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Yes I hope to - and will move it up the priority list! Thanks for the suggestion.

May not be dense enough for surgical anesthesia. However should be good for postoperative analgesia - can perform it after turning them lateral for the spinal anesthetic.

@@KiJinnChin apart from SA , do you perform combined regional nerve block for # hip in frail pts ? Thx

Thanks for the suggestion. It's on my to-do list! There have been some recent articles on it, including the recommendation (which I agree with) that it should more properly be called the sacral multifidus plane block.

I consider the DCIA more of a structure to be avoided rather than a surrogate endpoint target. It also usually sits superficial to transversus abdominis, so it's separated from fascia iliaca by this muscle. As such, I don't expect to see lifting of the artery, nor am I looking for it. I just want to avoid it as I insert the needle, and then I want to see spread under fascia iliaca pushing the muscle down. Hope that helps!

I think this comment is for the SIFI block video? If so - I think that the bow tie approach is another good and safe alternative, but that utilizes an infrainguinal insertion point, which may not always be accessible. The suprainguinal puncture point is physically closer to the target nerves, so possibly spread will be greater, and may increase probability of a good block in more patients. It's always good to have multiple "tricks" up one's sleeve

@@KiJinnChin yes, I was refering to the SIFI block, sorry for the confusion (misclicking on the smartphone probably). your answer makes a lot of sense to me, even if I prefer an in-plane view, and the respective orientation for cathether insertion seems intuitive. thank you for the video and tips, keep up the great content :)

You can do either - depending on your resources. We only have automated continuous infusion, not int boluses - so those would have to be given manually. CI works quite well; and again with a catheter you have the flexibility to vary dosing, and LA type. Something more dilute along the lines of 0.2% ropivacaine or 0.25% bupivacaine usually provides noticeable benefit, and has a better chance of preserving more quads motor function (e.g. straight leg raise), although cannot guarantee full strength.

if you want the flexibility to extend the block. You can run infusion or give int boluses as you wish. Quad weakness depends somewhat on LA conc - more dilute, less so. There can be a sweet spot for analgesia and mobility, but hard to give a one size fits all recipe in medicine.

Good question. It will be deeper in some than others; but in a slim patient, you could compress the site quite effectively against the bony ilium if there was a concern.. I think if you stay more lateral, and avoid the branches of the deep circumflex iliac vessels, it is as safe as any other fascial plane block. It's worth noting that the Pajunk E-cath II has a 21G needle (within an 18G introducer cannula), so that may offer some added safety vs a 17G Tuohy needle with other sets.

Hi Shin Yuet! Good question - the answer is that you rely on the Parasagittal Oblique (PSO) view to visualize the paraspinous/paramedian window on both right and left sides, and determine which is wider (it will be on the convex side). Mark that and aim for it, as described in my video on thoracic epidurals - ua-cam.com/video/DrAO5kJyfeE/v-deo.htmlsi=XNrkW0nB5VBdMbXD. The PSO view has become my most important US view, even for lumbar neuraxial blocks since the paraspinous / paramedian windows are always easier to see and access in difficult patients.

@@KiJinnChin Thank you! I tried it today and it worked!!

If you are approaching from the posterior aspect of the knee, as we usually are, then superficial is with reference to the skin surface, and is posterior with reference to the artery.

@@KiJinnChin Thank you for explaining.

It means being definitively deep to the erector spinae muscle, and within the intertransverse connective tissue complex.

I have never deliberately done it. It could be effective - it may depend how lateral to the tip of the TP you are; because the lumbar plexus diverges more anteriorly the more lateral you go. So this lowers the probability of LA reaching the LP. The question to ask yourself is why you would choose it over other techniques.

@@KiJinnChin Thanks a lot. You are right, The QLB would be with very unpredictable effect.

I usually advocate to perform it in the middle of the range of operative levels. So L3 in this case. Some advocate for bi-level injections; but this will take more time.

I was fortunate enough to have grown up in a relatively resource-poor era of anesthesia 😆And there are times when simple is good.

@@KiJinnChin So was I. Exactly the same technique (in Sweden). Nice to see it revisited. NYSORA actually said correct land-marque technique could be safer than US guided.

@@M_J_nan I believe there is some basis to that remark by NYSORA that it is a safer technique. If the operator cannot track the needle tip in the US-guided approach, there is a real risk of causing a pneumothorax. With this landmark-guided approach, and a flat needle trajectory, there is minimal-to-no risk of hitting the lung. The more likely negative outcomes are failure to locate the vein, or an arterial puncture if the needle is directed too cranially.

I would recommend that you be comfortable with both. I agree with your sensible suggestion that you focus on midline first, then once you are competent in that, actively seek to learn paraspinous as the other arrow in your quiver. This way if you find yourself struggling with paraspinous in a given patient (as may happen early on in the learning curve), you can fall back to the more-commonly practiced midline approach.

Thankyou sensei for your kind reply and feedback.

There are ultrasound sequences interspersed e.g. at 2min; nevertheless thanks for the feedback, which I will incorporate in future videos to try and better illustrate the key principles. I will say that in my experience, success in placing the arterial line depends a lot on the handling of the cannula during insertion, not just the ultrasound imaging, which I hope this video demonstrates.

Thanks for the helpful tips! I have found getting the wire to thread into the correct place more of an issue with right-sided placements; and will definitely try them out when I next do one.

Do you continue to the Supra inguinal region from the same femoral puncture point or do another cranial puncture?