Mod IV: Regional Anesthesia - Part 2 Flashcards by Olivier Mba

_{Regional Anesthesia}

Choosing the right anesthetic: what’s the right way to do a case?

THERE IS NO ONE RIGHT WAY TO DO A CASE!!

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_{Regional Anesthesia}

Considerations when formulating an anesthetic plan

Surgical procedure

Patient

Anesthetist

Surgeon

Facility

Pre-op and PACU staff

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_{Regional Anesthesia}

Surgical procedure considerations when formulating an anesthetic plan:

Laparoscopic/open

Size of incision

Positioning

Length of procedure

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_{Regional Anesthesia}

Patient considerations when formulating an anesthetic plan: who makes the final determination?

The patient is the one who makes the final determination!!

They must consent to your plan

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_{Regional Anesthesia}

Patient considerations when formulating an anesthetic plan include:

Comorbidities

Demeanor

Habitus

Ability for self care

Cooperative

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_{Regional Anesthesia}

Patient considerations when formulating an anesthetic plan - Contraindications to RA include:

Contralateral paralyzed diaphragm

Severe aortic stenosis

Preexisting peripheral neuropathy

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_{Regional Anesthesia}

Anesthetist considerations when formulating an anesthetic plan:

Skill in performing GA, sedation, and blocks

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_{Regional Anesthesia}

Surgeon considerations when formulating an anesthetic plan:

Surgical skill

Comfort with the anesthetist

Comfort with the block

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_{Regional Anesthesia}

Facility considerations when formulating an anesthetic plan:

Rural 2 OR hospital

1000 bed tertiary like MUSC

Outpatient surgery center

US available

Drugs available

Do they have required monitors?

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_{Regional Anesthesia}

Pre-op and PACU staff considerations when formulating an anesthetic plan: what question to you want answered?

Do they have the ability to care for a pt with your anesthetic plan

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_{Regional Anesthesia}

Blocks you all Should Know:

Interscalene

Axillary

Femoral

Popliteal

_{<em>Can cover 90% of all peripheral blocks you will need to cover</em>}

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_{Regional Anesthesia}

There are so many choices of blocks, including:

Brachial Plexus (ISB, SCB, ICB, AX)

Radial, Ulnar, Median - Axillary Nerve

Intercostobrachial

Cervical plexus (Deep and Superficial)

Scalp Blocks (Occipital, Auricular)

Eye Blocks (RBB, PBB) - Airway Blocks

Facial Blocks (Trigeminal, Lingual)

TAP - Rectus Sheath - Illiohypogastric, illioinginal

Lateral femoral cutaneous - Paravertebral

Intercostal - PEC - Suprascapular

Median Branch blocks - Lumbar Plexus

Femoral (Adductor Canal) - Fascia iliaca - Obturator

Saphenous nerve

Sciatic (Trans/sub Gluteal, mid shaft - Popliteal)

Ankle Blocks - Digit blocks - Penile

Pudendal

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_{Regional Anesthesia}

Case Study:

68 yo Male 6’0” 250lbs

Crushed hand hooking up a trailer to farm tractor

Pt a/o x 3, pain 8/10

Hx: MI 2002 s/p 2 stents

Moderate Aortic stenosis

Pt has not seen cardiology in about 1 year

Last visit: Cardiac stable

DM2, HTN, ↑Lipids

Former smoker quit 2002

NPO status: 0700Full breakfast, Injury 1000

1600 Add on case

Hospital treatment - ER:

Morphine 10 mg

Zofran 4mg x 2

Fentanyl 100 mcg

Hospital treatment - Inpatient Floor:

Dilaudid 2 mg 1430

Phenergen 25mg

What would you do?

What I did:

Pre-op:

^{<strong>US guided Axillary block</strong>}

^{30 ml 0.5% Marcaine w/ EPI}

^{60 minute soak time}

OR:

^{IV versed 4 mg total}

^{1500 ml LR}

PACU:

^{Awake and comfortable}

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_{Regional Anesthesia}

Regional Anesthesia can be used alone or combined with other anesthetic techniques. What are possible Anesthetic combinations?

Sole anesthetic

Regional Anesthesia (RA) with a TIVA or MAC

GA with RA for post-op pain control

Combined RA techniques

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_{Regional Anesthesia - Anesthetic Options}

Examples of cases where Regional Anesthesia could be used as sole anesthetic:

SAB for C-section

Wrist block for carpal tunnel

Infraclavicular block for AV fistula

Intra-articular block for knee arthroscopy

Topical lidocaine for cataracts

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_{Regional Anesthesia - Anesthetic Options}

RA with a TIVA or MAC:

Rotator cuff repair

^{Interscalene block (ISB) with versed during case}

Carotid Endarterectomy

^{Superficial cervical plexus with surgeon supplement infiltration of LA}

Bier Block for carpal tunnel with propofol infusion

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_{Regional Anesthesia - Anesthetic Options}

GA with RA for post-op pain control:

Robotic hysterectomy with TAPs blocks

Rotator cuff repair with interscalene block (ISB) and continuous catheter

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_{Regional Anesthesia - Anesthetic Options}

Example of combined use of Spinal anesthesia and Adductor canal continuous catheter techniques:

Used in Uni-compartmental knee replacement

Spinal primary anesthetic, and

Adductor canal continuous catheter to go home with

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_{Regional Anesthesia - Local Anesthetic Choices}

Characteristics to consider when choosing a LA:

Onset

DOA

Depth of blockade desired

_{Regional Anesthesia - Local Anesthetic Choices}

Why use “Additives” with LA?

As markers

Prolong duration

Speed onset

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs:

Lidocaine

^{Fast onset, short duration - Dense block}

Mepivicaine

^{Fast onset, short duration - Dense block}

Bupivicaine

^{Slower onset, long duration - Dense block}

Exparel = Liposomal Bupivicaine

^{Very slow onset - Very long acting}

Ropivicaine

^{Slower onset, long duration - Less profound block}

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with Fast onset:

Lidocaine

Mepivicaine

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with Slow onset:

Bupivicaine

Ropivicaine

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with Very slow onset:

Exparel = Liposomal Bupivicaine

_{Regional Anesthesia - Local Anesthetic Choices} Commonly seen LAs with short duration:

Lidocaine Mepivicaine

_{Regional Anesthesia - Local Anesthetic Choices} Commonly seen LAs with long duration:

Bupivicaine Ropivicaine

_{Regional Anesthesia - Local Anesthetic Choices} Commonly seen LAs with very long duration:

Exparel = Liposomal Bupivicaine

_{Regional Anesthesia - Local Anesthetic Choices} Commonly seen LAs with Dense block:

Lidocaine Mepivicaine Bupivicaine

_{Regional Anesthesia - Local Anesthetic Choices} Commonly seen LAs with less profound block:

Ropivicaine

_{Regional Anesthesia - Local Anesthetic Choices} Common "Additives" to LA:

Epinephrine Phenylephrine Dexamethasone Clonidine Bicarb

_{Regional Anesthesia - Local Anesthetic Choices} "Additive" to LA to acts as intravascular marker:

Epinephrine

_{Regional Anesthesia - Local Anesthetic Choices} "Additive" that prolong duration of LA by decreasing uptake:

Epinephrine Phenylephrine

_{Regional Anesthesia - Local Anesthetic Choices} "Additives" that generally prolong duration of LA:

Epinephrine Phenylephrine Dexamethasone (Decadron) Clonidine

_{Regional Anesthesia - Local Anesthetic Choices} "Additive" that Speed onset of LA:

Bicarb

_{Regional Anesthesia} Complications and Risks of Peripheral nerve blocks:

Infection Hematoma Incidental blockade Pneumothorax Nerve injury Intravascular injection LA Toxicity Total spinal anesthesia

_{Regional Anesthesia - Infection risk} How is the risk of infection with Regional anesthesia?

**Very low risk \<1%** cPNB ↑ risk over single shot ↑ risk at Femoral and axillary sites

_{Regional Anesthesia - Infection risk} Localized infection has been noted to occur more frequently than full sepsis.

TRUE

_{Regional Anesthesia - Infection risk} How to lower infection risks?

Avoid puncture of **infected tissue** Ensure good **aseptic technique** Judicious **Pt selection** Reduce **trauma** r/t block placement

_{Regional Anesthesia - Infection risk} Lowering infection risk by ensuring good aseptic technique; how?

Good skin prep ^{Betadine – vs – Chlorhexadine} Sterile technique Catheter dressed well ^{Biopatch, chlorhexadine dressing}

_{Regional Anesthesia - Infection risk} What if Already septic or infected surgical site?

**No clear** data for what to do Some say **no increased risk for SS** I would not place **continuous catheter!!!**

_{Regional Anesthesia - Infection risk} Factors that may ↑ infection risk:

Recent **trauma** Recent **ICU** admission Compromised **immunity** ^{Including Diabetes mellitus} **Catheter** in place for **\>48hrs** **Absence of ABX use**

_{Regional Anesthesia} Risk of Hematoma increased with:

Prolonged **needling** Larger **needle size** **Trans-arterial** technique Pt with **coagulopathy** (Rx and patho)

_{Regional Anesthesia - Hematoma} Current Neuraxial Anticoagulation guidelines apply to RA. What's the Caveat?

It is commonly and well accepted to judiciously practice outside of guidelines Different blocks carry different risks

_{Regional Anesthesia} What you can do to decrease the risk of Hematoma:

Consciously **avoid vascular structures** _{Avoid both deep and superficial structures}

_{Regional Anesthesia - Hematoma} You my pierce a vein and not see it nor get bloody aspiration. How come?

**Veins collapse easily** with minimal pressure from needle or US

_{Regional Anesthesia - Hematoma} How long should you hold pressure after inadvertent vascular puncture?

**5 minutes** or **Longer** for arterial puncture

_{Regional Anesthesia - Hematoma} How can Hematoma cause nerve i**njury**?

↑pressure on nerve