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Peripheral Nerve Block Part 1
This document provides a comprehensive overview of regional anesthesia and its historical development, detailing local anesthetic methods for pain management during surgical procedures while maintaining patient consciousness. It discusses the anatomy, physiology, classification of anesthesia techniques, advantages, and disadvantages, as well as complications and contraindications related to peripheral nerve blocks. Additionally, it emphasizes the importance of modern equipment, such as ultrasound and nerve stimulators, in improving the efficacy and safety of these procedures.
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Peripheral Nerve Block Part 1
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- 2. 2 SPEAKER Dr. DEBDIPTA DAS 1STYear PGT, Anesthesiology Medical College, Kolkata MODERATOR Dr. RITA HALDER Associate Professor, Anesthesiology Medical College, Kolkata
- 3. INTRODUCTION Local anesthetic inducedblockade of peripheral nerve impulses from a targeted body part with preserved level of consciousness Injecting local anesthetic near the course of a named nerve • Surgical procedures in the distribution of the blocked nerve 3
- 4. HISTORY4 EARLIER • South AmericanIndian --- Cocaine as LA 1880 • Basil Von Anrep injecting Cocaine in his arm --- numbness to his skin • Halsted & Hall --- inject Cocaine to peripheral site for minor Surgery 1884 • Freud prompted Koller’s discovery • Cocaine as topical anesthesia in eye surgery 1900s • Procaine, Dibucaine, Tetracaine discovered 1901 • Crile --- RA as blocking “surgical shock”, presaging “pre-emptive alalgesia”
- 5. 5 1923 • Labat populariseRA • American Society of Regional Anesthesia (ASRA) 1963 • Bupivacaine • Cardio-toxicity proved (1979) 1972 • Nerve stimulator --- guide LA drug Inject 1977 • Sclander --- Continuous axillary nerve block 1985 • European Society of Regional Anesthesia HISTORY
- 6. 6 1991 • Asian-Oceanic Societyof Regionalk Anesthesia & Pain Medicine 1994 • Kapral --- USG guided LA drug inject • The New York School Of Regional Anesthesia (NYSORA) website HISTORY
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- 9. PHYSIOLOGY9 Aα MOTOR (A) largestdiameter and highest degree of myelinization ----- highest speed of impulse propagation and a relatively low threshold level C PAIN (B) Smaller diameter and very little or absence of myelinization ---- lowest speed of impulse propagation and a relatively high threshold level Aδ MOTOR Smaller diameter and smaller degree of myelinization than Aα MOTOR
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- 11. PHYSIOLOGY11 A certain minimumcurrent intensity is necessary at a given pulse duration to reach the THRESHOLD LEVEL OF EXCITATION The lowest threshold current (at infinitely long pulse durations) is called RHEOBASE The pulse duration (pulse width) at double the rheobase current is called CHRONAXIE
- 12. CHRONAXIE OF DIFFERENT NERVES NERVEFEATURE CHRONAXIE-ms C Unmyelinated 0.40 Aδ myelinated 0.17 Aα myelinated 0.05 - 0.10 12
- 13. WHAT IS HZ?13Cycles/second
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- 17. ADVANTAGES Avoids general anaesthesiacomplications Pt remains awake .....pt will & helpfull for suegeon---- feedback Postoperative analgesia----continue / catheter Less PONV-----less opiods need Less post ops sedation------less confusion (cognitive functions) in elderly 17
- 18. Early discharge Cheep &relatively safe in remote location hemodynamic stability than neuraxial & GA Sole anesthetic technique , supplemented with monitored anesthesia care (moderate sedation) Preemptive analgesia 18
- 19. Less immunosuppressive thanGA Excellent alternative to GA • Hemodynamically compromised • Too ill to tolerate GA • Malignant hyperthermia • PONV is risk Growing popularity of RA & PNB • Modern equipments—USG,Nerve stimulator ect 19
- 20. DISADVANTAGES TIME DELAY • 15-30MIN –Procedure & onset • Onset is shortened by adjuvant like clonidine PATIENT FACTORS • Discomfort due to procedure & positioning & awake during surgery • Distress due to paralysis & numbness---both intra & post-operative • Managed easily—benzodiazepine & opiods SURGEON FACTORS • Irritated by awake & conversation with surgeon ANAESTHETIST FACTORS • Skill, knowledge & proper equipments BLOCK FAILURE / PATCHY BLOCK 20
- 21.
- 22. DISADVANTAGES22 NERVE DEMAGE • Chronicparesthesias • Permanent Nerve damage FAILURE RATE-----10% - 20%, varies SURGERY OUTLASTS THE BLOCK • If No catheter----GA • Adjuvant like dexamethasone prolong duration of block. LOCAL ANAESTHETIC TOXICITY SPECIFIC COMLPICATIONS RELATED TO NERVE BEING BLOCKED • Respiratory failure-phrenic N Block • Seizures ---intra-arterial injection
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- 25. ABSOLUTE COTRAINDICATIONS Patient refusal Major coagulationdisorders & drugs • Hemophilia • DIC • Anticoagulant drugs Infection at site 25
- 26. 26 Related to specificN Block • Interscalene block • with contra lateral phrenic N paralysis • Severe pulmonary disease Increased risk of LA toxicity • Multiple Intercostal blocks LA Allergy-anaphylaxis Ring block at site---end arteries---LA containing Adrenaline • Penile block, toes, fingers, tip of nose etc
- 27. RELATIVE COTRAINDICATIONS Dementia , uncooperativepatients Placing block under GA Surgeons who feel uncomfortable Uncertain duration of surgery Septicemia Preexisting peripheral neuropathy 27
- 28. COMPLICATIONS Local anaesthetic toxicity Nervedamage Vasoconstrictor problems Infection 28
- 29. 29 Haematoma • Bleedingdisorder • Anticoagulant drugs Wrong drug Pneumothorax • supra & infra clavicular • inter costal block Psychological reaction • Vasovagal –mistaken as LA toxicity • Anxious pt--sedate
- 30. 1.LA TOXICITY30 Immediate ordelayed-----signs & symptoms (CNS & CVS)
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- 32. 32 Prevention ---always • MaintainIV line before • Have resuscitation equipments & drugs • Always aspirate before injecting • Inject slowly & aspirate after every 3-5 ml • Stabilize needle ……short fine bore plastic tubing b/w needle & syringe (isolated needle technique) • Observe pulse,ECG & sign of IV injection 1.LA TOXICITY
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- 34. PROTOCOL FOR TREATMENTOF LA TOXICITY 34
- 35.
- 36. 36 Cont. observe Terminate neurological sym at once,control seizure
- 37. 37 Standard ACLS protocol, CPRin case of unconsciousness of cardiovascular collapse Start INTRALIPID
- 38. IMMEDIATE TREATMENT OF LOCALANAESTHETIC TOXICITY 38 CALL FOR HELP Stop injecting ABC – 100% OXYGEN, INTUBATE, IV ACCESS. CONTROL SEIZURES. CPR IF INDICATED FOLLOWING STANDARD ALS PROTOCOLS CONSIDER TREATMENT WITH LIPID EMULSION (IV bolus 20%intralipid 1.5ml/kg over 1minute. Start an intravenous infusion of Intralipid® 20% at 0.25 ml/kg/min. Give two further boluses if necessary. Increase infusion rate of Intralipid® 20% to 0.5 ml/kg/min if necessary.)
- 39. 2.NERVE DAMAGE Direct byneedle or by injection of LA Eliciting paraesthesia technique -----can damage • Withdraw 1-2 mm after eliciting paraesthesia-before injection Incidence • 1 in 1000 blocks • Most of paresthesia or pareseis resolve—few months • 1 in 10000 blocks=permanent demage 39
- 40. RECOMMENDATIONS TO REDUCE RISKOF NERVE DAMAGE Use short bevel needle Use nerve stimulator & insulated short bevel needle Avoid rapid,forceful injection • STOP –undo resistance & severe pain-----withdraw & then reinject Avoid block under GA 40
- 41. 3.VASOCONSTRICTOR PROBLEM General rule—epinephrine shouldnot be used in concentration > 1:200000 (5ug/ml) in PNB • Skin ----- 1:300000 or 1:400000 sufficient • Dentist –1:80000 but in small vol Never use----areas of endarteries Careful-----ischemic areas---varicose leg ulcer 41
- 42. 42 H/O IHD-----avoid/reduce dose----can cause palpitation, angina, HTN. Avoid adrenalin containing LA Pregnancy-----epinephrine in significant quantity reduce placental circulation ----- avoid /reduce dose Max recommended dose of epinephrine--- 4 ug/kg Epinephrine sol-----lower pH--pain on injection-----can be reduced by • Adding sodium bicarbonate • phenylephrine in stead of epinephrine • Warming the sol to body temp
- 43. 4.INFECTION Aseptic technique No needleprick through infected skin except abscess Use antiseptic Alcoholic Betadine(povidone/ iodine in ethanol) • 1% chlorhexidine in 75% alcohol— allergic to iodine 43
- 44. PREPARATION FEW GOLDEN RULES •Designed procedure room—block room • Insert an intravenous line before • Monitor (pulse oximetry, ECG , BP) • Practice proper aseptic technique . • Resuscitation equipments at hand • Patients informed consent • Adequate knowledge of the correct tehnique and know how to handle complications 44
- 45. PREMEDICATION Anxiolysis with Benzodiazepines and/oropiods Light sedation----elicitation of paraesthesia technique, nerve stimulator. O2 supplementation 45
- 46.
- 47. EQUIPMENTS Nerve stimulator—ECG Electrode Unipolarinsulated Bevel needles • different lengths ( 25- 150 mm)and (20 to 25G). • tip may angled at 15 or 30 degrees. • catheters Ultrasounds machine Syringes Local anaesthetic 47
- 48.
- 49.
- 50. NERVE STIMULATOR50 RED/+VE/ANODE CONNECTED TOPATIENT BLACK/-VE/CATHODE CONNECTED TO STIMULATING NEEDLE
- 51.
- 52. IDEAL ELECTRICAL CHARACTERISTICS OFA PNS Constant current (DC)generator Monophasic rectangular output pulse i.e. the current flows in one direction only. Ability to vary pulse duration (0.1 - 1ms) Digital display of actual flowing current Safety features like • circuit disconnection alert, • impedence alerts, • low battery and • malfunction alert Leads should be clearly marked to avoid confusion as to which is cathode and anode 52
- 53. NERVE STIMULATOR Current rangefrom 0.1-6.0 mA • Linear & constant • Low output Pulse Frequency • 1 Hz -Mixed nerve • 2 Hz - Sensory nerve 53
- 54. SETTINGS OF PNS Desiredinitial---USUALLY • current (1 - 2mA), • pulse duration (0.1ms) and • frequency (2hz). A threshold current of less than 0.5ma usually results in a successful block current less than 0.2ma, increased resistance on injection or pain on injection may suggest intraneural needle placement 54
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- 58.
- 59.
- 60. TOUHAY SET FORPERIPHERAL NERVE CATHETERIZATION 60 Stimulating catheter
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- 62.
- 63.
- 64. MEDIAN NERVE CATHETER 64 postoperative painrelief after hand surgery. Continuous infusion of levo-bupivacaine 0,125% - 2-5 ml/h
- 65.
- 66.
- 67. Direct visualization ofnerves & other structures Visualization of LA spread Re-position of needle in case of misdistribution of LA Avoidance of side effect- due to excess dose of LA ADVANTAGES OF USG67
- 68. Avoidance of painfulmuscle contractions due to PNS Faster onset Longer duration of blocks Improved quality Blocks under GA 68
- 69. Short Axis (SAX)– • probe is aligned perpendicular to the axis of the nerve, the nerve is seen in cross section Long Axis (LAX) – • probe is aligned parallel to the axis of the nerve Short Axis View is preferred due to easy identification of nerves, more stable view & allows to visualize circumferential spread of LA------ “Doughnut” sign BASIC VIEWS ON USG69
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- 71.
- 72. TRANSDUCER MANIPULATION72 SLIDING (A),TILTING (B), COMPRESSION (C), ROCKING (D), ROTATION (E)
- 73. In plane (IP)– long axis of the needle is oriented to the long axis of the probe • Entire needle can be seen Out of plane (OP) – the long axis of the needle is the oriented perpendicular to long axis of the probe • Only part of the needle is seen NEEDLE APPROACHES73
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- 75.
- 76. 76 Schematic representation ofthe views and needle approaches for nerve blocks with ultrasound imaging. A. Short axis view of a nerve with an out-of-plane needle approach. B. Short axis view of a nerve with an in-plane needle approach. C. Long axis view of a nerve with an out-of-plane needle approach. D. Long axis view of a nerve with an in-plane needle approach. Modified6.
- 77. 77 Picture showing theorientation of the ultrasound probe and the needle for placement of an interscalene block with the in-plane needle approach VIEW SHORT / LONG ?
- 78. TECHNIQUES Single injection Multiple injections---axillaryblock Using catheters • Intermittent dose • Continuous Field block---superficial cervical plexus block • Large vol of LA in general location of cutaneous N • Minor/superficial surgery • Supplement to PNB & Neuraxial blocks 78
- 79.
- 80. CHOICE OF LOCAL ANAESTHETICS Purposeof block • Anaesthesia or analgesia Onset Duration of block Site & area of block—vol Degree of sensory Vs motor block Maximum toxic dose 80
- 81.
- 82. LA DRUG INMAJOR NERVE BLOCK 82
- 83. 83 LA DRUG INMINOR NERVE BLOCK
- 84.
- 85.
- 86. CONCENTRATION ANALGESIC BLOCK • 0.125%Bupivacaine, 0.2% Ropivacaine, • Opiods, Clonidine. 86
- 87. PNB PLACEMENT TECHNIQUES Anatomy Loss of resistanceand tactile feedback Evoked paraesthesia Nerve stimulator (goal 0.2-0.5 mA) Ultrasound guided Percutaneous electrical guidance 1 2 3 4 5 6 87 OTHERS 1.Droppler 2.CT LA-- in Perineural area
- 88. CONCLUSION Centralize your equipment Selectproper block Good knowledge of anatomy Know about potential complications and treatment 88
- 89. Select right siteof right patient Be confident about your block But still if you fail--Failures are the stepping stones for success 89
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- 91.
- 92.
- 93. SCALP BLOCK :AWAKE CRANIOTOMY
- 94. SCALP BLOCK :AWAKE CRANIOTOMY SUPRAORBITAL NERVE needle at a perpendicular angle immediately superior to the supraorbital notch
- 95. SCALP BLOCK :AWAKE CRANIOTOMY SUPRATROCHLEAR NERVE target area for insertion is on the supraorbital ridge approximately 1cm medial to the supraobital notch, between the notch and the bridge of the nose
- 96. SCALP BLOCK :AWAKE CRANIOTOMY TEMPORAL BRANCH OF THE AURICULOTEMPORAL NERVE Immediately posterior to the superficial temporal artery at the level of the auditory meatus. Injection is superficial and subcutaneous
- 97. ZYGOMATICOTEMPORAL NERVE SCALP BLOCK: AWAKE CRANIOTOMY emerges from the temporalis fascia near the lateral border of the orbit Field infiltration above the zygoma through the temporalis muscle and almost down to the periosteum of the temporal bone
- 98. GREATER & LESSEROCCIPITAL NERVE LESSER OCCIPITAL -- deep or superficial to the fascia at the upper, posterior border of sternocleidomastoid GREATER OCCIPITAL – middle third of a line between the mastoid process and the external occipital protuberance along the superior nuchal ridge SCALP BLOCK : AWAKE CRANIOTOMY
- 99. SCALP BLOCK :AWAKE CRANIOTOMY GREATER AURICULAR NERVE involved blockade of the entire superficial cervical plexus at the border of the sternocleidomastoid muscle USG guided GAN block (superficial location on the anterior surface of the sternocleidomastoid muscle)
- 100. maxillary nerve eventually entersthe face through the infraorbital canal, where it ends as the infraorbital nerve. The infraorbital nerve supplies SENSORY BRANCHES TO THE LOWER EYELID, THE SIDE OF THE NOSE, AND THE UPPER LIP. INFRAORBITAL NERVE BLOCK : UPPER LIP SURGERY
- 101. INFRAORBITAL NERVE BLOCK :UPPER LIP SURGERY easily blocked by a facial approach Locate infraorbital foramina with respect to supraorbital foramina or upper teeth Needle Placed through the skin and aimed at the foramen in a perpendicular direction
- 102. EAR BLOCK POSTERIOR Br.GREAT AURICULAR NERVE LESSER OCCIPITAL NERVE ANTERIOR Br. GREAT AURICULAR NERVE AURICULOTEMPORAL NERVE Blocking the entire ear (with the exception of the area supplied by the vagus nerve)
- 103. EAR BLOCK inserting theneedle at the black dots and infiltrating along the dotted lines TEMPORAL Br. AURICULO TEMPORAL nv. LESSER OCCIPITAL nv. GREAT AURICULAR nv.
- 104. OTHER NERVE BLOCKOVER AROUND FACE : IN BRIEF 104
- 105.
- 106. NASOCILIARY AND ANTERIOR ETHMOIDALNERVE BLOCKS 106
- 107.
- 108. NASAL BLOCK108 SUPPLIMENTED WITHINFRAORBITAL NERVE BLOCK
- 109. POSTERIOR SUPERIOR ALVEOLAR NERVEBLOCK 109
- 110. MIDDLE SUPERIOR ALVEOLAR NERVEBLOCK 110
- 111. ANTERIOR SUPERIOR ALVEOLAR NERVEBLOCK 111
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- 113.
- 114. MANDIBULAR NERVE BLOCKS 114 below thezygomatic arch at the midpoint of the notch of the mandible until the pterygoid plate is felt Another type -- AKINOSI closed-mouth Mandibular block
- 115. INFERIOR ALVEOLAR NERVE BLOCK 115 2inches deep, 1 inch superior and just medial to the 3rd Mandibular molar
- 116. MENTAL NERVE BLOCK116 Mentaland incisive nerves are the terminal branches for the inferior alveolar nerve Sensory - lower lip skin mucobuccal fold at or anterior to the mental foramen. This lies between the Mandibular premolars
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- 118.
- 120. INDICATION Vocal cord surgery- medialization thyroplasty Cervicogenic headache Carotid endarterectomy Zenker diverticulum excision in a patient with ankylosing spondylitis Drainage of dental abscess in adults with difficult airways Drainage of submandibular and submental abscesses
- 121. INDICATION Minimally invasive parathyroidectomy Carotidbody tumor excision in a patient with Eisenmenger syndrome Postoperative analgesia after clavicle surgery Thyroid surgery under general anesthesia Management of neuropathic cancer pain
- 122. BLOCKADE BOTH SUPERFICIAL &DEEP CERVICAL PLEXUS BLOCK -- skin of the anterolateral NECK and the ante- and RETROAURICULAR areas. In addition, the DEEP CERVICAL BLOCK anesthetizes three of the four strap muscles of the neck, geniohyoid the prevertebral muscles Sternocleidomastoid levator scapulae the scalenes Trapezius and the diaphragm
- 123. TECHNIQUE : SUPERFICIAL CERVICALPLEXUS SUPINE OR SEMI-SITTING POSITION WITH THE HEAD FACING AWAY Landmark & needle insertion point Fanning of drug
- 124. TECHNIQUE : DEEP CERVICALPLEXUS DEEP CERVICAL PLEXUS BLOCK IS A PARAVERTEBRAL BLOCK OF THE C2 TO C4 SPINAL NERVES C2 transverse process lies 1 to 2 cm caudal to the mastoid process --- 1.5-cm intervals C3, C4 Drug delivered by paravertebral block technique by guided over transverse process single injection of 10 to 12 mL at the C4 transverse process
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- 126. NERVE BLOCK FORAWAKE INTUBATION ophthalmic and maxillary divisions of the TRIGEMINAL NERVE supply the nasal cavity and turbinates oropharynx and posterior third of the tongue are supplied by the GLOSSOPHARYNGEAL NERVE VAGUS NERVE innervate the epiglottis and more distal airway structures
- 128. NERVE BLOCK FORAWAKE INTUBATION PREPARATION FOR AWAKE INTUBATION Premedication Topical anesthesia by spraying LA drug LA soaked cotton pledgets or swabs Inhalation of Aerosolized (Atomized) LA Vasoconstrictor can be used to reduce mucosal bleeding
- 129. BLOCKADE OF THE TRIGEMINALNERVE NASAL INTUBATION PALATINE NERVE ANTERIOR ETHMOIDAL NERVE greater and lesser palatine nerves --- the nasal turbinates and the posterior two thirds of the nasal septum TOPICAL APPLICATION OF LA PTERYGOPALATINE GANGLION block remaining portions of the nasal passages INHALATIONAL OR SPRAY TOPICALIZATION
- 130. BLOCKADE OF THE GLOSSOPHARYNGEALNERVE oropharynx, soft palate, posterior portion of the tongue, and the pharyngeal surface of the epiglottis INTRA-ORAL APPROACH
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- 133. BLOCKADE OF THEVAGUS NERVE SUPERIOR LARYNGEAL NERVE sensory innervation to the base of the tongue, posterior surface of the epiglottis, aryepiglottic fold, and the arytenoids RECURRENT LARYNGEAL NERVE sensory innervation to the vocal folds and the trachea INNERVATION the epiglottis and more distal airway structures
- 134. patient is placedsupine with the head extended greater cornu is encountered -- pulsation of the carotid artery inserted in an anteroinferomedial direction until the lateral aspect of the greater cornu walked downward toward the midline thyrohyoid membrane is pierced internal branch alone is blocked
- 135. TRANSTRACHEAL BLOCK the cricothyroidmembrane is located in the midline of the neck Needle is passed perpendicular to the axis of the trachea and pierces the membrane advanced until air is freely aspirated Instillation of local anesthetic - -- results in coughing local anesthetic is dispersed diffusely
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- 137. INTERCOSTAL BLOCK & INTERPLURALCATHETER
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- 139. INTERCOSTAL BLOCK : TECHNIQUE Patientis placed in the PRONE POSITION WITH A PILLOW PLACED UNDER THE ABDOMEN to reduce the lumbar curve primary rami of T1 through T11. T12 is a subcostal nerve At the posterior angle of the rib, the nerve lies in the costal groove accompanied by the intercostal vein and artery
- 140. INTERCOSTAL BLOCK : TECHNIQUE 12thrib (last rib palpable inferiorly) 7th rib (lowest rib covered by the angle of the scapula) Spinous process C7 (the most prominent spinous process in the cervical region when the neck is flexed)
- 141. INTERCOSTAL BLOCK : TECHNIQUE Determiningmidline and spinous processes Insertion point is marked at 6-8 cm lateral to midline and inferior edge of each rib is palpated at desired level of block Needle is inserted at the tip of the finger until it rests on the rib walks the needle 3 to 5 mm off the lower rib edge can be performed in the supine patient at the midaxillary line A perpendicular or caudal angulation of the needle can cause the block failure; maintenance of the 20° cephalic angle
- 142.
- 143. INTERPLURAL CATHETER : TECHNIQUE 6thor 7th intercostal space is identified Mark 10 cm lateral from the posterior midline epidural needle tip is advanced until it rests on the cephalad edge of the rib below the intercostal space syringe filled with saline or air attached advanced slowly over the superior edge of the rib parietal pleura --- - ve intrathoracic pressure catheter is then inserted approximately 5 to 8 cm into the interpleural space catheter placement for management of postoperative pain results with cholecystectomy have been most favorable
- 144. INTERCOSTAL BLOCK & INTERPLURALCATHETER : COMPLICATION
- 145. PARAVERTEBRAL BLOCK : THORACIC& THORACO- LUMBAR
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- 147. ANATOMY & LANDMARKS 12thrib (last rib palpable inferiorly) 7th rib (lowest rib covered by the angle of the scapula) Spinous process C7 (the most prominent spinous process in the cervical region when the neck is flexed)Iliac crest (corresponds to L3- 4 or L2-3) 1 2 3 4 1 2 3 4
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- 149. INDICATION :THORACIC Pain relieffor thoracotomy Major breast surgery Implantable cardioverter defibrillator and laser lead extraction Right lobe hepatectomy Postoperative analgesia after robotic-assisted coronary artery bypass graft Open cholecystectomy Abdominoplasty Submuscular breast augmentation
- 150. Radiofrequency ablation ofa metastatic carcinoid liver lesion Single-injection/continuous block technique for major renal surgery in children Thymectomy performed with a bilateral thoracoscopic approach Video-assisted thoracic surgery procedures Percutaneous transhepatic biliary drainage Thoracoabdominal esophageal surgery Conventional on-pump cardiac surgery INDICATION :THORACIC
- 151. Multiple rib fracture Minimallyinvasive direct coronary artery bypass surgery Pleuritic pain Esophagogastrectomy INDICATION :THORACIC
- 152. INDICATION :THORACO- LUMBAR Outpatient lithotripsy Inguinalhernia repair Ventral hernia repair Hip arthroscopy Femoral-popliteal bypass in high-risk patient Labor analgesia
- 153. TECHNIQUE Spinous process ofdesired level marked Another mark at 2.5 cm lateral to it Needle inserted at this point until it contact transverse process (depth of 3 to 5 cm) needle is then redirected to walk off the caudad edge of the transverse process 1 to 2 cm (the thickness of the transverse process) beyond this point local anesthetic is injected patient is positioned in the sitting or lateral decubitus position and supported by an attendant
- 155. TECHNIQUE The fingers ofthe palpating hand should straddle the paramedian line and fix the skin to avoid medial-lateral skin movement
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- 157.
- 158. ANATOMY & LANDMARK TRIANGLEOF PETIT
- 159. INDICATION expect analgesia betweenT10 and L1 with a single injection postoperative analgesia for laparotomy Appendectomy laparoscopic surgery Abdominoplasty cesarean delivery, abdominal hysterectomy Appendectomy, hernia repair Bilateral blocks can be used for midline incisions or laparoscopic procedures as an alternative to epidural anesthesia for operations on the abdominal wall
- 160. TECHNIQUE & COMPLICATION • ENTRYPOINT – LUMBAR TRAINGLE OF PETITY • feeling double “pops” as the needle traverses the external oblique and internal oblique muscles LOSS OF RESISTANCE (BLIND INJECTION) • probe is placed several centimeters superior and parallel to the iliac crest • in-plane approach ULTRASOUND -GUIDED Peritoneal puncture liver hematoma
- 161.
- 162. ANATOMY & LANDMARK arisefrom the L1 spinal root pierce the transversus abdominus cephalad and medial to the ASIS lie between the transversus abdominus and internal oblique muscles caudal and medially - pierce the internal oblique muscle – branches pierce the external oblique and provide sensory fibers to the skin
- 163. ANATOMY & LANDMARK •Anterior and inferiorly to the inguinal ring • exits to supply the skin on the proximal, medial portion of the thigh ILLIOINGUINAL NERVE • nerve supplies the skin in the inguinal region ILLIOHYPOGASTRI C NERVE
- 164. INDICATION Analgesia following INGUINALHERNIA REPAIR Lower abdominal procedures Analgesia following suprapubic incision
- 165. TECHNIQUE & COMPLICATION Mark ismade 2 cm cephalad and 2 cm medial to ASIS Needle inserted perpendicular to the skin Passes through EOM – IOM by Loss of resistance Drug injected EOM-IOM plane & IOM-TAM plane Repeat the same in fanning Perforation of large & small bowel Pelvic hematoma Lower limb weakness
- 166. needle is insertedin- plane in a medial to lateral orientation. Double pop – needle at IOM-TAM plane TECHNIQUE The nerves should appear as hypoechoic ovals between the IOM and TAM muscles
- 167. RECTUS SHEATH BLOCK INDICATION postoperative analgesiafor umbilical hernia repair other umbilical & para-umbilical surgery
- 168. TECHNIQUE transducer placed atthe level of the umbilicus immediately lateral Color Doppler – epigastric artery needle is inserted in-plane in a medial to lateral orientation. (obese – out plane) pearce through the anterior rectus sheath upto posterior sheath Perforation of large & small bowel Pelvic hematoma
- 169.
- 170.