Anatomical Landmark Technique Research Articles

Bloqueio dos nervos ílio‐hipogástrico/ilioinguinal em correção de hérnia inguinal para tratamento da dor no pós‐operatório: comparação entre a técnica de marcos anatômicos e a guiada por ultrassom

ObjectivesThe purpose of this study is to compare the efficacy of iliohypogastric/ilioinguinal nerve blocks performed with the ultrasound guided and the anatomical landmark techniques for postoperative pain management in cases of adult inguinal herniorrhaphy. Methods40 patients, ASA I–II status were randomized into two groups equally: in Group AN (anatomical landmark technique) and in Group ultrasound (ultrasound guided technique), iliohypogastric/ilioinguinal nerve block was performed with 20ml of 0.5% levobupivacaine prior to surgery with the specified techniques. Pain score in postoperative assessment, first mobilization time, duration of hospital stay, score of postoperative analgesia satisfaction, opioid induced side effects and complications related to block were assessed for 24h postoperatively. ResultsVAS scores at rest in the recovery room and all the clinical follow‐up points were found significantly less in Group ultrasound (p<0.01 or p<0.001). VAS scores at movement in the recovery room and all the clinical follow‐up points were found significantly less in Group ultrasound (p<0.001 in all time points). While duration of hospital stay and the first mobilization time were being found significantly shorter, analgesia satisfaction scores were found significantly higher in ultrasound Group (p<0.05, p<0.001, p<0.001 respectively). ConclusionAccording to our study, US guided iliohypogastric/ilioinguinal nerve block in adult inguinal herniorrhaphies provides a more effective analgesia and higher satisfaction of analgesia than iliohypogastric/ilioinguinal nerve block with the anatomical landmark technique. Moreover, it may be suggested that the observation of anatomical structures with the US may increase the success of the block, and minimize the block‐related complications.

Iliohypogastric/ilioinguinal nerve block in inguinal hernia repair for postoperative pain management: comparison of the anatomical landmark and ultrasound guided techniques

ObjectivesThe purpose of this study is to compare the efficacy of iliohypogastric/ilioinguinal nerve blocks performed with the ultrasound guided and the anatomical landmark techniques for postoperative pain management in cases of adult inguinal herniorrhaphy. Methods40 patients, ASA I–II status were randomized into two groups equally: in Group AN (anatomical landmark technique) and in Group ultrasound (ultrasound guided technique), iliohypogastric/ilioinguinal nerve block was performed with 20ml of 0.5% levobupivacaine prior to surgery with the specified techniques. Pain score in postoperative assessment, first mobilization time, duration of hospital stay, score of postoperative analgesia satisfaction, opioid induced side effects and complications related to block were assessed for 24h postoperatively. ResultsVAS scores at rest in the recovery room and all the clinical follow-up points were found significantly less in Group ultrasound (p<0.01 or p<0.001). VAS scores at movement in the recovery room and all the clinical follow-up points were found significantly less in Group ultrasound (p<0.001 in all time points). While duration of hospital stay and the first mobilization time were being found significantly shorter, analgesia satisfaction scores were found significantly higher in ultrasound Group (p<0.05, p<0.001, p<0.001 respectively). ConclusionAccording to our study, US guided iliohypogastric/ilioinguinal nerve block in adult inguinal herniorrhaphies provides a more effective analgesia and higher satisfaction of analgesia than iliohypogastric/ilioinguinal nerve block with the anatomical landmark technique. Moreover, it may be suggested that the observation of anatomical structures with the US may increase the success of the block, and minimize the block-related complications.

Continuous Anterior Sciatic Nerve Block: A Case Series

Continuous Anterior Sciatic Nerve Block: A Case Series Sciatic nerve block is classically performed through posterior or lateral approaches. With the increased use of ultrasound, the anterior approach has gained popularity. An anterior approach should be considered in patients after trauma and severe postoperative pain where patient positioning can be challenging. The anatomical landmark techniques can be difficult for anterior approach and cannot always be relied on due to inconsistency in extremely obese population. The presence of large blood vessels in the needle path and increasing use of anticoagulants, call for the use of ultrasound guidance for anterior approach to sciatic nerve

Internal jugular vein thrombosis from rhino-cerebral mucormycosis: Be careful before cannulation.

Sir, Rhino-cerebral mucormycosis is a relatively uncommon fungal infection of the nasal cavity and para-nasal sinuses that can rapidly progress to the central nervous system and orbit.[1] Immunocompromised patients such as uncontrolled diabetic, bone marrow transplant and those on cancer chemotherapy are at high risk of developing this condition. This condition has also been seen in the absence of clinical risk factors.[2] A 47-year-old female patient was admitted in our hospital with complains of rhinorrhea, ptosis, proptosis and gradually progressive visual loss. Subsequently, she was diagnosed to be a case of rhino-cerebral mucormycosis in the background of uncontrolled diabetes mellitus. Magnetic resonance imaging head shows involvement of the left maxillary and ethmoid sinuses with involvement of the ipsilateral orbit. A thrombus was noted in the cavernous sinus also. She was started on intravenous amphotericin B, and appropriate glucose control measures were also taken. Anesthesia team was requested for central venous access as she had poor peripheral venous access. An ultrasound guided right sided internal jugular vein (IJV) cannulation was planned. On ultrasound scanning of the neck vein, a thrombus in the entire length of right IJV in the neck was noticed [Figure 1]. On the left side, even larger size of a thrombus almost completely occluding the IJV was noticed. We abandoned the procedure and asked for a radiological evaluation of the neck veins. An ultrasound Doppler revealed the presence of thrombus in both IJV. Figure 1 Thrombus in the right internal jugular vein seen in ultrasound image Mucormycosis tends to involve blood vessel and leads to vascular thrombosis. Cavernous sinus thrombosis and internal carotid artery thrombosis has been reported even in clinically stable patients.[3] IJV thrombosis is a rare but potentially fatal condition. Trauma to the vein, coagulopathy, neck infection and malignancy are most important causes of IJV thrombosis.[4,5] It can give rise to septic and pulmonary embolism. As these patients require long-term intravenous drug therapy anesthesiologists are often asked to put a central venous access. When a thrombus is in situ, there will always be a significant possibility that the thrombus may dislodge distally at time of venipuncture, guide wire insertion or catheter insertion. because of nonavailability of ultrasound machine in many circumstances, IJV cannulation is being performed by anatomical landmark technique. These patients may be at risk of embolic complications from “blind” IJV cannulation. Hence looking for and exclusion of IJV thrombosis before neck vein cannulation is very important for safety of the patients. Hence, we recommend that blind IJV cannulation should be avoided in these patients, and an ultrasound Doppler screening may be made before attempting IJV cannulation.

Real-Time Two-Dimensional Ultrasound Guidance for Central Venous Cannulation

Wu, Shao-Young*; Ling, Quan†; Cao, Long-Hui*; Wang, Jian*; Xu, Mei-Xi*; Zeng, Wei-An* Author Information

Comparative study of ultrasound guided subclavian venous cannulation versus conventional technique: Advantages and disadvantages

Background: Procedures involving pediatric group is always challenging. Our aim is to compare conventional anatomical landmark technique versus the ultrasound-guided technique for Subclavian vein (SCV) cannulation in pediatric cardiac surgical patients. Material and Methods:100 patients between 2-12 years who required Subclavian vein (SCV) cannulation received catheter insertion either by conventional [n=50] or by ultrasound-guided technique [n=50] in cardiac surgeries. We observed time taken for preparation for the procedure, failed catheter placement, risk of complications, number of attempts and time to successful catheterization and infection rate, cost, incidence of venous thrombosis by ultrasound on removal of catheter in both the group

Assessment of the Ability of Anaesthetists to Locate the Internal Jugular Vein by the Anatomic Landmark Technique with Ultrasonography: Right or Left, Does it Make any Difference?

To assess senior and junior anaesthetists' ability to locate the right and left jugular vein (IJV) using the anatomic landmark technique. A total of 45 anaesthetists were included in this study. Initially, a questionnaire assessing the experiences of the anaesthetists was completed. The anaesthetists were grouped into two groups, junior and senior. The anaesthetists, who were blind to the screen, were asked to point to the internal jugular vein bilaterally on the neck of a healthy volunteer using an ultrasound probe with the midpoint as an 'imaginary needle'. The success rates for locating the right and left IJV in both junior and senior groups were assessed separately. The success rate for locating the right IJV was 88% (n=26, 23/26) in the senior and 68.4% (n=19, 13/19) in the junior group (p<0.001). The success rate for locating the left IJV was 69% (18/26) in the senior and 78% (15/19) in the junior group (p<0.001), while the difference in success rates for locating the right and left IJV in the senior group was found to be statistically significant (p<0.001). Both use of the anatomic landmark technique and experience increased the success rate. Especially in the less preferred left IJV catheterization, use of the anatomic landmark technique independent of the experience factor could increase the success rate.

Real-time Two-dimensional Ultrasound Guidance for Central Venous Cannulation

Use of ultrasound-guided techniques to facilitate central venous cannulation (CVC) may reduce the risk of misplacement and complications. A meta-analysis was conducted to compare real-time two-dimensional ultrasound (RTUS) guidance technique with anatomical landmark technique for CVC to determine whether RTUS has any advantages. Randomized studies comparing outcomes in patients undergoing CVC with either RTUS or landmark technique were retrieved from PubMed, ISI Web of Knowledge, EMBASE, and OVID EBM Reviews from their inception to March 2012. Twenty-six studies involving 4,185 CVC procedures met the inclusion criteria. Compared with landmark technique, patients with RTUS had a pooled relative risk (RR) of 0.18 (95% CI: 0.10-0.32) for cannulation failure, 0.25 (95% CI: 0.15-0.42) for arterial puncture, 0.30 (95% CI: 0.19-0.46) for hematoma, 0.21 (95% CI: 0.06-0.73) for pneumothorax, and 0.10 (95% CI: 0.02-0.54) for hemothorax from random-effects models. However, RTUS did not show a reduction in the risk of cannulation failure (RR = 0.26, 95% CI: 0.03-2.55), arterial puncture (RR = 0.34, 95% CI: 0.05-2.60), hematoma (RR = 0.13, 95% CI: 0.01-2.42), pneumothorax (RR = 0.40, 95% CI: 0.02-9.61), and hemothorax (RR = 0.40, 95% CI: 0.02-9.61) in children or infants when the limited data were analyzed. Among adults receiving CVC, RTUS was associated with decreased risks of cannulation failure, arterial puncture, hematoma, and hemothorax. Additional data of randomized studies are necessary to evaluate these outcomes in pediatric patients.

Internal jugular vein cannulation: A comparison of three techniques

Context:Ultrasound-guided internal jugular vein (IJV) cannulation is known for increasing success rate and decreasing rate of complications. The ultrasound image can be used as a real time image during cannulation or to prelocate the IJV before attempting cannulation.Aims:This study compares both the ultrasound-guided technique with the classical anatomical landmark technique (central approach) for right IJV cannulation in terms of success rate, complications, and time for cannulation.Settings and Design:A prospective, randomized, observational study was conducted at a tertiary care hospital.Material and Methods:One hundred twenty patients requiring IJV cannulation were included in this study and were randomly allocated in three groups. Number of attempts, success rate, venous access time, catheterization time, and complications were observed in each group.Statistical Analysis Used:Statistical analysis was performed using STATA-9 software. Demographic data were compared using one-way analysis of variance (ANOVA). Nonparametric data were compared using the Kruskall–Wallis test, and multiple comparisons were done applying The Mann–Whitney test for individual pairs of groups. Nominal data were compared by applying the Chi-square test and Fisher exact test.Results:Successful cannulation (≤3 attempt) was achieved in 90.83% of patients without any statistical significant difference between the groups. Venous access time and catheterization time was found to be significantly less in both the ultrasound groups than the anatomical land mark group. Number of attempts and success in first attempt was similar between the groups.Conclusions:Both the ultrasound techniques are found to be better than the anatomical landmark technique. Further, ultrasound-guided prelocation was found to be as effective as ultrasound guided real-time imaging technique for right IJV cannulation.

The success rate and safety of internal jugular vein cannulation using anatomical landmark technique in patients undergoing cardiothoracic surgery

Landmark-guided internal jugular vein (IJV) cannulation is a basic procedure, which every anesthetist is expected to acquire. A successful first attempt is desirable as each attempt increases the risk of complications. The present study is an analysis of 976 IJV cannulations performed in adults undergoing cardiothoracic surgery. The IJV was cannulated with a triple lumen catheter using the anatomical landmarks. The following data were recorded: Patient demographics, age, sex, body mass index, diagnosis, operative procedure, operator (resident/consultant), site of cannulation (central approach, right IJV, left IJV, external jugular vein), number of attempts and duration of cannulation, length of insertion of the catheter, number of correct placements on X-ray and any complications. The success rate of IJV cannulation was 100%. In 809 (82.9%) patients, cannulation was performed in the first attempt. Residents performed 792 cannulations and the consultants performed 184 cannulations. In 767 patients, the residents were successful in inserting the catheter and in 25 they failed after 5 attempts, hence, they were cannulated by the consultant. The time taken for insertion of the catheter was 6.89 ± 3.2 minutes. Carotid artery puncture was the most common complication, it occurred in 22 (2.3%) patients. IJV cannulation with landmark technique is highly successful with minimal complications in the adult patients undergoing cardiothoracic surgery. Basic training of cannulating the IJV by landmark technique should be imparted to all the traines as ultrasound may not be available in all locations.

Anatomical landmark technique for internal jugular vein cannulation in patients with cyanotic congenital heart disease: A word of caution

Anatomical landmark technique for internal jugular vein cannulation in patients with cyanotic congenital heart disease: A word of caution

The Clavicular Notch as an Alternate Anatomical Landmark for Internal Jugular Vein Cannulation in Infants and Children: A Descriptive Study

Objective: To evaluate an alternate anatomical landmark technique for internal jugular vein cannulation in infants and children. Aim: To evaluate the success and safety of the clavicular notch as a bony landmark for central venous cannulation in infants and children. Background: Central venous cannulation can be particularly difficult in infants and children. While ultrasound-guided techniques are well established, the majority of central venous catheters are placed using landmark guidance with variable success rate. This prospective study documents the success and safety of a modified landmark technique using the clavicular notch as a bony landmark for central venous cannulation in this group of patients. Materials and methods: One hundred and fifty children under 12 years of age belonging to ASA grade I to III were included in the study. All children were placed in 150 trendelenberg position with head rotated 40o to the opposite side. The relationship of the IJV to the carotid artery was noted by audio Doppler. The notch technique was used only if the IJV was detected by Doppler at the notch. Using the standard seldinger technique the IJV was cannulated and the complications were noted. The traditional approach was our rescue method. Results: The IJV was localized at the clavicular notch in 95.33% (143/150) cases by audio Doppler and the overall successful cannulation rate was 98.6% (141/143). We encountered complications in 13 (8.6%) cases, none of which had any adverse outcome. Conclusion: This study confirms the consistent location of IJV at the clavicular notch. Therefore, the ‘Notch technique’ can be used successfully for IJV cannulation in infants and children.

Multiple left subclavian venous catheterizations in premature infant

Multiple left subclavian venous catheterizations in premature infant

Malposition of Central Venous Catheter – Three case reports

Central Venous Cannulation is a routine procedure done in the Operation Theatre and the Intensive Care Unit. Malpositioning is a very common occurance with the regular anatomical landmark technique. As the central venous catheters are essential in various critical care scenarios, hence any misplacement can hamper its purpose. Here we have three cases where in we saw the migration of the Right Subclavian Vein Catheter into the Ipsilateral Internal Jugular Vein, Contralateral Subclavian Vein and into the Ipsilateral External Jugular Vein radiologically. Hence a thorough knowledge of normal and variant anatomy is required for the proper positioning of Central Venous Catheters. Also radiological techniques like ultrasound guided cannulation may avoid inadverdent arterial puncture but may not be able to avoid malpositioning.

Ultrasound-guided infraclavicular axillary vein puncture is effective to avoid pinch-off syndrome: a long-term follow-up study

Pinch-off syndrome (POS) is a serious complication encountered during the long-term management of totally implantable access ports (TIAPs). The aim of this study was to examine the effect of ultrasound-guided infraclavicular axillary vein puncture to avoid POS in patients with long-term use of a TIAP. This was a retrospective review of 207 consecutive TIAPs: one hundred devices implanted using an anatomical landmark technique were used as historical controls (Landmark group), while 107 devices were implanted using an ultrasound (US)-guided puncture method (US group). The pinch-off grade (POG) was determined using chest X-ray findings following the definition of Hinke, and the progression of POG during the follow-up period of the Landmark and US groups was compared. Sixteen cases in the Landmark group were POG-1 and 3 were POG-2, while all cases in the US group were POG-0 at the time of venipuncture (p < 0.001). Eleven patients in the Landmark group showed some degree of progression of the POG during the follow-up period. In contrast, there were no cases showing progression of the POG in the US group (p = 0.002). US-guided infraclavicular axillary vein puncture was found to effectively make it possible to avoid POS for the long-term management of TIAPs, as well as at the time of implantation.

059 Pacemaker implantation using real-time ultrasound guidance for subclavian vein access

BackgroundSubclavian vein access using anatomical landmarks for guidance is widely used and is known to carry risks of serious complications. While the use of ultrasound imaging in cannulating the internal...

Dorsal penile nerve block for male pediatric circumcision – randomized comparison of ultrasound‐guided vs anatomical landmark technique

Dorsal penile nerve block (DPNB) is a commonly performed regional anesthetic technique for male circumcision. Traditionally, DPNB is based on an anatomical landmark technique. Recently, an ultrasound-guided technique for DPNB has been described. The aim of our study was to compare the anatomical landmark technique with this ultrasound-guided technique. The hypothesis to be tested was that ultrasound guidance of DPNB would lead to less administration of opioid when compared to the anatomical landmark technique. Boys of ASA status I/II scheduled for day case circumcision were prospectively recruited and randomized. DPNB was performed under general anesthesia using the anatomical landmark technique or ultrasound guidance. Fentanyl was administered intraoperatively and immediately postoperatively if patients demonstrated signs of pain. Similarly, oral codeine was given prior to discharge if required. The primary outcome measure was the number of patients requiring fentanyl. Secondary outcome measures included initial pain score on emergence from general anesthesia, requirement for codeine predischarge, and time to perform block. A total of 32 patients were recruited to the landmark group and 34 to the ultrasound group. There was no significant difference between the two groups in terms of fentanyl administration. The ultrasound technique took longer to perform but was associated with a reduction in codeine requirement prior to discharge. This study does not support the routine use of ultrasound for the performance of DPNB in male pediatric circumcision. Nonetheless, an associated reduction in codeine administration postoperatively suggests some benefit in terms of postoperative pain.

Internal jugular vein thrombosis associated with venous hypoplasia and protein S deficiency revealed by ultrasonography

A 41-year-old woman, who had no thrombotic risk factors and past history except congenital scoliosis, underwent central venous catheterization (CVC) before correction of the scoliosis. When internal jugular vein (IJV) catheterization using the anatomical landmark technique failed, CVC under ultrasound guidance was tried. As a consequence, thrombosis and hypoplasia of the right IJV were incidentally detected by ultrasonography. Central venous catheters were then successfully placed in other veins under ultrasound guidance. Also, after examinations to rule out the possibility of pulmonary embolism and to clarify the causes of the IJV thrombosis, the patient was found to have protein S deficiency. CVC under ultrasound guidance should be recommended to prevent the failure of cannulation and complications such as thromboembolism in patients who could possibly have anomalies of vessels as a result of anatomical deformities caused by severe scoliosis, even if patients do not have thrombotic risk factors such as a history of central catheter insertion or intravenous drug abuse, cancer, advanced age, cerebral infarction, and left ventricular dysfunction. Also, if venous thrombosis is found in patients without predisposing risk factors, one should ascertain the cause of the hypercoagulable state, for example protein S deficiency, and perform appropriate treatment and prevention of venous thromboembolism.

Is Ultrasound Guidance Advantageous for Interventional Pain Management? A Review of Acute Pain Outcomes

Ultrasound (US) guidance for peripheral nerve blockade has gained popularity worldwide. The reported benefits of real-time sonographic visualization compared with traditional nerve localization techniques generally apply to procedural and technical block-related outcomes whereas acute pain-related outcomes are featured less prominently. In this review, we evaluated the effect of US guidance compared with traditional nerve localization techniques for interventional management of acute pain and acute pain-related outcomes. We performed a systematic search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials (from January 1990 to January 2011) to identify randomized controlled trials evaluating the effects of US guidance on acute pain and related outcomes compared with traditional nerve localization techniques. Studies were excluded if they did not report at least one of the following acute pain outcomes: pain severity, opioid consumption, sensory block duration, and time to first analgesic request. Related outcomes were classified as follows: patient related (opioid-related adverse effects, patient satisfaction, postoperative cognitive deficit); anesthesia related (unwanted motor block, perineural catheter failure, morbidity, development of chronic pain); surgery related (hospital readmission, ability to ambulate); and hospital related (length of stay, cost). Promising novel applications of US guidance for acute pain management were also sought for discussion purposes. We identified 23 randomized controlled trials, including 1674 patients, that compared US guidance with and without peripheral nerve stimulation with peripheral nerve stimulation alone or anatomical landmark techniques. Of the 16 studies that evaluated pain severity, 8 reported improvement with US guidance; however, only 1 study reported a difference between US guidance and the comparator of >1 interval on the numeric rating pain scale. Eight studies evaluated sensory block duration and 3 of these reported prolonged block duration with US guidance. Seven studies evaluated opioid consumption, of which 3 reported a reduction with US guidance. Three studies evaluated time to first analgesic request, of which 2 favored US guidance. We uncovered no significant differences between US guidance and traditional nerve localization techniques for any other related outcome. US guidance was not found to be inferior compared with traditional nerve localization techniques for any outcome. Nonrandomized data suggest that US-guided transversus abdominis plane blocks may offer analgesic benefit over standard analgesic therapy, but has not been compared with an anatomical landmark technique. At present, there is insufficient evidence in the contemporary literature to define the effect of US guidance on acute pain and related outcomes compared with traditional nerve localization techniques for interventional acute pain management.

Utility of Ultrasound Versus Landmark-Guided Axillary Artery Cannulation for Hemodynamic Monitoring in the Intensive Care Unit

Objectives. To assess the utility of ultrasound-guided axillary artery catheterization compared with anatomical landmark technique catheterization in the intensive care unit. Design. Randomized controlled trial. Setting. University hospital surgical and neurosurgical intensive care unit. Patients. A total of 33 critically ill patients undergoing arterial line placement. Interventions. Axillary arterial line placement under ultrasound guidance or by using anatomical landmarks. Measurements and main results. Procedure duration, number of attempts (skin punctures), needle repositionings, and aborted procedures were compared. A total of 33 patients were randomly assigned to either the ultrasound group (n = 18) or the anatomical landmark group (n = 15). Aborted procedures were significantly greater in the landmark group (n = 4) than in the ultrasound group (n = 0); P = .019. Procedure duration (mean ± SD) in the ultrasound group was 7.01 ± 4.40 minutes compared with 9.29 ± 10.00 minutes in the landmark group; P = .360. A significant reduction in overall procedure duration for fellow operators (5.83 ± 3.64 minutes) versus resident operators (11.46 ± 9.41 minutes) was noted; P = .012. The number of attempts in the landmark group was 3.07 ± 2.96 compared with 2.44 ± 1.72 in the ultrasound group; P = .46. The number of needle repositionings was 4.06 ± 2.86 times per procedure in the ultrasound group, compared with 10.00 ± 13.45 in the landmark group; P = .077. Conclusion. Ultrasound-guided axillary arterial catheter placement increases the success rate of line placement with no significant decrease in the duration of the procedure and the number of needle punctures or repositionings.