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Peripheral Nerve Block Review Feburary 12, 2009. Esi Rhett, MD Erikka Limbrick-Washington, MD. Why do nerve blocks?. Less post-operative pain Less use of narcotics with the accompanying side effects Good alternative to patients who have severe PONV Less cognitive impairment esp in elderly

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peripheral nerve block review feburary 12 2009

Peripheral Nerve Block ReviewFeburary 12, 2009

Esi Rhett, MD

Erikka Limbrick-Washington, MD

why do nerve blocks
Why do nerve blocks?
  • Less post-operative pain
  • Less use of narcotics with the accompanying side effects
  • Good alternative to patients who have severe PONV
  • Less cognitive impairment esp in elderly
  • Less immunosuppressive than general
  • 6 of the most common blocks reviewed here
outline type of block
Outline: Type of Block
  • Indication
  • (Relative) contraindications: patient refusal, severely demented or combative, coagulopathy, pre-existing hematoma, pre-existing peripheral neuropathy

C. Landmarks

D. Muscle stimulation

E. Amount of drug

F. Special consideration/Complications

brachial plexus interscalene approach
Brachial Plexus: Interscalene approach
  • Surgery of the shoulder (reduction) or upper arm
  • Avoid in patients with significantly impaired pulmonary function because the phrenic n.lies over the anterior scalene m

C. (1) Clavicle (2) Posterior border of the SCM, (3) one inch (2.5 cm) above the clavicle,

brachial plexus interscalene approach1
Brachial Plexus: Interscalene approach

D. Pectoralis, deltoid (controversial), arm, wrist, hand

E. Local anesthetic (Ropivicaine) 30-40ml to cover entire plexus, slowly, frequent aspiration

F. Horners syndrome (miosis, ptosis, anhydrosis) phrenic nerve palsy, pneumothorax.

brachial plexus axillary approach
Brachial Plexus: Axillary approach

A. Procedures distal to the elbow

B. No absolute (transarterial, paresthesia, nerve stimulator, ultrasound, perivascular)

C. Find the pulse of the axillary a,

median nerve is superior, ulnar is inferior and radial is interior-posterior

D. Ulnar (4th,5th digit-adduction of the thumb and little finger)/Median(1st-3rd fingers-flexion of distal IP joints and flexion of proximal IP and MCP joints) /Radial (flexion and supination of the forearm-triceps, hand extensors Musculocutaneous (biceps, skin on lateral forearm)

brachial plexus axillary approach1
Brachial Plexus: Axillary approach

E. 30-40ml of local with frequent aspiration to avoid axillary a injection

F. Avoid intra-arterial injection, possible increased risk of post-op neuropathies, must get muculocutaneous to complete block (lies deep in the coracobrachialis m)

sciatic n classic or posterior lithotomy anterior
Sciatic N. (classic or posterior, lithotomy, anterior)
  • Surgery on the knee, tibia, ankle, and foot
  • Inability to position the patient well
  • 1. Greater trochanter

2. PSIS and sacral hiatus

sciatic n classic posterior approach
Sciatic N (classic, posterior approach)

D. Twitching of the calf, foot or toes

E. Low volume of LA 20-25ml

F. Advise pt and RN to frequently turn to avoid sitting/laying on the anesthetized nerve

femoral n
Femoral N.
  • Procedures on the thigh and knee (not good for groin and lateral thigh)
  • No specific contraindications

C. Femoral crease and the femoral a, 2 cm lateral to the pulse (remember NAVL)

D. Movement of the patella and quadriceps

E. 20-30ml of LA after 1ml shows fade of motor activity

F. Negative aspiration of blood

fascia iliaca lateral femoral cutaneous femoral obturator and genitofemoral nn
Fascia Iliaca (Lateral femoral cutaneous, femoral, obturator and genitofemoral nn)
  • Surgery on the hip, thigh and knee

B. No absolute contrain

C. ASIS, pubic tubercle, inguinal ligament 2cm

D. No muscle stimulation needed, two “pops” as the fascia lata and fascia iliaca are penetrated

fascia iliaca
Fascia Iliaca

E. 25-30ml of LA

F. Similar complications as other PNB

ankle block
Ankle Block

A. Surgery on the distal foot ie. toe amputation, bunion removal, hammer toe correction

B.Compromised blood supply to the foot

C. 5 nerves (saphenous, deep peroneal, posterior tibial nerve, sural and superficial peroneal nerve

ankle block1
Ankle Block
  • Saphenous: medial malleolus in a ring around anterior aspect
  • Posterior tibial: medial malleolus and the pulse of the posterior tibial a, nerve is posterior to the a.
  • Deep peroneal:anterior aspect deep to tibialis ant tendon (lines up with the big toe)
  • Sural: posterior to the lateral malleolus
  • Superficial peroneal: lateral and anterior aspect

D. No muscle stimulator needed

E. 5-8ml of LA for each nerve

ankle block2
Ankle Block

D. No muscle stimulator needed

E. 5-8ml of LA for each nerve

F. NO EPINEPHRINE, injection with large volumes can cause hydrostatic damage

references
References
  • www.nysora.com
  • Morgan and Mikhail. Clinical Anesthesiology.(New York: McGraw-Hill, 2006), pp.324-347.
  • Sciard and Matuszcak. Landmarks for Peripheral Nerve Blocks. (Texas: Life Tech, Inc, 2003)