Mod IV: Regional Anesthesia Part 1 Flashcards by Olivier Mba

_{Regional Anesthesia}

The first local anesthetic

Cocaine

Spanish Jesuit, Father Burnabe Cobo

1653 Wrote about chewing the leaves of the coca plant to relieve a toothache

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_{Regional Anesthesia}

Sigmund Freud (1883-1887) wrote many articles detailing the virtues of cocaine:

Stimulant

Analgesic

Addiction treatment?

It has been argued that much of his early works on psychoanalysis were influenced by his cocaine use

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_{Regional Anesthesia}

Karl Kollar, college and friend of Freud, in 1884 demonstrated the local anesthetic properties of cocaine allowing him to perform

“painless” surgery on the eye

This is the first documented application of a drug to produce localized anesthesia

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_{Regional Anesthesia}

William Halsted & Alfred Hall, only 8 weeks after Kollar’s announcement they began experimenting with injecting nerves with cocaine, in December 1884 published injecting cocaine SQ into forearm and were able to produce:

Analgesia

Injected directly into Ulnar N. and produced complete anesthesia to its distal distribution

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_{Regional Anesthesia}

Complete anesthesia to its distal distribution

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_{Regional Anesthesia}

Brachial plexus blocks were performed by Halsted using a cut-down technique and injecting cocaine directly into:

each nerve root

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_{Regional Anesthesia}

1st Percutaneous Blockade performed by G. Hirschel in 1911 was:

Axillary brachial plexus block

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_{Regional Anesthesia}

Selective anesthesia and analgesia that is achieved by exposing selected nerves to LA is also known as:

Regional Anesthesia

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_{Regional Anesthesia}

Which discipline tells us where nerves travel and what they do?

Applied Anatomy

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_{Regional Anesthesia}

We can choose how dense and how long the block will last by using which scientific discipline?

Applied Pharmacology

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_{Regional Anesthesia}

What are the different types of Regional Anesthesia?

Topical

Local infiltration

Field Block

Intravenous Regional – Bier block

Peripheral nerve block

Neuraxial

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_{Regional Anesthesia}

What are the possible uses of topical anesthesia?

IV placement

Eye procedures

ENT procedures

Awake fiber optic intubations

Dental pain

Surgical wound closure

Acute/chronic pain management

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_{Regional Anesthesia}

Which agents are used for topical anesthesia?

EMLA cream/patch

^{Eutectic Mixture of Local Anesthetics}

^{Mixture of 2.5%Lidocaine and 2.5%Prilocaine}

Cocaine, Tetracaine, Proparacaine (Alcaine)

Benzocaine spray

^{Methhemaglobinemia}

Lidocaine jelly/ointment

Skin refrigerant spray

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_{Regional Anesthesia}

What the composition of EMLA cream/patch?

Eutectic Mixture of Local Anesthetics

Mixture of 2.5%Lidocaine and 2.5%Prilocaine

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_{Regional Anesthesia}

Possible complication a/w the use of Benzocaine spray

Methhemaglobinemia

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_{Regional Anesthesia}

What are advantages of Topical anesthesia?

Extremely Easy

Low skill

Low risk

Great for mucous membranes

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_{Regional Anesthesia}

What are disadvantages of Topical anesthesia?

Short duration 1-4 hours

Slow onset over skin (Needs soak time!!!)

Doesn’t work well or at all on inflamed or infected tissues

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_{Regional Anesthesia}

Type of regional anesthesia where a LA is injected directly into a tissue:

Local infiltration

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_{Regional Anesthesia - Local Infiltration}

What the uses for Local Infiltration?

Traumatic Wound closure

^{Laceration closure in ER}

Surgical Wound closure

^{Injected as wound is closed}

Pre-emptive analgesia

^{Trocar sites - Joint injection}

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_{Regional Anesthesia - Local Infiltration}

Advantages

Fast and Easy

Low skill

Lower risk

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_{Regional Anesthesia - Local Infiltration}

Disadvantages

Short duration 1-6 hours

Doesn’t work well or at all on inflamed or infected tissues

Requires provider to place injections systematically to ensure good coverage

^{Patchy coverage can be commonplace}

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_{Regional Anesthesia}

Infiltration of LA around an area you wish to anesthetize:

Field blocks

_{Regional Anesthesia - Field blocks}

Uses:

Carotid endarterectomy

^{Superficial cervical plexus}

I&D of wounds

Intercostobrachial and medial brachial cutaneous nerves

Dentistry

Plastic surgery

_{Regional Anesthesia - Field blocks}

Advantages:

Fast and Easy to perform

Low risk procedure

Multiple LA options

Can be used to supplement patchy peripheral or neuraxial blocks

_{Regional Anesthesia - Field blocks} Disadvantages:

Inconsistent coverage Only covers superficial structures Relatively short duration of action

_{Regional Anesthesia} Injection of LA into the venous system of an exsanguinated extremity to produce surgical anesthesia for short procedure:

**IV Regional Anesthesia** or **Bier Block**

_{IV Regional Anesthesia or Bier Block} Uses:

Best suited for **short soft tissue upper extremity** procedures Can be used for **lower extremity**

_{IV Regional Anesthesia or Bier Block} Advantages:

Relatively easy to perform Provides surgical anesthesia quickly

_{IV Regional Anesthesia or Bier Block} Disadvantages:

**Tourniquet pain** limits useful duration Tourniquet must be inflated for at least **20 minutes** Must be able to obtain **IV access on operative limb** Pt habitus must be suitable for proper **tourniquet fit**

_{IV Regional Anesthesia or Bier Block} Pt habitus must be suitable for proper tourniquet fit. Failed tourniquets risk:

**Acute LA Toxicity** Large volume LA immediately entering central circulation

_{Bier Block - Procedure} IV Heplock established; where?

Hand preferably

_{Bier Block - Procedure} Double Pneumatic tourniquet to upper arm. What should you do with the arm prior to protect it?

**Pad with cotton**

_{Bier Block - Procedure} How do Exsanguinate Arm/leg prior to Bier block?

**Raise arm/leg** up Apply **Esmarch bandage** in a spiral from hand/leg to proximal cuff of tourniquet

_{Bier Block - Procedure} Tourniquet pressure to:

50-100mmHg above SBP

_{Bier Block - Procedure} Tourniquet cuff Sequence:

1 – Inflate Distal cuff 2 – Inflate Proximal cuff 3 – Deflate Distal cuff

_{Bier Block - Procedure} Injection of LA:

**30-50ml** 0.5% **Lidocaine** 3mg/kg MAX Use NO OTHER LA!!

_{Bier Block - Procedure} When should you remove **Heplock**?

After you have injected LA

_{Bier Block - Procedure} After injection of LA, how long till onset?

\< 5 minutes

_{Bier Block - Procedure} What should you do when tourniquet pain starts?

**Inflate distal** cuff, then ## Footnote **Deflate proximal**

_{Bier Block - Procedure} From injection, never deflate cuff less than

20 minutes

_{Bier Block - Procedure} When would you use Two stage tourniquet deflation?

For short procedures (\<30-45minutes)

_{Bier Block - Procedure} What happens during Two stage tourniquet deflation?

Deflate for 10 seconds Inflate for 1 minute

_{Bier Block - Procedure} What's the result of Two stage tourniquet deflation?

more **gradual LA washout**

_{Regional anesthesia} When is Peripheral Nerve Block indicated?

Surgical anesthesia Post-op pain control Vascular dilation Chronic pain

_{Regional Anesthesia - Peripheral Nerve Block} What are some applications Peripheral Nerve Blockade?

Podiatry ^{Hammer toe, bunion, etc} Hand and wrist ^{Trigger finger, carpal tunnel} Hernia ^{Inguinal hernia repair} Chronic pain ^Trigeminal Airway blocks Eye blocks etc.

_{Regional Anesthesia - Peripheral Nerve Block} Advantages:

Specific control of what is being blocked ^{And possibly more import what is not blocked} ^{Requires working knowledge of fine anatomic detail} Can avoid systemic side effects of neuraxial techniques Continuous Perineural catheters can be used

_{Regional Anesthesia - Peripheral Nerve Block} Disadvantages:

Anatomical variability and technical difficulty can lead to failure ^{Especially in landmark techniques} Inadvertent blockade of nerves due to proximity ^{Phrenic nerve block}

_{Regional Anesthesia - Peripheral Nerve Block} Which nerve should you be concerned about inadvertently blocking with a Peripheral Nerve Blockade approach?

**Phrenic nerve** "C3, C4, C5 Keep the diaphragm alive"

_{Regional Anesthesia} Neuraxial approaches include:

Epidural, Spinal, Caudal

_{Regional Anesthesia - Neuraxial} Indicated for pain control when?

**Surgical** and **Post-op** pain control

_{Regional Anesthesia - Neuraxial} Uses:

OB Hip and lower extremity Multiple Thoracic, Abdominal, and pelvic surgeries ^{Esophagectomy} ^Lobectomy ^Prostate ^etc

_{Regional Anesthesia - Neuraxial} Advantages:

Provide coverage to large sections of the body Catheter placement allows for analgesic control

_{Regional Anesthesia - Neuraxial} Disadvantages:

Can be technically difficult Sympathectomy Contraindicated for many comorbidities and pt specific factors

_{Regional Anesthesia - Neuraxial} Contraindicated for many comorbidities and pt specific factors, including:

Coagulopathy/anticoagulation Uncooperative pt Stenotic heart valve lesions etc.