Table Of ContentUltrasound-Guided Regional
Anesthesia
A Practical Approach to Peripheral Nerve
Blocks and Perineural Catheters
Ultrasound-Guided Regional
Anesthesia
A Practical Approach to Peripheral Nerve Blocks
and Perineural Catheters
Fernando L. Arbona
Babak Khabiri
John A. Norton
Illustrated by Charles Hamilton and Kelly Warniment
CAMBRIDGE UNIVERSITY PRESS
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Arbona,FernandoL.
Ultrasound-guidedregionalanesthesia:apracticalapproachto
peripheralnerveblocksandperineuralcatheters/FernandoL.Arbona,
BabakKhabiri,JohnA.Norton.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN978-0-521-51578-8(Hardback)
1. Conductionanesthesia. 2. Operativeultrasonography.
3. Ultrasonicimaging. I. Khabiri,Babak. II. Norton,JohnA.,
1971– III. Title.
[DNLM:1. NerveBlock–methods. 2. Anesthesia,Local–methods.
3. Anesthetics,Local. 4. Catheterization,Peripheral–methods.
5. PeripheralNerves–ultrasonography. 6. Ultrasonography,
Interventional–methods. WO300A666u2010]
RD84.A732010
617.9064–dc22
2010008737
ISBN978-0-521-51578-8Hardback
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Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateand
up-to-dateinformationwhichisinaccordwithacceptedstandardsand
practiceatthetimeofpublication.Althoughcasehistoriesaredrawnfrom
actualcases,everyefforthasbeenmadetodisguisetheidentitiesofthe
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makenowarrantiesthattheinformationcontainedhereinistotallyfree
fromerror,notleastbecauseclinicalstandardsareconstantlychanging
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advisedtopaycarefulattentiontoinformationprovidedbythemanufac-
turerofanydrugsorequipmentthattheyplantouse.
FernandoL. Arbona
Thisbookisdedicatedtomywife,Melissa,andmythreebeauti-
fuldaughters,Olivia,Sophia,andMia,whoprovidemewiththe
love, support, and inspiration that help me in all of life’s
endeavors.
BabakKhabiri
For my parents Badi Khabiri and Mahin Raz Khabiri who
instilled in us a love for learning and helping others; and my
threeolderbrothersRamin,Shahriar,andHoomanwhoshowed
me the way.
John A.Norton
I would like to thank my wife Kavitha for always providing a
foundation of loving support in my professional endeavors, and
our beautiful children, J. P., Meera, and Joshua for their daily
inspiration.
v
Contents
Preface ix
Acknowledgments xi
–
Section 1 Introduction 12 Sciatic nerve block: lateral popliteal
fossa/distal thighapproach 101
13 Femoral peripheralnerveblock 116
1 Pharmacology: local anesthetics and
additives 1 14 Ultrasound-assisted ankle block 125
2 Introduction to ultrasound 10
–
Section 4 Peripheral perineural
3 Application ofultrasound in regional
catheters
anesthesia 24
–
Section 2 Upper extremity peripheral
15 Introduction to continuous perineural
nerve blocks catheters 133
16 Interscalene continuous perineural
catheter 143
4 Upper extremity anatomy for regional
17 Supraclavicularcontinuous perineural
anesthesia 31
catheter 152
5 Interscalene brachial plexus block 37
18 Infraclavicular continuous perineural
6 Supraclavicularbrachial plexus block 49 catheter 160
7 Infraclavicular brachial plexus block 58 19 Sciatic continuous perineural
catheters: proximal and lateral
8 Axillaryperipheral nerve blocks 68
popliteal fossa 170
9 Additional upperextremity peripheral
20 Femoral continuous perineural
nerve blocks 78
catheter 182
–
Section 3 Lower extremity peripheral
nerve blocks
Index 191
Freeaccesswebsiteatwww.cambridge.org/arbona
10 Lower extremity anatomy for regional
containingnumerousultrasoundloopsandvideo
anesthesia 83
clipsshowingnerveblockandperineuralcatheter
11 Sciatic nerve block: proximal techniques being performed.
approaches 89
vii
Preface
Ultrasound guidance in regional anesthesia provides techniquesisprovided.Forthebeginner,thesechapters
real-time imaging during the placement of nerve areimportant,andtheyarewrittentobeeasytofollow
blocks and perineural catheters, improving patient with information and nomenclature that will become
comfort, decreasing many procedure times, and commonplaceasyouimplementultrasoundintoyour
revealing valuable anatomic information, which may practice.
enhance patient safety. It therefore comes as no sur- Themiddle sectionsofthetext(Sections2and3)
prisethattheuseofultrasoundinregionalanesthesia discuss the placement of ultrasound-guided single-
continues to grow in popularity, opening new doors shotregionalblocksthatcanberoutinelyusedinmost
to physicians in their practice where barriers may busy anesthesia practices. Section 2 focuses on upper
have once existed. As regional anesthesiologists, we extremity peripheral nerve blocks, while Section 3
have written this text for residents, fellows, and staff turns to blocks of the lower extremity. Each chapter
physicians desiring to learn and begin incorporating is introduced with a discussion of pertinent anatomy
the use of ultrasound into the scope of their busy in the block region. An understanding of anatomical
practices. structures and relationships is key when ultrasound
This book introduces the use of ultrasound tech- imaging is undertaken during scanning and block
nology for the placement of peripheral nerve blocks placement. All chapters provide specific instruction
andperineuralcatheters.Ourgoalinwritingthistext onblockselectionandsetup,needlepositioning,local
wastoprovideaneasy-to-readsourceofinformation anestheticinjection,andtroubleshooting.
with particular attention to the steps and detail Section 4 includes chapters detailing the practical
involved with ultrasound imaging, as well as block placement and positioning of continuous perineural
and catheter placement. cathetersunderultrasoundguidance.Wefeelthisisa
We have organized the text into four major unique feature of this text.
sections, beginning with chapters to introduce basic While we do summarize procedures for quick,
concepts in regional anesthesia including local anes- easy reference, portions of each procedural chapter
thetics, ultrasound physics and imaging, as well as arewrittenasiftheinstructorwerethereperforming
anatomy. The chapter on local anesthetics is written the block with you. Further, our “Key points” or
to convey basic pharmacologic concepts about the “Additional considerations” paragraphs outlined
medications commonly used in peripheral nerve within the text of each chapter are there to provide
blocks. Multiple, more in-depth sources other than additional hints, reminders, or instructions, which
thistextareavailableforreview.Ourintentionhereis mayimproveblocksuccessorenhancesafetyinyour
to introduce agents common to the practice of practice.
regional anesthesia with concise, retainable informa- Much of the information in these chapters we
tion for anesthesiaproviders. draw from our own experience as instructors at a
Theintroductiontoultrasoundisdividedintotwo major academic medical center and a fast-paced
separate chapters (Chapters 2 and 3). The first of ambulatory setting. The “Authors’ clinical practice”
thesechaptersdiscussesbasicprinciplesofultrasound sections highlight our own personal practice and
physics and imaging, while the second covers the opinions regarding topics covered in the preceding
current utilization of this technology in a regional chapter.Wedevelopedthesediscussionsasa“seehow
anesthesia setting. An in-depth discussion of probe we do it” section for quick, easy reference at the end
ix
manipulation,imageoptimization,andtroubleshooting ofeachchapter.Thesearetheanswerstoquestionswe
Preface
are often asked when teaching these techniques. later for quick and easy review. And just as we teach
Though we do not attest that this is always the pre- our residents, we advocate becoming proficient
ferredorbestwaytoachieveaspecificdesiredresult, with single-shot peripheral nerve blocks utilizing
wehavefoundthepointsmadeinthesediscussionsto ultrasound before attempting perineural catheter
bemost efficaciousin our own practice. placement.
Forthosenewtoultrasoundinregionalanesthesia This book was written to organize and convey to
anda particular block approach,we find thebestuse others the instruction we use and teach in our daily
ofthisbookisinreviewofthedetail-orientedsections practice. If you are interested in picking up an ultra-
prior to undertaking new techniques. Summary soundprobetoassistwithyournextperipheralnerve
sections within each chapter can then be referred to block, this book was written foryou.
x
