1. Lower Extremity and Trunk Ultrasound Guided Blocks Andrew Biegner CRNA, FAAPM Anesthesia Staffing Consultants Hillsdale Community Health Center Hillsdale, MI

2. Lower Extremity Regional Anesthesia Blocks Lumbar Plexus Psoas Compartment Nerve Block Psoas Compartment Nerve Block Sciatic Nerve Block *Femoral Nerve Block *Saphenous nerve *Saphenous nerve Lateral Femoral Cutaneous Nerve Block Fascia Iliaca Block *Popliteal Fossa Block Obturator Nerve Block Ankle Block

3. Lumbar Plexus Anatomy Genitofemoral Lower branch L1 and branch of L2 Lower branch L1 and branch of L2Obturator Anterior divisions of L2, L3 and L4 Anterior divisions of L2, L3 and L4Femoral Large branches of the posterior divisions L2 and L3 Large branches of the posterior divisions L2 and L3 Posterior division of L4 Posterior division of L4 Lateral Femoral Cutaneous Small branches of the posterior division of L2 and L3 Small branches of the posterior division of L2 and L3

7. Femoral Nerve Block

8. Produces anesthesia to the anterior portion Upper leg Upper leg Medial calf Medial calf Results in inability Abduct the leg Abduct the leg Extend the lower leg Extend the lower leg Adjunct for postoperative pain relief

9. Femoral Nerve Block Indications Surgical procedures of the anterior thigh Complete or partial analgesia to: Painful conditions of the upper leg Painful conditions of the upper leg Femoral shaft and neck fractures Femoral shaft and neck fractures Knee surgery Knee surgery

12. Femoral Nerve Anatomy 1. Inguinal ligament 3. Femoral vein 4. Femoral artery 5. Femoral nerve 10. Adductor longus muscle

13. Femoral U/S Nerve Block Patient position Supine or recumbent with groin exposed Supine or recumbent with groin exposed Transducer location Placed axially between the inguinal crease to the inguinal ligament Placed axially between the inguinal crease to the inguinal ligament In-Plane approach Needle size 100mm 100mm LA volume 20 ml 20 ml

14. Femoral Nerve Block Landmarks Landmarks

15. Femoral Nerve Block* Landmarks Landmarks

16. Femoral Nerve Block Complications Intravascular injection Hematoma Direct nerve injury

17. Popliteal Fossa Nerve Block

18. Popliteal Fossa Diamond-shaped area bounded Provides innervation to distal lower extremity Except medial aspect of the leg Except medial aspect of the leg Saphenous nerve Contains Posterior tibial nerve Posterior tibial nerve Common peroneal nerve Common peroneal nerve Abundance of fat Abundance of fat Connective tissue Connective tissue Popliteal vessels Popliteal vessels

19. Popliteal Fossa Nerve Block Indications Foot and Ankle Surgery Foot and Ankle Surgery Improved tourniquet tolerance over ankle block for foot surgery Improved tourniquet tolerance over ankle block for foot surgery For complete anesthesia / analgesia below the knee combine with Femoral nerve block or Femoral nerve block or Saphenous nerve block Saphenous nerve block

22. Popliteal Fossa U/S Nerve Block Patient position Supine, prone or lateral decubitus Supine, prone or lateral decubitus Transducer location Popliteal fossa crease Popliteal fossa crease In-Plane approach Needle size 50 mm 50 mm LA volume 20 ml 20 ml

23. Popliteal Nerve Block: Anatomy External & Internal Landmarks External & Internal Landmarks

24. Popliteal Nerve Block: Anatomy External & Internal Landmarks External & Internal Landmarks

25. Popliteal Fossa Ultrasound Nerve Block: Positioning ProneLateral

26. Popliteal Fossa Nerve Block Complications Intravascular injection Intraneural injection Block failure

27. Saphenous Nerve Block

28. Saphenous Nerve Block Indications Medial lower leg surgery Ankle surgery Medial Medial Used with popliteal fossa block for complete anesthesia / anesthesia of lower leg

30. Saphenous U/S Nerve Block Patient position Supine with thigh and leg externally rotated Supine with thigh and leg externally rotated Transducer location Transverse Transverse In-Plane approach Needle size 50 mm 50 mm LA volume 10 ml 10 ml

31. Saphenous Nerve Block Anatomy

32. Saphenous Nerve Block*

33. Blocks of the Trunk TAP Para vertebral Intercostal Rectus sheath block

35. Transversus Abdominus Plane Block (TAP)

36. Transversus Abdominus Plane Block (TAP) Indications Lower abdominal procedures Hysterectomy C- section under GA Abdominoplasty

37. Transversus Abdominus Plane Block (TAP) Landmarks Triangle of Petit Triangle of PetitAnteriorly External Oblique External ObliquePosteriorly Latissimus Dorsi Latissimus DorsiInferiorly Illiac Crest Illiac Crest http://www.usra.ca/sb_tap

38. Transversus Abdominus Plane Block Patient position Supine Supine Transducer location Transverse between the margin of the 12 th rib and superior iliac spine Transverse between the margin of the 12 th rib and superior iliac spine In-Plane approach Needle size 100 mm 100 mm LA volume 20 - 30 ml bilaterally 20 - 30 ml bilaterally

39. Transversus Abdominus Plane Block http://www.usra.ca/sb_tap

40. Transversus Abdominus Plane Block http://www.usra.ca/sb_tap

41. Successful U/S Regional Anesthesia Time management Monitoring Use 27g needle and pH adjusted local for skin wheels Music....headphones for the patient Use a Ultrasound machine

42. Successful U/S Regional Anesthesia Needle selection Small movements of the needle Evaluate frequently and touch-up early Identification of difficult landmarks

43. Successful U/S Regional Anesthesia Use rabbits feet, rubbing stones, beads, and other totally ridiculous luck charms.

44. Questions / Comments mnnavycrna@aol.com C: 517-607-5969