UGRA

4 – Scanning technique with the ultrasound guided ilioinguinal/iliohypogastric nerve block

– Place the patient supine

– Identify the anterior superior iliac spine (ASIS) with palpation and ultrasound

– Place the high-frequency linear probe on the line connecting the ASIS and the umbilicus and with the lateral end of the probe just superior to the ASIS

– Identify the layers of the abdominal wall and the iliohypogastric and ilioinguinal nerves and the deep circumflex artery inside the neurovascular fascial plane between the transverse abdominis and the internal abdominal oblique (see next page)

– Insert the needle with in-plane technique from the lateral end of the probe and advance the needle tip to the neurovascular plane. Inject 15 mL of local anaesthetic

Image missing — In-plane approach to block the ilioinguinal/iliohypogastric nerves with ultrasound guidance
Ca = caudad, cr = cranial

2 – Anatomy of the iliohypogastric nerve

The iliohypogastric (IH) nerve emerges at the lateral margin of the psoas major – typically together with the ilioinguinal (II) nerve

The IH descends across the anterior surface of the quadratus lumborum and it pierces the posterior aponeurotic extension of the transverse abdominis; it runs along and on top of the iliac crest sandwiched between the transversus abdominis and internal oblique. It innervates the inferior portions of these two muscles

The lateral cutaneous branch innervates the iliac crest and the skin of the hip between the iliac crest and the greater trochanter

The IH/II nerve block does not anaesthetize the lateral cutaneous branch of the IH nerve

The anterior cutaneous branch pierces the anterior aponeurotic extension of the external oblique muscle and innervates the skin above the medial part of the inguinal ligament

5 – Sonoanatomy of the ilioinguinal/iliohypogastric nerve block

Local anaesthetic is injected into the fascial plane between the transverse abdominis and the internal oblique muscles

6 – Supraclavicular anatomy

The brachial plexus runs across the first rib in close relationship to the subclavian artery

On top of the first rib the branches of the brachial plexus are located postero-superior to the artery

8 – The corner pocket

The lowermost branches of the brachial plexus – originating from the C8 and T1 spinal nerve roots – run across the first rib in the corner between the rib and the subclavian artery

This is called the corner pocket

7 – Supraclavicular approach: the brachial plexus is a cluster of black profiles

Align the pulsatile subclavian artery to the center of the monitor

Rotate and tilt the transducer to obtain the best possible SAX view of the pulsatile subclavian artery and brachial plexus nerve divisions

Adjust depth, gain and focus

The hyperechoic first rib has to be exactly underneath the vessel. The pleura is posterior to the first rib. (Note air artifact, periodic

9 – Always place the probe on top of the first rib and you will see the pleura

It is important to locate the probe on top of the first rib

With in-plane needle approach the needle tip will impinge on the rib instead of producing a pneumothorax, if the needle is inserted too deep

11 – Always insert the needle with in-plane technique

It is mandatory to insert the needle with in-plane technique for the supraclavicular brachial plexus block in order to minimize the risk of pneumothorax

10 – Always inject local anesthetic in the corner pocket

Local anesthetic has to be injected in the angle between the subclavian artery, the first rib and the bundle of nerve divisions

SA = subclavian artery

nd = bundle of nerve divisions

p = pleura

c1 = first rib

5 – How to place the probe for the supraclavicular block

– Position the patient supine with the head turned contralateral

– Align the anatomical target and the monitor in the same visual field

– Select a linear, high-frequency probe 15-10 MHz

– Place the probe is in the supraclavicular fossa in the coronal oblique plane