Upper Peripheral Nerve Blocks - Quiz 6 Flashcards by Donny Le

What considerations should be taken for Placing a Peripheral Nerve Block?

Tourniquet Placement

Bone Grafting

Duration of Surgery

Single Injection vs Continous Peripheral Nerve Block

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What are the Risks and Contraindications of Placing a Peripheral Block?

Patient Cooperation
Bleeding Disorders
Sites of Infection
Nerve Injury
Local Anesthetic Toxicity
Catheter Retention
Retroperitoneal Hematoma
Falls from Femoral Nerve Catheter

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What should you think about when choosing a Local Anesthetic for a Peripheral Block?

Desired Onset

Desired Duration

Desired Sensory/Motor Block

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Procaine

Max Dose w/wo Epi?

Duration of Action w/wo Epi?

Without Epi
Max: 5mg/kg
Duration: 20-30 min

With Epi
Max: 7mg/kg
Duration: 30 min

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Chloroprocaine

Max Dose w/wo Epi?

Duration of Action w/wo Epi?

Without Epi
Max: 11mg/kg
Duration: 15-30 min

With Epi
Max: 14mg/kg
Duration: 30 min

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Lidocaine

Max Dose w/wo Epi?

Duration of Action w/wo Epi?

Without Epi
Max: 4mg/kg
Duration: 30-120 min

With Epi
Max: 7mg/kg
Duration: 3 hrs

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Mepivacaine

Max Dose w/wo Epi?

Duration of Action w/wo Epi?

Without Epi
Max: 4mg/kg
Duration: 90-180 min

With Epi
Max: 7mg/kg
Duration: 20-30% Longer

Avoid in Pregnancy

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Prilocaine

Max Dose w/wo Epi?

Duration of Action w/wo Epi?

Without Epi
Max: 7mg/kg
Duration: 30-90 min

With Epi
Max: 8mg/kg
Duration: 2 hrs

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Bupivacaine

Max Dose w/wo Epi?

Duration of Action w/wo Epi?

Without Epi
Max: 2mg/kg
Duration: 2-4 hrs

With Epi
Max: 3mg/kg
Duration: 3-4 hrs

Avoid in Pregnancy til term

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Ropivacaine

Max Dose w/wo Epi?

Duration of Action w/wo Epi?

Without Epi
Max: 5mg/kg
Duration: 2-6 hrs

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What are the different Block Techniques?

Field Block

Paresthesia

Nerve Stimulation

Ultrasound

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What is the Field Block Technique?

Local Anesthetic targets terminal cutaneous nerve to minimize incisional pain

Dont use if its going to be in the way or if there is tissue acidosis

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What is the Paresthesia Technique?

Used to be the Main Technique

Needle is placed near target nerve until there is paresthesia, then inject the LA

Gotta know anatomy

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What is the Nerve Stimulation Technique?

Wire attached to Insulated needle is placed near nerve and causes muscle contractions at less than 0.5 mA

Inject 30-40 mL of LA w/ gentle aspiration and divided doses

(< 0.2 mA = Intraneural)

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What is the Ultrasound Technique for Peripheral Block Placement?

Used Alone or w/ other Techniques

Piezoelectric crystals emit high-frequency sound waves thru different tissues and return a signal to transducer at 1-20 MHz

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How does the amplitude of the return signal of an Ultrasound create the picture?

The crystals deform to make and electronic 2D image

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What is Echogenicity?

How efficient sound passes thru a substance

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What is Hypoechoic?

Sound easily Passes

Appear Dark or Black

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How do Hyperechoic structures appear on the Ultrasound?

Bright & White

What is Anechoic?

No Ultrasound Reflection

What is the Linear Ultrasound Probe used for?

High Frequency High-Res w/ less tissue penetration

Superficial Nerves

First Choice

What is the Curvilinear Ultrasound Probe used for?

Low Frequency w/ more tissue penetration

Low-Res & Poor Image

Good for Deeper Structures

What do Nerves look like on the Ultrasound?

Honeycomb

Best seen in Cross Section

What is In-Plane Needle Alignment when using Ultrasound?

Needle is placed along the long side of the transducer so you can see the entire shaft & tip

Need great hand-eye

Easy to lose image

What is the Out-of-Plane Needle Alignment when using Ultrasound?

Needle is placed perpindicular to the transducer Need to move transducer as needle advances Easier Approach

What are Single Injection Nerve Blocks?

Local Anestehtic is given one time

What is involved in placing a Continous Peripheral Nerve Block?

Percutaneous catheter next to peripheral nerve, then give Local Anesthetic to prolong effects

What are the types of Brachial Plexus Blocks?

Interscalene Supraclavicular Infraclavicular Axillary

What are the types of Terminal Nerve Blocks?

Median Nerve Ulnar Nerve Radial Nerve Musculocutaneous Nerve Digital Nerve Intercostobrachial Nerve

What is a type of Intravenous Regional Anesthesia?

Bier Block

What are characteristics of an Interscalene Block?

Used for Shoulder/Upper Arm Procedures Mostly blocks C5-C7 roots (possibly C3-C4 branches) C8-T1 Ulnar Nerves Spared Dont use for Elbow or lower surgeries

What are Contraindications for a Interscalene & Supraclavicular Blocks?

Local Infection Severe Coagulopathy Local Anesthetic Allergy Patient Refuse

Why should extra caution be taken when placing an Interscalene Block for pts w/ Pulmonary Disease?

Interscalene blocks will block the ipsilateral Phrenic Nerve

What are the possible complications of Interscalene Blocks?

Horner's Syndrome Recurrent Laryngeal Nerve Palsy - Hoarseness & Resp Distress Seizure d/t Vertebral Artery Injection Spinal/Epidural Injection Pneumothorax

What is Horner's Syndrome?

Complication of Interscalene Block Local Anesthetic travels to Cervicothoracic Ganglion causing myosis, ptosis, and anhydrosis

What are the characteristics of a Supraclavicular Block?

Used for Elbow or lower surgeries Unreliable for Axillary & Suprascapular Nerves High risk for PTX using Paresthesia & Nerve Stimulator Techniques

What are the possible complications of Supraclavicular Blocks?

Ipsilateral Phrenic Nerve Palsy Horner's Syndrome Recurrent Laryngeal Nerve Palsy Pneumothorax Subclavian Artery Puncture

What are characteristics of an Infraclavicular Block?

Blocks @ Level of Cords Used for Elbow or Lower Procedures Spares Intercostobrachial Nerve (T2)

What is effected by an Axillary Block?

Multiple injections of LA at the lateral border of Pectoralis Minor blocks entire arm below the elbow

What are the Contraindications to an Axillary Block?

Local Infection Neuropathy Bleeding Risk

When are Terminal Nerve Blocks used?

Minor procedures w/ Limited Field Supplement Incomplete Brachial Plexus Block Can be anywhere along nerve, but Elbow & Wrist Preferred

When is a Bier Block used?

Short Procedures - 45-60 min, Carpal Tunnel Release

How long must the turniquet be inflated when placing a Bier's Block?

15-20min to avoid Rapid IV Sytemic Bolus of LA then slowly, incrementally deflate

What are the Lower Extremity Peripheral Nerve Blocks?

Femoral Nerve Lateral Femoral Cutaneous Nerve Obturator Nerve Posterior Lumbar Plexus Saphenous Nerve Sciatic Nerve Ankle

What are the types of Peripheral Nerve Blocks of the Trunk?

Superficial Cervical Plexus Intercostal Paravertebral Transverse Abdominis Plane

After which type of Blocks does a rapid absorption of LA occur leading to toxicity?

Intercostal Block Caudal-Lumbar Epidural Brachial Plexus Block Sciatic-Femoral Block Subcutaneous Block