UPMC St. Margaret Nerve Block Rotation

1. UPMC St. Margaret Nerve Block Rotation Guidelines for 1 month Block Rotation

2. Staff • Student Clinical Coordinator • Rachel Gray, CRNA • Co-coordinators • Andy Miller, CRNA • Mary Lou Taylor, CRNA • Chief Anesthesiologist • Jay Roskoph, MD • PA/CRNP • Bethany Mitchell, PA-C • Carolyn Garver, CRNP

3. First Day • Please report to the OR lounge at 0600. • You will be given you access to the scrub machine and provide you with an orientation of our preoperative holding area. • If Rachel Gray, Andy Miller or Mary Lou Taylor will orient you.

4. Overview and Expectations • Become familiar with performing regional anesthesia for a variety of orthopedic cases. Most of the training will occur in the preoperative area using both interactive and didactic techniques. • Create an understanding of the benefits and risks of regional anesthesia • Become familiar with the fundamentals of regional anesthesia • Become familiar with all anatomical landmarks utilized in regional anesthesia

5. Objectives • Describe specific anatomical landmarks for sciatic, femoral, popliteal fossa, and lumbar plexus blocks. • Describe signs and symptoms of an intravascular injection and the treatments for it • Describe regional anesthesia related procedures • Demonstrate an understanding of the medications used for regional anesthesia • Perform regional anesthesia as directed by supervising anesthesiologist • Assist with starting IVs and the positioning and monitoring of patients receiving regional anesthesia • Review and follow departmental procedures and policies for administration and management of anesthesia, documentation of narcotics and emergencies • Give daily evaluations to the PA, CRNP or anesthesiologist

6. Sciatic Nerve Blocks • This technique can be used for surgery and postoperative pain management in patients undergoing a wide variety of lower leg, foot, and ankle surgeries. • It is particularly well-suited for surgery on the knee, calf, Achilles tendon, ankle, and foot. It provides complete anesthesia of the leg below the knee with the exception of the medial strip of skin, which is innervated by the saphenous nerve. When combined with a femoral nerve or lumbar plexus block, anesthesia of almost entire leg is achieved. • A typical onset time for this block is 10-25 minutes, depending on the type, concentration, and volume of local anesthetic used. The first signs of blockade onset are usually reported by the patient in the form of a feeling that the foot is "different" or an inability to wiggle the toes. It can take up to 30 minutes for full sensory-motor anesthesia to develop. • Continuous infusion of 0.1 – 0.2 % Ropivacaine is maintained at 2-5 mL/hr after a bolus is given. This bolus is withheld until the patient is out of surgery because they must be able to demonstrate full plantar and dorsiflexion of the ankle. • Complications and how to avoid them: • Infection – aseptic technique is used • Hematoma/vascular puncture – avoid deep needle or multiple needle insertions; avoid in patients undergoing anticoagulant therapy. • Local anesthetic toxicity – avoid large volumes and doses due to the close proximity of muscle beds. • Patients must be instructed on care of insensate extremity and will need frequent repositioning. References: Chelly, J.E. (Ed.). (1999). Peripheral Nerve Blocks: A Color Atlas. Philadelphia: Lipincott, Williams and Wilikins. Hadzic, A., Vloka, J.D. (2004). Peripheral Nerve Blocks Principles and Practice. New York: McGraw-Hill Professional.

7. SRNA Responsibilities • Report to preop holding area every morning by 0600 to assist in setting up the block trays for the day • Start IVs for all patients receiving blocks. During “down time” you may assist with other IVs as well • Fill out the block paper work for the chart and for billing purposes on the block cart. Examples are provided • Monitor the patient during and after the block, recording BP, HR, pulse ox readings. Record any sedation given. • Report off to the on-call anesthesiologist after all blocks are completed

8. Please remember… • An anesthesiologist MUST be present to perform regional ansethesia • Make sure the cubicle is equipped with an Ambu bag and the suction is functional • A time out must be completed with at least two people including pt name, MR number and laterality • Know the drugs, techniques, risks, complications, anatomy and physiology involved in the specific block

9. Additional Information • The following is a study guide created by Bethany Mitchell, PA-C. Please become familiar with this before the first day of your block rotation • Review your regional website for more specifics on regional anesthesia

10. Femoral Nerve Blocks • This block is well suited for quadriceps muscle biopsy, knee surgery (arthroscopy), quadriceps tendon repair and postoperative pain management after femur and knee surgery. When combined with the block of the sciatic nerve, anesthesia of the almost entire lower extremity from the mid-thigh level can be achieved. • The femoral nerve supplies motor fibers to the quadriceps muscle (knee extension), the skin of the anteromedial thigh, and the medial aspect of the leg below the knee and foot. • The most common indications for this block include postoperative analgesia after knee arthroplasty, ACL repair and femoral fracture repair. • Continuous infusion is initiated after a bolus of local anesthetic. Ropivacaine 0.2% is routinely used for the infusion at a rate of 5-8 mL/hr. • This nerve block not only affects sensory fibers of the femoral nerve, but also some motor fibers. This results in quadriceps weakness. The femoral nerve supplies muscular branches of the iliacus and pectineus, and the muscles on the anterior thigh, except the tensor fascie femoris. • Complications of nerve block: • Infection – aseptic technique is used; catheters are removed 48-72 hours after insertion • Hematoma/vascular puncture – stop advancing needle when patient reports pain; if vein or artery is punctured pressure is applied before injecting solution at site. • Nerve injury – a nerve stimulator is used and a specific muscle contraction is found; parasthesias are no longer desirable. References: Chelly, J.E. (Ed.). (1999). Peripheral Nerve Blocks: A Color Atlas. Philadelphia: Lipincott, Williams and Wilikins. Hadzic, A., Vloka, J.D. (2004). Peripheral Nerve Blocks Principles and Practice. New York: McGraw-Hill Professional.

11. Popliteal Fossa Nerve Block Nerves Located in the Popliteal Fossa and their Motor Functions • This technique can be used for surgery and postoperative pain management in patients undergoing a wide variety of lower leg, foot, and ankle surgeries. • Continuous infusion is initiated after an initial bolus of local anesthetic through the catheter. For this purpose, we routinely use 0.2% ropivacaine (15-20 mL). The infusion is maintained at 10 mL/hr or 5 mL/hr when a PCA dose is planned (5 mL). • Usually these patients are discharged the day after surgery and are given disposable Stryker pumps. These pumps can be adjusted to control the patient’s pain, usually running at 5-7 mL/hr. • Breakthrough pain in patients on continuous infusion is always managed by administering a bolus of local anesthetic. • A typical onset time for this block is 10-25 minutes, depending on the type, concentration, and volume of local anesthetic used. The first signs of the onset of blockade are usually reported by the patient. The foot "feels different" or an inability to wiggle toes is reported. Sensory anesthesia of the skin with this block is often the last to develop. • Complications and how to avoid them: • Infection – Aseptic technique is used • Local Anesthetic Toxicity – absorption of local anesthetic from the popliteal fossa is slow because of the low vascularity of the adipose tissue in the area • Hematoma/vascular puncture – avoid medial redirection of the needle to avoid the vascular sheath • Nerve injury – do not inject if the patientif the patient complains of pain or if stimulation at < 0.2 mA References: Chelly, J.E. (Ed.). (1999). Peripheral Nerve Blocks: A Color Atlas. Philadelphia: Lipincott, Williams and Wilikins. Hadzic, A., Vloka, J.D. (2004). Peripheral Nerve Blocks Principles and Practice. New York: McGraw-Hill Professional.

12. Lumbar Plexus Nerve Blocks • The Lumbar Plexus is made up of the nerve roots originating from L1-L4. These roots go on to make up the genitofemoral nerve, lateral femoral cutaneous nerve, femoral nerve, and obturator nerves. • This technique can be used for postoperative pain management in patients undergoing hip, femur, and knee surgery. • Lumbar plexus blocks provide anesthesia or analgesia to the entire distribution of the plexus, including the anterolateral and medial thigh, the knee, and the saphenous nerve below the knee. • Continuous infusion is always initiated after an initial bolus of dilute local anesthetic through the catheter. For this purpose, we routinely use 0.2% ropivacaine (15-20 mL). The infusion is maintained at 10 mL/hr or 5 mL/hr when a PCA dose is planned (5 mL/q30 minutes). • Breakthrough pain in patients on continuous infusion is always managed by administering a bolus of local anesthetic. • When the bolus injection through the catheter fails to result in blockade after 30 minutes, the catheter should be considered dislodged and it should be removed. • Complications and how to avoid them: • Infection – aseptic technique is used • Hematoma/vascular puncture – avoid use in patients on anticoagualant therapy, avoid deep needle insertion • Local anesthetic toxicity – large volumes of long-acting anesthetic should be avoided in elderly patients, frequent aspiration necessary; avoid fast, forceful injecting • Nerve injury – if stimulation occurs at <0.5 mA, withdraw needle before injecting • Hemodynamic consequences – every patient receiving a lumbar plexus block should be monitored to the same extent as a patient receiving an epidural since the anesthetic can spread into the epidural space if the sheath is punctured. References: Chelly, J.E. (Ed.). (1999). Peripheral Nerve Blocks: A Color Atlas. Philadelphia: Lipincott, Williams and Wilikins. Hadzic, A., Vloka, J.D. (2004). Peripheral Nerve Blocks Principles and Practice. New York: McGraw-Hill Professional.

13. Nursing Care • Goals for Nerve Blocks: • Decreased opioid use • Improved mobility allowing for improved participation in PT • Improved patient satisfaction • Shorter length of stay • Types of pumps: • Mechanical, programmable • Rate can be changed according to order set based on pain scores and sensory level • Stop pump infusion every morning at least 2 hours before scheduled physical therapy • If no pump with patient who has a nerve block catheter placed, notify anesthesia immediately. Tubing, batteries, etc. located in PACU. • After pump is discontinued, return to PACU for cleaning. • Non-Mechanical • Used for outpatients and short stay patients • Rate can be adjusted based on pain level • Pump can be left on for physical therapy because patients are generally non-weightbearing Nursing Duties: • Every 4 hours, every shift, or after activity: • Monitor BP, Pulse, Respiratory rate, Neurological status and level of pain relief • Monitor sensory and motor function (It can take 24 hours after surgery for motor function to return) • Check dressing and site for leakage, swelling, redness or bleeding. • Check catheter for patency • Nurses can: • Reinforce or change dressing if Regional anesthesia unavailable (sterile 4x4s can be placed under the dressing using sterile technique) • Remove catheter after the pump is empty (Stryker); an order must be given to discontinue the pump otherwise. Removal of entire catheter with blue tip intact must be documented in Progress Notes in patient chart. • Notify Anesthesia if: • Patient notes tinnitis, metallic taste or other signs of local anesthetic toxicity. Ropivacaine is used for continuous infusion due to its lower risk of cardiac toxicity. • Excessive Sedation or change in neurological status • Systolic BP <90 mmHg • Inadequate pain relief (>5 of 10) • Leakage around the dressing site or if catheter has come out accidentally • Change in level of sensory status or motor function