Transcript
- Welcome to the webinar today on ultrasound guided regional
anesthesia for hip surgery.
Before we begin, please be advised all attendees are muted.
You may type your questions into the q
and a box in the toolbar located at the bottom
or side of your screen at any time.
We will conduct a q and a session at the end
of the presentation and live demo.
This webinar will be recorded in archived
for future reference with us today,
we have Dr. Richard Teams.
Dr Teams is a dedicated anesthesiologist
with a unique background in nursing who excels in working
with trauma and critical care patients.
He trained at the busiest trauma center in the US
and has exceptional regional skills
and ultrasound technique in multiple nerve block modalities.
He is currently the director
of regional Anesthesia at John Peter Smith Hospital, as well
as National Clinical Director
of Regional Anesthesia at Envision Physician Services.
Dr. Teams is an officer in the United States Army
Reserve Medical Corps.
His clinical interests include acute pain management,
regional anesthesia, advanced airway techniques,
and cardiovascular and anesthesia.
He has a genuine interest in enthusiasm
for teaching clinical and acute pain regional anesthesia,
and is a bilingual English Spanish patient advocate.
Thank you so much for being here today with
with us Dr Teams.
And with that, I'll turn it over to you.
- Thank you very much, Laura.
It's very nice to be with you and good afternoon
and good evening to everybody.
I'm really happy to, to be here to,
to do this next series in the behind the scan.
Today we're gonna be talking a lot about hip procedures,
hip fractures, and also hip arthroplasties
and how to do really good regional anesthesia
for these types of procedures.
There's some other types of procedures that also kind
of falls into the category of the blocks
that we're talking about, and I'll try
to highlight them here today.
So without further ado, let's kind of go into this
and we're gonna do some live scanning
and we're gonna do a little bit of
education on particularly two blocks.
The first is let's just go over what the options are.
So historically, PO IV pain medications, grandma falls,
breaks her hips, what do we give her?
We gork her out on narcotics, right?
We can also do spinal anesthetics.
This is pretty popular throughout the United States,
sometimes plus minus using derm work just like in the OB
population to help manage postoperative pain
for hip surgeries.
But then we come into these other blocks,
fascia iaca blocks, also known as FI block.
So if I, if I say FI blocks as I'm, I'm referring
to fascia icca blocks,
and then this newer block, which is ping block.
And I'll be talking about both of these today
and I'll show you how to scan both of them
and what the nuances are for each
of these two different nerve blocks, modalities,
but also when one is more important
to use versus another 'cause.
There there is a little bit of that.
So if we look at the indications for some of these,
so clearly hip surgeries, femoral rods,
nails, hardware removal, hip fractures,
and then even anterior lateral skin grafts can be used,
particularly with the fascia ICA block.
Maybe not so much for the P block,
and we'll talk a little bit about that.
But first what we're gonna do is I'm gonna talk about the
fascia ACA block, and then we will scan the fascia ACA block
and then go in and do the P block.
So first of all, fascia ACA block, it's known
as the three in one block
where three nerves can be numbed or blocked.
Primarily you've got the femoral nerve,
the lateral femoral cutaneous nerve.
Those two nerves are pretty reliably blocked
with a fascia block.
The third nerve, the opterator nerve may
or may not get blocked.
It's, it sometimes it does, sometimes it's not.
The, the, the, the amount of distance
that local anesthetic has to traverse in order to get a lot
of the ator nerves,
and particularly a lot of the ones
that are gonna be used in hip surgeries may
or may not get blocked,
but pretty reliably lateral fem cutaneous
and femoral nerve blocks.
And those are particular branches, particularly
of the femoral nerve
that dive deep into the hip capsule are the ones
that are gonna get blocked when you do a fascia AKA block.
Okay. Now, fascia aka block is more of a high volume block.
I usually use about 50 mls,
and this is an example of what you can use.
So I'll dilute 30 mls
of 0.5% ropivacaine down to 0.3%,
which is basically adding 20 ccs of saline to 30 ccs
of 0.5% ropivacaine, and that will gimme 50 ccs total.
You can also use BPI gain.
That's a, that's another good option as well.
And then let's go, I'm gonna rely, I'm gonna go back to this
slide a second time because it is really important
and critical to understand what fractures, what
nerve dermatomes of the femur itself can
and reliably get, get blocked
by these various different blocks.
So you have 50% of our
fractures are gonna be, you know, femoral neck fractures,
and then you have intra enteric fractures,
which makes up a pretty good percent.
But then you have the sub trocanter fractures or,
or more of the shaft of the femoral or the of the femur.
Now a fascia iaca block can reliably get all three types
of these fractures, okay?
But a ping block,
and I'm gonna refer back to this again when we talk about
ping block, A ping block is really only gonna be pretty
reliable for the first two, meaning the femoral neck
or intract enteric femoral fractures, but is not,
however, gonna be really effective
for a subtrochanteric femur fracture.
So if you're doing like a femoral nail
because they're, you know, it's a subter fracture,
you're better off doing a fascia IA block
because of the nerve distribution of a ping block.
And we're gonna get into that.
But fascia IA block is gonna block most
of the femoral nerve, including all those articular branches
that dive into this proximal part of the femur
and get all the, the nerves that, that,
that interate this part.
That's why it's gonna be effective for all three of these.
Okay? There are clearly some limitations
to doing a fascia block.
One of them, if you're doing this for hip arthroplasties,
you know, a lot of our orthopedic surgeon colleagues really
like having our patients ambulate pretty quickly
after those hip arthroplasties.
Well, if you do a fascia block,
you know you are getting the femoral nerve and so
because you're getting the femoral nerve,
you're gonna get those, the quad weakness that comes along
with it, which can be a limiting factor for doing a lot
of PT after after surgery.
So that's one of the limitations for fascia block.
When we go in and talk about pain block, that's actually one
of the benefits of a pain block is that you miss a lot
of those motor neurons.
And so it's kind of the, if you will,
the the adductor canal block of the hip
because with a pain block, you're, you're missing a lot
of those motor neurons of the femur.
And we'll get into that here in a little bit.
But when we talk about fascia ACA blocks,
what we're really covering,
and this is how this works, if you can imagine that the,
the, that syringe actually pointing superiorly as opposed to
where it's kind of going as a,
like a, a femoral nerve block.
But going superiorly,
that local anesthetic will go into the iliac fossa,
which is all that area that's highlighted in yellow
and what lays on top of those, the muscles,
there are those three nerves, particularly the femoral nerve
that is coming from the, the lumbar plexus as well
as the lateral femur cutaneous nerve.
All right? And that's where, that's
where the magic happens with this block.
That's where the local anesthetic works,
is it works up in the iliac fossa,
even though we're injecting more coddly, if you inject it,
if you aim it superior medially, it's gonna,
that local anesthetic is going to go up towards
that iliac fossa and get those nerves.
Now I really like this cartoon kind of showing a little bit
of what the anatomy is here.
So you have the muscle that's just at the bottom here,
which is the iliac as muscle.
And then to the right, you obviously see the vessels
and you see the femoral nerve.
Well the fascia ICA covers the
iliacus muscle
and then it also covers over the top of the femoral nerve.
So you can see that there's one continuous fascial plane
there that is continuous,
that encompasses where the femoral nerve is.
And that's actually how you get a lot
of the femoral nerve weakness is
because it is inside that fascial plane, that little muscle
that's kind of poking out to the far left,
that's the sartorious muscle.
And we're gonna be talking quite a bit about the sartorious
muscle and using that as an anatomical landmark.
When we look for, and we scan for this nerve block,
but here is another anatomy of that.
You can see the live from cutaneous nerve coming off
to the far left and you see the
femoral nerve coming straight down.
And then you got some of those operator nerves
coming out as well.
That, again, like I was saying,
because of how far that local anesthetic has
to traverse up the so as muscle,
sometimes it can be a little challenging
to get the ator nerve.
So when we talk about scanning for a fascia block,
I always talk about home base,
and I'll use home base, the term home base quite a,
quite a bit here because it will be the same for P block.
Home base is just a place that everybody can go to
that everybody's very familiar with.
Everybody is very familiar with doing, for the most part,
doing a femoral nerve block.
You go to the inguinal crease, scanned medially
until you see the vessels, particularly the femoral artery.
And then just lateral to the femoral artery,
you're gonna see the femoral nerve.
So from there, what you can do is scan laterally
very slightly.
And actually I'm gonna see if I can,
I'm gonna use this little highlighter.
Let me, let me try something. Here we can, there we go.
I'm sure everybody can see my little highlighter there.
So here we got our femoral artery here,
we got our femoral nerve,
and then just laterally this little nick right here
of a muscle, this is the sartorious muscle.
And you can see kind of what I call the pyramid
of the iliacs muscle,
but just lateral to that is gonna be our sartorious muscle.
So from here you can just scan, start scanning laterally
until you see more and more of the sartorious muscle.
When you see more and more of the sartorious muscle,
what you wanna do is rotate your probe
until it's pointing towards the umbilicus like this.
Okay? There's another scanning technique,
which doesn't use the home base,
but it's basically starting from the A SIS
or the anterior superior iliac spine coming a
little bit off of it.
And then where the inguinal ligament is,
and then putting your probe in this orientation
and then just kind of scanning medially
until you start seeing sartorious and the inter inter
and the inter oblique or the internal oblique muscle.
That way it's a, it's a,
it's, that's the classic bow tie sign
that we usually talk about quite a bit when we're talking
about the fascia aka blocks.
So this is what this kind of looks like using
that other cartoon superimposed our probe here
you have the ultrasound probe pretty much bisecting the,
the inguinal crease in the inguinal ligament.
And then our needle is gonna go from coad
to cephalad aiming towards the
umbilicus, which is right here.
Okay? And what that does is
that's gonna push our local anesthetic CE lab.
It's gonna push it up into this iliac fossa,
which is right here, which is where all those
nerves kind of live.
And there are a lot more proximal there
as you can see in this image.
Okay? And then if you look at it, I really like this slide
'cause it shows kind of what, what's happening here.
I you put your needle.
So coad is gonna be the sartorious muscle,
which is this muscle here, cephalad.
This is gonna be our internal bleak muscle.
And basically my,
and this is the iliac as muscle down
below my lo my needles going
through the sartorious muscle,
and it is going cephalad
underneath this internal bleak muscle.
And you can see it here down below.
This is kind of the, the tip of the sartorious muscle.
You penetrate the sartorious muscle, you get
underneath the fascia yaka,
and then you start your local infiltration
and you track your needle a little bit more cephalad
underneath the internal bleak muscle.
So this local anesthetic is gonna dive down in,
and you clearly can't see it in this image,
but it's diving down into that iliac fossa
and it's getting those nerves.
It's basically bathing all of those nerves.
Here's another cartoon showing that.
So you have the needle going through.
This is actually our bow tie.
So there's a bow, this is the tie,
this is the, this is the bow.
Now I get a lot of people,
and I get a lot of questions about this, like, well,
I can't really see the bow tie.
I can't, you know, I just, it's really hard for me,
you know, how, how can we make this a little bit better?
I'm gonna talk about that here just in the next slide.
But, but this is how
you know your needle positioning should go.
And I always, always, always go
through the sartorious muscle
and I pop out the other end of the sartorious muscle,
because if you do that, you're always gonna be
underneath the fascia ia and not in between it
or on top of it, which is what you wanna try to avoid.
If you go through and through the sartorious muscle,
you're almost assured to get in underneath
that iliacs muscle.
A lot of times people will get above the fascia ia,
which your block won't be very efficacious.
Now this slide I intentionally didn't label which side is
coda and which side is cephalad, okay?
But this here is our iliac muscle, okay?
And this line here is our fascia ica.
Now you can see in this image there's two distinct bow ties.
You can see this one looks like muscle.
This makes, this makes a lot of sense.
I can understand this is muscle, this is clearly muscle,
this looks very, but if you go over on this side,
this looks a little bit more schmutzy, we'll call it.
It's a little bit more granular.
And actually what what's happening here is this is a little
bit more adipose tissue, a little bit more
of a fatty fattier muscle.
A lot more fat will show up more hyper coic like this.
And this is why a lot
of people I think get really frustrated with the bow tie is
because they'll see this,
but this will just look like schmutz.
Well, this here is your sartorious muscle.
And the cool thing about the sartorious muscle is it always
sits right on top of the iliac muscle.
And no adipose tissue accumulates between this fasci layer.
Okay? That's a really cool ultra sonographic finding
that is consistent regardless of your patient's body habits.
It is always, always, always gonna be like this,
where the sartorious sits right on the iliac muscle
with no adipose tissue in between
versus the internal oblique,
which is normally a little bit more
of a fattier muscle anyway.
And then you can get this accumulation of fat
underneath the internal oblique
and makes it look like this, makes it look really schmutzy.
So 95% of our patients, this is what you're gonna see.
It's gonna look just like this, okay?
And I don't care if you're a bodybuilder
or not, you're always gonna have some amount
of adipose tissue accumulation here.
And this is why this is not gonna look the same.
As a matter of fact, this image comes off of a patient
who was 32 years old and a BMI of 28.
So clearly not a big patient,
but you can see the discrepancy
and the difference here on the, on the, the muscles.
Okay? This is a muscle,
but a lot more adipose tissue versus
this, which is not so much.
So, okay, this is actually one of my most favorite images
of, of all my collection.
And the reason why this is one of my favorite images is
'cause when I was deployed to Fort Hood many years ago,
I taught 'em how to do fascia yaka blocks.
And this was actually a picture that someone sent me, one
of the soldiers sent me after I taught them.
And I had, and I had left, and they said, is this right?
Is this the right, am I doing this right?
Am I putting the local anesthetic in the right spot?
And I saved this and I put this in my slides
because the answer is yes, it is.
And you can see here, they put their needle
through the sartorius.
This is the sartorious muscle right here on the left
and on the right, this is the internal oblique.
But the key is, is they got underneath the fascia ileka.
A lot of times when you do this block, you'll see this,
this, we call it speculation.
It looks very, it looks, you know, like a lot of, a lot
of people might think it's muscle
and they're inside the muscle.
But what's really happening here is this is actually
connective tissue.
'cause the fas ICA sits on top of the iliac muscle.
Well, when you put local anesthetic in between the,
the fascia and the muscle, the,
there's still connective tissue there.
And so that's what this is.
This is just a little bit of connective tissue connecting
the muscle to the fascia ileka.
And so when it separates,
you get a little bit of this going on.
All right, I'm gonna go back just to this slide
because one thing I I like to tell people is a lot
of people ask, well, how far up should I go?
A lot of times you'll see these vessels,
these are called the deep circumflex, iliac arteries are,
and vessels that are, that are here
underneath the internal obl, I'll usually put my needle up
to where, where those
vessels are just right underneath them.
And that's where I stop and I start my infiltration.
And then maybe when I have 10 more ccs left to go,
I'll slowly back my needle up
as I'm injecting, as I come out.
Okay? So this is, this is actually,
after they've done that, this is all local aesthetic
and they're actually backing up.
And you can see local anesthetic going over
top of the internal bleak.
This is exactly how that goes.
So what we're gonna do now is we're gonna scan the fascia
and I'm gonna kinda show you how to scan that.
Okay? So let's come here
and let me get, get this ready,
just like that.
Very good. Okay, so,
so we talked about home base.
Home base for this is gonna be the femoral nerve block.
Okay? So that's what I'm gonna do.
I'm gonna, I'm gonna put the probe right here in the
inguinal crease, which is right there, and very nice.
So you can see pumping artery. Okay, looks really good.
And then just lateral to that, I'm gonna,
I'm gonna do this real quick.
So here's my artery here.
This is my, this is my femoral
femoral nerve right here.
And if I start scanning laterally, I'll start seeing this.
This is my sartorious muscle, okay?
You see that little wedge right there?
That's my sartorious muscle.
Now, one big pitfall
to this block is some people will be too cephalad.
If you're too cephalad, your sartorious muscle goes away.
And I'm gonna show you that right now.
So I'm gonna scan cephalad.
Now, look, if I go medial, I can still see my artery,
I can see it still see my nerve.
But when I go lateral, look, I don't see,
I don't see the, the muscle at all.
And the reason why is
because the sartorious muscle attaches to the A SIS,
which is what I'm pointing to right here, okay?
And because it attaches there, if I'm, if I'm
above it, I'm never gonna see it.
So I, I wanna make sure I'm in the inguinal
crease when I do it.
And I'm gonna scan lateral,
let me go a little bit more caught out.
There we go. So I'm gonna scan lateral
until I see my sartor muscle, which I see it right here,
kind of p poking out.
Whoop, sorry, right there. I'm seeing it right there.
Now from there, all I'm gonna do is I'm just gonna rotate my
probe until now it's pointing towards the umbilicus.
Okay? So here you can see my
sartorious muscle here.
We can clearly see some vessels here.
Now, up here, notice the difference.
So this looks a little bit more schmutzy then this,
this is, this is normal.
Okay? So this is actually my bow tie sign.
So this is my sartorious here.
This is my deep circumflex iliac vessel,
which is right there.
I'm gonna move this arrow outta the way,
but that is classic bow tie sign.
And then where I would put my needle
is I go right here.
Okay? What I'm gonna do is I'm gonna track my needle co add
to cephalad, so superior medially.
Okay? So basically my needle is,
is aiming up towards the bolus.
Now, if I go back here to this image, this right here,
this line is my fascia ica.
Okay? So I'm gonna try to go through the tip
of the sartorius underneath it,
but just on top of it, this iliac muscle, once I start,
once I get my needle there, I start my infiltration
and the, the iliac muscle will drop,
and then I'll just advance my needle superiorly until I get
to about right here underneath those circumflex vessels.
Now, once you get there
and you've started infiltrating, you're gonna see
that iliac muscles start dropping, okay?
And, and opening up with all the local anesthetic.
And then you'll see the local anesthetic keep going up
cephalad, okay?
Up here into the iliac faucet.
We'll just keep diving down in there.
One cool thing you can do, and I'd recommend you doing
after you've done this block is go back to home base.
Okay? Go back to home base and find your femoral nerve,
because if you've done this block correctly,
you'll see your femoral nerve floating in a bath
of local anesthetic, okay?
Because it's underneath the fascia aca, okay?
One question I always get is, well,
why don't I just do a really lateral femoral block?
It's a lot easier. That's the question I always get.
And, and it's true, it is easier
because again, finding home base is pretty easy.
So what people say is like, okay,
well I have my artery here, I have my nerve here.
Well, why don't I just put my needle right
here and then just go there?
Will that work? And the answer is yes,
it probably will work.
But one of the beauties of doing the bow tie sign is I'm
directing my local anesthetic superiorly.
And the reason why that's important is
because there's a lot of little articular branches
that come off of the femoral nerve
and they dive deep into the hip.
And when you, when you push it up,
cephalad into the iliac faucet, it's gonna get those nerves.
Whereas when you put it right here laterally, it may
or may not go up into up cephalad to in order to get that.
Okay? So that is why I advocate doing the bow tie sign.
Once I get sartorious, I rotate around and there we go.
I see my sartorious here on the left,
I see my internal bleak on the right,
and then I can just go up
underneath the probe in plain going this way with my needle,
and then I'll put, show it on the ultrasound here, go
through the tip of the sartorius,
make sure you get under the fascia just on top
of the muscle, and then push my local anesthetic
superior medially towards the bolus.
All right? And that's gonna get all those, all those nerves.
Okay? So
what I'm gonna do now is I'm gonna switch gears just a
little bit and we're gonna go over P blocks, alright?
And which is kind of the new and vogue block.
Everybody likes hearing about it.
Everybody likes talking about it,
and it's a real fun block to do.
So, P block actually was invented by a guy named by Dr.
Pang Th Pang is actually his name back in 2018.
He kind of described the anatomy of this.
And so it's, it's referred to
as the Peric capsular nerve group,
or peri capsular end nerve group is another way I've heard
it being said.
But the key of this is it gets these articular branches
of the femoral and the ator nerve.
We talked a little bit about the ator nerve
before when we were talking about the fasci block,
but we're gonna talk a little bit about more about it
here again.
Now I'm, as I mentioned, I'm going back to this image
that I showed you about hip hip fractures, okay?
Now, if you're doing a hip arthroplasty, it's,
it's gonna be fine to use either a fascia or a ping block.
But here for, for hip fractures,
it's gonna be really important
that the fracture is either one of these two.
It's either a femoral neck or a intra panter fracture.
If it's a subter fracture, a P block is not gonna work.
And the reason why it's not gonna work is
because what we're blocking are the articular branches
of the ator and the femoral nerve,
and they terminate on the greater trocanter, okay?
They don't really go past the greater trocanter a whole lot.
So if I have a, a sub trocanter fracture,
those nerves are gonna be inter that that fracture
and that part of the femur is gonna be innervated
by branches of the femoral nerve
that come off a little bit more distally, all right?
Whereas the ones we're getting here are ones
that have broken off from the femoral layer,
a lot more proximal.
Okay? But, so for a P block, femoral neck fractures,
intra cont enteric fractures are gonna be very beneficial.
And hip arthroplasties also gonna be very beneficial.
Another surgical procedure
that would benefit from this would also be
acid tabular fractures.
And lemme go to this next image
and we can kind of show you this a little bit.
So here you can actually see where these branches are.
This is actually a little d study showing where the,
where the dye is once you do a ping block, as it kind
of runs off down here, over the top of the,
this is the pelvic, the pelvic brim, also known as the
pubic eminence, which is right here.
We'll talk a little bit more about that in minute.
But, but that's where these little branches go,
go right over the top of the IOP pubic eminence,
and they dive here into the hip capsule right there.
And so if you have an acetabular fracture, it's right there,
you can, you, you know, you can reliably get a lot
of those nerves that are innervating, that acetabulum,
but these nerves terminate right here on the greater
trocanter, and they don't go any further than that.
So doing a ping block
for a femoral nail is not gonna be very beneficial.
Doing a, a ping block for
hip arthroplasty can be very beneficial
because they're just gonna be the lock been off the head
of this, where the greater roc cantor is putting in a new
hardware and then, and then the patient's good to go.
So this is kind of what the anatomy,
the sono anatomy looks like when we're doing this.
Now I talk again a lot about home base.
And home base is the same for FASA as it is for a P block.
And that is to go to the femoral nerve block.
In fact, indeed here you can see that home base, right?
Right here we have the femoral artery,
and then we have the femoral nerve, okay?
And just deep to that,
you see this nice white hyper coic,
continuous white line.
It almost looks like a roller coaster, right?
It kind of comes down, it comes up, it goes down,
it comes up again, and it goes down and up again.
So this first little hump that's right
underneath the artery is called the IOP pubic eminence.
Okay? This is the Ileo SOAs notch.
We've called this the trough of Schwartz, though from a,
a fellow colleague of mine, if he's listening,
he's gonna get a nice laugh out of this.
But this next big hump right here is called the A IIS,
the anterior inferior IAC spine.
Now, if I were to keep going lateral,
you'd see another hump way up here, which is the A SIS,
which is again, where the sartorious muscle attaches.
But the big one that we're looking
for is this one right here, the A IIS,
the anterior inferior iliac spine.
And to get this image, again, you start at home base,
but really all you need to do, once you get to home base,
you need to get your depth right
where you are seeing a bony structure, okay?
If you're seeing a white hyper Coke structure,
you're in a good spot from home base.
Now, usually if you're caught add enough, like I was talking
to you about for a fascia ACA block,
you will see a bony structure.
But a lot of the time you'll see two white
lines that are kind of curved.
And I'll show you that when we scan here in a minute.
If you see that, what that is is that's the actual hip joint
and the ace tableau, okay?
So that means you're a little too caught at.
So I will move the probe a little bit more cephalic till I
see one white line.
And then it's all about angling the probe.
Usually it's oblique, the probe just a little bit.
And I'll show you that when I scan how that looks.
And the key is you want to try
and get your probe in an area
where you're seeing one continuous
white line like this, okay?
Because this, the, the pelvic brim
or the IOP pubic imminence area, it's, it's, think of it
as a shelf, it's a pretty narrow shelf.
If you're too CE lab, you're off the shelf
and you're diving into the pelvic pelvis.
If you're too caught add, you're into the actual hip joint,
you're seeing the acetabulum and the, and the hip
and the femoral hip bone going into the,
into the ACE tablum.
And so it's a pretty narrow shelf that's about a shelf
that's about two centimeters wide.
And so you have kind of two centimeters to see this,
a nice continuous white line.
So here's a nice little cartoon of this.
There's been some debate about location, of spread
of local anesthetic or,
or better said, location of needle insertion, okay?
In this image, this is kind of the classic way of doing it,
which is putting the lo local anesthetic lateral
to the SOAs tendon,
and we'll show you the SOAs tendon here in a minute.
And then seeing local anesthetic lift up the SOAs tendon.
Now, one warning I'm gonna tell you is
about this is usually this space is very tight.
So even when I get in this space
and I, I touch the bone, I'm right where I need it to go,
and you start injecting your injector person is gonna be
like, I can't inject anything.
It's really tight. And sometimes it can be really tight
and you have to kind of finagle it a little bit.
I kind of do this little cork screw technique to try
to get it through the fascia that's covering the,
the ileal sous notch here, and then,
and then get it underneath the, the sous tendon.
And then you want this local anesthetic to kind
of go this way in that way.
Now, lateral here, where the a IIS is, this is where all
of those articular branches
of the femoral nerve are gonna be medial
to the SOAs tendon is where the articular branches
of the ator nerve are gonna be.
Okay? And so it's important
to see spread on both sides if you can.
Another option is, is going over the top of the SOAs tendon
and hitting the IPE ileal pubic eminence.
And then you'll see the local anesthetic go
underneath the SOAs tendon.
Okay? When we, when we scan here in a minute, a lot
of times you'll see this interfacial layer in
between the ileal SOAs muscle, okay?
That can throw a lot of people off.
Usually it's very hyper coic,
and a lot of people think this is the SOAs tendon usually
scanning up and down a little bit.
You'll see that it's not,
and this is actually this nice round structure.
Sometimes it's gonna look like a crescent
and it looks like it's a SOAs tendon,
but that's kind of throwing people off a little bit.
The last thing I wanna talk to you about is we, one
of the benefits of a ping block is the fact
that you can cause femoral nerve sparing, okay?
So that, you know, you can do, this is a great block
for hip arthroplasties
because I can do this block,
it's very effective at controlling pain,
but I don't get the motor component associated
with a fascia block, okay?
I'm missing the femoral nerve,
or rather stated I'm missing the motor nerve
components of the femoral nerve.
I'm still getting articular branches of the femoral nerve,
which are down here, which are diving in
and innervating the bone,
but I'm missing the motor component.
So that's great from a, from a,
a motor post-op physical therapy standpoint.
I just want to give you a word of caution though.
When you do this block, can you get motor weakness?
And the answer is actually yes.
And how we, we did a cadaver study about this
not too long ago,
and we, we inadvertently, we did this block
and it looked beautiful, everything looked great,
and we did it under fluoro and, and we put dye in there,
and then we and these cadavers, and then we dissected them.
And lo and behold, we saw staining
of local anesthetic on one of our blocks
of the femoral nerve, and we were just head scratching.
Why did that happen?
Why did we get staining of the femoral nerve?
And what we found out was we were not underneath the fascia
that was covering this muscle.
If you think of this muscle, kind of like a sausage
and a sausage casing, right?
So if you put your local anesthetic in between the sausage
and the casing, that local anesthetic is gonna wrap around
that sausage casing, okay?
And that is how it's gonna get the femoral nerve, okay?
And that's what happened because we were not through
and through the sausage casing on the other side
between the bone
and the fascia, we were getting the femoral nerve.
So it's really important that you put your local anesthetic
in between the bone and the fascia,
because if you don't, you can actually have
that local anesthetic go all the way
around the ilio SOAs muscle
and inadvertently get the femoral nerve.
So there have been some reported cases in literature about,
you know, quad weakness from a pain block,
and everybody's scratching their head, well,
this is why it's happening.
It's because you're not deep enough,
you're not under the fascia covering the ilios muscle you're
in, you're in between the fascia and the muscle itself.
So you need to be between the, the bone
and the fascia so that that doesn't happen.
Okay? So this is a great image kind of showing that.
So where D is here, this is the area we're looking at,
and here's the A IIS, here's the, here's the SOAs tendon,
here's the IPE, this is home base, femoral artery,
femoral nerve, right there.
And then notice, this is
what I want you to notice in this image.
Notice how the probe is oriented. See how oblique it is.
So you need to oblique it like
how this line in D is, okay?
A lot of, when you're doing a classic femoral block,
it's not as oblique usually.
So this is what you kind of have to
finagle a little bit when you're doing this.
Now I'm gonna go to a video that I made
that's gonna show two different ways of doing a ping block.
And I want you to particularly notice the very last one.
What I did initially with the local anesthetic.
- In this video, a left sided ping block is being performed.
Local anesthetic was initially injected on the lateral
aspect of the SOS tendon.
The needle was retracted back
and later moved to the medial aspect of the SOAs tendon
until the needle contacts the IOP pubic eminence.
You can see local anesthetic being injected there,
and the local anesthetic spreads medially
underneath the femoral artery.
In this video, another left-sided pain
block is being performed.
The needle is moved to the lateral aspect of the SOAs tendon
until it contacts the iop pubic eminence.
At this point, local anesthetic is injected.
Initially you can see local anesthetic being injected
above the fascial plane just
to the lateral aspect of the SOAs tendon.
Later the needle is advanced
and you can now see local anesthetic being injected
underneath the is tendon moving medially.
- Okay? So that last video, as I kind of explained
to you guys about that sausage, you know, technique, the,
the, the local anesthetic initially,
and you could appreciate that the local anesthetic initially
was kind of in the muscle
or in between the muscle and the fascia.
And so I had to advance my needle further
to get underneath that fascia.
And then when you, when you saw that, you saw
that local anesthetic spreading just right in
between the bone and the fascia, that's,
that's what you need to see.
That's the money for, for this block.
It's very important that you see that when you,
when you do a ping block.
Otherwise, again, like I was saying,
you can get a femoral nerve block.
And, and, and that's how it happens.
A lot of people haven't figured out why that happens.
Well now, you know, that's, that's the explanation for it.
So lemme show you how to scan for a ping block. Okay?
So, all right, here we go.
So let, let's go to a classic,
classic approach here, okay?
And then this is, this is right in the inguinal crease.
All right? So you can see my artery
and you can see my nerve right there.
Now look, I, I said one of the things you need
to do is you need to go deeper.
So I'm gonna go one deeper until I see a bone
and sure enough, I see, oh, let me go back to this.
There we go. I see a bone.
Now I was telling you, if you see two white lines is
because you're too co add.
And so this is actually the, the, the head of the femur.
All right? So all you need
to do is go a little bit cephalad and look what I did.
I went cph la. Now I just see one line here.
It kind of dies off here.
So all I'm gonna do is oblique it a little
bit and look at that.
I just oblique it a little bit
and I just kind of did a little adjustment
and sure enough, I see this nice white
continuous line.
Okay, so this at, at the top here, this is the A IIS
or the anterior inferior iliac spine.
I can see my femoral nerve right here. I can see my artery.
Now this I actually wanna talk about.
So see you see some hyper isity here.
That little crescent I was telling you about is
that inter fascia.
And I see this little, this this little kind
of round circular thing here,
but I also see a round circular thing here.
So if you kind of scan up
and down just a little bit, you can appreciate
what is SOAs tendon.
And actually I think this right here where my arrow is,
that is actually the SOAs tendon.
Yep. So I'm just kind of scanning up and down a little bit
and this, see how this kind of dies away.
This is actually all inter muscle fascia,
this little line right there.
So this is kind of messed up A lot of people, a lot
of people think this is the so is tendon,
but in reality here, it's actually right here.
So what you can do is you can come down here
with your needle and then put your local anesthetic right
there and try to lift up that SOAs tendon.
Don't try to go through the SOAs tendon.
A lot of people will try to get through the SOAs tendon.
The SOAs tendon. When you, when you hit it with a needle,
it will fill like a rock
and you will not be able to drive a blunt block needle
through the SOAs tendon.
It's gonna be neither impossible.
Not only that, you probably shouldn't do it anyway
because that can actually cause some
tendonitis if you do that.
So you either want to go on the lateral aspect of it
or the medial aspect of it.
Maybe hit the IPE here.
So this is where you would go on the medial aspect of it.
Again, if you only see medial spread,
you're probably only gonna get a lot
of the ator nerve component,
which is right here on this lateral aspect here.
This is actually where all the femoral nerve
components are gonna be.
So this is, lemme go back and scan it again.
So this right here is home base
looks great, looks I can see the artery.
I'm clearly deep enough
because I see some white structure and that's all you need to do.
You go from home base, just go deep enough
until you see a white structure.
In this case I see a white structure, but I see two of 'em.
So that means I'm too caught out
because this is actually my hip right there.
This is actually the ace tablum.
So I'm gonna go north until I don't see,
until I don't see two lines.
Now I only see one white line, but it's not continuous.
So all from, all I'm gonna do from there is I'm just gonna
oblique it a little bit
and look, once I oblique it a little bit,
I can see if I go lateral,
I can see the A IIS if I keep going more lateral.
This is actually the A-A-S-I-S.
You can see way up here in the top left, this is the A IIS.
Right here you see the this nice,
it's almost like a ski jump here,
roller coaster going all the way down here
and then medial, you see the IPE.
Okay, so, so that is how you would scan a ping block.
Now where do you go with your needle?
So my needle, I'm gonna go, I'm gonna go lateral to medial.
Okay? Just right here.
Just like I would do a a just like I would do a,
a femoral nerve block
and I would just go underneath in plain underneath my probe.
And ideally I would go here lateral
to the SOAs tendon and inject underneath the SOAs tendon
and try to lift it up, okay?
Making sure that I'm not inside the muscle
because if I'm inside the muscle, local anesthetic can track
around that muscle
and get to my femoral nerve, which is right there.
But if I'm below the muscle
or below the fascia, rather in between the fascia
and the bone, it's gonna stay in that nice plane
where those articular branches of the femoral
and the ator nerve live.
Okay? And if I do that, it's gonna be a really great block.
Another cool feature about this block I'm just gonna tell
you is it usually lasts a long time
because it's such a tight space
that local anesthetic will just kind of hang out there.
So even if you use for example, say ropivacaine, okay,
I've seen that block lasting almost a day and a half
and it just kind of stays there.
Alright, the last thing I'm gonna tell you about is
if you are doing a, an anterior hip, alright,
this block will work for anterior
and for lateral hip arthroplasties.
I know the new invoke thing is to do anterior hips.
And so if you do anterior hip,
you'll probably miss the incision.
So what you can do is you can ask your surgeon
to just infiltrate the incisional pain
just where the incision is.
And that will get the incisional pain.
If you're doing lateral hips, you may need
to combine a lateral femoral cutaneous nerve block
with like five to eight ccs, sometimes 10 ccs
of local anesthetic for that.
The other thing I didn't tell you is
how much local anesthetic to put in there.
So you can put 20 to 30 ccs.
Most the most of the studies is actually just 20 ccs
of local anesthetic.
So if you have, if you're using ropivacaine
or bupivacaine, you could use 0.5%, 20 ccs of 0.5%
ropivacaine or bupivacaine.
And then you can use the 10 ccs if you're doing a lateral
hip to put and get the lateral femme cutaneous nerve.
So let me go back to the slides
'cause this is very important to always keep calm
and just do a regional aesthetic.
So with that, what we're gonna do is we're gonna turn
to any questions that we have.
And this, well, this was really good.
All right, so we, it was 45 minutes, so we have 15 minutes
to go over any questions that anybody might have.
I think, I think you just write type 'em in if I,
if I remember right.
And then Laura will moderate.
- Yeah, we have a couple questions already, Dr teams great.
First question, can you use a continuous catheter
with a fascia IAC for pain?
Or what about biz mol or buca
- Li liposomal vacate, - Yeah.
- Yes. So, so yes you can, so you can use
catheter techniques for this.
I actually have a really funny story about using a catheter
with a fascia ica I did for a hip fracture.
We put a, a fascia ICA catheter in,
and i, I summarily got called by the radiologist.
I'm like, who calls anesthesia?
What, what radiologist has ever called anesthesia?
Like that never happens. Well, they called me
and they said, Hey, you, you put the catheter inside the,
the peritoneal cavity.
And I'm like, don't think I did.
But they said, oh yes you did. So I'm
like, all right, where's your dark room?
So I went down to the dark room and,
and they pulled up the CT scan
and knowing what we talked about today,
where the local anesthetic is going into the iliac fossa,
that catheter was laying inside the iliac fossa,
but in between the iliac fossa
and the bottom part of the perineum or the pelvis is.
And so I showed that to him
and he could see the local anesthetic there,
the fluid collection under there.
He thought it was in the pelvis, but then you look
and you slice the CT scan,
you can clearly see the bottom of the peritoneum.
So it was in the iliac fossa, but, but,
but underneath the peritoneum,
so right where it needed to be.
So it was right, it was right where you needed to do.
So the answer is yes, you can use catheter for this.
As far as pain blocks, pain blocks is, are
is considered a, a fascial plane block.
And so it is considered on-label use
for liposomal bupivacaine fascia
ICA technically is a little in the gray area,
although I actually did a, a little mini study to, to test
between what using it for liposomal vacating
and it works really well for fascia ica,
but I don't think technically it's on label for that.
But, but you can use both modalities for, for these blocks.
- Great. And kind of a clarifying question on, on
that topic, what about ideal location
for fascia iliac catheter is near the deep circumflex iliac
vessels Questions?
- Yes. So that's where I would drop it off.
So I would use my local anesthetic to open it.
Again, you wanna use a lot of volume,
so I'll use like 50 ccs, open it up
and then I'll thread my catheter into that, that space.
And usually again, I'll have my catheter tip right
where the deep circumflex iliac artery is,
and then I'll just thread it and it's gonna thread down
that ramp down into the iliac faucet.
And that's where I thread it
and, and that's where I leave it.
Yeah. So fa fasci iliac catheters, I mean they,
they don't ever really get dislodged
'cause it's in such a deep kind of goalie, you know,
and it's threaded way down in there.
And so that's, that's where you put it.
- Okay, great. What tips do you have for fascia, iata,
and ping on patients who have round firm abdominal regions
- Who have round firm abdominal?
Did I hear that right? Round firm abdominal regions?
- Yes. - Okay.
We like to, I'm, I'm here in Texas, so we like
to call them Texas small p people.
So I think, I think I'm picking up what you're putting down,
but yes, that is, that is a, that can be a problem.
So, and, and I'm actually glad you brought that up
because one of, when I do my workshops, one
of the things I talk about is to not
be a panist peaker.
You don't want to be a
panist peaker when you're scanning this.
And what I mean by that is you don't want to use your probe
and you, you wanna be, you want your probe like this, oh,
well here, I'll show you like that.
You want your probe like this. Okay.
Very parallel to the, to the ground.
What a lot of people do is if someone has a big panis here,
what they wanna do is they wanna do this, they wanna try
to peek underneath the panis.
Okay, well if you do that,
it's gonna distort your sono anatomy.
So the best thing to do, one, there's two things, excuse me.
Number one is you want your patient completely flat
because if they're sitting up a little bit,
that pen is gonna kind
of flop in your way, so you don't want that.
Number two is you either need someone to kind
of retract up a little bit,
or if you're scanning, if you, if I scan with my left hand,
and I, I've done this a lot, so if you're scanning
with your left hand, I use my left hand to kind
of hold the panis up.
So my, the panis is right here, so I kind
of hold it up like this
and then with my right hand, I'm gonna drive it in there,
all that so that you can keep your ultrasound probe
nice, nice and flat.
Okay, that's a great question
because it, it, it does pose a big challenge for fascia,
especially with patients that are in shape, you know,
round is a shape.
So, you know,
- Right.
- That, that, that can be, that can be a little challenging.
I, I totally get it.
But those are, those are two key tech techniques.
So don't be labeled a pan peaker. Okay, just take that home.
- Got it. Great question.
Is the QL block effective for hip arthroplasty analgesia?
- Oh, that is a good question.
So the, it's a little complicated of a thing.
Well, I'm gonna uncomplicated the, the short answer is yes
and maybe, so it depends.
QL three blocks, which for all intents
and purposes, a QL three block is basically a lateral,
slightly lateral lumbar plexus block.
And we know lumbar plexus block from literature are good
for getting the lumbar plexus,
which those same nerves are going down
and getting into the hip capsule.
So yes, a QL three block is good,
and there's actually good literature
to support QL three blocks for,
for hip fractures.
So to clarify what a QL three block is, that local
and aesthetic you're depositing between the so as muscle
and the,
and the quadras lumborum muscle, okay,
that is a QL three block.
Now will a QL one block
or a QL two block work for hip fractures
or for hip arthroplasties or, or the like,
and the answer is, is maybe,
and that's where that maybe comes from.
I do a lot of QB two blocks
and I would say I, well I've only had two patients
that have had non clinically significant quad weakness.
So that should tell you something right there, right?
So if I'm getting, most of my patients
with a QL two block are not getting quad weakness,
that means I don't, I'm not getting a high concentration
of wil anesthetic around all of the lumbar plexus
to probably be effective for a,
for a hip fracture.
Whereas a QL three block, most
of the time you're gonna get quad weakness
because you're right there by the lumbar plexus.
So hopefully that complicates it a little bit for you.
But so that, that's the, that's the short answer.
- Okay. - Hopefully that was helpful.
- That sounds great. Can a perfectly done ping block
make a zero
for zero outta 10 pain per patient? That's a hard question.
- Well, it depends how many psych
psych meds is this patient on?
No, I'm kidding. I'm kidding.
So that's a, that's interestingly worded question.
So it depends
for plain arthroplasties where they're not messing
with the acetabulum, yeah, you can get really,
really good analgesia if you're doing it.
It's, it's a little comp more complicated than that, right?
Because, you know, if you're doing a lateral hip, okay, we,
you need to make sure we're getting
that lateral from a cutaneous nerve
because if I do a ping block that's great
for a hip arthroplasty, that's great.
Maybe I'm getting all the pain for the hip arthroplasty,
but the patient's still 10 out of 10
because their lateral hip and their incision hurts.
Well, so, so that, that's, that's a little complicating.
If, if they're reaming the ace tablum
and putting a whole new socket in right?
Then they may have some posterior pain, which comes off
of the sciatic nerve.
It's a very small amount,
but there is still some there,
which clearly we're not getting when
we're doing a pain block.
So usually the patients are a little uncomfortable in there.
I wouldn't say it's like a deep throbbing pain,
it's just kind of a dull achy pain when they,
when they ream the acetabulum
and you're doing a ping block, if they're just doing a, a,
you know, just the, the proximal hip or whatever,
and it's not that that that big a deal then, or,
or if they're just putting a nail in
through the greater tro cantor or,
or by the, the femoral neck just to,
you know, nail it all together.
Yeah, those patients do extremely well.
By and large, they do very well with a P blocks.
I, I've been very impressed with the analgesia I get off it.
So you kind of set me up
for failure on that question, right.
You know, am I gonna get
- A zero 10? Yeah.
- Gosh. Yeah. So just, just find out how many
psych meds are on, you'll know,
- Right.
What about the relationship of the ping block to the ureter?
Is there a risk of injury?
- Yeah, so I've actually seen that in, in literature too.
If you go on, if you go on the YouTubes, you know,
there's gonna be some pretty awesome videos about
all these blocks, right?
Gosh, one of my favorite is peck blocks. Oh my gosh.
Go go onto YouTube and find the videos on pex blocks
and don't actually, please don't do that
because there's some really crazy ludicrous
stuff on there about that.
But one of the things that's on there about,
about p blocks is getting the ureter well, so if you,
if you look at the anatomy there, there's actually this,
this, and I know where this, this question is coming from.
There, there was a u urethral injury
and they claimed it on the, on the pan guac.
Well, if you, if you know, understand
where the ureters are coming in
and attaching to the bladder,
it's actually a lot more posterior.
And then they come in and then they go
through the UV junction and they dive into the bladder.
So either one of two things happen.
One is, is the person
who is doing this ping block just really got lost
and was not looking at the anatomy
and not looking at the bone
and somehow got the ureter, which I don't know
how they did it, or they did a medial to lateral approach
as opposed to the lateral to medial approach
and they dove into the pelvis.
Yeah, you could probably bag the ureter very unlikely.
Or the other likely thing is,
is the surgeon got it right when they were kind of
doing whatever they were doing, if they're doing an anterior
hip, maybe something happened, but,
but yeah, it's, yeah, as long
as you see the IOP pubic eminence
and that one continuous white line
and you're going down to it,
the ureter is a lot more posterior than
that in the pelvis, you're not gonna get it.
And that's why it's also important, I think, going lateral
to medial as it if, as opposed to going medial to lateral.
I don't know why you would ever do that,
but I would, I would not advocate for that.
- Okay. Got it. And I'm not quite sure
what this question is, Amy,
but I'll just read it exactly as it says.
What is the LA
and volume amount you like for your ping blocks for TKA?
- Okay, so local anesthetic volume amounts for to
TKA total knee arthroplasties?
- Yeah, I guess so.
- Well, I wouldn't do, I wouldn't do a ping block for a TKA.
Okay. I would only do it for a hip,
so a TAH total.
- Oh, - T-H-A-T-H-A.
- Yeah. - Total hip arthroplasty. Yes. Okay.
Yeah, so for that great question.
So for the ping block, I would do 20 ccs
and as a ping block, like we just described it,
and at our hospital we, we do a lot of lateral hips,
so I take that other 10 ccs
and I do a lateral femoral cutaneous nerve
block in addition to that.
So, so 20 ccs, again, like I was saying, that
that space is very tight.
So 20 ccs is gonna go a long way.
Could you do 30 ccs? Yes. Have I done 30 ccs in the past?
Yes. But
after doing a cadaver study on that,
I think 20 ccs is plenty
because what was cool on the cadaver thing,
when once we went down
and looked at the dye,
it dove all the way down into the back of the iliac fossa
underneath the, that ilio SOAs
muscle all the way down there.
20 ccs was all we used and,
and it really got back there quite a bit
and just bathed the whole thing and,
and dye in local anesthetic.
So, so yeah, 20 ccs is really all you need for this
because the, the space is so tight.
- Right. Okay. We have two more questions. Question.
I know we're at the top of the hour, so I'm hoping
to squeeze these last two questions in.
Okay. Would a fi block
or pain block be better for hip arthoscopy?
If you had to choose which is better?
- Hip arthoscopy? Well, for hip,
that's a, that's a good question.
So hip arthroscopies, a lot of that, a lot of the,
the pain is gonna be a lot more superficial
because it's basically the, the scopes
and the, the, the, the stuff,
they're not doing a lot of stuff on the bone.
So I'd probably lean more towards the fascia because,
because of that, maybe very dilute
because again, I probably don't wanna bag the
bag the, the femoral nerve.
And if I do, I just don't want it, the, the motor component
to last very long.
So hip art or hip arthroscopes are not very painful
because they're not really doing a lot with the bone per se.
So it's a little bit more superficial stuff.
So I would, I'd probably go with the fasci
with a lot more dilute low anesthetic.
- Okay, great. And where do you leave the tip
of the catheter in continuous pain block
and at what rate of infusion?
- Yeah, so great question.
So where you could leave it is just, I, I would, again,
I put my local or my needle right at the crux of
where the sous tendon is
and I just kinda leave it right there.
So it kind of sits underneath the SOAs tendon if I can.
And then, you know, so it's underneath the SOAs tendon
or buy it one or two centimeters.
And then because it's a tight space,
you don't need it run at a, at a high rate.
So, you know, six
to eight ccs an hour is really all you would need in order
to, to to, to cause it, you know,
to make it be efficacious. So.
- Okay. And I'm gonna squeeze one more in,
because we talked about this before we started, just the,
the couple of us on the call earlier.
A for an elderly hip fracture patient,
what sedation would you use, if any, to perform an FI
or ping block for pain control prior to surgery?
- Oh, that's actually, you know, you know,
that was one thing we actually didn't talk about.
So this block, I, I do when I,
or you can do when they're completely asleep,
but you can also do when they're awake too.
So I've done these blocks.
We, we have a hip fracture protocol at our hospital.
So a lot of times they, you know, you know,
grandma falls and breaks her hip.
We get a consult within a couple hours
and we'll do one of these blocks for, for the,
for the, for the patient.
We might do a single shot at that time.
Sometimes we'll do a catheter.
It just depends and,
and clearly they're awake when they're doing that.
But I've also done this when they're
asleep on our anesthesia.
So they go in, they get their hip done, they, they
at the end of the case and then I get called, hey,
we're done with the, we're done with the case.
And then I'll do it when they're, when they're asleep.
And the reason why it's okay is
because you know, it, there are playing blocks.
I'm not targeting a specific nerve with my needle.
I'm not, you know, I'm not gonna ishka bob a nerve
with my needle based on this anatomy.
If you do this approach versus doing like a inner scanning
super cloud, I always do them with, with them awake.
But these ones I can do when they're,
when they're fully asleep, P
and fascia, I've done em that way
because I'm putting in a fascial plane just like I do QL
blocks when they're asleep.
PEX blocks I do when they're asleep.
Tap blocks you can do when they're asleep,
but you can also do 'em when they're awake too.
Now as far as sedation, you know, that's up to you
because it's a plain block, I'm okay sedating 'em
'cause I'm not worried about checking to see
what their paraesthesia are.
Like I would be for like an inner scanning or a super cloud.
So if you wanna gork 'em out on Burset
and Fentanyl, go right ahead.
You know, just make sure they don't get happen it.
- Right, right. We still have a couple more questions.
I mean, do you have a few more minutes
or do you want me to We can take, sure.
- I mean if people, are people still
listening to me right now? This
- Is great.
Yeah, we still got quite a few people on.
This is pretty great. Any experience doing an
FI or hip fracture?
Surgical anesthesia without spinal or ga?
- Okay, so actually I didn't go over this in my slide,
it was in my slide, but I didn't mention it.
So fascia is a good analgesia block,
but it's not gonna cause complete anesthesia.
Okay. Meaning I, I,
I can't really do a surgical fascia I block.
Likewise, I can't really do a surgical pain block.
I'm sure somewhere, someplace in, you know, Tibet,
maybe they've done that,
but as far as I know, I've, I've never done that
because again, the reliability of operator is,
is really hard to, to get.
Plus again, if they're doing stuff
with the acet, you're gonna miss it.
So, so it's gonna cause good analgesia to that area,
but it's not gonna cause complete anesthesia,
meaning it's not gonna be a fascia, a surgical block.
Likewise, I mentioned that it is a volume block, so
you know, when I do my surgical blocks I'll use, you know,
2% mepivacaine or 2% lidocaine
because it causes a dense, really super dense block.
And you know, if I do 20 ccs of 2% mepi, well
that's not enough volume to really get all
what I need up in the fascia, the Okta.
So, so good anal, good analgesia,
not perfect surgical anesthesia.
- Got it. Okay. Okay, great.
Well, I mean, we're past the hour
so I really wanna be respectful of your time.
But thank you so much Dr. Teams.
I've learned a ton on this webinar.
This was, this was exceptional content
and I think everyone will agree.
- Thank you. - Thank you so much.
I really appreciate your time
and we will definitely do some more work together.
I'm sure. Thank
- You all so much. Thanks for being here.
- Thank you everyone for joining us.
Join Dr. Richard Teames in a lively discussion of techniques and indications for performing ultrasound-guided Pericapsular Nerve Group (PENG) and Fascia Iliaca Compartment Block (FICB) blocks for hip surgery. In this webinar, Dr. Teames will share best practices while performing live scans, then open the discussion for Q&A.
What You'll Learn
- Identify tissue planes for PENG and FICB blocks
- Understand the benefits and limitations to PENG and FICB blocks
- Learn tips and tricks for successful block placement
Dr. Richard Teames is a dedicated anesthesiologist with a unique background in nursing who excels in working with trauma and critical care patients. He trained at the busiest trauma center in the U.S. and has exceptional regional skills and ultrasound technique in multiple nerve block modalities.
He is currently the Director of Regional Anesthesia at John Peter Smith hospital as well as the National Clinical Director of Regional Anesthesia for Envision Physician Services. Dr. Teames is an Officer in the United States Army Reserve Medical Corp. His clinical interests include acute pain management, regional anesthesia, advance airway techniques, and cardiovascular anesthesia. He has a genuine interest and enthusiasm for teaching clinical and acute pain/regional anesthesia and is a bilingual (English/Spanish) patient advocate.
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.