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https://www.youtube.com/watch?v=9xvEZLSYB2E
Transcript

- Welcome to the Sonosite Behind the Scan webinar,

Regional Block Perfection from Fundamentals

to Advanced Skills with our guest speaker, Bradley Quarles,

CRNA, from Salem Anesthesia.

My name is Chris Pinnell, and I'll be

hosting today's webinar.

Before we get started with this webinar, just to recap

the information in this webinar is

provided for general educational purposes as a supplement

to professional experience, education, and training,

and should not be considered the exclusive source

for this type of information.

At all times, it is the professional responsibility

of the practitioner to exercise independent clinical

judgment in each particular situation.

Fujifum Sonosite assumes no responsibility

or reliability for any misuse of this webinar.

Please be advised all attendees are muted,

and we will be conducting a Q&A session at the

end of the presentation.

And while the presentation is going, feel free

to send those questions in,

and we'll be sure to get to them at the

end of the Q&A session.

If you're on the Zoom stream,

you can type your questions into the Q&A box

and the toolbar located at the

bottom or the side of your screen.

And for our viewers on YouTube

and LinkedIn, you can enter your questions in the chat box

and I'll get those when we get to the que-

Q&A section as well.

This webinar will be recorded

and archived for future reference on our webinars page

and on the Sonosite Institute.

And there's a QR code on the slide right there

where you can scan to visit our webinars page.

To get started, let me introduce Bradley Quarles.

Bradley is a graduate from the University

of South Carolina School of Medicine

and works for Salem Anesthesia in

Greensboro, North Carolina.

For more than 30 years, Salem Anesthesia has

provided uninterrupted anesthesia services at as,

as a CRNA-owned practice, the longest

of its kind in North Carolina.

Bradley is a leader within Sa- Salem Anesthesia,

providing a plethora of ultrasound-guided peripheral nerve

blocks daily, formulating

and im- implementing a multi-

multimodal anesthesia protocol,

reducing patient's narcotic use postopera-

post-operatively and much more.

Bradley was awarded the order of the Silver Crescent

by Governor Harry McMaster,

which is the highest civilian honor in the state

of South Carolina for his work with suicide prevention.

With that, I'll get our presentation started in

just one moment here.

- In North Carolina. And I'm

so thankful for this opportunity.

I want to start this webinar

by thanking all the wonderful people at Sonicite

for reaching out to me to teach this webinar

and all the anesthesia professionals

who played a role in the anesthetist I am today.

Throughout this presentation,

we will discuss some foundational and global concepts,

but we will also touch on advanced topics

and some case studies as well.

So let's begin that by discussing the global benefits

of regional anesthesia.

The bullet points provided here are a synopsis derived from

a research article produced in 2024 titled The Influence

of Regional Anesthesia on the Systemic Stress Response,

and I would refer people to look at that article

for more in depth as it relates to overall information.

But overall, regional anesthesia inhibits the neuroendocrine

response by reducing the release of cortisol

and catecholamines, which maintains hemodynamic stability

and reduces myocardial oxygen demand.

Regional anesthesia also inhibits the sympathetic nervous

system, leading to improved cardiovascular outcomes.

It should also be noted

that regional anesthesia mitigates the inflammatory response

by reducing pro- inflammatory cytokine levels,

reducing the risk of

systemic inflammatory response syndrome, sepsis,

and pulmonary complications.

Regional anesthesia also reduces postoperative pain,

opioid consumption, and the incidence of cardio

and pulmonary complications,

especially in the elderly and high risk patients.

It's largely that I believe that regional anesthesia is the

future of healthcare when it's deemed safe,

and it's not contraindicated based upon the patient's

morbidities on the medications that they're taking

and what they, if they withheld certain medications such

as blood thinners, et cetera.

And as a result of performing a regional anesthesia,

we're really able to care for a larger sector of patients

who are more critical because we do not have to run them

on such a deep anesthetic depth

that it will suppress their sympathetic nervous system.

So it helps out as it relates to more access to care

to patients, and especially elderly obese patients

or cardiopulmonary patients who are the most optimized.

So as healthcare in America continues on in

that our patients are becoming sicker

and sicker, regional anesthesia really has more

of an important role in providing care to people.

And ultimately, regional anesthesia, with all the benefits

that I've discussed, it really helps those

reach their activities of daily living in a

more efficient manner.

And these are some of the overall benefits,

and I love performing regional anesthesia,

and I can't wait to continue to discuss some more

of the benefits and get into

it throughout this presentation.

Now that we have obtained a global 30,000 foot view about

regional anesthesia, let us begin to narrow our focus

to the ultrasound machine

and discuss some key terms that are important to know.

While these aren't all the terms that are important,

I would like to refer viewers

to a research article titled Ultrasound: Basic Understanding

and Lan- and Learning the Language.

Throughout this, throughout this presentation, you'll come

to find that half the battle

with regional anesthesia is just understanding the

terminology and the anatomical terminology

along with the landmarks.

So if you really understand this,

everything else can kind of build.

These are the very foundational concepts.

So let's start off with echogenicity.

It refers to the ability to reflect

or transmit ultrasound waves in the context

of the surrounding tissues.

Whenever there is an interface of structures

with different echogenicities,

a visible difference can be seen and compared

and contrast on the screen.

So based on the echogenicity, a structure can be categorized

as hyperacoic, which means white on the screen,

hypoacoic, which means gray on the screen,

and anechoic, which means black on the screen.

Bone, for an example, appears as black

or anachoic on the ultrasound

with a bright hyperacoic rim.

Because the ultrasound beam cannot penetrate bone,

it casts an acoustic shadow beyond it.

Cartilage, for an example, appears as hypoechoic

and is more penetrable by the ultrasound machine than bone.

Blood vessels appear as black or anochoic.

Veins are usually easily collapsible,

and they also appear as black or anechoic.

Arteries though, they are pulsatile, obviously,

and they're not as collapsible

and they do not collapse at all

with moderate pressure applied by the transducer.

There's a great feature that on the anesthesia ... Oh,

excuse me, on the ultrasound machine

that's the color Doppler,

and there's this acronym called BART,

which means blue away, red toward.

And when we utilize the color doppler, you'll see

that pulsatile flow of the artery as can serve

as a landmark, but when you see the blue going away red

toward, that's an acronym, acronym that you can utilize

as it relates to vein arteries and other landmarks.

Some other key terminology

to know is inplane versus outer plane.

The inplane approach directs the needle parallel

to the probe's long axis, providing a continuous view

of the entire needle from the tip to the entry point.

The outer plane method inserts the needle perpendicular

to the probe, showing the needle tip as a bright b-

bright dot against the long axis of the structure.

Inplane is used when you're trying to see the entire needle,

which is obviously very important

for all our regional blocks,

especially the upper extremity blocks such

as the supraclavicular interscalene,

and those will be featured later on here.

But the outer plane can be used in situations where

you need a different approach

or when space is more restricted, like inserting a catheter

or performing a biopsy in a tight area.

Two other important terms

that I want to talk about are added artifact,

which is an error in the image

and really that just comes with diagnosing what is going on.

Do you need more gel? Is it your contact

with the transistor to the patient's skin?

So that's one thing, but also gain and depth.

Gain will adjust the overall brightness

of the image on the ultrasound machine

by amplifying the return signals, while depth more

so discusses the the depth

of which your ultrasound is looking into the patient's body

habitus and it's looking into the body.

So if everything that you're looking at is very superficial

on the surface, you don't need a lot of depth,

but if something is if you can't examine exactly all

that you need to examine nerve-wise,

you can increase the depth to see that.

And we'll also go into talking about utilizing

linear probes versus curved linear to examine that depth.

So some fast facts about the ultrasound machine.

So ultrasound is a technique

by which images are created utilizing high frequency sound

waves as we see on this image feature below here.

And they're produced by the transducer.

So you put the transducer on a patient's body

and it emits sound waves at your target that you want to view,

and it reverberates back to the transducer,

and that's how you see an image.

The ultrasound transducer produces the sound waves,

and they can either be considered high frequency

or mid-frequency or low frequency.

High frequency probes are preferred for ultrasound images

that are very superficial, meaning very close to the s- skin

like two to four centimeters,

while mid-range frequency probes are

for slightly deeper structures

that are considered like five to six centimeters.

However, when the ultrasound imaging of deep structures such

as somebody who has a large body habitus

or you may have larger tissue to traverse to view something,

such as maybe you're doing an iPAC block

or you're doing a popliteal sciatic block on somebody

who has a larger leg, you may need a low frequency probe.

And this allows you to view deeper into the patient's body

with the ultrasound machine utilizing the transducer.

So really when you're determining the correct choice

between the probes, it's really all based upon the frequency

and the view that's presented, whether it be linear

or curve linear or any of the other transducer types

that you can utilize based upon the required depth

that is necessary to perform your task.

Anatomical positioning.

So this is really important,

and this is where we're starting to begin

to talk about building upon foundational concepts.

If you understand the key terminology, as I mentioned prior,

as well as these anakotomical terms,

you can really build upon your regional

anesthesia skills and knowledge.

So as you see in these images, not only on the left,

we talk about things being distal, proximal, medial,

lateral, superior, inferior, cephalic, call it,

knowing those terms not only in relation to the patient,

but also in relation to the patient and the transducer

and on the ultrasound those are really key.

You have to know what you're talking about as it relates to

the ebb and flow of the ultrasound machine

and really providing

and performing regional anesthesia as an art form.

And how I view it is the transducer is kind of your brush

and you're painting this picture when you perform regional

anesthesia based upon how the local anesthesia spreads

or how the pictures present on the ultrasound machine,

but you, the first key thing is you have to know how

to discuss anatomical positioning.

The other thing is the proper positioning.

I'll go on to discuss further on throughout this

presentation about the importance of positioning,

but I really relay utilizing

different transducers based upon securing an airway.

And the first thing I want to start off by saying here is,

imagine us as anesthetists,

if you're going to secure an airway, one

of the key things is proper patient positioning.

Give them in a sniffing position ensuring

that they can ventilate appropriately, et cetera.

Take that same mindset and that same intent

and apply that to your regional anesthesia blocks.

Having proper patient positioning is paramount to all things

that you do for regional anesthesia

because there's a dance that you have to do with the, you

and trying to visualize things on the ultrasound machine,

but also with the patient.

Make your life easier by positioning them optimally so

that you're not fighting them in a sense, if you will

with their poor positioning,

and you can't view everything you want to.

A lot of the issues can be resolved

with better positioning or optimizing it.

So obviously, so we see the prone, supine,

lateral recumbent, both right

and left, Valors and Trendelenburg.

Mainly predominantly we use the lateral recumbent position

for our lower extremity blocks

and kind of more of a semi-foulers for our interscalent

and supraclavicular blocks.

A lot of that's for airway patency,

while we don't utilize any kind of prone positioning,

always make sure that the patient can ventilate,

but I'll discuss further about how important

patient positioning is,

and I will parallel it very commonly

to securing an airway when we're going off to sleep

with the patient intubating-wise.

So now, building upon that,

let's talk about optimizing patient

positioning and how important it is.

Positioning is paramount.

It's first bullet point,

and I think if you don't learn anything else from this

slide, I think positioning is paramount.

Just be intentional. Take your time.

And the first key to success is setting yourself up

for it, and here we go.

So position the patient for a nerve block

with the same intent as you would if you're going to prepare

to intubate a patient.

Take the necessary time to have the patient positioned just

as you need them to optimize your needle placement

and to facilitate the execution of the nerve block.

You shouldn't rush your positioning when securing an airway,

so don't rush your positioning when you're trying

to perform a regional anesthesia block.

Patient positioning becomes even more important

as the patient's body habitus increases

because you're going to use different kind of a transducer,

maybe using a curve linear, things become

much more distorted if they've had a

prior surgery in the area.

So make your life simple

and make it as standardized as possible.

When positioning the patient,

always consider the patient's ventilatory status such

as if you're using sedative medication,

whether you're using Versed, Fentanyl, Precedex, ketamine,

whatever you may use,

always consider their airway in the process.

So now we're going to talk about executing an excellent nerve

block despite body, body habitus challenges.

There's always going to be challenges as it relates

to securing your airway on an obese patient

or performing a nerve block on an obese patient

or even getting obtaining an IV and obese patient.

And the way I always say is

that everybody looks good when everything is going really

well, but how do you mitigate

and how well do you do when challenges pose themselves, such

as dealing with larger body habitus that you have

to traverse either through needle-wise

or utilize different transducer types.

So let's talk about that

and let's talk about how we can mitigate some of that

and make our lives a little bit easier.

So again, the first bullet point, positioning is paramount.

So to be to expand upon that,

let's talk about ... I'm going to paint you a picture.

I think that's probably the best way for me to do this.

So you're preparing for your next nerve block,

and you're interviewing the patient,

and you examine their kilograms.

And for me, the first thing I think about is, okay,

what kind of block are we doing?

Is it upper extremity or is it lower extremity? Okay.

Once I have that, typically, if it's upper extremity,

I'm always using a linear probe

because the majority of everything is very superficial.

But if we're doing a lower extremity block,

am I going to use a linear probe

or am I going to use a curved linear probe?

And relating everything back to securing a patient's airway,

the way I view it is think of the linear probe

as your macro miller blade

and view the curve linear probe as a glide scope

as it relates to performing blocks on the lower extremity.

For simplicity purposes, let's do a comparison of contra-

and contrasting of a linear and curved linear probe.

For us, with the sunicide ST, the machine that we love,

and you'll see a video about this later on, we have a

curved linear probe, and we also have a linear probe.

So the linear probe is flat

and rectangular in terms of its probe face,

while a curved linear probe is curved.

The frequency of a linear probe is very high, which is good

for superficial structures, things that are very

close to the skin surface.

Curve linear is a low frequency to mid-frequency,

which allows us to see deeper through the patient's skin

and to the target that we need to see.

The image shape for a linear probe is re-

is a rectangular field

of view while the curved linear probe has more of a sector

or like a pie shape

and really practice use the curve linear probe on

individuals just

because you have to train your eye

to the differences in the imaging shape.

As it relates to the penetration,

you'll have poor penetration with a linear probe,

but high resolution at the surface.

With a curve linear, you'll have good penetration

for deeper structures, as I mentioned.

So when would a linear probe be good for?

Patients who are smaller in kilograms, not

that many kilograms, they're smaller patient size,

upper extremity blocks superficial structures,

while a curved linear is better for deeper structures,

abdominal type blocks or imaging OB

or deep musculoskeletal imaging.

So this is where we begin to expand upon

the foundational concepts

and start getting into more of the higher level.

And this, with the nerve anatomy in this image,

it's really essential to understand this

and we'll build upon a little bit further as I talk about

understanding objective versus subjective signs

that our block will work.

And again, this is just an art form with anesthesia.

This is regional anesthesia.

This is really the fun part in my mind.

So understanding nerve anatomy is really important

and necessary for anyone who wants

to perform regional anesthesia on a consistent basis.

Understanding nerve anatomy also keeps the patient safe

as you're a more knowledgeable provider.

In this image, we're examining the nerve from a broad view

as it transitions from the epineurium

to the perineurium to the endonurium.

We gain a more in depth view of

what makes the prephal nerve.

To speak very broadly, peripheral nerves are part

of the nervous system that connect the central nervous

system, our brain and spinal cord, to the rest of our body.

They carry sensory, motor,

and autonomic signals between the central nervous system,

organ, skin, and muscle.

So let's talk about the structures.

So nerve fibers are bundles of myelinated

or unmyelinated axons that transmit an electrical impulse.

Myelinated fibers transfer an electrical singer faster than

those that are unmyelinated.

The myelin sheath will act as an insulator,

and the electrical signal jumps

between the gaps in the sheath called the node of Ron Viera.

This is a process called sultitory conduction.

Unmyelinated axons conduct signals continuously along the

length of the axon, which is significantly slower.

The epineurium is the outer layer of conduct-

connective tissue that encloses the entire nerve.

Encloses all the fasticles, which are the nerve bundles,

and they contain blood vessels that supply the nerve.

It also acts as a cushion against external forces.

A nerve fascicle is a bundle of nerve fibers

or axons within a nerve,

particularly in the preferal nervous system

that are held together by a layer

of connective tissue called the perineurium.

Multiple fasticles along

with other structures form a main nerve trunk

and are surrounded by other sheath known as the epineurium.

Vesicles are the fundamental structure,

structural units of a nerve trunk.

A single main nerve can have many fasticles.

So now let's talk about the endonurium.

The endonurium is a connected tissue surrounding

individual nerve fibers.

The endonurium supports the individual nerve fibers

and contains the blood vessels that supply them.

It helps maintain the internal environment

for the axons and the swan cells.

And lastly, the perineurium.

These are connected tissue surrounding bundles

of nerve fibers called vesicles.

So there are three types of nerves.

We have sensory, motor, and mixed.

So let's talk about sensory.

Sensory nerves carry sensory information from the body

to the central nervous system.

Motor carry motor commands from the central nervous system

to muscles and mixed are just as they sound,

they contain both sensory and motor fibers.

Understanding this image

and how all this works really helps

the practitioner develop the why

behind why a block may work or may not,

and really beginning to understand that art form of

what the patient presents as

and how the block is beginning to take effect, such as

they're starting to feel their arm feel a little tingly

or it's harder to lift up

or whatever pain they had is starting to sus- to subside.

And really also,

once you perform regional anesthesia on a consistent basis,

you'll begin to almost develop a, a tangible sensation

as you traverse through patient's tissues,

but also get into different things such as a local sheath

that we'll talk about in the

popliteal sciatic block section.

So just understanding that anatomy is just paramount

to be a safe practitioner,

but also to understand the why behind everything

as it relates to nerve conduction and regional anesthesia.

So now we'll discuss objective versus subjective

signs of block success.

So when I first started performing regional anesthesia

I really was trying to understand, well,

how do I know a block's going to work?

The obvious sign is that

you're performing a lower extremity block like a popliteal

sciatic block and

after performing the block, the patient has

really the inability to dorsiflex and plantar flex the foot.

And once they lost that motor control, I knew

that in the foot that is, I knew that, well,

the block should be successful.

That's an objective sign that I can see that when comparing,

let's just say, for example, the right foot,

which is the operative foot that I blocked to the left

the left is much stronger

and is, as it was prior, the right foot was prior.

But now that the right foot, the operative foot is showing

that it c- it doesn't have that medical control

and they feel hard, it's heavy for them to move it.

Those are objective signs.

But building upon the last slide,

let's talk more about the why in the nerve fibers.

So anesthesia and performing ultrasound guided peripheral

nerve block is, is an art form like I discussed.

There is a delicate dance which is conducted

between the anesthesia professional and the patient.

Whenever I'm performing a nerve block, I look for subjective

as well as objective signs

that the peripheral nerve block will

work in the operating room.

This slide is extremely important to understand for those

who perform nerve blocks on a consistent basis

because it further reinforces your understanding of the why

behind the changes we see when we're performing a block and

after the block is finished.

In this image, we see local anesthesia

which are the blue dots surrounding a nerve.

Within each nerve, you have an array of nerve fibers,

B fibers, C fibers, A delta, gamma, beta, alpha,

and vascular core,

as you see on this image over here to the left.

The outermost fibers are our B fibers,

which controls our autonomic functions,

and these are the first

to be blocked while our motor function within the A alpha

are the last to be blocked by the local anesthesia.

Therefore, when one is performing a block

and the patient states, "My arm

or my leg is starting to feel tingly, warm or heavy,

or the pain, like I said, is starting to go away,"

then we know based upon this anatomy that you see

of the nerve where the local anesthesia is starting to bathe

and how it's starting to progress throughout it.

So let's talk a little bit more about the nerve fibers.

So A delta fibers are thinly myelinated,

like we discussed last time, fast onset

because of the myelination,

and they transmit information primarily related

to acute pain

and facilitate a withdrawal reflex upon the synapse

and the dorsal horn of the spinal cord.

C fibers are smaller

and they're unmyelinated that require a higher threshold

of stimulus than the A delta fibers.

These are responsible for the slower onset

and deeper dull pain after initial insult.

And they're let's talk about now decreasing dia-

diameter and the velocity.

So you have proprioceptors, you have mechanic receptors,

and you have nociceptors and thermal receptors.

So proprioceptors are the A- alpha and A beta.

The mechanal receptors are A- beta

and L- L- L A delta, excuse me,

and the nosioreceptors

and thermal receptors are Adelta and the C fibers.

When you look at this image here, you'll see

that the thickest nerve fiber is the A fibers.

The thicker a nerve fiber is, the harder it's going to be

for you to get local anesthesia around there,

and that's going to take a longer time for that to have onset.

So as I mentioned, painting another picture for you,

if you're performing a nerve block

and the patient says, "Oh, my arm's starting

to feel a little warm." Well, okay,

or tingling, then we know which nerves are starting to kind

of bathe in this one.

And then as they start to say, "Well, you know, it's hard

for me to start lifting my arm." Well, then, you know,

based upon this picture that is

provided, if they start to, start to lose that

motor control, then you know you've densely started to have

that nerve block surround all these other kind

of nerve bases, and your block should be

successful in the operating room.

So some of the subjective is what the patient tells you.

Like it feels heavy, it feels tingly.

I can start to feel it on my fingers.

Okay, that's subjective. Now we know we're starting

to work a little bit, start at the onset,

but when we start observing the objective of motor loss,

of control, or you start to see that their extremity starts

to become a little more vascular looking,

like you can see their veins more,

or their extremity feels warm due

to regional anesthesia providing a vasodilatory type

process, then we know that we're, that's objective.

We can see that this is starting to really work

and it's going to be just fine for the patient.

So yeah, understanding this slide is paramount

and it really helps you understand the progression of

how the nerve block is flowing throughout them.

And every patient's different.

There's sometimes that you'll do a nerve block

and quickly they'll have a motor response

or they'll lose that motor control

with the same milliamps on the nerve stimulant,

the same target of everything,

but it's just all based upon their anatomy,

their perfusion, et cetera.

And that's some of the challenges,

but also the fun in regional anesthesia

is that it's always different.

The next few slides are ultrasound images of blocks

that I personally have conducted on patients at our center.

This is a popliteal sciatic block, which is evident

by the common peroneal nerve, which can be seen on the left

and the tibial nerve on the right.

They are seen by their honeycomb hypercholic-like image.

Below the tibial nerve is the popliteal artery.

This block is indicated for foot and ankle procedures.

Our podiatrist and orthopedic surgeon will commonly request

this block at our facility.

The patient position for this block is the

lateral recumbent position.

Once the patient is positioned in a lateral position,

we place a pillow in between their legs,

and the first thing I do is place the transducer

behind the popliteal phosphate crease

and the longitudinal orientation with the transducer.

I will first identify the popiteal artery, and

after I identify this,

the tibial nerve should be superior to the popliteal artery.

I will then move the transducer cephalad to watch

for the common peroneal nerve to begin

to meet the tibial nerve.

The part where the two nerves are almost touching is

where I will block the two nerves

by utilizing a nerve stimulator between 0.3

to 0.5 milliamps.

I will commonly use a linear transducer for this block

unless the patient has a larger or more muscular leg.

The image to the right, it shows the ultrasound needle

and the spread of local anesthesia around the tibial nerve.

We call this local spread the donut sign,

as it spreads in a circumferential manner around the nerve.

This portion of the block is a motor block.

Commonly for us, we'll utilize a 22 gauge four inch needle,

short bevel needle that is, for this portion,

and we administer a total of 20 milliliters of 0.5%

bupivacaine with a one to 400,000 epinephrine

as a cardiac marker to ensure, you know,

we're safe for the patient.

Once you perform a lot of these blocks, you'll begin to

become really one with the ultrasound machine

and the short bevel as you traverse through the skin

and through all the tissues.

And the one thing I wanted to mention

how it's like an art form is there's this thing called the

vlocus sheath and it surrounds the tibial

and the common peroneal nerve.

And once you penetrate this sheath

with your ultrasound needle, you almost feel a release.

And when I'm in this space, this is where I ask for the p-

the nerve stimulator to be turned on,

and I have to go all the way up to.

5 milliamps just to see for that motor response.

And the motor response

and the nerve stimulator is really important

to all the motor blocks that we do

because this is another objective sign that I see

what I think I see

and this nerve stimulator is confirming all of this.

It's almost like a double a safety check for the patient,

but also to prove to me as well

that we are correct, we are where we were supposed to be.

And to further expand upon that, if you have a patient

that's of larger body habitus,

and despite optimal patient positioning

and all attempts to facilitate the block,

the nerve stimulator can be your best friend.

And when you get near the nerve,

it will elicit a motor response

and that will help you identify the correct area

and where to inject local anesthesia.

So that's just another tidbit there to kind of help you out.

So just another that's, that's there, that's that there.

And a further note about VLOCA sheath is

that it's a connective tissue that encloses the sciatic

and sciatic nerve that is

and surrounds the main divisions between the tibial nerve

and the common peroneal and the popliteal fossa.

So now, as I mentioned, I'll discuss a case study for this

to get some more mileage out of it.

So the case study is the patient,

this patient here in particular arrived to the facility

for a total ankle replacement by one of our podiatrists.

It was actually the first one done at the facility

which was very exciting

and I really wanted to be a part of the case.

We performed this popliteal sciatic block along

with the saphenous nerve block for this patient,

and we use Exparel based upon how involved the procedure is.

And XPERL is approved for a Dr. Canal static nerve blocks.

The patient received a general anesthetic

after they had the nerve block and pre-op with an LMA.

They were provided 30 mics micrograms of Precedex

two milligrams of Versed was

provided them to them in the preoperative area

for the block, and I gave them the 30 mics

of Precedex throughout the time period

of them being in the operating room.

They got 15 milligrams of Toradol, 100 micrograms

of fentanyl, eight milligrams of Decadron,

and four milligrams of Zofran.

And this is just kind of discussing some

of the multimodal approach of what we do.

The patient was called two days postoperative, five days,

and 10 days postoperatively,

and actually I called them personally where we work

we collect a lot of data as it relates to our nerve blocks

just to keep us honest as to say that we know

that we're doing a good job, but also we want to, we want to see

and hear from the patient as to how did we do.

So it's a constant review.

So we call every nerve block patient

and to ask them how are they doing.

Us from an anesthesia personnel, we call them.

So that way, if we're having some patients

that are more in pain, well, we'll review the ultrasound

images to see how could we have done better.

Actually, with this patient,

with utilizing the Exparel on the block that was

provided to them, believe it

or not, this lady never took a narcotic,

and I, that's exactly why I called her two days

postoperatively five days and 10 days.

And by the fifth and 10th day, I told, I told the patient,

I said, "You know, you don't have to be nice.

You can be honest and tell me if you're in pain or not.

" You know it's been 10 days post the total ankle

and I was looking over the drape

and seeing how involved it was.

They said, no, my pain was at a two at maximum

and ibuprofen took care of my pain.

So this patient received a total ankle

procedure at our facility, the first one,

and never took a narcotic.

Only received a hundred mics

of fentanyl throughout the whole process.

So limited narcotic, but we were we gave a good block,

we used Exparel, and we touched other receptors

as it relates to their pain, and it never took a narcotic.

And that's something I'm really proud of.

I actually talked to the podiatrist last week as to

how the patient's doing,

because it's been several months out.

They're doing great with physical therapy.

So these are some of the things that's a full anesthetic

and even caring about them even

postoperatively to have a call with them.

This is what I really enjoy about the job

and performing regional anesthesia,

that they can have an involved procedure,

but never take a narcotic

postoperatively, so that's really enjoyable.

This next block is a fun one.

This is an ultrasound image of an IPAC block, which stands

for interspace

between the popular artery and the capsule of the knee.

We perform this block along with genicular,

lateral femoral cutaneous saphenous nerve

and nerve to the vastus medialis for our orthopedic surgeon

for knee arthroplasty and cruciate ligament repairs.

The patient positioning is, for this block,

is the lateral recombinant position similar

to the popliteal sciatic.

The benefit of this of the knee blocks that we provide is

that they're all motor sparing.

We don't provide spinal anesthetics at our facility

so it really helps the patient maintain their quadricep

strength for early physical therapy postoperatively.

For these blocks, as it relates to the eye pack,

I'll utilize the curve linear probe

because it helps me look for anatomical structures such as

the femur of the epicondyles the popliteal artery.

It gives a more in depth view,

and that's why I use a curve linear for this one.

Some patients, if they're really thin, I can use a linear,

but I'll lean towards the curve linear transducer.

So I'll place the curved linear transducer in a longitudinal

orientation behind the patient's popliteal crease, just as I

did with the popliteal sciatic block.

I'll slide the transducer cephalad ever so slightly

to find the point where the posterior surface

of the femur begins to show

and form a solid hyperacoic line.

I will place the needle inferior to the popular artery,

but superior to the posterior surface of the femur,

and we'll provide 20 milliliters of quarter percent,.

25% bupivacaine in this location.

When I have the needle in the optimal location,

which is superior to the posterior surface of the femur

and inferior to the popular artery,

I will advance it past the popiteal artery,

and I'll have our wonderful pre-op nurse nurses aspirate

to ensure that we're not any kind of vasculature,

but give five milliliters at a time.

And then I'll move the needle back a little bit,

and then I'll have them aspirate and repeat this process

and administer another five ccs of the quarter percent

of bupivacaine, all the way up to 20 ccs.

It's very interesting when you look at images as to

how unnervated the knee is,

because our overall goal is

to anesthetize the small articular sensory nerves from the

popliteal plexus and the obturator nerves

which will result in anesthesia of the posterior capsule

of the knee, and it's very unnervated.

This is the iPAC block is one

that you really cannot skip if you're trying to

provide a good service to a patient

receiving larger knee surgery.

And I want to talk about a case study for this.

One is actually a kind of a funny story.

So the patient is, was actually around kind of my age,

so it led to a very good experience preoperatively,

kind of building a relationship with the patient.

So the patient skated and they skied a lot

and during the summer and the winter months

which ended up leading to their knee injury.

They were a really nice patient.

And so the first time I met the patient took care of them

and I wore this tie-dye cap

and performed the knee block, had a really good experience,

called them, doing really well.

And the next time, lo

and behold, they come back for the next knee,

but I didn't know they were going to have their next knee,

and I see them in the pre-op bay,

and he said, "Man, what happened?" I'm

like, "What's, what are you talking about?

" You know, and he's like, "Where's your tie-dye cap?"

So I go back to the locker room, I put on my tie-dye cap

to give him another knee block,

and this is actually of the second knee block that I

provided, but these are some of the relationships

that I enjoy in the preoperative setting that

I think helps calm patients down with the,

the nerve block experience,

and just performing that that rapport with your patients.

And that's, that's all something I really enjoy

preoperatively, not just the postoperative outcomes,

but developing that relationship

with patients preoperatively.

So we

provided this, the iPak along with the plethora

of other blocks that I discussed moment,

moments ago for the knee procedure.

He was having to appreciate ligament repair did really well,

but I tell you, we don't do any spinal anesthetics at our

facility, our orthopedic surgeon doesn't ask for them due

to all the blocks that we provide that are motor sparing.

But what's interesting is I've worked at facilities

where we provide a spinal along with all these blocks,

but without, without the spinal, I can honestly

say there is no sympathetic stimulation.

When you make surgical incision,

once you perform all these blocks this patient

was 28 years old.

You know, I provided 40 mics of Precedex

to this patient throughout the time period of the procedure,

just because I wanted to ward away any kind

of emergent delirium issues, gave them 100 mics of fentanyl

two milligrams of versa preoperatively, eight milligrams

of Decadron and four milligrams of Zofran.

They received an LMA

with general anesthetic and sevoflurane.

They did fantastic both times.

Both times called them

postoperatively, pain score out of three.

But the iPAC is really the essential block

to ensure patient comfort

intraoperatively and postoperatively.

This is the same patient from the prior slide,

but I wanted to include this in here

because these are some of the additional blocks

that we provide for our orthopedic surgeon as it relates to

these larger knee procedures.

And so what we're looking at here is an ultrasound image

of the patient's artorius muscle, which forms a roof

over the patient's femoral artery,

which can be seen in the middle of the image.

The hypercholic nerve, which is immediately lateral

to the femoral artery, is the saphenous nerve.

Usually I'll provide 10 milliliters

of 0.25% bupivacaine at the saphenous nerve.

And when you approach the saphenous nerve,

you'll almost feel this release.

Again, this is that art form

and really beginning to have a tangible experience

with performing the regional anesthesia.

You'll f- and that's the vastuaductor membrane

that you're penetrating there

that you'll feel like this release and that's that there.

The hypercoag nerve that is lateral to the saphenous nerve

is the nerve to the vastus medialis.

With this one, I will have, utilize the nerve stimulator

and place the electrode on the patient's thigh,

and I'll ask our wonderful pre-op nurses

to turn the nerve stimulant to 0.5 milliamps,

and we'll examine for a twitch on the patient's thigh.

And once I see that twitch, I'll inject another

10 milliliters of the 0.25% bupivacaine here

for further coverage of the patient's knee

and the surrounding medial

and anterior portions of the operative area.

This is an ultrasound image of an interscalene block.

The patient position for this is a semi-sitting

like semi-Fowler's position with the head rotated

to the opposite side of the operative extremity.

There, these are some of my favorite blocks to perform due

to the complexity of them,

but also the images

that can come from a well-done block as well.

The block is performed for shoulder arthroscopies

and total shoulders, which we perform at our center.

The goal here is to spread local anesthesia

around the superior

and middle trunks of the brachial plexus in the interscalene

space between the anterior and middle scaling muscles.

For this block, I'll use a 22 gauge, two inch needle,

and we'll give 15 milliliters,

but honestly, it really depends upon the

patient's kilograms.

I kind of stop at 20 milliliters at maximum if they're

larger kilograms and if they're, you know, they can handle

that, but commonly I'll remain at 15 milliliters.

I utilize our nerve stimulator on all of our mot-

motor blocks, as I mentioned prior.

Like I said, this is another objective way

that I can ensure patient safety, especially in this area

where you're dealing with a lot of the

vital structures here, as well

as the phrenic nerve, et cetera.

You really want to make sure you can visualize

your whole needle here.

I'll use a linear transducer for this block,

and we begin by placing the transducer in a transverse

orientation over the patient's neck, two

to three centimeters superior to the clavicle

and over the external jugular vein.

This is an end plain block,

and as you advance your needle, I will examine

for the nerve stimulation of the patient's arm.

I'll ask a pre-op nurse to aspirate,

and once we've develo- obtained optimal placement,

we'll inject five milli- five milliliters, a.

5% bupivacaine in increments up to 15 to 20 milliliters.

We'll commonly utilize Exparel for these blocks as well,

since they're approved for it.

And let's talk about a case study for this interscalene.

So this patient actually sat story was

they damaged their shoulder by dropping their

coffee, believe it or not.

And when they tried to reach for their coffee,

they put their hand out

and everything kind of ... They braced themselves

with their hand, but everything kind of

reverberated back up to their shoulder.

And here we were, that was kind of, I said, you know,

"You just got to let the coffee go.

You can come back to Starbucks." We

provided this patient interscalene block.

We gave them two milligrams of Versed

throughout the process of providing the block.

I did provide this patient 0.1 milligrams of glycopyrrolate

and four milligrams of Zofran

as we were rolling into the OR.

There's research that if you provide four milligrams

of Zofran, you can blunt some of the

peripheral serotonin receptor activation,

and this patient's surgery was

to be conducted in a B chair position,

and I wanted to inhibit the Besogiris reflex, as it's noted

that the Bezogiers reflex can be stimulated

and activated by peripheral 5-HT3 or serotonin receptors.

The patient was provided a general anesthetic

with a general ET tube

and they were relaxed due to their positioning.

100 micrograms of fentanyl was

provided, 20 micrograms of Precedex

and eight milligrams of Decadron was also given.

They woke up with a numb arm and no pain.

Their block lasted them three days.

And one of the fun things that I like to do

with the patient sometimes is to I'll ask, you know,

how well can you move your shoulder?

And then after we block them, I'll

sometimes have them say like, you know,

"How well can you raise up your arm now?" And some

of the great things they're like,

"I can't raise my arm at all.

" You know, they've really developed that motor block

and that goes back to that slide discussing how well

that local anesthetic is starting to bathe some

of those inner and very thick nerve fibers.

So the next time after listening to this lecture,

which I'm very appreciative of those who are,

next time you perform a nerve block, begin to examine how

that nerve block begins to progress.

And as they start to discuss some of the subjective things

that they feel, and then once they start to develop

that motor response goes away,

or if you start to notice

that their extremities becoming warm, all

of these things refer back to slide 10,

and you'll begin to see

how the block has really progressed throughout.

It's really, really interesting,

but the patient had a great result

and next time just drop the coffee, don't worry about it.

This is an ultrasound image

of a supraclavicular nerve block.

We perform these blocks for our hand surgeon as our goal is

to anesthetize the trunks

and divisions of the hypoechoic oval structures

called the brachial plexus.

The patient position for this is semi-sitting, just

as I mentioned for the last one,

like a semi-Fowler's position with the head rotated

to the opposite side of the operative extremity.

The initial landmark by which I will place the transducer

is at a transverse orientation approximately at the midpoint

of the patient's clavicle.

The brachial plexus will be visualized laterally

and superficial to the subclavian artery,

which is the main landmark for this block.

The subclavian artery will appear

as an anachoic round structure.

The pleura is a hypercholic linear structure visualized

below and on both sides of the artery.

The first rib is a hypercholic linear structure located deep

to the sapklavian artery.

These are key landmarks we want to identify

and we do not want

to advance our ultrasound needle anywhere past these

structures as the pleural can be penetrated.

When performing this block, tilt the transducer codully

toward the chest to obtain a view of the subclavian artery

and insert the needle in plain

while maintaining a very shallow depth, again,

to be very conservative

and you don't want to get anywhere near the pleura.

When you enter the plexus sheath,

you will feel this nice release.

Again, that's kind of that art form of learning

how things feel tangibly with your ultrasound needle.

And then this is where you turn on your nerve stimulator

and you'll examine a motor twitch response,

which will indicate you're in the correct location.

I'll then ask the pre-op nurse, as I always do, to aspirate

and provide five millimeter increments of 0.5%

bupivacaine up to 25 milliliters.

Again, it all depends upon the patient's kilograms

whether we give them more or we give them less.

But it's important to inject some local anesthetic

around the lower trunk of the brachial plexus

to ensure a block coverage of the median

and ulnar nerve occurs.

So once you get the needle to the lower trunk,

then I usually withdraw my needle carefully

and provide local anesthesia around the middle

and upper trunk so they receive full coverage.

This is a very satisfactory block as well, just

because of really just looking at those bundle of grapes

of the brachial plexus is very fun to do.

I actually performed one of these blocks today

and an interscalene block today, so that's kind of fun.

But this block in particular, as well as interscalene

and with all blocks, it's very important

to visualize your whole entire needle,

especially the distal tip of your needle just due

to the vital structures that are around there

and really utilizing all the proper body mechanics

and ensuring patient positioning

and you really have to be squared away with this block just

because you don't want to penetrate the pleural.

And as you see in these pictures you can see the

ultrasound needle on the right.

The left one is just an initial photo

where you can see those two hypercholic

lines, as I mentioned.

You can see the subclavian in those bundle of grapes,

but on the right image, you can see that ultrasound needle,

even the distal tip of it, as I'm kind

of right in the middle trunks, I would say there.

So supraclavicular blocks, they're really fun to perform

but you always have to just visualize your needle.

That's the biggest takeaway there.

So I like to discuss a case study

for the supraclavicular block.

So this patient was to undergo a left proximal

row carpectomy.

This patient was prof- provided a supraclavicular

block in the pre-op area.

Again, I gave them two milligrams

of Versed for patient comfort.

There are times where I don't always provide patients

two milligrams of Versed.

Sometimes I may provide them some Precedex.

It all depends upon their age or how they may present to me,

or I may provide more than Precedex excuse me, Versed,

and I may provide them Precedex in addition to the Versed.

As I will discuss in a free future slide,

there is a multimodal aspect to providing medications such

as Precedex, or dexmitomidine, and dexamethasone,

or AKA Decadron, as it relates to

prolonging a block, as well as its effects on really

just making it more a profound block.

But this patient was provided two milligrams

of Versed for patient comfort.

I provided the patient 25 milliliters of 0.5% bupivacaine.

The patient was taken back to the operating room.

They were provided an LMA

with general anesthesia, no relaxation.

For this case, eight milligrams of Decadron was

provided, 15 micrograms of Precedex, four milligrams

of Zofran and 100 micrograms of fentanyl.

The patient reported a pain score of two on post-op day two.

Procedure was very involved

but again, utilizing this multimodal eight milligrams

of Decadron, you, and you all have probably seen this trend

now where there's some Decadron is some Precedex

in the picture there, just

because of its positive effects on the nerve block

and local anesthesia spread.

So this is a really fun portion of the presentation here,

and we get to talk about how we utilize the Sonosite STs

features to facilitate a nerve block.

We're about to play this video for you all,

and it's me scanning one of my colleagues,

and one of my favorite features

of the Sonosite ST machine is the Activate Voice feature.

The pre-op nurses really get a kick out of it

because they know when I really like a

block, I save a lot of images.

But also it's really cool

because you could use the color Doppler

and it really has made things more streamlined,

and I think you all really enjoy this video,

but I really wanted to show off how great

of a product Sonosite has produced

with this Sonosite ST machine, so enjoy this video here.

Hey, everybody.

Bradley Korls here, nurse anesthetist with Salam Anesthesia.

Just want to take a moment to talk about some

of the features that we enjoy with the Silencite ST machine,

as it helps facilitate a lot of the things that we do

to provide a patient a great experience when

they're receiving their nerve block.

I have my colleague here laying down

and we're going to examine his popular artery

and his common peroneal tibial nerves.

So we really enjoy this image.

We can see the popular artery bounding there,

so we'll say activate voice, color on.

You can see that there. Color off.

Okay, so we'll just do an initial picture.

So we'll say image save. Okay?

Let's say, as we see them sort

of bifurcate here and come together.

Okay, starting to film that local sheath here momentarily.

Now, if we like this image, we'll say image save.

We can even say brighter, brighter, darker,

darker, okay?

And then we'll scan more distal. Clip save.

And this will save a video for you to tell the story of

how they were bifurcating

and they came together with the two nerves to give you

that populace block.

So as you can see, that these are some of the features

that we really enjoy with the ST machine,

and it really helps us facilitate as well as tell the story

of the nerve blocks that we provide.

This is a great thing because it helps us study the nerve

blocks after we perform them so

that we can get extra mileage and learn,

and that way we can better

impact our patients in the future.

We hope you enjoy the machine as much as we do.

Thank you so much. So now we're going to discuss

multimodal anesthesia.

So as I mentioned in some of the case studies,

and you've probably noticed the trends of the utilization

of Decadron or dexamethasone and Precedex or dexmitomidine.

So we utilize two medications

to enhance our peripheral nerve blocks.

Dexmetomidine, also known as Precedex, prevents the firing

of new action potentials.

These action potentials are what generate further eliciting

of nerve stimulation.

So it prevents that new firing.

It also has an effect on C fibers,

and its facial constrictive properties via alpha-2

adrenergic receptor activation near blood vessels extends

the effect of the local anesthetic.

So those are all great key features there.

Also helps smoothen out your anesthetic synergistically

meaning that, you know, it helps the patient emerge from

anesthesia more smooth due to the fact

that Precedex will inhibit norepinephrine release,

and norepinephrine is our stimulus

for arousal or being awake.

It kind of keeps them nice in that bay.

It's a very smooth anesthetic with Precedex.

Commonly, I'll use. 25 mics per kilogram

for emergent delirium,

but it all depends upon really

what the patient is presenting to you on the monitor.

If it's a a very dense early block, then

if they're not showing you any sympathetic signs for you

to utilize Precedex, then you don't use it.

That's why sometimes I will utilize Precedex in the

preoperative area where maybe the patient will

be a little bit nervous.

I'll give them a little Precedex

to go ahead and get it on board.

But it won't, but once you make that transition

to the general anesthetic

and everything's more relaxed, sometimes it's harder

to work in that Procedex as a result

of its alpha-2 properties.

The next medication that we utilize is

dexamethasone or Decadron.

It prolongs the peripheral nerve block duration

and reduces pain via anti-inflammatory properties.

We give all of these medications

systemically, meaning through the IV.

We don't put any of these medications in our

actual syringes.

There's been data that's come out that says it's equally

efficacious if you just utilize it systemically.

So that's what we utilize.

For Decadron, you know, we'll use four eight milligrams,

but we really tend towards giving eight milligrams.

A lot of our patients preoperatively will get a hundred

they'll get a, a, a gram of Tylenol

and 300 milligrams of gabapentin.

So there's a lot

of multimodal anesthesia occurring at our facility,

and I work at an ambulatory surgery center.

So of course, you know, the whole key there is just to

have smooth emergencies enhance recoveries

after surgery, limit nausea, limit

limit fluid retention or urinary retention.

So all of these things really just help

facilitate the flow of the patient.

And I think the one thing that I was learning

as a new anesthetist is

that it's a different mindset when you work in these

ambulatory outpatient surgery centers

because your focus a lot is on the recovery

and the the PACU.

But as one anesthetist told me once,

your wake-up begins in pre-op and that's never left me,

but these are some of the great medications that we utilize

to help facilitate the multimodal anesthesia,

but also the great outcomes we enjoy

with the regional anesthesia.

So now let's talk about the future of regional anesthesia.

I think regional anesthesia is really going to begin

to have more of a role in the overall care being

provided in America.

I think as our patient populations become sicker,

and when it's not contraindicated

and the comorbidities allow for regional anesthesia

to be administered, I think it will be beneficial

to administer it and to facilitate to allow the patient

to have this nerve block

because you're blocking the pain right at

the source of generation.

If the patient's hypers- hypertensive, you know,

providing regional anesthesia prevents them from being in

pain, more hypertensive if their cardio

have cardiovascular supply demand issues,

you limit the sympathetic nervous system response

and release so they won't have such a higher heart rate,

not putting a demand on the heart

so they have better oxygen delivery as it relates

to pulmonary patients, you know, who have lung issues

allowing them to take a deep breath

to prevent atelectasis is essential.

So all the major vital organs

and really just preventing the overall cascade

of histamine cytokine release that occurs from pain

is it's a second to none.

I think regional anesthesia is only going to have more

of a profound role to play in overall care of the patient.

But I do believe newer drug additives will become on the

market to prolong the block duration.

I discussed a few of them, Exparel, Decadron, Dixmetomidine,

such as Precedex in this presentation,

but of course, like everything else,

there will be new things that will come out.

I think that's going to help out with performing nerve blocks.

I think new nerve block techniques,

which will better target our surgical sites will come on

to the foray of options that you can provide to a patient

and more widespread knowledge of ultrasound machine

among all medical professionals.

And I think that's really essential.

I think more knowledge,

and this is why I'm so thankful for this webinar

and to have this opportunity, is just

because I get to play a role in

that in helping spread some knowledge about the ultrasound

machine and

how regional anesthesia can benefit patients in various

populations, so I thank sinusite for that.

And I think also there'll be increased acceptance

of regional anesthesia and its benefit to the patient.

Sometimes regional anesthesia can have you know,

it can appear as though we're trying, we're,

we're slowing things down

or you have to fit it into the schedule.

But it's essential for patient outcomes

and care in their, in their recovery after surgery.

And it's all about the patient. It's all about the patient.

It's all about the patient laying in the bed

and the ability to

eliminate all these negative effects of them taking

narcotics postoperatively.

I'm not saying that regional anesthesia is the magic,

the magic wand that no patient will ever take a narcotic

again postoperatively.

Some patients may have to take a narcotic and that's okay.

But it vastly reduces it.

They have a better patient experience

with regional anesthesia.

It's my hope that you all enjoyed this as much

as I enjoyed crafting it,

and let's just keep advocating for the patient,

keep seeking great patient outcomes.

And I thank everybody, and Ithana site for this opportunity.

So thank you all very much.

- All right. Thank you so much, Bradley.

I think it's time for our Q&A section.

It looks like we've had quite a few

questions come in so far.

And Bradley, you've been doing a great job

of answering those throughout the

presentation, so thanks for that.

Is there anything else that you want to kind of talk about

with regards to your blocks that you do?

- No. Can you hear me okay? - Yeah, it sounds great.

- No. Thank you all for tuning in today.

This is a huge honor and thank you again to Sonosite

and Salem- Salem Anesthesia

and all the people who've helped me get here today.

No, I don't have anything really more

to add other than I really enjoy doing it.

You see the benefits of providing it.

I know a story I can tell about last week was

that this lady came in she essentially,

what she told me, now her arm was all banj- bandaged up, was

that she got in a car crash

and her thumb was, I mean, poking out of her, her, the bone

of her thumb was poking out performed a supraclavicular

block for her, and it literally had the effect on her

as if placing an epidural in a laboring woman.

You could just see her just kind of melt

and f- in her eyes,

you could see the patient becoming more comfortable.

And I think that's what I enjoy about it.

You can just you have, there's a lot of subjective signs

that the patient demonstrates, but also the objective.

And ultimately, there's nothing better than having a pretty

involved procedure

and the patient waking up feeling comfortable.

And to provide that is, it's really cool

and it's really interesting to do.

And that's what I really enjoy

most about regional anesthesia.

And it's, it's just always a challenge.

It can always be a challenge and nobody's ever the same.

I, I think one of the people within the Q&A

was asking, "Do you usually do the femoral condyles

or do the shaft?" And it all really depends as to

what the patient's anatomy is and how they present.

I can't say that I empirically do all of one thing

or give everybody all the same haircut.

It all depends upon when I place

that transducer upon the patient, what is presented,

and we tackle it from there.

And it's really just a dance between you, the patient,

and utilizing that transducer as your your pain brush

and try to perform it as best as possible.

Well,

- That's awesome, Brad.

Thanks so much for joining us.

It doesn't look like we have any more questions coming in.

So look like we're a little bit past the hour here,

but thanks so much for joining us today, Bradley.

Really appreciate it. Everybody else like we said,

we're going to have this recorded

and up on the Sonosite.com/behindthscanwebinars page,

and you can go ahead

and scan that QR code there to go right there.

And it'll also be up on the Sonosite Institute as well.

So once again, thank you so much, Bradley,

for taking the time to put together this presentation

and hanging around to answer questions and stuff for us.

We really appreciate you sharing your expertise.

- Well, thank you so much, and I appreciate all the great

team at Sonaside, and thank you for the great products

that help us deliver great results

for our patients. We appreciate it.

- Awesome. Thanks so much. We'll see

you guys at the next webinar. Thank you.

- Thank you.

This Sonosite Behind the Scan webinar, “Regional Block Perfection from Fundamentals to Advanced Skills,” shows how ultrasound-guided regional anesthesia can strengthen perioperative care—from the first probe placement to advanced decision-making in real cases. You learn why regional anesthesia matters beyond pain control: it can help blunt the stress response, supports hemodynamic stability, reduces inflammation, and lowers opioid use and related cardiopulmonary risk—benefits that become even more important as patients present with higher acuity and more comorbidities.

The educational webinar builds practical skills step by step. It reviews essential ultrasound language and image interpretation (echogenicity, artifacts, gain, depth, Doppler, in-plane vs out-of-plane needle approaches) and connects those fundamentals to safe, consistent block performance. You also learn how to choose the right transducer for the job—especially when deeper targets and larger body habitus demand different imaging strategies.

A major takeaway is the role of patient positioning. The webinar frames positioning with the same intent you use for airway management: set up correctly, protect ventilation when sedation is used, and make the block easier, safer, and more reproducible.

You then move into applied block technique with clear ultrasound examples and workflow tips for common procedures: popliteal sciatic, iPACK and adductor canal–regional blocks for knee surgery, and interscalene and supraclavicular blocks for shoulder and hand cases. Case studies highlight opioid-sparing outcomes, motor-sparing strategies for early mobilization, and how objective and subjective signs confirm block success. You also learn how multimodal medications (given IV) can extend and strengthen analgesia.

Finally, the webinar demonstrates Sonosite ST features—like voice activation, image/clip capture, and Doppler—to streamline scanning, document findings, and support ongoing learning and quality improvement.

What You'll Learn

  • Brief overview of the benefits of regional anesthesia
  • The importance of proper patient positioning
  • Performing ultrasound guided peripheral nerve blocks on various body sizes
  • Utilizing Sonosite ST’s features to promote patient safety
  • The positive impact of intraoperative multimodal medication administration on postoperative outcomes
  • The future of regional anesthesia and its impact on patient care
Bradley Quarles, CRNA, professional headshot portrait in clinical setting
Presenter: Bradley Quarles
Job title: MNA, CRNA

Bradley Quarles, MNA, CRNA is a graduate from the University of South Carolina School of Medicine and works for Salem Anesthesia in Greensboro, NC. Bradley is a leader within Salem Anesthesia, providing a plethora of ultrasound guided peripheralnerve blocks daily, formulating and implementing a multimodal anesthesia protocol, reducing patient's narcotic use postoperatively and much more. Aside, Bradley was awarded the Order of the Silver Crescent by Governor Henry McMaster, which is the highest civilian honor in the state of South Carolina for his work with suicide prevention. His advocacy for suicide prevention while he was a student at USC has led to the signing of the "Student Identification Card Suicide Prevention Act" which took effect July 1, 2022.

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This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.