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Pediatric Ultrasound guided blocks “ block under vision “. Dr. Amr Abdulfatah Sayed (M.D.) Associate prof. of Anesthesia, Chronic Pain Management Ain Shams Univ. , Cairo , EGYPT Oct. 2012. Imagine . NO clicks No pops No paresthesia No trans-arterial . Under vision in real time

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pediatric ultrasound guided blocks block under vision

Pediatric Ultrasound guided blocks“block under vision “

Dr. Amr Abdulfatah Sayed (M.D.)

Associate prof. of Anesthesia, Chronic Pain Management Ain Shams Univ. , Cairo , EGYPT

Oct. 2012

  • NO clicks
  • No pops
  • No paresthesia
  • No trans-arterial
  • Under vision in real time
  • How L.A. behaves
  • How catheter lodge
  • Reinjection with inconsistent block
basic principles
Basic Principles
  • Mechanical sound energy.
  • Sinusoidal.
  • Pulse longitudinalwavealternating compression (high pressure) & rarefaction (low pressure)
  • P = pressure
  • T = wave length
  • F= frequency
  • distance one peak to other peak is a wavelength

one peak to other peak is a wavelength

generation of an ultrasound waves
  • electric field is applied to a piezoelectric crystals.
  • mechanical distortion of the crystals
  • sound waves (i.e. mechanical energy)
ultrasound tissue i nteraction
Ultrasound & Tissue Interaction
  • U/S beam travels through different tissues
  • Subjected to attenuation(Energy Loss).

1) absorption.2) reflection.3) scattering.

  • Factors affecting attenuation :
    • Frequency ( high highatten ) ( low lowatten)
    • Travel distance
    • Tissue nature

The Ultrasound Transducer Source of Energy and Image

Energy progressively degraded (attenuate)as it enters deeper tissues

lateral & axial resolution improved with higher frequency transducers,decrease with increasing tissue depth

  • Structures typically seen as hyperechoic or echogenic include bone, tendons, pleura, and nerves below the clavicles.
  • In contrast, blood, fluids, and nerves above the clavicles are hypoechoic.
  • Generally speaking, a high frequency wave is subjected to high attenuation thus limiting tissue penetration
  • low frequency wave is associated with low tissue attenuation and deep tissue penetration.
gain time gain compensation tgc
  • receiver amplification is called the Gain.
  • Gain increases overall brightness of the entire image, including the background noise.
  • (TGC) selectively amplify the weak returning (attenuated) signals from deeper structures.



tissue echogenicity
  • Tissue impedance
  • resistance of a tissue to US passage
  • Strong wave reflection = hyperechoic (white)
  • Weak reflection= hypoechoic (greyish)
  • No reflection = anechoic. (black)
tissue echogenicity3
  • Bone : High tissue impedance
  • Strong reflection
  • ++ hyperechoic lines with a hypoechoic shadow underneath
neural tissue e chogenicity
Neural Tissue Echogenicity


or honeycomb appearance


Reflection is high for air

  • Air has extremely low acoustic impedance (0.0004)
  • acoustic coupling medium on the transducer surface to eliminate any air pockets
  • Otherwise ultrasound waves will be reflected limiting tissue penetration.

large dropout artifact.

acoustic shadow artifact
Acoustic Shadow Artifact
  • deep to hyperechoic bone outline is a beam attenuation
  • Ultrasound beams subjected to attenuation by bone, penetration is severely impeded.

Linear array probe

  • High frequency( > 6MHz)
  • Superficial structures
  • Depth max. 6 cm
  • High clarity
  • Curved probe
  • Low frequency (2-5 MHz)
  • Deep structures > 6cm
  • Less resolution

Hokey stick 25mm

probe orientation
Probe Orientation
  • Transducer marker
practical recommendations
Practical Recommendations
  • Needle probe orientation
  • Handling of probe resting hand on pt. body
  • Non dominant hand
  • More steep angle of needle = difficult visualization
The more perpendicular the needle is to ultrasoundbeam, the stronger (brighter and solid) the needle will appear on the monitor
needle selection
Needle Selection
  • Large bore needles (e.g. 17 G)
    • Better visualization
    • easier to direct.
    • Preferred for deep blocks (e.g. infraclavicular block, sciatic ) when needle insertion is steep (> 45 degrees)
  • Smaller bore needles (e.g. 22 G)
    • easily visualized for more superficial blocks e.g., the axillary block, when the angle of needle insertion is shallow.
movement of probe art
Movement of Probe (ART)
  • A ( Alignment )
  • R ( Rotation)
  • T ( Tilting)
proper body ergonomics
Proper Body Ergonomics
  • Proper handling the transducer and the needle, to view the screen, and to position the patient are essential for block success and to avoid operator fatigue and body injury.
proper body ergonomics1
Proper Body Ergonomics

Improper body position

Proper body position

proper body ergonomics2
Proper Body Ergonomics

Proper operator and screen orientation

Improper operator and screen orientation

proper body ergonomics3
Proper Body Ergonomics

Improper hand and arm positions

Proper hand and arm position

local anesthetic injection
Local Anesthetic Injection
  • Aim to surround the neural structure
  • Doughnut sign.
  • Saline of D5% ( if PNS) Prior to L.A
  • Aspirate 1st
femoral nerve
Femoral Nerve
  • doughnut” sign.



Doughnut sign.


Glut. max

Sc. N.

ultrasound with against
Ultrasound With & Against



  • improve success rates
  • simplify the technical challenges
  • decrease performance times
  • reduce complications
  • lack of controlled trials
  • High expense
  • equivocal nature of images
  • Requires sustained training.
pediatric usgra tips
Pediatric USGRA Tips
  • Adults USGRA can be performed in children
  • Plan @ pre-op visit
  • Explain for partents ( legal guardian )
  • Ped. USGRA performed under anesthetized
  • light sedation ( esp. > 8 yrs , diff. airway ,MH).
  • EMLA 1 hrs in advance
  • Small muscle bulk = high f probe (13-6 MHz, “hockey-stick,” 26-mm footprint)
pediatric usgra tips1
Pediatric USGRA Tips
  • Insulated needle
  • Epidural 22G for catheter ( long term post op).
  • In-plane > out off plane
  • Calculate full dose ( volume 0.3–0.5 mL/kg )
  • < 5 yrsBupi. 0.25 %, Ropi. 0.2%, Lido 1%
  • 5 yrsBupi. 0.375 %, Ropi. 0.5% +epi. (Allison Ross et al. , A & A July 2000 vol. 91 no. 1 16-26)
upper limb blocks
Upper Limb Blocks
  • Interscalene
  • Supraclavicular
  • Infraclavicular
  • Axillary
  • Median N.
  • Ulnar N.
  • Radial N.

0.25 -0.5ml /kg

0.25% bupivacaine , 1% lidocaine , 0.25% ropivacaine

  • Most cranial approach
  • Not popular ( Phrenic N.)
  • Indication : shoulder , upper arm, lateral clavicle.
  • Scanning :
    • Medial to lateral survey
    • Trace Back Method
  • Injectate “Perfect Block”=

0.15-0.3ml /kg

front, in the sheath& behind

trace back
Trace Back


Sc. m

Sc. a


ColourDoppler : to identify vertebral vs &

branches of transverse cervical artery below C6

supraclavicular spinal of ul1
Supraclavicular (Spinal Of UL)
  • Clinical tips
    • The usual volume of L.A. 0.3-0.5ml/kg.
    • (Corner Pocket ) above the 1st rib, next to subclavian a. to anesthetize the lower trunk.
    • In plane approach is a must
    • All U.L
    • ???? Shoulder surgery
    • 2/3 L.A. @ Corner
infraclavicular cords
Infraclavicular (Cords)

Local anesthetic injected posterior to the   axillary artery resulting in a U shape spread around the artery   is associated with complete blockade of the arm, forearm and hand.

axillary approach terminal branches of the brachial plexus
Axillary Approach (terminal branches of the brachial plexus )
  • Below elbow surgeries



Inject : MCN +12 & 6 O’clock

Inject : MCN + 10 , 2 , 6 O’clock

In Plane



superficial to the Ilio-Psoas Muscle (IPM)

Base touching CFA, extending lateral to it.


Surgery on femur , knee




Dermatomes and osteotomes of the lumbosacral plexus are illustrated. (Courtesy of Mayo Foundation.)

The American Society of Regional Anesthesia and Pain Medicine. 2005


Plus femoral : whole LL block

Single for ankle & foot surgery

advantages usgra
Advantages USGRA
  • Real time
  • L.A. behaves
  • Less L.A.
  • Cath. Fixation
  • Less vasc. & pleural insults
  • L.A. Re-deposition @ insufficient block
  • All benefits of R.As
complications of pnb
Complications of PNB
  • Neuronal ( neuritis, neuro – praxia)
  • L.A. toxicity
  • Vascular trauma
  • Pleural
thank you

Thank you

Dr. Amr Abdulfatah Sayed M.D.