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Peripheral blocks
- 1. Pain management – Different peripheral nerve block with their landmark technique Presenter Moderator Dr Divakar Goyal Dr Madhur Uniyal Mch Resident Assistant Professor Department of Trauma Surgery
- 2. Definition An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage International Association for Study of Pain 16/07/2020
- 3. Emergency • Pain is most common complaint – 50-80% • Analgesics – 30-56% • Procedural pain is very common in ED Novoa et al - assess the analgesic efficacy of small doses of ketamine with morphine to decrease procedural pain during open wound care, over 60% of patients did not receive any analgesic before the procedure
- 5. Anekar AA, Cascella M. WHO Analgesic ladder. StatPearls [Internet]. 2020 Feb 17.
- 6. Indications PNBs might be preferable to GA : • At risk of respiratory depression Suspected difficult airway • High risk of postoperative nausea and vomiting • Patients who desire to remain conscious or avoid systemic medications PNBs might be preferable to neuraxial anesthesia : • on antithrombotic medication /coagulopathy • aortic stenosis • high risk of urinary retention PNBs might provide the optimal means of analgesia in: • At risk of respiratory depression due to opiods • Outpatients • Patients with acute, severe pain Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: evidence-based indications. Curr Opin Anaesthesiol 2013; 26:467.
- 7. Contraindications ABSOLUTE • Patient refusal • Allergy to LA RELATIVE • Preexisting neural diseases • Active infection at the site
- 8. Pharmacology Anesthetic Onset (min) Duration of anesthesia (hours ) Duration of analgesia (hours ) Maximum dose (mg/kg ) Without/ with epinephrine 2% lignocaine 10-20 2-5 3-8 4.5/7 1.5% mepivacaine 10-20 2-5 3-10 5/7 0.2 % ropivacaine 15-30 NA 5-16 3/3.5 0.5% ropivacaine 15-30 4-12 5-24 3/3.5 0.25% bupivacaine 15-30 NA 5-26 2.5/3 0.5% bupivacaine + epinephrine 15-30 5-15 6-30 2.5/3 Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional anesthesia: essentials of our current understanding, 2008. Reg Anesth Pain Med 2009; 34:134.
- 9. Adjuvants • Epinephrine : 1:200,000 to 1:400,000 • Clonidine : Prolong duration • Sodium bicarbonate : decrease onset time • Dexamethasone : prolong duration Avoided due to S/E • Opioids : no benefit Capogna G, Celleno D, Laudano D, Giunta F. Alkalinization of local anesthetics. Which block, which local anesthetic? Reg Anesth 1995; 20:369.
- 10. Complications • Nerve injury - 0.015 to 0.09 % • Hematoma • LA toxicity • Allergic reaction (within 72 hrs ) • Infection : 0-3.2% • Myotoxicity : very rare Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anaesth 2010; 105 Suppl 1:i97.
- 11. PAIN ASSESSMENT
- 12. • Crying • Facial expression • Verbalization • Activity of Torso • Touching • Response of Lower limbs CHEOPS Wong-Bakers FACES – Pain Rating Scale
- 14. Blocks – Landmark Techniques Upper Extremity Block Truncal Block Lower extremity Block Brachial plexus • Interscalene • Supraclavicular • infraclavicular • axillary Paravertebral block Femoral block Cubital Region block Intercostal Block Sciatic block Wrist Block Popliteal block Ankle block
- 17. Interscalene block (Winnie Technique) Indications • Shoulder , clavicle and upper arm • Frozen shoulder , peri arthritis , shoulder arthritis • Dislocated shoulder • Adjunct to stellate ganglion block Ulnar nerve is spared Dose :20-30 ml Side effects • Horner’s syndrome (stellate ganglion block), • hoarse voice (RLN ), • 100% ipsilateral paralysis of the diaphragm (phrenic nerve) • Hematoma • Ecchymosis
- 20. Supraclavicular- Trunk and Division Indications Elbow and hand surgery Alternative to stellate ganglion block Dose : 10 ml Complications Phrenic nerve block (50%) Horner syndrome Pneumothorax (6%) Never direct the needle medially
- 21. Plumb bob approach Lateral to subclavian
- 22. Infraclavicular – Cords • Indications are similar to those for axillary block; • Below elbow surgeries • hand, forearm, elbow, and arteriovenous fistula surgery. • No need to abduct arm • B/L can be given • Risk of pneumothorax • Inadveretent – axillary artery injection Dose : 30 ml
- 23. Modified Raj Approach AVOID • Too medial insertion of the needle • Depth of needle insertion >6 cm • Medial direction of needle
- 25. Paracoracoid
- 26. Axillary Block • Forearm, wrist, or hand • Median, musculocutaneous • ulnar and radial nerve block • If incomplete mid humeral block • Dose : 8-10 ml Complications • Intravascular • Hematoma • LA toxicity
- 28. Cubital Region Block Ulnar Nerve Landmarks: Ulnar groove DO NOT inject between the medial epicondyle of the humerus and the olecranon process
- 29. Musculocutaneous - Lateral to the tendon of the biceps. Radial nerve – 1 ½ inch lateral to biceps tendon with medial and cephalad trajectory Median nerve : 1 ½ inch medial to brachial artery
- 30. Wrist Block Indications Hand and finger surgery Patients are usually able to tolerate a tourniquet on the arm without anesthesia for 20 minutes; a wrist tourniquet can be tolerated for about 120 minutes.
- 31. RADIAL NERVE
- 32. ULNAR NERVE DORSAL SENSORY BRANCH OF ULNAR NERVE ULNAR NERVE
- 34. Intercostal nerve block Indications • Rib fractures • postsurgical pain MC site -angle of the rib (6–8 cm from the spinous processes Blockade of the two dermatomes above and the two below the level ofsurgical incision is required.
- 35. • Best -site for ICNB is the angle of the rib, about 7 cm lateral to midline in adults. • Subcostal groove -20 degrees cephalad. • Above T7 may be difficult because of the scapulae
- 36. Paraverterbral block Indications • Multiple rib fracture • Post operative analgesia • VATS • Pleuritic chest pain • Postherpetic neuralgia • Liver capsule pain after BTA Complications • vascular puncture (3.8%), • hypotension (4.6%), • Pleural puncture (1.1%), • pneumothorax (0.5%).
- 37. • Depth : 3-4 cm • Advancement not more than 1.5cm • Avoid directing the needle medially to prevent inadvertent epidural or intrathecal needle misadventure. 5 CM
- 40. Femoral Block • surgery on the anterior aspect of the thigh • surgery on the medial aspect of the leg • Femoral neck/shaft # • supplement a sciatic or popliteal block Contraindications • Previous ilioinguinal surgery • large inguinal lymph nodes or tumor, • Local infection, • peritoneal infection • preexisting femoral neuropathy.
- 41. Sensory – medial aspect of thigh and leg Motor – knee extension
- 43. Sciatic block • Classic approach – Labat Supine position • anterior approach - George Beck in 1963 • lithotomy approach - Prithvi Raj in 1975
- 45. Sciatic block • lower-limb surgery, combined with a femoral or psoas compartment block • surgery below the knee, • complete anesthesia of the leg below the knee (except medial strip of skin)
- 46. Twitch of any of the hamstring muscles can be accepted as a reliable sign of localization of the sciatic nerve
- 47. 4-5 CM distal to femoral crease and 1cm depth
- 49. Popliteal block • Anesthesia of the calf, tibia, fibula, ankle, and foot • Corrective foot surgery, foot debridement, short saphenous vein stripping, repair of the Achilles tendon • Anesthetizes the leg distal to the hamstring muscles, allowing patients to retain knee flexion • Posterior approach- Duane Keith Rorie • Lateral approach-Jerry Vloka
- 50. There are two types of motor responses that can be elicited with sciatic nerve stimulation at the level of the popliteal fossa. Common peroneal nerve stimulation results in dorsiflexion and eversion of the foot, whereas stimulation of the tibial nerve results in plantar flexion and inversion
- 51. Needle is inserted perpendicularly between tendons of the biceps femoris and semitendinosus muscles Look for toe or foot twitch, if not withdraw and redirect 15 degrees laterally 7 cm above to the midpoint of 2 tendons Depth – 3-5 cm
- 53. After the femur is contacted, the needle is redirected 30 degrees posterior to the plane in which the femur was contacted. VL, vastus.
- 55. Ankle block • well suited for ambulatory foot surgery. • toes amputation, debridment).
- 56. Foot innervation • Medial – saphenous nerve (branch of femoral nerve ) • The rest of the foot is innervated by branches of the sciatic nerve: • The lateral aspect is innervated by the sural nerve arising from the tibial and communicating superficial peroneal branches • The deep ventral structures, muscles, and sole of the foot are innervated by the posterior tibial nerve, arising from the tibial branch • The dorsum of the foot is innervated by the superficial peroneal nerve, arising from the common peroneal branch • The deep dorsal structures and web space between the first and second toes are innervated by the deep peroneal nerve
- 57. • At the level of the malleoli, the saphenous, superficial peroneal, and sural nerves are relatively superficial and subcutaneous. • The posterior tibial and deep peroneal nerves are deep to the flexor and extensor retinaculi, respectively
- 58. • The posterior tibial nerve passes with the artery posterior to the medial malleolus deep to the flexor retinaculum, giving off a medial calcaneal branch to supply the lower and posterior surface of the heel. • The nerve and artery then become superficial and more accessible as they curve behind and underneath the sustentaculum tali, a bony ridge on the calcaneus about 2–3 cm below the medial malleolus. The nerve then divides into medial and lateral plantar nerves.
- 59. • The deep peroneal nerve passes lateral to the anterior tibial artery, extensor hallucis longus, and tibialis anterior tendons, and medial to the extensor digitorum longus tendon, deep to the extensor retinaculum. • It becomes more superficial to travelwith the dorsalis pedis artery on the dorsum of the foot, where it is easily accessible.
- 60. Superficial and deep Peroneal Nerve Block Posterior tibial nerve block
- 61. Saphenous nerve Sural nerve
Editor's Notes
- Risk factorsExtremes of age (ie, <4 months or >79 years) Cardiac conduction disease Ischemic heart disease Renal dysfunction Hepatic dysfunction Pregnancy Carnitine deficiency Highly vascular block site Signs and symptoms* LAST can occur >15 minutes after injection of LACNS:¶ Tinnitus Circumoral numbness Metallic taste Agitation Dysarthria Seizures Loss of consciousness Respiratory arrest Cardiovascular:¶ Hypotension Bradycardia Ventricular arrhythmias Cardiovascular collapse Treatment of LA toxicity Stop injection or infusion Call for help and lipid emulsion While stabilizing the patient, arrange for cardiopulmonary bypass Airway management: Ventilate with 100% oxygen, prevent hypoxemia, hypercarbia, and acidosis Suppress seizures: Benzodiazepines preferred (avoid large doses of propofol) Manage arrhythmias and cardiac arrest per ACLS EXCEPT: Reduce individual epinephrine boluses to ≤1 mcg/kg Avoid vasopressin, calcium channel blockers, beta blockers, and LA Administer amiodarone as the first line antiarrhythmic Institute lipid emulsion therapy with 20% lipid emulsion Adults >70 kg: Bolus 100 mL IV over 2 to 3 minutes, followed by infusion of 200 to 250 mL over 15 to 20 minutes Children or Adults <70 kg: Bolus 1.5 mL/kg IBW IV over 2 to 3 minutes, followed by infusion at 0.25 mL/kg/minute Repeat bolus once or twice and double infusion rate for persistent cardiovascular instability Continue infusion for at least 10 minutes after hemodynamic stability is achieved Maximum dose lipid emulsion approximately 12 mL/kg IV Note: Propofol is not a substitute for lipid emulsion Institute cardiopulmonary bypass for LAST unresponsive to lipid emulsion and ACLS
- Needle is directed caudal, posterior, and medial with a 45-degree angle. • Parasthesisa generally encounterde at ¼ to 1 inch If the needle tip is inserted too posterior, a contraction of the levator scapulae muscle by stimulation of the dorsal scapular nerve can be confused with a deltoid contraction. Placing one hand over the scapula can make a differential. • Contraction of the diaphragm by stimulation of the phrenic n., which runs over the lateral border of scalenus anterior m. behind the prevertebral fascia, means that the needle tip is inserted too anteriorly.
- SPINAL ANESTHESIA OF UPPER LIMB BECAUSE IT IS DENSE
- Line along the lateral border of the clavicular head of the SCM. • Line along the clavicle. • Intersection of these two lines. • Subclavian artery in the supraclavicular fossa. Parasthesia encounter at ¾ inch to 1 inch
- B/L can be given as no risk of injury to phrenic nerve
- Posterior cord is deepest – posterior movt of little finger . Has to be block for complete anaethseia Needle should not be medial to SCM insertion
- Intercosto brachial sparing and musculocutaneous sparing
- Ulnar nerve With the elbow flexed, the needle is introduced at the apex of a triangle, with the line from the medial epicondyle to the olecranon process as a base ½ inch just proximal to sulcus needle is inserted and 6-7 ml injected DO NOT inject between the medial epicondyle of the humerus and the olecranon process As ulnar nerve is surrounded by fibrous band so it will get compressed there
- RADIAL NERVE : Five milliliters of LA is injected subcutaneously just above the radial styloid while advancing the needle medially The infiltration is then extended laterally, using an additional 5 mL of LA. Superficial Radial Nerve : The dorsal sensory branch of the radial nerve is blocked by inserting the needle 1 cm proximal to the radial styloid, which is radial to the radial artery .This branch of the radial nerve exits from between the brachioradialis and extensor carpi radialis longus 5–8 cm proximal to the radial styloid. The needle is advanced to the Lister tubercle, and if there are no paresthesias, 5 mL of LA is injected subcutaneously throughout this area. Sensory branch of ulnar
- Ulnar nerve : The ulnar nerve is anesthetized by inserting the needle under the tendon of the flexor carpi ulnaris muscle close to its distal attachment just above the styloid process of the ulna. The needle is advanced 5–10 mm to just past the tendon of the flexor carpi ulnaris. Three to 5 mL of LA solution is injected. A subcutaneous injection of 2–3 mL of local anesthesia just above the tendon of the flexor carpi ulnaris is also advisable in blocking the cutaneous branches of the ulnar nerve, which often extend to the hypothenar area. Sensory branch of ulna : The dorsal sensory branch of the ulnar nerve is blocked by inserting the needle at the level of the ulnar styloid because it travels from palmar to dorsal in the area of the ulnar styloid. Start the injection at the flexor carpi ulnaris and extend subcutaneously dorsally toward the distal radioulnar joint. Five milliliters of LA is injected subcutaneously throughout the area.
- The median nerve is anesthetized by inserting the needle between the tendons of the palmaris longus and flexor carpi radialis (Figures 80F–10 and 80F–11; see Figure 80F–8). The needle is inserted until it pierces the deep fascia. Three to 5 milliliters of LA is injected. Although the piercing of the deep fascia has been described to result in a fascial “click,” it is more reliable to simply insert the needle until it contacts the bone. At that point, the needle is withdrawn 2–3 mm and the LA is injected. Figure 80F–12 demonstrates the spread of the LA after injection of 5 mL using the described technique.
- The depth at which the transverse process is contacted varies (3–4 cm) and depends on the build of the individual and the level at which the needle is inserted. The depth is deeper at the cervical and lumbar spine level and shallower at the thoracic levels. During needle insertion it is possible to miss the transverse process and inadvertently puncture the pleura. Therefore, it is imperative to search and make contact with the transverse process before advancing the needle too deep and risking pleural puncture. To minimize this complication, the block needle should initially be inserted only to a maximum depth of 4 cm at thoracic and 5 cm at cervical and lumbar levels At a point just below and 1½ inches lateral to the spinous process, the skin is prepared with antiseptic solution. A 22-gauge, 3½-inch needle is attached to a 12-mL syringe and is advanced perpendicular to the skin, aimed at the middle of the transverse process. The needle should impinge on bone after being advanced about 1½ inches (Fig. 68.6). After bony contact is made, the needle is withdrawn into the subcutaneous tissues and redirected inferiorly and walked off the inferior margin of the transverse process (Fig. 68.7). As soon as bony contact is lost, the needle is slowly advanced about ¾ inch deeper until a paresthesia is elicited in the distribution of the thoracic paravertebral nerve to be blocked. Once the paresthesia has been elicited and careful aspiration reveals no blood or cerebrospinal fluid, 5 mL of 1.0% preservative-free lidocaine is injected.
- Needle angle to contact the transverse process (A) and to walk off the transverse process inferiorly (B). Once the transverse process is contacted, the needle is walked off and inserted 1.5 cm deeper while paying attention to the depth marks or using a rubber stopper
- PARASETHESIS AT dEPTH OF ½ TO ¾ INCH WITHDRAW NEEDle 1mm For knee extension ask the patient to lift foot Postopeartve quadriceps weakness – fall in TKR so adductor canal block is given
- Medial strip supplied by saphenous nerve
- Observe dorsi and plantar flexion of foot – depth of 2 ½ to 3 inches Lateral decubitus position THe foot on the side to be blocked should be positioned over the dependent leg so that twitches of the foot or toes can be easily noted.
- Twitch of quadriceps muscle
- the sciatic nerve is not enveloped by the same tissue sheath as are the popliteal vessels; consequently, the concept of the neurovascular sheath is not applicable to this block. Instead, in the popliteal fossa, the sciatic nerve components are lateral and superficial to the popliteal artery and vein. This anatomic characteristic is important in understanding why vascular punctures and systemic toxicity are so rare after popliteal blockade.
- The first signs of block onset are usually that the patient reports that the foot “feels different” or that they are unable to wiggle the toes
- Landmarks for the popliteal block, intertendinous approach. The landmarks can be accentuated by asking the patient to flex the leg. This maneuver tightens the hamstring muscles and facilitates more accurate palpation of the tendons. The needle is inserted perpendicularly between tendons of the biceps femoris and semitendinosus muscles. In case no foot or toe twitch can be elicited, withdraw and redirect 15 degrees laterally. In case no foot or toe twitch can be elicited after redirection, withdraw needle completely, reinsert 1 cm laterally, and repeat the procedure starting with perpendicular needle insertion. The arrow indicates attachment of the biceps femoris tendon; + sign indicates site of needle placement. The foot on the side to be blocked should be positioned so that even the slightest movement of the foot or toes can be easily observed. This is best achieved by allowing the foot to protrude off the edge of the bed.
- A 10-cm, 22-gauge needle is connected to a nerve stimulator inserted in a horizontal plane between the vastus lateralis and biceps femoris muscles, and advanced to contact the femur (see Figure 82E–10). The contact with the femur is important because it provides information on the depth of the nerve (typically 1–2 cm beyond the skin–femur distance) as well as on the angle at which the needle will need to be redirected Keeping the fingers of the palpating hands firmly pressed and immobile in the groove, the needle is then withdrawn to the skin, redirected 30 degrees posterior to the angle at which the femur was contacted, and advanced toward the nerve
- For blockade at the level of the malleoli, the saphenous, sural, and superficial peroneal nerves are blocked with a circumferential subcutaneous injection of 10–15 mL of local anesthetic along a line just proximal to the malleoli and anterior from the Achilles tendon medially to laterally (Figures 82F–8 through 82F–10). The deep peroneal nerve is blocked by injection of 5 mL of local anesthetic just lateral to the extensor hallucis longus tendon deep to the retinaculum along the same circumferential line (Figure 82F–11). The posterior tibial nerve is blocked by injection of the same volume of local anesthetic just posterior to the posterior tibial artery if palpable, or midway between the Achilles tendon and medial malleolus deep to the retinaculum