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Ultrasound Guidance in Regional Anaesthesia This page intentionally left blank Ultrasound Guidance in Regional Anaesthesia Principles and Practical Implementation SECOND EDITION Peter Marhofer, MD Professor of Anaesthesia and Intensive Care Medicine Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria 1 1 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York © Oxford University Press 2010 The moral rights of the authors have been asserted Database right Oxford University Press (maker) First edition published as Ultrasound Guidance for Nerve Blocks, 2008 Second edition published 2010 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose the same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data Data available Typeset in Minion by Glyph International, Bangalore Printed in Great Britain on acid-free paper by Ashford Colour Press Ltd., Gosport, Hampshire ISBN 978–0–19–958735–3 10 9 8 7 6 5 4 3 2 1 Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding. Dedicated to my parents who supported me always This page intentionally left blank Contents Acknowledgements xi Foreword by Professor Admir Hadzic xiii Foreword by Professor Narinder Rawal xv Foreword: The surgeon’s view by Professor Christian Fialka xvii Contributors xix How to use this book xxi Abbreviations xxiii 1 Basic principles of ultrasonography 1 1.1 Nature of sound waves 1 1.2 Piezoelectric effect 2 1.3 Pulse-echo instrumentation 2 1.4 Resolution and electronic focusing 4 1.5 Time-gain compensation 6 1.6 Measuring velocity with pulsed ultrasound 8 1.7 Ultrasound imaging modes 9 1.8 Common image artefacts 14 1.9 Needle visualization 16 1.10 Equipment needed for ultrasound imaging 18 2 The scientific background of ultrasound guidance in regional anaesthesia 21 3 Initial considerations and potential advantages of regional anaesthesia under ultrasound guidance 23 3.1 History of ultrasound-guided regional anaesthesia 23 3.2 Possible advantages of ultrasound-guided regional anaesthesia 24 4 Technique limitations and suggestions for a training concept 33 4.1 Technical limitations 33 4.2 Non-technical limitations 33 4.3 Suggestions for a training concept in ultrasound-guided regional anaesthesia 34 viii CONTENTS 5 Have we reached the gold standard in regional anaesthesia? 37 6 Technical and organization prerequisites for ultrasonographic-guided blocks 41 6.1 Technical considerations 41 6.2 Organization 53 6.3 Post-operative observation 54 6.4 Other considerations 54 7 Ultrasound-guided regional anaesthetic techniques in children: current developments and particular considerations 57 7.1 Management of minor trauma in children 58 8 Ultrasound appearance of nerves and other anatomical or non-anatomical structures 63 8.1 Appearance of nerves in ultrasonography 63 8.2 Strategies when nerves are not visible 66 8.3 Appearance of neuronal-related structures in ultrasonography 67 8.4 Appearance of other anatomical structures in ultrasound 71 8.5 Appearance of artefacts in ultrasound 76 9 Needle guidance techniques 81 9.1 Out-of-plane (OOP) needle guidance technique 82 9.2 In-plane (IP) needle guidance technique 82 9.3 How to approach a nerve? 85 10 Pearls and pitfalls 87 10.1 Setting and orientation of the probe 87 10.2 Pressure during injection 87 10.3 Jelly pad for extreme superficial structures 88 11 Nerve supply of big joints 89 11.1 Shoulder joint 89 11.2 Elbow joint 89 11.3 Wrist 90 11.4 Hip joint 90 11.5 Knee joint 91 11.6 Ankle 91 12 Neck blocks 93 12.1 General anatomical considerations 93 12.2 Deep cervical plexus blockade 93 12.3 Superficial cervical plexus blockade 95 12.4 Implication of neck blocks in children 100 CONTENTS 13 Upper extremity blocks 101 13.1 General anatomical considerations 101 13.2 Interscalene brachial plexus approach 102 13.3 Supraclavicular approach 108 13.4 Infraclavicular approach 111 13.5 Axillary approach 114 13.6 Suprascapular nerve block 120 13.7 Median nerve block 122 13.8 Ulnar nerve block 125 13.9 Radial nerve block 128 13.10 Implications of upper limb blocks in children 130 14 Lower extremity blocks 133 14.1 General anatomical considerations 133 14.2 Psoas compartment block 133 14.3 Femoral nerve block 137 14.4 Saphenous nerve block 140 14.5 Lateral femoral cutaneous nerve block 145 14.6 Obturator nerve block 148 14.7 Sciatic nerve blocks 151 14.8 Ankle blocks 163 14.9 Implications of lower limb blocks in children 169 15 Truncal blocks 173 15.1 General anatomical considerations 173 15.2 Intercostal blocks 173 15.3 Ilioinguinal-iliohypogastric nerve blocks 176 15.4 Rectus sheath block 178 15.5 Transversus abdominis plane (TAP) block 183 15.6 Implications of truncal blocks in children 184 16 Neuraxial block techniques 189 16.1 General considerations 189 16.2 Epidural blocks 189 16.3 Paravertebral blocks 193 16.4 Implications in children 196 17 Peripheral catheter techniques 203 18 Future perspectives 205 18.1 Regional blocks for particular patient populations 205 18.2 Education 205 18.3 Technical developments 206 ix