Auyong Adductor Canal Catheter Placement

Introduction

Hi, this is Dave Al Young and Neil Hansen from the Department of Anesthesiology at Virginia Mason Medical Center.

Today we're gonna demonstrate a selective femoral nerve block or adductor canal block after a total knee replacement.

Preparation

We're gonna start by prepping with chlorhexidine alcohol combination, the area of the medial upper thigh, and we'll get our sterile probe cover over our probe.

We're using a 15 to six megahertz probe, linear array transducer.

I'm gonna place the transducer halfway between the knee and the inguinal crease.

We're gonna now look to our ultrasound image.

Ultrasound Imaging and Anatomy

In our ultrasound image, we see a pulsating femoral artery.

Beneath that is the femoral vein.

As I let pressure go, you can see the vein collapsing and expanding.

The muscle above the vasculature is a sartorious muscle.

The muscle to the left of the vasculature is the VASIs medias, and you can see the femur even more to the left.

The muscles to the right of the vasculature are your adductor muscles.

Once I identify the vasculature, lateral to the vascular is gonna be a hyper colic area.

This is a area where the nerves of this block lie.

Needle Insertion

Now that I have my target on the screen just lateral to the artery or to the left of the artery, I'm gonna make a skin.

We will start our needles several centimeters away from the probe because we will have a better image of the needle.

As we advance to our target, we have a two e needle.

This is a seven gauge, 17 gauge, two e needle, along with a 19 gauge catheter.

We're already loaded the catheter into the needle, so we're able to drop the catheter off immediately after placing our needle in the correct area.

We have loaded into our syringe 20 milliliters of lidocaine.

We can now focus back on our ultrasound screen.

I'm gonna place my target on the screen, just slightly medial here, and we're going to advance our needle.

From the lateral side, again, we're starting our needle two centimeters away in this patient, and we're gonna advance the needle on the screen.

My needle is now advancing between the VASIs medias and the sartorious muscle.

And as we advance, we're going to inject some local anesthetic and create a pocket of local anesthetic for me to advance my needle into.

This nerve block would be amazingly easy if there wasn't a vein just underneath the artery.

At all times, I'm gonna recheck that vein by letting pressure from the transducer go and make sure I'm not advancing inadvertently into that vein, and I'm gonna continue my needle advancement to get good spread around the nerve.

When we see the injection like this, we're pushing the nerve more superficial towards the sartorious muscle.

This is where we want to be and where we want to leave our catheter for this nerve block.

You can see from an anatomical standpoint, the needle has been advanced from lateral to medial or anterior to posterior aiming between the artery and vein.

We have avoided our nerve structures and slipped just beneath them by injecting some local anesthetic below them.

And we have positioned the needle just lateral to the artery, yet still above the vein.

Catheter Placement

Next, I'm going to advance the catheter out of my needle.

I'm gonna take the needle, hold my needle with my pinky finger and ring finger and advance the catheter out of the needle.

And you can now see some of the catheter coming out of the needle being left behind right where my needle was.

As I advance it, it coils up and leaves a lot of extra catheter.

Over the next couple days, as we run this infusion, the catheter does not get displaced away from this nerve.

Now that the needle's out, I'll hold my catheter so it doesn't come out anymore.

And we're gonna focus back now on the ultrasound screen.

We see our same target there.

We see our artery, our vein deep to it, and our nerve target just lateral to the artery.

I'm gonna slide until I locate my catheter.

Now we can see some of the catheter, the double line, just lateral to the artery.

Dr. Hanson now is going to inject and we'll see some of the spread just lateral to the artery and you can see the local and kind of surrounding that entire nerve.

Next, we're going to take the needle off of the system here and our catheter has been left behind.

Securing the Catheter

One thing that absolutely improves the longevity of continuous catheters is putting some type of surgical glue or cement on the area as a catheter insertion site.

This prevents leakage of the catheter and prevents the loosening of any of your bandages or dressings.

After letting the surgical glue dry for a few seconds, we're gonna place a small clear occlusive dressing over the top.

Conclusion

This is the adductor canal nerve block or selective femoral nerve block after a total joint knee surgery.