Peripheral Nerve Block Presentation
-
Upload
shikha-soni -
Category
Documents
-
view
163 -
download
9
Transcript of Peripheral Nerve Block Presentation
Thomas Drye, MDMadison Anesthesiology Consultants, LLP
Definition:Local anesthetic induced blockade of peripheral or spinal nerve impulses from a targeted body part with preserved level of consciousness
Categories:◦Intravenous (Bier block)◦Neuraxial (spinal, epidural)◦Peripheral nerve blocks (PNB)
Truncal (e.g. paravertebral, TAP blocks) Plexus (e.g. brachial plexus, lumbar plexus) Distal (e.g. femoral, sciatic)
More hemodynamic stability c/w neuraxial Anticoagulation less of an issue Increasing popularity due to advances in
ultrasound technology Introduction of perineural catheters
prolongs post-operative pain control benefits
Avoidance of general anesthesia◦Primary regional anesthetic vs. combination
with “light” general anesthetic◦Most patients request intra-operative
sedation◦Decreased PONV, sore throat, delirium,
airway obstruction and respiratory depression
◦Decreased time to discharge from PACU◦Increased patient satisfaction
Post-operative pain control◦Decreased narcotic requirements and
associated adverse side effects (e.g. nausea, pruritis, sedation, confusion, respiratory depression)
◦Earlier recovery of bowel function◦Improved tolerance of physical therapy◦Improved pain scores, but not always in
PACU◦Increased patient satisfaction
Infrastructure requirements and potential for surgeon delays
Failed Blocks Intraoperative awareness and non-operative
discomfort (e.g. positioning) Motor block Variable duration (approx. 4-40 hours) Rare serious complications (e.g. local
anesthetic toxicity, nerve injury)
Needle phobia or otherwise uncooperative Excessive sedation (adults) Infection (local and untreated systemic) Anticoagulation? Pre-existing nerve injury? Surgery specific (e.g. motor block and post-
op neurological examination) Block specific (e.g. pulmonary disease and
interscalene block)
Anatomy Loss of resistance and tactile feedback Evoked paresthesia Nerve stimulator (goal 0.3-0.5 mA) Ultrasound guided
Monitoring Availability of resuscitation equipment
(suction, airway management) Availability of resuscitation drugs (induction
agents, ACLS drugs, lipid emulsion) Pre-procedure confirmation (“timeout”) Aspiration before injection Incremental injection Do not inject when paresthesia present
Block voltage gated sodium channels on nerve cells preventing impulse conduction
Two classes: amide and ester local anesthetics
Rare allergic reactions Variable onset and duration
◦ Quick onset, short acting (lidocaine, mepivacaine)e.g. 1-2 hours following subcutaneous infiltration
◦ Slow onset, long duration (bupivacaine, ropivacaine) e.g. 2-8 hours following subcutaneous infiltration
Intravascular injection (immediate onset)
Systemic absorption (delayed onset) Central nervous system signs
◦1st excitation: perioral tingling, tinnitus, agitation
◦2nd depression: blurred vision, slurred speech, loss of consciousness
◦Seizure Cardiovascular toxicity
◦Cardiac arrhythmia and/or circulatory collapse◦Requires ~ 3x blood concentration that causes
seizures
For use in the treatment of life threatening local anesthetic toxicity
Novel therapeutic indication for an old medication (component of TPN)
First case reported in 2006, now with over a dozen reported cases
Mechanism of action unknown (“lipid sink?”)
Local anesthetic toxicity Bleeding/hematoma Infection Nerve injury
◦Transient paresthesias 1-3%◦Permanent nerve injury ~1/10,000
Failed block
Brachial plexus◦ Interscalene block◦ Supraclavicular block◦ Infraclavicular block◦ Axillary block
Lower extremity◦ Lumbar plexus block◦ Femoral nerve block and saphenous nerve block◦ Sciatic nerve blocks: anterior, gluteal, and
popliteal Truncal
◦ Paravertebral block◦ Transversus abdominis plane (TAP) block
Interscalene
Infraclavicular
Supraclavicular
Axillary
“Between the scalenes”
Anterior scalene muscle
Middle scalene muscle
IJ
CA
Primarily for shoulder or proximal humerus surgery - distal arm and hand are often sparred
Multitude of unique complications because of location in neck:◦ Vertebral artery injection- seizure with only very
small local anesthetic volume◦ Accidental epidural or spinal injection◦ Pneumothorax- pleural puncture, dome of lung
• Hemidiaphram paralysis (phrenic nerve blockade)
◦ 100% of interscalene blocks◦ May cause dyspnea, even respiratory failure,
depending on severity of underlying lung disease• Hoarseness (recurrent laryngeal nerve
blockade)• Horner’s syndrome (stellate ganglion blockade)
Myosis- constriction of the pupil Ptosis- drooping eyelid Anhidrosis- lack of sweating
“Spinal of the arm”- blocks shoulder, upper arm, forearm, and hand
50% incidence of phrenic nerve block with traditional technique, 0-20% with low volume US-guided technique
Risk of pneumothorax Risk of bleeding: non-compressible site
AV
Effective for procedures of the elbow, forearm, and hand
Safe alternative in patients with lung disease since phrenic nerve is sparred and no PTX risk
Safe alternative in anticoagulated patients due to easy compressibility and no at risk adjacent structures
Disadvantages: higher failure rate and tourniquet discomfort
Femoral nerve
Post-operative pain control for surgery of the thigh or knee, most commonly used for ACL repair and total knee arthroplasties (TKA)
“Only numbs the front”- incomplete analgesia after knee surgery because sciatic nerve innervates posterior knee compartment
Tibial nerve
Peroneal nerve
“Popliteal approach to the sciatic nerve” Effective for procedures of the leg distal to
the knee, particularly foot and ankle surgery
Longer duration than ankle block or subcutaneous infiltration
The terminal branch of the femoral nerve, the saphenous nerve (sensory only), innervates the medial ankle and requires separate block
Used increasing for breast surgery, either primary anesthetic or post-operative analgesic
Surgical block requires injections at multiple levels
Pneumothorax is most common serious complication
Paravertebral space
Tranversus Abdominis Plane
Used for post-operative analgesia for lower abdominal surgery (e.g. inguinal hernia, abdominal hysterectomy, Caesarean section)
Midline incisions require bilateral injections
Serious complications are extremely rare, and this block can be safely performed in an anesthetized patient
Peripheral nerve blocks are increasing in frequency due to recent advances in ultrasound technology
PNB’s have many advantages including decreased narcotic requirements and increased patient satisfaction
Serious complications are rare but do occur Choosing to perform PNB requires
consideration of each patient and surgical procedure, as well as individual surgeon preferences