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Regional Techniques

Regional Techniques. Mackenzie Kuhl , DO Marquette General Hospital August 2013. Regional Techniques. Neuraxial nerve blocks Spinal anesthesia Epidural anesthesia Peripheral nerve blocks Upper extremity (Brachial plexus blocks) Axillary nerve block Supraclavicular nerve block

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Regional Techniques

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  1. Regional Techniques Mackenzie Kuhl, DO Marquette General Hospital August 2013

  2. Regional Techniques • Neuraxial nerve blocks • Spinal anesthesia • Epidural anesthesia • Peripheral nerve blocks • Upper extremity (Brachial plexus blocks) • Axillary nerve block • Supraclavicular nerve block • Interscalene nerve block • Lower extremity • Femoral nerve block • Sciatic nerve block • Popliteal nerve block

  3. Neuraxial techniques • Neuraxialtechniques are used for pain control for operative anesthesia, obstetric anesthesia, and chronic pain management • Spinal • Single shot technique in which local anesthesia +/- narcotic is placed into the subarachnoid space, used for surgical anesthesia • Epidural • Catheter based technique in which local anesthesia +/- narcotic is placed into the epidural space, mainly used for postoperative pain control

  4. Spinal Anesthetic • Local anesthetic +/- narcotic placed in subarachnoid space • Usually done at lumbar vertebrae (L3-L4, iliac crests) • Dermatomal level • T4 level for C-section • T10 level for hip and knee procedures • Lidocaine • 1 hour duration • Bupivacaine • 2-3 hours duration

  5. Dermatomal patterns

  6. Neuraxial techniques • Catheter placed in the epidural space under aseptic conditions

  7. Epidural Anesthetic Catheter based technique in which local anesthetic +/- narcotic is placed in epidural space Usually done at lumbar and thoracic vertebrae for postoperative pain control (cervical nerve roots for chronic pain management)

  8. Catheter being placed

  9. Indications for neuraxial techniques • Orthopedic • Total knee and hip arthroplasties, ankle surgeries • General • Exploratory laparotomies, breast cancer surgeries • Vascular • AAA repair • Genitourinary • TURP’s, nephrectomies, open prostatectomies • Obstetric • Cesarean section

  10. Absolute contraindications to neuraxial anesthesia • Infection at the site of injection • Patient refusal or inability to cooperate • Coagulopathy or other bleeding diathesis • Platelets>100,000 and INR <1.4 • Severe hypovolemia • Increased intracranial pressure • Severe mitral/aortic stenosis • Allergy to local anesthetics

  11. Complications of neuraxial techniques • Physiologic responses • Urinary retention • Hypotension • High block • Nausea • Pruritus • Related to needle/catheter placement • Backache • Postdural puncture headaches • Neural injury • Catheter shearing or tearing • Inflammation • Infection • Bleeding • Drug toxicity • TNS • Caudaequina syndrome • Systemic local anesthetic toxicity • Respiratory depresssion

  12. ASRA guidelines • Subcutaneous UFH (5000U BID) • Twice daily dosing (5000U) • No contraindication to neuraxial technique • Because HIT may occur, ASRA recommends that patients receiving heparin for more than 4 days receive a platelet count prior to epidural placement or removal • Thrice daily dosing • Must weigh risks vs benefits on individual basis • LMWH • Once daily dosing (40mg SQ) • Must wait 12 hours from last dose for neuraxial technique • Twice daily dosing • Must wait 12 hours from last dose for neuraxial technique, must remove epidural catheter postoperatively before instituting • Dabigatran • Must wait 72 hours prior to neuraxial procedure

  13. Benefits • 528, 495 patients undergoing primary knee or hip arthroplastyMemtsoudis, et al. Anesthesiology May 2013; 118: 1046-1058 • Decreased 30 day mortality • Decreased prolonged length of stay • Decreased transfusion requirements • Decreased in-hospital complications • Pulmonary embolism • Pulmonary compromise • CVA • Acute renal failure

  14. Benefits • Reduction of postoperative mortality and morbidity with epidural or spinal anesthesia: results from overview of randomized trials (9559 patients) Rodgers, et al. BMJ December 2000; 321(7275): 1493 • Decreased DVT by 44% • Decreased PE by 55% • Decreased transfusion requirements by 50% • Decreased pneumonia by 39% • Decreased respiratory depresion by 59% • Decreased myocardial infarctions

  15. Benefits • Anesthetic Technique for Radical Prostatectomy Surgery Affects Cancer Recurrence, Biki, et al. Anesthesiology Aug 2008; 109: 180-187 • Open prostatectomy with GA plus epidural postoperative analgesia was associated with less risk of biochemical cancer recurrence

  16. Why? Altered coagulation Increased blood flow Improved pulmonary mechanics Reduction in surgical stress responses

  17. Peripheral nerve blocks • Peripheral nerve blocks • Upper extremity (Brachial plexus blocks) • Axillary nerve block • Supraclavicular nerve block • Interscalene nerve block • Lower extremity • Femoral nerve block • Popliteal nerve block • Sciatic nerve block

  18. Peripheral nerve blockade • Primary anesthetic for peripheral limb surgery • Mainly done with direct visual ultrasound and nerve stimulation • Inject local anesthesia around nerves to obtain surgical anesthesia or postoperative pain control • Benefits • Excellent pain control • Decreased narcotic use • Risks • Bleeding • Infection • Nerve damage • Systemic local anesthetic toxicity

  19. Brachial plexus The brachial plexus is responsible for cutaneous and muscular innervation to upper arm except with two exceptions: The trapezius muscle innervated by the spinal accessory nerve and an area of skin located in the axilla which is innervated by the intercostobrachial nerve

  20. Brachial plexus blockade Axillary nerve block Supraclavicular nerve block Interscalene nerve block

  21. Axillary nerve block • Anesthesia to arm, elbow, FOREARM and HAND • Blocks median, ulnar and radial nerves • Usually misses musculocutaneous nerve, must block separately

  22. Axillary nerve block

  23. Supraclavicular nerve block • Anesthesia to ARM, ELBOW and hand (“spinal of upper extremity”) • Blocks median, ulnar and radial nerves • Risk is pneumothorax

  24. Supraclavicular nerve block

  25. Interscalene nerve block • Anesthesia to SHOULDER, upper arm and elbow • Blocks median, ulnar and radial nerves • Patients may develop ipsilateral Horner’s syndrome and diaphragmatic paralysis (due to phrenic nerve block)

  26. Interscalene nerve block

  27. Lower extremity nerve blocks Femoral nerve block Sciatic nerve block Popliteal nerve block

  28. Femoral nerve block Anesthesia to anterior thigh and anterior knee

  29. Femoral nerve block • Anesthesia to anterior thigh and anterior knee

  30. Sciatic nerve block Anesthesia to posterior aspect of the thigh, hamstring, part of hip and knee joint, and the entire leg below the knee except for medial aspect of lower leg (innervated from saphenous nerve)

  31. Popliteal nerve block • Anesthesia for ankle and foot surgery

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