided Regional Anesthesia 11 December

Femoral Nerve Block Sciatic Nerve Block Obturator nerve block

Ultrasound Guided Regional Anesthesia 11 December

Saphenous Nerve Block Ankle Block

Ultrasound Guided Regional Anesthesia 11 December

Femoral Nerve Block

Ultrasound Guided Regional Anesthesia 11 December

Sciatic Nerve Block

Ultrasound Guided Regional Anesthesia 11 December

Obturator Nerve Block