This video demonstrates how to perform an ultrasound-guided iPACK (infiltration between the popliteal artery and the knee capsule) block as an adjuvant technique for postoperative pain control in a pediatric patient presenting for anterior cruciate ligament repair.
Specialty: Anesthesiology
Pediatric Ultrasound-Guided Adductor Canal Block
This video demonstrates how to perform an ultrasound-guided single-shot adductor canal block for postoperative pain control in a pediatric patient presenting for anterior cruciate ligament repair.
Intermediate Cervical Plexus Nerve Block
This video demonstrates how to perform an ultrasound-guided intermediate cervical plexus nerve block for postoperative pain control in a pediatric patient presenting for cochlear device implant.
Ultrasound-Guided Rectus Sheath Block for Intraoperative and Postoperative Pain Management in Pediatric Patients
In this video, a bilateral ultrasound-guided rectus sheath nerve block is demonstrated on a 7-year-old male child undergoing umbilical hernia repair. After the induction of general anesthesia, nerve block time-out is conducted. Following this, the periumbilical area is cleansed using chlorhexidine. A high-frequency linear ultrasound probe is then placed in a transverse orientation lateral to the umbilicus to identify the rectus muscle and its posterior rectus sheath. The three lateral abdominal wall muscles—internal oblique, external oblique, and transversus abdominis—are also visualized lateral to the rectus muscle.
Using an in-plane technique, a 22-gauge, 50-millimeter-long Pajunk needle is inserted from lateral to medial direction. The needle is advanced through the subcutaneous tissue and the body of the rectus muscle until it reaches the target plane between the rectus muscle and the posterior rectus sheath. Correct needle placement is confirmed through hydro dissection with normal saline, where proper spread is indicated by separation of the rectus sheath from the muscle or by the rectus muscle lifting up.
Next, 0.2% Ropivacaine, a local anesthetic, is incrementally injected. The procedure is then repeated on the opposite side with total drug volume typically ranging from 0.05 ml/kg to 1.0 ml/kg up to a maximum total volume of 10 to 20 ml. The patient tolerates the procedure well and does not require any opioids intraoperatively or postoperatively in the post-anesthesia care unit.
Pediatric Ultrasound-Guided Caudal Block
This video demonstrates how to perform an ultrasound-guided single-shot caudal block for postoperative pain control in a pediatric patient about to undergo bilateral inguinal hernia repair.
Ultrasound-Guided Pudendal Nerve Block for Intra and Postoperative Pain Management in Pediatric Penoscrotal Surgery
In this video, a bilateral ultrasound-guided pudendal nerve block is demonstrated on a 15-month-old healthy child undergoing circumcision and penoscrotal fusion repair. After the induction of general anesthesia, a nerve block time-out is conducted. Subsequently, the patient is positioned in the frog-leg stance by an assistant, and the perineum is cleaned using chlorhexidine. Using a high-frequency linear ultrasound probe, the ischiorectal fossa is identified between the ischial tuberosity and the anus at the 3 and 9 o’clock positions relative to the anus. A 22-gauge, 50-millimeter-long Pajunk needle is then inserted using an out-of-plane technique, advanced 1-2 cm deep and medial to the ischial tuberosity, until a subtle change in resistance or “pop” is felt, confirming the correct placement below the sacrospinous ligament. The local anesthetic (0.3 to 0.5 mL/kg of 0.2% Ropivacaine or 0.25% Bupivacaine on each side) is then incrementally injected, observed as spreading medially and beneath the ischial tuberosity. The block is then repeated on the other side. Our patient tolerated the procedure well and did not require any opioids intraoperatively, postoperatively in the post-anesthesia care unit, or at home following discharge.
Ultrasound-Guided Arterial Catheterization in a Pediatric Patient
This video demonstrates an overview of radial arterial cannulation in a pediatric patient using real-time ultrasound (US) guidance. Ultrasound imaging is a useful tool in the armamentarium for guiding arterial line placement, and its use has become commonplace due to increased accessibility and improved technology. Ultrasound imaging facilitates the detection of abnormal anatomy and abnormal findings (e.g. thrombosis). It also allows for real-time guidance for arterial cannulation, which is especially valuable during difficult insertions such as in neonates or small infants, patients with weak or absent pulses or landmarks, and those with multiple prior cannulations. There is evidence of higher success rates with first attempts and decreased complications compared to the traditional landmark and palpation techniques.
Ultrasound-Guided Insertion of Pediatric Central Venous Catheter
This video demonstrates the placement of a central venous catheter (CVC) in the internal jugular vein (IJV) in an infant using real-time ultrasound (US) guidance. Traditionally, the landmark approach has been the technique used to guide CVC placement. Presently, the use of ultrasound (US) for guiding placement has become commonplace due to increased accessibility, improved technology, and evidence of increased first-attempt success rates and decreased complications. Real-time US-guided central venous cannulation is now the recommended technique over the landmark technique by professional organizations. The experienced use of US allows for the detection of abnormal anatomy or findings (e.g. vein thrombosis) and allows for real-time visualization, which is especially helpful during difficult insertions, absence of landmarks, and in challenging patient groups such as in small infants.
Medialization Thyroplasty A continuous endoscopic viewing under General anaesthesia
Medialization thyroplasty is used for the management of vocal fold paralysis. During this procedure, a prosthesis is placed lateral to the inner perichondrium of the thyroid lamina. The structural integrity of the vocal fold is preserved with effective closure of the pre-phonatory gap, the result being vocal efficiency.
In our series of 4 patients in the last 1 year, we tried a new method of anesthesia which enabled us to get a view of vocal cords during the entire surgery and hence helped us in gauging the extent and the level of medialization during the procedure.
This procedure may be advocated in cases where we feel the patient may not cooperate with local anesthesia and a general anesthesia would result in medialisation being done without the view of the endolarynx, resulting in suboptimal results.
Electromyography Endotracheal Tube in Thyroid Surgery
This video explains how electromyography endotracheal tubes work during thyroid surgery. Also known as, EMG ET tubes, these are a type of Intraoperative Neuromonitoring (IONM) which serve a big role preventing nerve injury by monitoring recurrent laryngeal nerve activity. Placement of the tube during intubation is important as the surface electrodes should be in contact with the vocal cords. Incorrect placement would render the tube ineffective and could cause damage to the nerve. Both, macintosh and video laryngoscopes can be used if there is poor visibility during intubation.
During surgery the tube may shift from its correct position for several reasons, primarily movement of the neck, so it’s important to check its correct placement throughout the duration of surgery. The tube itself has electrodes located at the tip. These electrodes come into contact with the vocal cords and detect electrical signals produced by the nerves. These signals are transmitted to a monitoring system which allows for continuous monitoring throughout the surgery. Once the EMG ET tube is properly placed, it can detect electrical signals produced by the nerve by using a stimulation probe. Whenever the nerve is stimulated surgeons and anesthesiologists can view the signals on a screen and listen to the sounds produced by pressing directly above the vocal cords.
The EMG signals are transmitted to a real-time monitoring system which helps surgeons view the signals on a screen and evaluate nerve integrity. During surgery this feedback helps surgeons adjust their technique to avoid nerve damage. Stimulation of the nerve creates a sinusoidal wave on the nerve integrity monitor along with an audible signal confirming its intactness. These waveforms, also known as electromyograms. In a normal resting state, should show very little electrical activity. The intensity can be seen by the amplitude of the wave. And the duration can provide information about the speed of muscle activation. A decrease or loss of EMG signals in response to nerve stimulation can indicate nerve damage or irritation.