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NUNA 693 Obs/Regional > upper and lower blocks > Flashcards

upper and lower blocks Flashcards

1
Q

common PNB goals

A

post op pain control
reduction/elimination of necessity for parenteral opioids and pain adjuncts
avoidance of GA
avoidance of airway elimination
reduction of GA side effects (cardiac effects, lung irritation, and PONV)

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2
Q

the use of ___________ is increasingly seen as standard and demonstrated to increase safety, improve efficacy, and reduce untoward events

A

ultrasound

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3
Q

contraindications for regional anesthesia

A

patient refusal
coagulopathy
infection at site of block
tolerance to procedure itself

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4
Q

___________ may prevent use depending on specific block and severity of the abnormal lab value

A

coagulopathy

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5
Q

coagulopathy would prevent a _____ block but not a _____ block

A

central
digital

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6
Q

identification of coagulopathy risk remains a key component of the patient history rather than

A

reliance on lab testing alone

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7
Q

consideration of the potential for uncontrolled _________ is a primary concern

A

hemorrhage

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8
Q

infection at the site of the block might decrease ________ of the block due to the __________ of the tissue being below ______ values which increases the __________ portion of the drug and does not allow nerve entry

A

efficacy
pH
pKa
ionized

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9
Q

______ to the procedure itself and a non-general anesthetic must be considered when deciding a plan

A

tolerance

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10
Q

can the patient with an altered mentation tolerate lying on the OR table for the procedure ________ or _______ if a regional anesthetic is used instead of GA

A

sedated or unsedated

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11
Q

further risk associated must be explored, if a pneumothorax would be life threatening, a ____________ block should probably be avoided

A

supraclavicular

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12
Q

risk for ______ _______ should always be kept in mind when combining blocks and _____ administration, as surgeons may also be introducing ______

A

LA toxicity
LA
LA

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13
Q

questions to ask that are key to block selection

A
  • what surgical area needs coverage?
  • are there significant risks?
  • note specifically which blocks include the shoulder
  • note specifically which blocks cover anterior and posterior aspects of the leg
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14
Q

_______ _______ _________ and ________ _______ are the most common methods of approaching the nerve, with landmark techniques falling out of favor r/t higher complications and greater failure rates

A

peripheral nerve stimulation and ultrasound guided

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15
Q

with any technique, it is critical to know what _______ _______ should be anesthetized and ensure that the nerve blockade is adequate for that space

A

anatomical structures

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16
Q

the actual needle insertion should occur only after ruling out _______, ______ _______, and consideration of ________ ________

A

contraindications, informed consent, and consideration of supplementary sedation

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17
Q

a skin prep should be utilized prior to localization and needle placement; a __________ and ________ mixture is commonly used bc __________ is considered neurotoxic

A

chlorhexidine and alcohol
betadine

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18
Q

for actual needle placement, a small injection of ____-____ of ___ __________ using a ____ or ____ gauge needle may be used to numb the skin at the block needle insertion site

A

0.5-1 mL
1% lidocaine
27 or 30 gauge needle

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19
Q

for nerve stimulation, a _____ _____ system is used

A

two lead system

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20
Q

a ________ surface lead is connected to an EKG sticker while the ________ lead is connected to the electrical attachment of a nerve stimulating needle

A

positive
negative

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21
Q

block need design has a ________ shape as opposed to the long bevel of a ________ needle

A

conical
hypodermic

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22
Q

this design reduces the likelihood of impaling the nerve by _________ rather than _________ the fiber

A

displacing
piercing

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23
Q

additionally, the _________ action of beveled needles has potential to transect _______ and is uncommon for blocking needles

A

shearing
fibers

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24
Q

finally, block needles have an ________ property designed to transfer the electrical stimulus to the ______ ___ ___ _______ rather than along the _____ ______

A

insulating
tip of the needle
full length

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25
Q

this allows the clinician to recognize _____ location based on muscle twitch response

A

tip (only)

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26
Q

further quantification of proximity of the needle tip to nerve is accomplished by adjusting the _______ _______

A

milliamp stimulation

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27
Q

a qualitative appreciation of muscle movement is used to

A

gauge the distance from the nerve

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28
Q

similar muscle contraction response with ________ _______ indicates the needle tip is approaching the nerve

A

decreasing milliamps

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29
Q

target range for proximity is satisfactory muscle response at _____-_____

A

0.3-0.5 mA

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30
Q

a greater amount of mA required suggests the needle tip is

A

too far from the target nerve

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31
Q

a persistent muscle response at less than ______ increases the likelihood of ______

A

0.3
intraneural injection

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32
Q

in order to determine the needle is in the correct location, it is helpful to know what nerve controls what muscle response less “any” muscle movement could be interpreted as

A

correct needle placement

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33
Q

use of ultrasound improves _______, ______, and _______ with block function

A

safety
efficacy
satisfaction

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34
Q

the ability to identify nerves allows more _______ ______ under visualization thereby achieving a more _______ and _______ block while necessarily avoiding adjacent structures and reducing ________ _______ risk

A

precise placement
complete and dense
intravascular injection

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35
Q

a ______ ______ of the structure to be scanned should ________ the placement of the probe

A

cognitive visualization
precede

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36
Q

a _______ _______ ______ or sterile ______ ______ must be used to interface the probe with the tissue

A

water soluble lubricant or sterile ultrasound gel

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37
Q

use of a _______ _______ _______ is recommended to avoid contamination of the needle or injection space with a non-sterile probe

A

sterile probe cover

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38
Q

anatomy of the nerve can be identified in the _____ _____ and centered on the screen

A

short axis

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39
Q

then the needle can be inserted toward the nerve from the side of the probe maintaining a short axis of the nerve but a _____ _____ of the needle

A

long axis

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40
Q

the advantage of long axis on the needle is a full view of the needle is maintained throughout the procedure reducing the chance that the needle tip is _______ “_____ ___ ______”

A

lost “out of plane”

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41
Q

once needle is adjacent to the nerve, _________ followed by the injection of the _____ is visualized on the screen

A

aspiration
LA

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42
Q

when viewing a 3D structure with a 2D image, the clinician has to choose between or alternate between a _________ ________ or _____________ view

A

cross section or longitudinal

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43
Q

short axis is called the

A

SAX

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44
Q

long axis is called the

A

LAX

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45
Q

the SAX and LAX are created by “_______” or _________ the probe over the anatomy

A

spinning
rotating

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46
Q

ultrasound emits a beam that lies only _______ ______ the probe

A

directly under

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47
Q

one technique to assist with this to identify structures in _____ first and then rotate to _____

A

SAX
LAX

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48
Q

________ is essential to achieving proficiency

A

practice

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49
Q

many of the upper extremity blocks involve accessing the

A

brachial plexus

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50
Q

plexus larger to smaller elements of the plexus are noted as:

A

ventral rami (roots) > trunks > divisions > cords > branches

real texans drink cold beer

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51
Q

a key value in knowing the divisions is the ability to determine

A

which nerves will be affected based on the site of injection

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52
Q

4 classic approaches to deliver LA to brachial plexus

A

interscalene blocks - trunks
supraclavicular blocks - divisions
infraclavicular blocks - cords
axillary blocks - branches

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53
Q

ideal placement is inside the _____ ______ that surrounds the nerves, however, given sufficient ______ and ______

A

fascia sheaths
time and dosing

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54
Q

LA that is absorbed prior to ______ ______ will generate an effect

A

vascular uptake

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55
Q

interscalene provides easy access with fewer risks as as coverage of the _________. it also does not generally cover the _____ _____/ _______ to the hand

A

shoulder
ulnar nerve/sensory to the hand

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56
Q

the supra and infraclavicular do not cover the shoulder and are much closer proximity to the _____ ____ of the ______

A

pleural space of the lung

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57
Q

infraclavicular and axillary provide increased coverage of the ________ and _______ ______ compared to the interscalene

A

forearm and musculocutaneous nerves

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58
Q

in the case of specific nerve distributions, or plexus blocks that need additional focused coverage, blocking specific nerves for this extra coverage may be accomplished through ______ ______ with or without ______

A

direct localization
ultrasound

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59
Q

volume of injection is commonly

A

about 20 ml

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60
Q

one element to be aware of is ______, but with _________ approach there is no risk for this

A

pneumothorax
axillary

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61
Q

______ _______ of the diaphragm is another complication of brachial plexus block. this is related to close proximity of the _____ ______

A

ipsilateral hemiparesis
phrenic nerve

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62
Q

this should be of particular concern in any patient where surgical or existing physiologic compromise might cause _______ ______ _______

A

inadequate spontaneous ventilation

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63
Q

______ ______ is a known side effect from sympathetic blockade

A

horner’s syndrome

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64
Q

uptake of LA into the head and neck may result in sympathetic blockade to nerves affecting ______ _______

A

facial structures

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65
Q

________, ________, and ________ are the features of horner’s syndrome

A

ptosis, miosis, and anhidrosis

drooping of one eye, pupil constriction, absence of sweat on the affected side are self limiting for the duration of the block

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66
Q

inadvertent _____________ __________

A

non-compressible hemorrhage

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67
Q

because in these blocks, the vasculature intermittently weaves around bone structure, the potential for a needle stick to cause bleeding that cannot be _______ _______ and should warrant consideration of ______ vs ______ (particularly with anticoagulation)

A

directly compressed
risk vs benefit

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68
Q

interscalene approach: locate by identifying the sternal head of the __________ muscle, moving laterally to clavicular head, then further lateral to the space between the _______ and _______ ________ muscle

A

SCM
anterior and middle scalene

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69
Q

all this take place vertically at the level of the cricoid cartilage which corresponds with

A

C6

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70
Q

a posterior and inferior directed needle approaches should address the plexus in perpendicular fashion, envisioning the nerves leaving the ______ and following down the _____

A

neck
arm

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71
Q

axillary approach - landmark technique has fallen out of favor as it is less _______ and involves intentional __________ of the ________ _______ to determine the location of the needle

A

precise
puncture of the axillary artery

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72
Q

nerve stimulation may be _______ by some measures, but still involves a decreased measure of ________

A

safer
precision

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73
Q

for ultrasound approach, it is important to have a concept of the layout of the _______ within the ______

A

anatomy
axilla

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74
Q

median nerve is ___________, closest to ultrasound probe and skin where the needle goes. it is located adjacent to the ____________ muscle as a landmark. it is anterior

A

superficial
coracobrachialis

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75
Q

________ is opposite the median on the deep side of the axillary artery

A

radial

76
Q

musculocutaneous nerve is on the ______ side, is hyperechoic

A

biceps

77
Q

ulnar is opposite side of the ______ ______ and opposite of the ________ _______ on the triceps side. it is posterior

A

axillary artery
median nerve

78
Q

recall the MC nerve generally requires _______ _______ by a _______ _______ for interscalene and axillary

A

selective blockade by a field block

79
Q

the ______, _______, and _______ nerve can be selectively blocked at the elbow with any of the previously mentioned approaches

A

ulnar, radial, and median nerve

80
Q

caution with ________ only approaches due to risk of direct ________ ________

A

anatomic only
nerve trauma

81
Q

risk of vasculature compromise generally weighs against the use of _________ below the elbow

A

epinephrine

82
Q

a general volume maximum should be ______ noting the risk of ________ _________ / _________ particularly with ulnar blockade

A

5 mL
compartment development/entrapment

83
Q

Bier block technique does not require any special equipment other than reliable ________ _________ as the _______ ______ is injected through an ____ site

A

surgical technique
local anesthetic
IV

84
Q

some limitations of a bier block include:

A

tourniquet must be left inflated for at least 20 mins
duration of procedure shouldnt last longer than an hour (2 hours may be possible with special technique)
IV must be started in operative arm as distal as possible
arm must be able to tolerate an arterial tourniquet

85
Q

methods to increase the duration/density of the block includes:

A

additives and field blockade of the upper arm to diminish tourniquet pain

86
Q

additives may essentially include any agent that would otherwise be acceptable for IV administration including:

A

clonidine
toradol
ketamine
decadron
fentanyl

87
Q

bier block chronology

A

small gauge IV in operative arm
placement without inflation of tourniquet on upper arm after padding is in place
notation of radial pulse
elevation of the arm
esmarch bandage exsanguination
inflation of tourniquet
confirmation of the absence of the pulse
**injection of 50 ml of preservative free 0.5% lidocaine
removal of the IV

88
Q

tourniquet must be on the _______ and lidocaine must be free of _______

A

humerus
epinephrine

89
Q

use of forearm tourniquets may be used occasionally however the incidence of failure is higher due to greater difficulty in _______ ________ against two bones

A

arterial occlusion

90
Q

the use of a double tourniquet allows a ____ _____ to occur naturally from under a portion of the tourniquet which allows for temporary _____ _____

A

field block
pain relief

91
Q

at the beginning of the case, the _______ tourniquet is inflated and when the tourniquet pain is noticed, the _______ tourniquet is inflated

A

proximal
distal

92
Q

then after confirmation of the ______ inflation, the ______ ________ is deflated as the painful cause

A

distal
proximal tourniquet

93
Q

to further decrease tourniquet pain, cast padding or equivalent can be used _______ the _______ to avoid ______ _____ injury

A

under the tourniquet
soft tissue

94
Q

interscalene analgesia to

A

shoulder and upper arm

95
Q

supraclavicular analgesia to

A

entire upper extremity distal to the shoulder

96
Q

infraclavicular analgesia to

A

elbow and below

97
Q

axillary analgesia to

A

distal to elbow

98
Q

intercostal analgesia to

A

chest and upper abdominal wall

99
Q

TAP analgesia to

A

anterior abdominal wall

100
Q

femoral analgesia to

A

anterior thigh and knee, medial aspect of the lower leg

101
Q

fascia iliaca analgesia to

A

hip, femoral shaft and knee

102
Q

sciatic analgesia to

A

below the knee sparing the area of the medial side of the lower leg (saphenous distribution)

103
Q

popliteal analgesia to

A

below the knee sparing the area of the medial side of the lower leg

104
Q

ankle analgesia to

A

the foot and distal ankle

105
Q

the value of an intercostal block is _____ duration (several hours) block that is not _____ to perform and can reduce surgical ______ or allow improved efficacy of painful _______

A

medium
complex
pain
respirations

106
Q

the block is performed in the ___-_____ line and allows for blockage of the intercostal level of injection

A

mid-axillary

107
Q

because intercostal uptake is one of the ______ sites for LA, caution should be taken to avoid _____ _____

A

highest
toxic doses

108
Q

_______ may be added to reduce vascular uptake even if it does not increase _______ of _______

A

epinephrine
duration of action

109
Q

_____, ______, ______ in descending order, follow the inferior border of the rib and injection should be by ___-___ml under the _______ border of the rib

A

vein, artery, nerve
2-3ml
inferior

110
Q

_______ is a prominent risk

A

pneumothorax

111
Q

use of a _____ needle rather than __________ needle can reduce this risk along with slow and methodical movements

A

block needle
bevel hypodermic

112
Q

the inferior edge of the rib should be passed only by ___–___ before injection

A

2-3mm

113
Q

TAP block provides analgesia to the _______ ______ (if done bilaterally) suitable for most open and laparoscopic procedures as a support for a mixed anesthetic technique or for post-operative pain

A

abdominal compartment

114
Q

it can be done ____ to surgical case or _____

A

prior
after

115
Q

the _____ _____ _____ that surround the abdominal cavity are identifiable on ultrasound

A

3 muscle layers

116
Q

spread of LA between the ____ _____ and _____ ______ muscle layers creates a unilateral blockade of nerves _____-_____ (5 levels)

A

internal oblique
transversus abdominis
T9-L1

117
Q

a ____ ml bolus (each side) can be injected incrementally under direct _________ guidance

A

20 ml
ultrasound

118
Q

________ are sometimes used as with other PNBs

A

additives

119
Q

caution is used to avoid entry into the _______ ______

A

abdominal compartment

120
Q

limitations in value are the inadequate spread through the ______ _____ in which muscle or subcutaneous uptake affect the ________ of _________ and ______.

A

fascial plane
duration of action
levels

121
Q

for each of the blocks described, consideration of ________ is appropriate

A

sedation

122
Q

further, it is essential to provide ____ ____ prior to ______ ______

A

skin prep
needle insertion

123
Q

this is commonly done with a _________ and ________ mixture (______)

A

chlorhexidine and alcohol mixture (chloroprep)

124
Q

________ should be used with caution as it is neurotoxic

A

betadine

125
Q

the use of _______ injection (____ _____) for the block needle placement is appropriate

A

topical injection (skin wheel)

126
Q

0.5-1ml of ___ ______ is common

A

1% lidocaine

127
Q

avoidance of _________ of the ultrasound probe can be accomplished through several techniques that should be performed

A

contamination

128
Q

separation of the plane between the internal oblique and TA muscle is indicative of

A

an appropriately placed block

129
Q

moving the probe _____/_____ and ______/______ along the abdominal cavity space is often needed to identify layers clearly

A

anterior/posterior
superior/inferior

130
Q

cervical blockade is used occasionally for procedures such as ______ _______

A

awake endarterectomy

131
Q

cervical blockade is considered an _______ ______ with an increased risk of ________

A

advanced technique
complications

132
Q

the likelihood of complications includes such events as _______ _____ injection, _____-______ injection, _______ ______ paralysis (temporary), __________ injection, ______ and ______ blockade

A

vertebral artery injection
sub-arachnoid injection
phrenic nerve paralysis
intravascular injection
vagal and RLN blockade

133
Q

these should ONLY be performed:

A

unilaterally

134
Q

they address the cervical roots of ____, ____, _____

A

C2, C3, C4

135
Q

mid __________ muscle on the ________/_______ aspect is the point for injection in a field block technique using 10-20 mls

A

SCM
posterior/lateral

136
Q

development of thoracic wall analgesia (chest wall blocks) can be accomplished by an ever expanding host of individual _____ blocks, _____ blocks, and nerve ______.

A

nerve
plane
bundles

137
Q

_______ _______ provide a means of ongoing relief (due to catheter) at levels that can be adjusted with volume

A

thoracic epidurals

138
Q

risk for _______, _______, and _______ and ______ due to thoracic level _________ are all risks

A

infection, bleeding, and hypotension, and bradycardia
cardioreceptors

139
Q

thoracic epidurals commonly performed using _________ approach

A

paramedian

140
Q

first, identifying the level of the block to be performed , commonly the surgical level for a _________ would be the level of insertion

A

thoracotomy

141
Q

the transverse process is identified and a loss of resistance technique is used to identify the _______ ______ before placing the catheter

A

epidural space

142
Q

________ nerve blocks can be performed as a ______ block to cover the anterior wall and can be used for _____________ work

A

pectoralis
plane
thoracotomy

143
Q

an ultrasound is used at the origin of the pec near the anterior ______ ______ to identify muscles in short axis and LA is injected between the _____ ______ and _____

A

axillary line
pec major and minor

144
Q

paravertebral blocks are similar to the thoracic epidural except they are _____ ______ techniques

A

single injection

145
Q

the transverse process is identified at the target level (generally, ______ ______ are injected)

A

several levels

146
Q

the spinal or epidural needle is inserted to the transverse process and “______ ______” the process to an additional ______ of depth

A

walked off
1 cm

147
Q

further advancement significantly increases the likelihood of ______ ______ access and more importantly the ________ access

A

epidural space
intrapleural

148
Q

_____ per level is generally acceptable

A

5 ml

149
Q

as with intercostal blocks, uptake is fairly rapid and ___ _____ durations of effective analgesia is to be expected

A

4 hours

150
Q

________ ________ _______ block is a relatively new block that accomplishes similar effects as a paravertebral block and PEC block but with markedly simpler approaches and with _____ risk and ______ success rate

A

erector spinae plane block
less risk
higher success

151
Q

the idea of the plane block is that it spreads the LA across a space, between ____ ______ much like potential space between quilts on a bed

A

2 structures

152
Q

volume ______ the spread and absorption into the spinal nerves along the path which result in clinical effect

A

increases

153
Q

selection of lower extremity blocks is consistent with upper extremity blocks in that the nerves to anesthetized must be _______ with the ______ _____

A

matched with the surgical field

154
Q

lateral femoral cutaneous nerve

A

L2/3 - lateral thigh

155
Q

obturator nerve levels ______, ______ to adductor muscles of thigh and ______ to _______ thigh

A

L2/3/4
motor
sensory to medial thigh

156
Q

femoral nerve levels _______, separates to ______/_______ limbs at the _______ ligament

A

L2/3/4
separates to anterior/posterior limbs at inguinal ligament

157
Q

fem nerve block is a simple block providing pain relief to the _______, primarily ______ portion.

A

knee
anterior

158
Q

the nerve is approached _______ for the femoral artery and ______ the inguinal ligament using ultrasound or nerve stimulator

A

laterally
below

159
Q

no less than ______ of LA (___-___ ideally) is used for the block to secure adequate spread around the nerve

A

20 ml
20-30 ml

160
Q

fascia iliaca compartment block provides ________ nerve coverage but adds reliable coverage of the _______ _______ _________ nerve

A

femoral
lateral femoral cutaneous

161
Q

the addition of this blockade aids in _____ management of ______ sx

A

pain
hip

162
Q

ultrasound guidance to the _____ ______ is followed with guidance above the _______ ______ and then injection of LA

A

fascia lata
fascia iliaca

163
Q

the femoral nerve anatomy is adjacent to this facial plane and femoral nerve blockade occurs by default with this block; it simply has the additional lateral coverage by traveling along the _____, to the _____ _____ _____ nerve

A

plane
lateral femoral cutaneous nerve

164
Q

sciatic block covers _____ ______ of the leg not covered by the fem nerve

A

opposing portions

165
Q

______ ______ and lower _____/_____ coverage is supplied by the sciatic which later becomes the tibial and common peroneal nerve

A

posterior thigh
leg/foot

166
Q

complete anesthesia of the leg requires addition of this block opposed to ______ only

A

femoral

167
Q

for mid-level coverage, the sciatic is approached in the _____, while ankle coverage may be approached at the _______ ______ (______ block)

A

hip
posterior knee (popliteal block)

168
Q

nerve stimulation should address both the _____ and ______ distributions and LA admin at each site

A

tibial and peroneal

169
Q

tibial responses should be ________

A

plantar flexion

170
Q

peroneal distribution should cause ________

A

dorsiflexion

171
Q

adductor canal block (______ nerve) is a distal approach to the ______ nerve

A

saphenous
femoral

172
Q

it decreases the effect of the ______ _______ and ______ thus allowing more focused blockade of the knee

A

proximal branches and hip

173
Q

For total knee blockade, this approach increases the likelihood of ability to ______ _______ as it does not affect the ___.

A

ambulate early
hip

174
Q

The approach is mid-thigh and utilizes the _____ _____ as a landmark.

A

femoral artery

175
Q

popliteal block can be performed to cover the _____ _____ and _____ for total anesthesia coverage

A

lower leg
ankle

176
Q

the sciatic divides into the _______ and _______ nerves approx. ______ above the bend in the knee

A

tibial and peroneal
10 cm above bend in knee

177
Q

flor blockade, the patient in the ______ position can be blocked with nerve stimulation or ________ guidance

A

prone
ultrasound

178
Q

the nerves are lateral to the ______ and ______ and join superiorly above the knee

A

vein and artery

179
Q

a _____ injection around the nerve covers this block

A

20 ml

180
Q

if select blockade of the ankle is desired and cant/shouldnt be achieved by popliteal block, the _____ nerves of the ankle can selectively be blocked for coverage

A

5

181
Q

the five nerves are:

A

deep peroneal
saphenous
posterior tibial
sural
superficial peroneal

182
Q

deep peroneal

A

just above ankle, nerve slightly lateral to the anterior tibial artery

183
Q

saphenous

A

medial side anterior to malleolus

184
Q

post tibial

A

located just posterior to the posterior tibial artery

185
Q

sural

A

on lateral side, post to malleolus, this nerve is blocked in mirror to post tibial

186
Q

superficial peroneal

A

on lateral side anterior to malleolus

NUNA 693 Obs/Regional (13 decks)

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