Mod IV: Regional Anesthesia Part 3

Question 1

_{Regional Anesthesia}

Which blocks are a/w INCIDENTAL BLOCKADE?

Answer 1

IntraScalene

Supraclavicular

Superficial Cervical plexus

Paravertebral

Question 2

_{Regional Anesthesia - INCIDENTAL BLOCKADE​}

Which nerves can be accidentaly blocked as a result of IntraScalene/Supraclavicular/Superficial Cervical block

Answer 2

Phrenic nerve

Recurrent laryngeal n.

Sympathetic cervical ganglion

Question 3

_{Regional Anesthesia - INCIDENTAL BLOCKADE​}

Phrenic nerve block could cause:

Answer 3

Diaphragm paralysis

Which could cause ↓ ventilation

_{Very common!!!}

Question 4

_{Regional Anesthesia - INCIDENTAL BLOCKADE​}

Recurent laryngeal nerve block could cause:

Answer 4

Vocal cord paralysis

Question 5

_{Regional Anesthesia - INCIDENTAL BLOCKADE​}

Sympathetic cervical ganglion block could cause:

Answer 5

Horner’s Syndrome

_{Rare condition characterized by miosis (constriction of the pupil), ptosis (drooping of the upper eyelid), and anhidrosis (absence of sweating of the face). It is caused by <strong>damage to the sympathetic nerves of the face</strong>}

Question 6

_{Regional Anesthesia - Complications and Risks}

INTRAVASCULAR INJECTION could lead to:

Answer 6

LA TOXICITY

Question 7

_{Regional Anesthesia - Complications and Risks}

Most nerves run close to vascular structures. This is a blessing and a curse, why?

Answer 7

Facilitates identification of nerve structures, but

increase risk of INTRAVASCULAR INJECTION

=> LA TOXICITY

Question 8

_{Regional Anesthesia - Complications and Risks}

What is less worisome about intra-arterial injection of LA?

Answer 8

Most arteries flow to the periphery

Allows local some time to be absorbed by tissue

Question 9

_{Regional Anesthesia - Complications and Risks}

What’s the danger of Vertebral, Carotid injection of LA?

Answer 9

Direct flow to brain

Cause almost immediate seizure, neurological LA toxicity S/S

Even LA volumes of 1-3ml

Question 10

_{Regional Anesthesia - Complications and Risks}

Consequenque of intravenous injection of LA:

Answer 10

LA Systemic Toxicity (LAST)

Most veins flow directly to heart

Neurological S/S may be delayed or absent

CV instability may be first sign

Question 11

_{Regional Anesthesia - Complications and Risks}

What could be a reason why there would be No aspiration of blood during US/needling, even after IV puncture?

Answer 11

Compression of vessels may hide IV puncture

Question 12

_{Regional Anesthesia}

How to prevent Local Anesthetic Systemic Toxicity?

Answer 12

Monitors: ECG, BP, O2Sat

Communication with Pt

Frequent gentle aspiration every 3-5ml

Slow injection of LA

Avoid traumatic needling

Judicious dosing of LA

EPI marker in ↑ Vol blocks

_{<strong>Be prepared!!!</strong>}

Question 13

_{Prevention of Local Anesthetic Systemic Toxicity}

Which Monitors must be used and for how long after high dose blocks?

Answer 13

ECG, BP, O2Sat

Continuous monitoring for at least 30 min

Question 14

_{Prevention of Local Anesthetic Systemic Toxicity}

What are some symptoms of Local Anesthetic Systemic Toxicity that may be communicated/reported by the pt?

Answer 14

Metal taste

Ears ringing

Circumoral numbness

Anxiety

Question 15

_{Prevention of Local Anesthetic Systemic Toxicity}

Aspiration:

Answer 15

Frequent gentle aspiration every 3-5ml

Question 16

_{Prevention of Local Anesthetic Systemic Toxicity}

To prevent Local Anesthetic Systemic Toxicity, decrease dose for which pts?

Answer 16

Advanced age

Poor cardiac function

Preexisting conduction abnormalities

↓ Plasma proteins

Question 17

_{Prevention of Local Anesthetic Systemic Toxicity}

What could you use to prevent LAST if you must inject large volume of LA?

Answer 17

Use “EPI marker”

Question 18

_{Prevention of Local Anesthetic Systemic Toxicity}

When using EPI marker in ↑ Vol blocks, >10% ↑ HR may indicate:

Answer 18

IV injection

Question 19

_{Prevention of Local Anesthetic Systemic Toxicity}

While readying a plan to use in case of Local Anesthetic Systemic Toxicity, which checklist and flowchart are useful?

Answer 19

ASRA checklist

NYSORA flowchart

Question 20

_{Prevention of Local Anesthetic Systemic Toxicity}

Why should you have 20% Lipid Emulsion in the area where blocks are performed?

Answer 20

A lipid infusion improves success of resuscitation from cardiac arrest because of local anesthetic toxicity if given immediately after a local anesthetic overdose

Question 21

_{Regional Anesthesia - Detection of LAST}

Most important step:

Answer 21

Recognition/Diagnosis

Question 22

_{Regional Anesthesia - Detection of LAST}

Why is frequent communication with the pt important?

Answer 22

Make sure they know what symptoms to report

Question 23

_{Regional Anesthesia - Detection of LAST}

CNS symptoms:

Answer 23

May be subtle/absent

Metal taste, tinnitus, double vision, dizziness, circumoral numbness

Excitation: agitation, confusion, twitching, seizure

Depression: Drowsy, obtunded, coma, apnea

Question 24

_{Regional Anesthesia - Detection of LAST}

Benefit and drawback of Benzodiazepine sedation when suspecting LAST

Answer 24

May prevent seizure

Also may prevent Pt from reporting CNS symptoms

Question 25

_{Regional Anesthesia - Detection of LAST} Cardiovascular signs:

Answer 25

May be first/only **Excitation** followed by **depression** may be present **↑ BP, ↑HR,** _Ventricular ectopy_, multiform VT, VF Progressive **↓BP, bradycardia =\> asystole**

Question 26

_{Regional Anesthesia - Detection of LAST} Hallmarks of cardiac toxicity of LA

Answer 26

**_Ventricular ectopy_**, multiform VT, VF

Question 27

_{Regional Anesthesia - Detection of LAST} Hallmark of severe LA toxicity:

Answer 27

Progressive ↓BP, bradycardia =\> asystole

Question 28

_{Regional Anesthesia - Detection of LAST} How do S/s of LAST progress?

Answer 28

May be **slow** or **very fast** Some S/S may be **subtle** or **absent**

Question 29

_{Regional Anesthesia - Detection of LAST} ALWAYS BE VIGILENT IN MONITORING DURING AND AFTER RA!!

Answer 29

True

Question 30

_{Regional Anesthesia - Treatment of LAST} Why should you Get Help! Fast!

Answer 30

You **cannot** manage this **alone!** Call for **Lipid Emulsion** **ASRA** checklist, **NYSORA** flowchart Alert **Cardiopulmonary bypass** team Or **nearest facility** with one

Question 31

_{Regional Anesthesia - Treatment of LAST} Airway management interventions:

Answer 31

**100% via mask** Secure airway!!!! **ETT/vent**

Question 32

_{Regional Anesthesia - Treatment of LAST} How could you abolish seizure?

Answer 32

**Versed** **Propofol** ^{Avoid propofol if CV unstable}

Question 33

_{Regional Anesthesia - Treatment of LAST} How would you manage cardiac arrhythmias?

Answer 33

**CPR/ACLS** EPInephrine/vasopressin (controversial) **Amiodarone** (300/150) **Magnesium** 1-2 grams

Question 34

_{Regional Anesthesia - Treatment of LAST} In the management of cardiac arrhythmias, which drugs should be avoided?

Answer 34

**Calcium channel blockers** Beta blockers **Lidocaine** Phenytoin **Vasopressin** (controversial)

Question 35

_{Regional Anesthesia - Treatment of LAST} 20% Lipid Emulsion Therapy - When to start?

Answer 35

Based on clinical severity and rate of progression Use your professional judgment

Question 36

_{Regional Anesthesia - Treatment of LAST} 20% Lipid Emulsion Therapy - BOLUS dose:

Answer 36

**1.5 ml/kg** **(~100ml)** Based on lean body weight

Question 37

_{Regional Anesthesia - Treatment of LAST} 20% Lipid Emulsion Therapy - INFUSION rate:

Answer 37

**0.25** ml/kg/min | (~18ml/min)

Question 38

_{Regional Anesthesia - Treatment of LAST} 20% Lipid Emulsion Therapy - If persistent CV collapse:

Answer 38

**Repeat BOLUS** Q 5minutes

Question 39

_{Regional Anesthesia - Treatment of LAST} 20% Lipid Emulsion Therapy - If hypotension continues:

Answer 39

**DOUBLE INFUSION rate** 0.5 ml/kg/min

Question 40

_{Regional Anesthesia - Treatment of LAST} 20% Lipid Emulsion Therapy - after CV stable:

Answer 40

**CONTINUE INFUSION** For at least **10 minutes** after CV stable

Question 41

_{Regional Anesthesia - Treatment of LAST} 20% Lipid Emulsion Therapy - Upper limit over first 30 minutes:

Answer 41

**10 mg/kg**

Question 42

_{Diagnosis and Treatment of LA Toxicity} NYSORA LA toxicity flow chart

Answer 42

NYSORA LA toxicity flow chart

Question 43

_{Diagnosis and Treatment of LA Toxicity} Checklist for Treatment of Local Anesthetic Systemic Toxicity

Answer 43

Checklist for Treatment of Local Anesthetic Systemic Toxicity ^{(American Society of Regional Anesthesia and Pain Medicine)}