Ultrasound Imaging in Obesity for Epidural / Spinal Anesthesia & Lumbar Puncture

[@KiJinnChin]

1:28 = General principles of US imaging in obesity 2:38 = Parasagittal oblique (PSO) view 6:39 = Transverse midline (TM) view 8:10 = AP and TP as surrogate indicator #1 9:40 = Absence of SP acoustic shadow as surrogate indicator #2 11:01 = Dynamic scanning of TM view 12:20 = Identifying SPs as surrogate indicator #3 14:14 = Paraspinous (paramedian) approach 15:02 = Tissue compression in obesity 16:10 = Needling phase 17:00 = Needle deflection 17:59 = Trajectory: Angle vs Depth 18:39 = Controlling skin movement 19:16 = Finding the midline 20:57 = Holding and manipulating the needle 24:17 = Final pointers 26:18 = Summary 27:23 = Bonus video: US-assisted rescue of difficult spinal

[@balajigovindharaj8258]

best explanation on this topic

[@blueteam8638]

Invaluable learning, many thanks for your time and effort.

[@jorgebentancur3231]

excellent video, very educational and illustrative, very useful for improving our practice

[@ZzzzZz-pk2yq]

Used this technique today, and it was incredibly helpful! Had the CSE in less than 5 min.

[@KiJinnChin]

I'm really happy to hear that! Congrats! Imaging in the larger patient is much more challenging.

[@bedazzledmeedo4141]

Thank you for you remarkable stepwise teaching approach ,, with your skillful appreciation of subtle visualizing tips and maneuvres using the ultrasound probe,, keep up the best practice👍🏼

[@sayedjubran8954]

Great wonderful explanation Thank you very much

[@dramitdikshit6235]

Will be more than happy to know your inputs (another video) on spinal in instrumented spine patients with USG. Thank you indeed in anticipation.

[@ferhan22]

Excellent lecture

[@drphilstagg6792]

absolutely brilliant.

[@claustrox]

Thank you for this great lesson, I am working in an ortophedic hospital from 2008 and In my opinion the 2 fingers technique isn't ideal . In my experience with one finger technique is easier an more reliable find and track the interspinal space. I insert the middle while am marking the insertion point whit my non-dominant thumb . In this way I can fix skin while exactly marking the inserting point. It is fun that till now I strongly suggest to my students to avoid using the 2 finger technique :-) I'll give a try to the 2 finger technique , who knows maybe after 15 years I could change my mind :-)

[@jessicaburjorjee3460]

Thank you so much for these excellent videos that show how to use ultrasound in challenging obese patients. At one point you comment that the depth for neuraxial should be estimated as sacral edge plus 2 cm. However, if the anterior complex is the reflection off of the posterior part of the vertebral process wouldn't this be too deep? For estimating depth for the dura/posterior complex when you can't see it directly, it would seem to be just about the same depth as the transverse processes if you can see them or alternatively 2 cm shallower than the anterior complex. Please let me know if I have interpreted this correctly? Again, thanks so much for all your work and guidance with regional anesthesia! It is amazing to be able to learn from an expert.

[@KiJinnChin]

Thanks for the comment. You are correct. I was trying to make a more practical point which may not have come across properly. First that the sacrum is always identifiable, and sets the depth at which you can expect to see anterior complexes - 2cm deeper. Yes, the posterior complex will be more superficial, probably about a cm or so "higher". This is more important when doing an epidural vs a spinal. Nevertheless by the time you factor in tissue compression, angulation of the needle, the studies on depth indicate that you should always allow for 1cm or so of error, and usually needle depth exceeds measured US depth. I tend to use US depth only as an estimate, to guide needle selection, and to give me a rough idea of when I might be approaching the space. Tactile endpoints are still key for me - sensing ligamentum flavum in particular.

[@jessicaburjorjee3460]

@@KiJinnChin Excellent, thanks again.

[@dramitdikshit6235]

In young obese do you still recommend quincke needle or pencil point needle? PDPH?

[@KiJinnChin]

Sometimes I will try with a long 25G first to reduce risk of PDPH, but if I find I have trouble keeping needle from flexing when trying to redirect and advance, I will switch to a 22G Quincke sooner rather than later.

[@SamtaniPradeep]

Sir I'm not getting why were measuring as depth of sacrum +2 cm or depth to anterior complex in PSO view as distance to epidural/intrathecal space from skin; whereas it should be depth to posterior complex as distance to epidural/intrathecal space from skin??

[@dramitdikshit6235]

If extra long needles are not available for some reason. Then to compensate for those few millimeters - is midline approach (Vs paramedian) with pressure application will improve success rate with USG assistance?

[@KiJinnChin]

yes, you can get up to 1cm further depth of needle advancement if the subcutaneous tissues are compressible. Paramedian will always be a slightly longer trajectory, but how much depends on angle.

[@rafiqnabil7413]

WONDERFUL!!!!!