Downloaded 1,021 times
More Related Content
Similar to Peripheral nerve blocks
Peripheral nerve blocks
- 2. Peripheral nerve blocksare gaining widespread popularity for perioperative pain management because: Pain relief with PNB avoids side effects such as nausea and vomiting, hemodynamic instability avoiding complications of general and central neuraxial anesthesia. Patients with unstable cardiovascular disease can undergo surgery under PNB without significant hemodynamic changes. Patients who have abnormalities in hemostasis or infection which contraindicate use of central neuraxial block can be candidates for surgery under PNB. A substantial savings in operating room turnover time can occur if PNB is done outside the operating room. Patients with a PNB can frequently position themselves. When used as part of a combined general regional technique, PNB facilitates lighter planes of anesthesia, avoiding the use of opioids and allowing a quick emergence and recovery.
- 3. Fully preparethe equipment and patient, including consent. Ensure intravenous access, monitoring and full resuscitation facilities. A linear ultrasound probe (Frequency 10-15 MHz) is used with the depth setting of 2-4 cm. A 50mm length insulated nerve stimulator needle is used to perform the block. Peripheral nerve stimulation (PNS) is desirable as an additional way of confirming nerve location but not essential. If PNS used, Initial settings should be 0.5 mA for current , frequency of 2Hz and pulse width of 0.1 msec. Higher currents may result in muscle contractions which cause the arm to move and make it difficult to maintain a stable ultrasound image. If a PNS is used, the usual precautions of a threshold potential > 0.3mA, immediate twitch ablation on injection and painless easy injection should be observed. It is not a requirement to seek out specific nerve stimulator twitches if the relevant anatomy is clearly identified.
- 5. The brachial plexusis formed by the ventral rami of the lower cervical and upper thoracic nerve roots (C5-T1). The trunks pass laterally and lies around the subclavian artery while passing over the first rib to enter the axilla, between the clavicle and the scapula. Behind the clavicle, each trunk splits into anterior and posterior divisions. These recombine to form the posterior , lateral and medial cords around the axillary artery. The upper roots (C5–7) tend to stay lateral, the lower roots (C8,T1) tend to stay medial and all roots contribute to the posterior cord, and therefore also to the radial nerve.
- 8. Interscalene Supraclavicular Infraclavicular Axillary
- 9. Indications operations onthe elbow, forearm, and hand. Blockade occurs at the distal trunk–proximal division level. Location- The three trunks are clustered vertically over the first rib cephaloposterior to the subclavian artery. The neurovascular bundle lies inferior to the clavicle at about its midpoint.
- 10. In the classictechnique, the midpoint of the clavicle is identified . The posterior border of the sternocleidomastoid is felt. The palpating fingers can then roll over the belly of the anterior scalene muscle into the interscalene groove, where a mark should be made approximately 1.5 to 2.0 cm posterior to the midpoint of the clavicle. Palpation of the subclavian artery at this site confirms the landmark
- 11. A 22-gauge,4-cm needle is directed in a caudad, slightly medial, and posterior direction until a paresthesia is elicited or the first rib is encountered. If a syringe is attached, this orientation causes the needle shaft and syringe to lie almost parallel to a line joining the skin entry site and the patient's ear. If the first rib is encountered without elicitation of a paresthesia, the needle can be systematically walked anteriorly and posteriorly along the rib until the plexus or the subclavian artery is located . The needle can be withdrawn and reinserted in a more posterolateral direction, which generally results in a paresthesia or motor response. 20 to 30 mL of solution is injected in incremental pattern.
- 12. Pneumothorax Phrenicnerve block (40% to 60%), Horner's syndrome Neuropathy.
- 13. Landmarks Thereis no proper landmark, besides the clavicle, which in most patients is easily felt. The subclavian pulse might be palpated above the clavicle, but that is not indispensable. The ultrasound probe is positioned in the supraclavicular fossa, pointing caudad, and moved laterally and medially, as well as in a rocking fashion, in order to locate the subclavian artery
- 14. Position of probeand needle:- -Probe is positioned just above the clavicle. It can be moved laterally or medially, and rocked back and forth until a good quality picture is obtained. -The needle is inserted from the lateral side of the probe, as the plexus lies lateral to the subclavian artery. It has to be exactly in the long axis of the probe. This is especially important for this block, in which the needle can easily cause a pneumothorax if not fully visible at all times.
- 15. Technique Once thesubclavian artery is visualized, the area lateral and superficial to it is explored until the plexus is seen, with a characteristic “honeycomb” appearance. Multiple nerves can be seen, or as few as two, depending on the level and the patient (Figure 1). A caudad-cephalad rocking motion is then used to find the plane where the nerves are best seen.
- 16. Figure 1: Leftsubclavian artery and nerves of the brachial plexus. The subclavian artery is seen beating at the center of the field. Underlying it is the first rib, with a bright cortical bone and a posterior shadow. The pleura are seen on each side of the rib, somewhat deeper, and moving with the patient’s respiration. The nerves of the brachial plexus can be seen lateral and a little superficial to the artery. The distribution is variable, with as little as two or as many as 10 nerves seen.
- 17. Indications- Hand,wrist, elbow and distal arm surgery Blockade occurs at the level of the cords of the musculocutaneous and axillary nerves. Anatomical landmarks: The boundaries of the infraclavicular fossa are pectoralis minor and major muscles anteriorly, ribs medially , clavicle and the coracoid process superiorly, and humerus laterally.
- 18. Technique- Classicapproach The needle is inserted 2 cm below the midpoint of the inferior clavicular border, advanced laterally and directed toward the axillary artery A coracoid technique consisting of insertion of the needle 2 cm medial and 2 cm caudal to the coracoid process has also been described
- 21. Described bywinnie in 1970. Indications- Surgery in shoulder ,upper arm and forearm. Post operative analgesia for total shoulder arthroplasty Blockade occurs at the level of the upper and middle trunks.
- 24. TECHNIQUE- Under sterileprecautions and development of a skin wheal, a 22- to 25-gauge, 4-cm needle is inserted perpendicular to the skin at a 45-degree caudad and slightly posterior angle. The needle is advanced until paresthesia is elicited. If bone is encountered within 2 cm of the skin, it is likely to be a transverse process, and the needle may be “walked” across this structure to locate the nerve. After negative aspiration, 10 to 40 mL of solution is injected incrementally, depending on the desired extent of blockade. contraction of the diaphragm indicates phrenic nerve stimulation and anterior needle placement; the needle should be redirected posteriorly to locate the brachial plexus.
- 25. Complications Ipsilateraldiaphragmatic paresis Severe hypotension and bradycardia (i.e., the Bezold- Jarisch reflex) Inadvertent epidural or spinal block Nerve damage or neuritis intravascular injection with Seizure activity Horner’s syndrome with dyspnea and hoarseness of voice. Puncture of the pleura may cause Pneumothorax. Hemothorax. Hematoma and Infection.
- 26. Indications – include surgery on the forearm and hand. Elbow procedures are also successfully performed with the axillary approach. Blockade occurs at the level of the terminal nerves. blockade of the musculocutaneous nerve is not always produced with this approach.
- 27. •The axillary arteryis the most important landmark • The median nerve is found superior to the artery, the ulnar nerve is inferior, and the radial nerve is posterior and somewhat lateral • At this level, the musculocutaneous nerve has already left the sheath and lies in the substance of the coracobrachialis muscle.
- 28. A transarterial techniquecan be used whereby the needle pierces the artery and 40 to 50 mL of solution is injected posterior to the artery; alternatively, half of the solution can be injected posterior and half injected anterior to the artery.
- 29. Complications- Nerveinjury and systemic toxicity intravascular injection Hematoma and infection are rare complications.
- 33.
- 36. Anesthesia forknee arthroscopy in combination with intraarticular local anesthesia and analgesia for femoral shaft fractures anterior cruciate ligament reconstruction total knee arthroplasty as a part of multimodal regimens.
- 42. This blockis chiefly used for foot and ankle surgery. Popliteal fossa block is preferable to ankle block for surgical procedures requiring the use of a calf tourniquet.
- 43. 1. Posterior approach 2.Lateral approach
- 47. Ankle blocksare simple to perform and offer adequate anesthesia for surgical procedures of the foot not requiring a tourniquet above the ankle
- 48. 1. posterior tibial 2.sural 3. superficial peroneal 4. deep peroneal 5. saphenous
- 54. parietal pleuraanteriorly Vertebral body, intervertebral disk, and foramen medially; posterior intercostal membrane laterally and the superior costotransverse ligament posteriorly.
- 55. Intercostal nerve, Dorsal rami and communications, sympathetic chain.
- 57. Anesthesia oranalgesia to patients undergoing intrathoracic,abdominal, or pelvic procedures or surgery to the breast Diagnosis and treatment of certain chronic pain disorders, including postthoracotomy and postmastectomy pain.
- 58. Epidural orsubarachnoid injection of local anesthetic Intravascular injection through the lumbar vessels, vena cava or aorta Pleural puncture and pneumothorax
Editor's Notes
- #7 Roots The ventral rami of spinal nerves C5 to T1 are referred to as the roots of the plexus. Trunks Shortly after emerging from the intervertebral foramina , these 5 roots unite to form three trunks. –The ventral rami of C5 & C6 unite to form the Upper Trunk. –The ventral ramus of C 7 continues as the Middle Trunk. –The ventral rami of C 8 & T 1 unite to form the Lower Trunk. •Divisions Each trunk splits into an anterior division and a posterior division. –The anterior divisions usually supply flexor muscles –The posterior divisions usually supply extensor muscles. Cords –The anterior divisions of the upper and middle trunks unite to form the lateral cord. –The anterior division of the lower trunk forms the medial cord. –All 3 posterior divisions from each of the 3 cords unite to form the posterior cord. –The cords are named according to their position relative to the axillary artery
- #8 In plane & out plane approach
- #11 in supine position with the head turned away from the side to be blocked. The arm to be anesthetized is adducted, and the hand should be extended along the side toward the ipsilateral knee as far as possible. After appropriate preparation and development of a skin wheal, the anesthesiologist stands at the side of the patient facing the patient's head.
- #23 Positioning- supine position with the head turned away from the side to be blocked. The posterior border of the sternocleidomastoid muscle is palpated by having the patient briefly lift the head. The interscalene groove can be palpated by rolling the fingers posterolaterally from this border over the belly of the anterior scalene muscle into the groove. A line extended laterally from the cricoid cartilage and intersecting the interscalene groove indicates the level of the transverse process of C6. The external jugular vein often overlies this point of intersection.
- #29 Nerve stimulation,paresthesia and usg guided
- #32 Lumbar plexus lies between the psoas major and quadratus lumborum muscles in the so called psoas compartment. The lower components of thenplexus, L2, L3, and L4, primarily innervate the anterior and medial thigh.
- #33 The anterior divisions of L2, L3, and L4 form the obturator nerve; the posterior divisions of the same components form the femoral nerve; and the lateral femoral cutaneous nerve is formed from posterior divisions of L2 and L3.
- #34 The sacral plexus gives off two nerves that are important for lower extremity surgery: the posterior cutaneous nerve of the thigh and the sciatic nerve. The posterior cutaneous nerve of the thigh and the sciatic nerve are derived from the first, second, and third sacral nerves plus branches from the anterior rami of L4 and L5, respectively. These nerves pass through the pelvis together, and the greater sciatic foramen and are blocked b the same technique. The sciatic nerve is a combination of two major nerve trunks, the tibial (i.e., ventral branches of the anterior rami of L4, L5, S1, S2, and S3) and the common peroneal (i.e., dorsal branches of the anterior rami of L4, L5, S1, S2, and S3), which form the sciatic nerve. The trunks separate at or above the popliteal fossa, with the tibial nerve passing medially and the common peroneal laterally.
- #42 The posterior muscles of the thigh are the biceps femoris, the semimembranosus, semitendinosus, and the posterior portion of the adductor magnus. As these muscles are traced distally from their origin on the ischial tuberosity, they separate into medial (semimembranosus, semitendinosus) and lateral (biceps) musculature, and they form the upper border of the popliteal fossa. The lower border of the popliteal fossa is defined by the two heads of the gastrocnemius. In the upper part of the popliteal fossa, the sciatic nerve lies posterolateral to the popliteal vessels. The popliteal vein is medial to the nerve, and the popliteal artery is most anterior, lying on the popliteal surface of the femur.
- #50 The posterior tibial artery is palpated, and a 25-gauge, 3-cm needle is inserted posterolateral to the artery at the level of the medial malleolus
- #57 Typically, the thoracic spinous processes are identified, and the needle is inserted 2.5 to 3 cm lateral to the most cephalad aspect of the spinous process and advanced perpendicular to the skin in all planes to contact the transverse process of the vertebra below, typically at a depth of 2 to 4 cm