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Regional Anesthesia for the Lower Limbs Dr. Prakash Ambardekar SeniorAnaesthesiologist Dept of Anesthesia SL Raheja Hospital, Mumbai. Diabetes Mellitus is not a simple endocrine disorder

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Regional Anesthesia

for the Lower Limbs

Dr. Prakash Ambardekar

SeniorAnaesthesiologist

Dept of Anesthesia

SL Raheja Hospital, Mumbai


Diabetes Mellitus is not a simple endocrine disorder

1] Cardio-vascular system - Angina pectoris,

silent small to massive Myocardial Infarcts ,

varying degrees of cardiomyopathies,

varying types of Conduction blocks etc

may be accompanied with Hypertension

2] Reno-vascular system - Nephropathies leading to Chronic renal failure

3] Central nervous system –Secondary effects

4] Autonomic nervous system -Sympathetic & Parasympathetic systems

causing Autonomic Imbalance

5]Immunological system – suppression, prone to infections

Contd…


Diabetes Mellitus is not a simple endocrine disorder

6] Septicaemia - following infection affecting various systems

7] Fluid & Electrolyte status altered.

8] Pulmonary system – alters ventilation and perfusion

9] G. I. system – slows gastric emptying - aspiration

10] Skeleto-muscular system - fusion of upper cervical vertebrae

with limited neck movement,

if accompanied with obesity & short neck

Thus, in Diabetes, the selection of Anesthesia

becomes a tricky and highly skillful job.


Why regional anaesthesia ?

1] Ideal for day-care patients

2] Safety in high risk patients

3] No intra-op regurgitation & aspiration

4] No PONV

5] Minimal alteration in drug schedule

-specially in diabetics


Why regional anaesthesia ? Continued….

6] Minimal effects on vital parameters

7] Safer in emergency situations

8] Can be repeated frequently

9] Conscious & arousable patient

at the end of the surgery

10] Reduction in morbidity & mortality


Why not other modes of Anesthesia ??

General Anesthesia: [besides usual precautions]

a] Risk of Aspiration and PONV

b] Difficult intubations

c] Resistant hypotension which may last for longer time

d] Management of ischaemic changes and arrhythmias

e] Management of blood sugar


Why not other modes of Anesthesia ??

Spinal & Epidural Anesthesia

a] Prevention and management of hypotension

b] Cannot be repeated frequently

[ except in continuous epidural analgesia ]

especially for small but painful procedures.


Limitations

1] Surgical time limit is between

1-3 hrs.

2] Patient’s co-operation is must

3] Failure or partially acted block


Types of blocks

1] Sciatic & femoral nerve block

2] Sciatic nerve block in lower thigh

3] Leg block

a] low

b] mid

c] high

4] Field Block (small infected cysts, abscess, carbuncles)


  • Pre-block preparation

  • Besides usual instructions….

  • Application of elastocrepe bandage

  • 2-3 days prior to surgery

  • Advantages :-

  • limb becomes soft & supple

  • reduced oedema , improved limb circulation

  • pH of tissue fluid alters

  • Success rate improves


Pre-block preparation

Counseling the patient

regarding the procedure

and the expectation from the patient

(compliance and accurate replies

regarding paresthesia)


Lower leg block or modified ankle block

Deep peroneal nerve – can be blocked by injecting subcutaneously

3-5 mm along the lat border

of the shin with 2 ml 2% xylocaine with 24 g 1.5 inch needle


Lower leg block or modified ankle block

Post. Tibial nerve –

Blocked by injecting

3-5 ml 2% xylocaine

at the junction of proximal 1/3rd with distal 2/3rd of medial malleolus to calcaneum, where normally pulsations of post. Tibial artery is felt.


Lower leg block or modified ankle block

Sural nerve

Inject 2% xylocaine between the tendoachilles and the calcaneaum on the lateral aspect


Lower leg block or modified ankle block

Ring block –

0.5 % xylocaine around the

leg to block cutaneous nerves


Lower leg block or modified ankle block

Calcaneal nerve block

2 Finger breadths

proximal to the

medial malleolus

Inject along the

direction of the nerve


Mid leg block

Anterior Tibial nerve

Inject 2- 4 ml 2% xylocaine

subcutaneously 5-7 mm along

the lateral border of the shin


Mid leg block

Posterior Tibial Nerve

Spinal needle no 23 G is inserted from the lateral side

of the leg over the ant. border of fibula going medially downwards just to slip the interosseous border of tibia , advance 1-2 mm & deposit 8-10 ml 2% xylocaine


Mid leg block

Sural nerve

Inject 2 – 3 ml 2% xylocaine

along a line extended proximally

tangential to the lateral border

of the tendo achilles


Mid leg block

Ring block

0.5 % xylocaine around the

leg to block cutaneous nerves


High leg block

Anterior Tibial nerve

Inject 3-4 ml 2% xylocaine

5-10 mm deep lateral to the

upper end of shin


High leg block

Posterior Tibial nerve

2-4cm below the neck of the fibula

Lateral approach –

Spinal needle no 23 G is

passed from the lateral side

of the leg over the ant.

border of fibula going

medially downwards

just to slip the interosseous

border of tibia ,

advance 1-2 mm &

deposit 8-10 ml 2% xylocaine


High leg block

Lateral Popliteal Nerve

2- 4 ml 2% xylocaine

injected around the

neck of fibula


High leg block

Ring block

0.5 % xylocaine around the

leg to block cutaneous nerves


High leg block

An alternate technique -

If patient has a pain-free leg,

then one may give sciatic nerve

block in the lower third of thigh alongwith

lat. Popliteal nerve block and ring block.


Steps to success with local blocks

Practice regularly

Your patience

The surgeons’ patience

The patients’ patience!

Patients’ comfort

The surgeons comfort

Your comfort

AND SAFETY!!


In diabetic foot

In Diabetic Foot

Blocks are the way to go!!


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