[20060519]Lower Extremity Peripheral Nerve Block

7/21/2019 [20060519]Lower Extremity Peripheral Nerve Block

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Lower Extremity

Peripheral NerveBlock

R4


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Lower ExtremityPeripheral Nerve Block

Lower Extremity Peripheral Nerve BlockTechniques Psoas compartment block

Femoral nerve block Lat Femoral cutaneous nerve block !aphenous nerve block Parasacral block !ciatic nerve block "nkle an# $oot block

Pharmacolo%ic &onsi#eration&omplications o$ Lower Extremity

Peripheral Nerve Blocks


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!ensory !upply "reas o$the Lumbosacral Plexus


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soas ompar menBlock'Lumbar plexus

block("nesthesia $or thi%h sur%ery) an# hip

$racture repair in combination with apara sacral nerve block

"nal%esia $ollowin% T*") T+" an# inthe treatment o$ chronic hip pain

&onsistent anesthesia in the#istributions o$ the $emoral)latcutaneous n o$ the thi%h) an# theobturator nn


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soas ompar menBlock'Lumbar plexus

block(


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Femoral Nerve Block

"nesthesia $or knee arthroscopy in

combination with intra,articular local

anesthesia"nal%esia $or $emoral sha$t $ractures)

ant cruciate li% reconstruction'"&L()

an# T+" in multimo#al re%imens

-,in,. block '$emoral) LF&) obturator n(


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Femoral Nerve Block


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Lateral Femoral&utaneous Nerve Block

"nesthesia #urin%

#ia%nostic muscle

biopsy an#

harvestin% o$ split

thickness skin

%ra$ts

Blin# /$an0technique with a

variable success

rate


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!aphenous Nerve Block

!upplies

the cutaneous

area o$ theme#ial aspect o$

the cal$ an# $oot

to the level o$the mi#$oot


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Parasacral Block 'P!NB(

1t has been use# to provi#e anal%esia$ollowin% ma2or $oot an# anklereconstruction

&onsistently block both components o$ thesciatic nerve an# the post cutaneous nerve o$the thi%h

The sympathetic n supply to the bla##er isalso in close promixity but problems withvoi#in% an# the nee# $or bla##ercatheteri3ation a$ter P!NB have not beenreporte#


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c a c erve oc the level o$ the 5luteus

6aximus


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!ub%luteal "pproachesto the !ciatic Nerve

!upine approach to the sciatic nerve in

the 7exe# hip position initiatin% the block

at the mi#point between the %reater

trochanter o$ the $emur an# the ischial

tuberosity

1#enti$yin% bony lan#marks in very obese

patients is sometimes #i8cult an# the

patient position requires a##itional

personnel to maintain


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c a c erve oc athe level o$ the Popliteal

Fossa


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"nkle an# Foot Block


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Pharmacolo%ic&onsi#erations

&omplete unilat blocka#e involves

multiple nerve blocks an# a lar%er

volume o$ local anesthetic solution

"ttention must be %iven to total local

anesthetic #ose

The concentration must also take intoaccount the #e%ree o$ sensory an#9or

motor block #esire#


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Epinephrine

Epi prolon%s the #uration an# quality o$

most local anesthetics use# $or lower

extremity peripheral block

:asoconstriction o$ the perineural vessels ;ecreases uptake an# increases the neural

exposure to the local anesthetics

Li#ocaine vs Ropivacaine

The #ecision to a## Epi an# the #ose o$ Epi &ar#iac or neural ischemia vs the ability to #iscern

an intravascular in2ection


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Epinephrine

The nearly equivalent e

vs >? 9ml) su%%est that the lowerconcentration is su8cient


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Bicarbonate

There was little reason to a## so#ium

bicarbonate with plain local anesthetics

or those with $reshly a##e# epinephrine

No #i@ bupivacaine

with alkalini3ation compare# to thosewho receive# a non,alkalini3e# solution

&omplications o$ Lower


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&omplications o$ LowerExtremity Peripheral Nerve

Blocks

!erious &x $ollowin% =.)=A PNBs in a >,

month perio#

ByAuroy et al. France

Per .?)??? PNBs) ?,=C #eath) ?-,4. car#iac arrests) ?>,4

neurolo%ic in2uries) an# -D,..= sei3ures

There is a paucity o$ reports o$ complications

specically associate# with lower extremityPNBs compare# to upper extremity PNBs Less common application rather than to inherent

sa$ety o$ the techniques


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Toxicity&omplications o$ Lower Extremity Peripheral

Nerve Blocks The apparent mar%in o$ sa$ety seems to vary

with in#ivi#ual block techniques The #i


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Toxicity&omplications o$ Lower Extremity Peripheral

Nerve Blocks Prevention

se o$ Epi as an intravascular marker

!low) metho#ical in2ection while avoi#in% hi%h,

in2ection pressure

Frequent aspiration

&onstant assessment o$ the pts an# vital si%ns

Pru#ent selection o$ local anesthetic

concentration an# volume


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Block(&omplications o$ Lower Extremity Peripheral

Nerve Blocks 1ntra$ascicular sprea# o$ the local anesthetic

proximally towar# the spinal cor#) resultin%

in central neuronal blocka#e

Nee#le placement at the level o$ the nerve roots orspinal nerves

Force$ul) $ast in2ections un#er hi%h pressure into

#ural cu


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&omplications&omplications o$ Lower Extremity Peripheral

Nerve Blocks !everal approaches $or PNBs o$ lower

extremity

Psoas compartment approach to the lumbar

plexus) the obturator nerve block) parasacral

an# classical approaches to the sciatic n

This block is less suitable in the settin% o$

anticoa%ulation as compare# to other)more sup$ lower extremity nerve blocks

1 $ ti & li ti


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1n$ectious &omplications&omplications o$ Lower Extremity Peripheral

Nerve Blocks

The inci#ence o$ bacterial complicationsassociate# with the use o$ continuous $emoralnerve blocks By Cuvillon et al.

1n their cohort o$ =? pts) >A@ ha# positive bacterialcoloni3ation o$ the catheter at 4 hrs postoperatively

There were no lon%,term sequelae relate# tothese positive catheter cultures


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Nerve Blocks ?4,.@ o$ all nerve block proce#ures

The symptoms o$ nerve in2ury a$ter PNB usuallymani$est shortly a$ter block resolution

1ntraneural in2ection is a well,knownmechansm o$ neurolo%ic in2ury associate#with PNBs There is no consensus on the techniques or metho#s

that can re#uce the risk o$ intraneural in2ection

6etho#s o$ nerve locali3ation 'ie) paresthesia vsnerve stimulation(

The a#vanta%es o$ short,bevel over sharper) lon%,bevel nee#les remain controversial


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Nerve Blocks Lancinatin% pain an# hi%h in2ection pr may

porten# intraneural in2ection o$ local

anesthetic) thus increasin% the potential $or

n in2ury Pain is not a reliable warnin% si%n o$ impen#in%

nerve in2ury

*i%h in2ection pr'G=? psi( with intraneural nee#le

placement lea# to nerve in2ury &linical perception o$ an abnormally hi%h resistance

an# pressure require# to in2ect is impossible to

veri$y


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Nerve Blocks Neuronal ischemia can occur $rom a variety

o$ sources ;isruption o$ the neuronal microvasculature

*i%h,en#oneurial pressures "##ition o$ vasoconstrictin% a%ents

Exo%enous compression $rom tourniquets

The potential $or neurotoxicity with a localanesthetics Function o$ its potency) concentration) the len%th

o$ exposure o$ the neuronal tissue to the a%ent


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Nerve Blocks Local anesthetics are use# in concentrations

that) un#er normal clinical con#itions) #o not

cause irreversible nerve #ama%e

Exposure o$ the en#oneurium to hi%h concentrationo$ local anesthetics

Hhile neurolo%ic &x o$ PNBs are uncommon)

they can an# #o occur even in the han#s o$

experience# practitioners an# may result insi%nicant pts su


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!ummary

Recent #evelopments in the el# o$ re%ional

anesthesia have lea# to an increase# interest in

lower extremity PNBs Transient neurolo%ic symptoms associate# with spinal

anesthesia 1ncrease# risk o$ epi#ural hematoma with the

intro#uction o$ new anti,thromboembolic prophylaxis

re%imens

Evi#ence o$ improve# rehabilitation outcome with

continuous lower extremity PNBs

!tan#ar#i3e# an# repro#ucible practice with

more clearly #ene# in#ications , both to

improve their clinical utility an# to re#uce the

risk o$ complications


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[20060519]Lower Extremity Peripheral Nerve Block

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