Peripheral Nerve Block Part 1

2
SPEAKER
Dr. DEBDIPTA DAS
1ST Year PGT, Anesthesiology
Medical College, Kolkata
MODERATOR
Dr. RITA HALDER
Associate Professor,
Anesthesiology
Medical College, Kolkata

INTRODUCTION
Local anesthetic induced blockade
of peripheral nerve impulses from a
targeted body part with preserved
level of consciousness
Injecting local anesthetic near the
course of a named nerve
• Surgical procedures in the distribution of
the blocked nerve
3

HISTORY4
EARLIER
• South American Indian --- Cocaine as LA
1880
• Basil Von Anrep injecting Cocaine in his arm --- numbness to his skin
• Halsted & Hall --- inject Cocaine to peripheral site for minor Surgery
1884
• Freud prompted Koller’s discovery
• Cocaine as topical anesthesia in eye surgery
1900s
• Procaine, Dibucaine, Tetracaine discovered
1901
• Crile --- RA as blocking “surgical shock”, presaging “pre-emptive
alalgesia”

5
1923
• Labat popularise RA
• American Society of Regional Anesthesia (ASRA)
1963
• Bupivacaine
• Cardio-toxicity proved (1979)
1972
• Nerve stimulator --- guide LA drug Inject
1977
• Sclander --- Continuous axillary nerve block
1985
• European Society of Regional Anesthesia
HISTORY

6
1991
• Asian-Oceanic Society of Regionalk Anesthesia & Pain Medicine
1994
• Kapral --- USG guided LA drug inject
• The New York School Of Regional Anesthesia (NYSORA) website
HISTORY

PHYSIOLOGY9
Aα MOTOR (A)
largest diameter and
highest degree of
myelinization ----- highest
speed of impulse
propagation and a relatively
low threshold level
C PAIN (B)
Smaller diameter and very
little or absence of
myelinization ---- lowest
speed of impulse
propagation and a relatively
high threshold level
Aδ MOTOR
Smaller diameter and
smaller degree of
myelinization than Aα
MOTOR

PHYSIOLOGY10
MOTOR FIBRE
PAIN FIBRE

PHYSIOLOGY11
A certain minimum current intensity is necessary at a given pulse duration to reach the
THRESHOLD LEVEL OF EXCITATION
The lowest threshold current (at infinitely long pulse durations) is called RHEOBASE
The pulse duration (pulse width) at double the rheobase current is called CHRONAXIE

CHRONAXIE OF DIFFERENT
NERVES
NERVE FEATURE CHRONAXIE-ms
C Unmyelinated 0.40
Aδ myelinated 0.17
Aα myelinated 0.05 - 0.10
12

CLASSIFICATION16
Regional
anaesthesia
Central
neuraxial
blocks
Subarachnoid
Epidural
caudal
PERIPHERAL
NERVE
BLOCKS
TRUNCAL PARAVERTEBRALTAP,
PARAVERTEBRAL
INTERCOSTAL
PLEXUS
BRACHIAL
LUMBER,
SACRAL
DISTAL
FIELD &
TOPICAL
IV regional
anaesthesia

ADVANTAGES
Avoids general anaesthesia complications
Pt remains awake .....pt will & helpfull for suegeon----
feedback
Postoperative analgesia----continue / catheter
Less PONV-----less opiods need
Less post ops sedation------less confusion (cognitive functions)
in elderly
17

Early discharge
Cheep & relatively safe in remote location
hemodynamic stability than neuraxial & GA
Sole anesthetic technique , supplemented with monitored
anesthesia care (moderate sedation)
Preemptive analgesia
18

Less immunosuppressive than GA
Excellent alternative to GA
• Hemodynamically compromised
• Too ill to tolerate GA
• Malignant hyperthermia
• PONV is risk
Growing popularity of RA & PNB
• Modern equipments—USG,Nerve stimulator ect
19

DISADVANTAGES
TIME DELAY
• 15-30 MIN –Procedure & onset
• Onset is shortened by adjuvant like clonidine
PATIENT FACTORS
• Discomfort due to procedure & positioning & awake during surgery
• Distress due to paralysis & numbness---both intra & post-operative
• Managed easily—benzodiazepine & opiods
SURGEON FACTORS
• Irritated by awake & conversation with surgeon
ANAESTHETIST FACTORS
• Skill, knowledge & proper equipments
BLOCK FAILURE / PATCHY BLOCK
20

DISADVANTAGES22
NERVE DEMAGE
• Chronic paresthesias
• Permanent Nerve damage
FAILURE RATE-----10% - 20%, varies
SURGERY OUTLASTS THE BLOCK
• If No catheter----GA
• Adjuvant like dexamethasone prolong duration of block.
LOCAL ANAESTHETIC TOXICITY
SPECIFIC COMLPICATIONS RELATED TO NERVE BEING BLOCKED
• Respiratory failure-phrenic N Block
• Seizures ---intra-arterial injection

CONTRAINDICATIONS
OF PNB
COTRAINDICATIONS
ABSOLUTE RELATIVE
24

ABSOLUTE
COTRAINDICATIONS
Patient refusal
Major coagulation disorders & drugs
• Hemophilia
• DIC
• Anticoagulant drugs
Infection at site
25

26
Related to specific N Block
• Interscalene block
• with contra lateral phrenic N paralysis
• Severe pulmonary disease
Increased risk of LA toxicity
• Multiple Intercostal blocks
LA Allergy-anaphylaxis
Ring block at site---end arteries---LA
containing Adrenaline
• Penile block, toes, fingers, tip of nose etc

RELATIVE
COTRAINDICATIONS
Dementia , uncooperative patients
Placing block under GA
Surgeons who feel uncomfortable
Uncertain duration of surgery
Septicemia
Preexisting peripheral neuropathy
27

COMPLICATIONS
Local anaesthetic toxicity
Nerve damage
Vasoconstrictor problems
Infection
28

29 Haematoma
• Bleeding disorder
• Anticoagulant drugs
Wrong drug
Pneumothorax
• supra & infra clavicular
• inter costal block
Psychological reaction
• Vasovagal –mistaken as LA toxicity
• Anxious pt--sedate

1.LA TOXICITY30
Immediate or delayed-----signs & symptoms (CNS &
CVS)

32
Prevention ---always
• Maintain IV line before
• Have resuscitation equipments & drugs
• Always aspirate before injecting
• Inject slowly & aspirate after every 3-5 ml
• Stabilize needle ……short fine bore plastic tubing
b/w needle & syringe (isolated needle technique)
• Observe pulse,ECG & sign of IV injection
1.LA TOXICITY

PROTOCOL FOR TREATMENT OF
LA TOXICITY
34

36
Cont.
observe
Terminate
neurological sym at
once, control seizure

37
Standard ACLS
protocol, CPR in
case of
unconsciousness
of
cardiovascular
collapse
Start
INTRALIPID

IMMEDIATE TREATMENT OF
LOCAL ANAESTHETIC TOXICITY
38
CALL FOR HELP Stop injecting
ABC – 100% OXYGEN, INTUBATE, IV ACCESS.
CONTROL SEIZURES.
CPR IF INDICATED FOLLOWING STANDARD ALS PROTOCOLS
CONSIDER TREATMENT WITH LIPID EMULSION
(IV bolus 20%intralipid 1.5ml/kg over 1minute. Start an intravenous infusion of
Intralipid® 20% at 0.25 ml/kg/min. Give two further boluses if necessary. Increase
infusion rate of Intralipid® 20% to 0.5 ml/kg/min if necessary.)

2.NERVE DAMAGE
Direct by needle or by injection of LA
Eliciting paraesthesia technique -----can damage
• Withdraw 1-2 mm after eliciting paraesthesia-before
injection
Incidence
• 1 in 1000 blocks
• Most of paresthesia or pareseis resolve—few
months
• 1 in 10000 blocks=permanent demage
39

RECOMMENDATIONS TO REDUCE
RISK OF NERVE DAMAGE
Use short bevel needle
Use nerve stimulator & insulated short bevel needle
Avoid rapid,forceful injection
• STOP –undo resistance & severe pain-----withdraw
& then reinject
Avoid block under GA
40

3.VASOCONSTRICTOR
PROBLEM
General rule—epinephrine should not be used in
concentration > 1:200000 (5ug/ml) in PNB
• Skin ----- 1:300000 or 1:400000 sufficient
• Dentist –1:80000 but in small vol
Never use----areas of endarteries
Careful-----ischemic areas---varicose leg ulcer
41

42
H/O IHD-----avoid/reduce dose---- can cause
palpitation, angina, HTN. Avoid adrenalin
containing LA
Pregnancy-----epinephrine in significant
quantity reduce placental circulation -----
avoid /reduce dose
Max recommended dose of epinephrine---
4 ug/kg
Epinephrine sol-----lower pH--pain on
injection-----can be reduced by
• Adding sodium bicarbonate
• phenylephrine in stead of epinephrine
• Warming the sol to body temp

4.INFECTION
Aseptic technique
No needle prick through infected skin
except abscess
Use antiseptic Alcoholic
Betadine(povidone/ iodine in ethanol)
• 1% chlorhexidine in 75% alcohol—
allergic to iodine
43

PREPARATION
FEW GOLDEN RULES
• Designed procedure room—block room
• Insert an intravenous line before
• Monitor (pulse oximetry, ECG , BP)
• Practice proper aseptic technique .
• Resuscitation equipments at hand
• Patients informed consent
• Adequate knowledge of the correct
tehnique and know how to handle
complications
44

PREMEDICATION
Anxiolysis with Benzodiazepines
and/or opiods
Light sedation----elicitation of
paraesthesia technique, nerve
stimulator.
O2 supplementation
45

EQUIPMENTS
Nerve stimulator—ECG Electrode
Unipolar insulated Bevel needles
• different lengths ( 25- 150 mm)and (20 to 25G).
• tip may angled at 15 or 30 degrees.
• catheters
Ultrasounds machine
Syringes
Local anaesthetic
47

NERVE STIMULATOR50
RED/+VE/ANODE
CONNECTED TO PATIENT
BLACK/-VE/CATHODE
CONNECTED TO
STIMULATING NEEDLE

IDEAL ELECTRICAL
CHARACTERISTICS OF A PNS
Constant current (DC)generator
Monophasic rectangular output pulse i.e. the current flows in one direction only.
Ability to vary pulse duration (0.1 - 1ms)
Digital display of actual flowing current
Safety features like
• circuit disconnection alert,
• impedence alerts,
• low battery and
• malfunction alert
Leads should be clearly marked to avoid confusion as to which is cathode and anode
52

NERVE STIMULATOR
Current range from
0.1-6.0 mA
• Linear & constant
• Low output
Pulse Frequency
• 1 Hz -Mixed nerve
• 2 Hz - Sensory nerve
53

SETTINGS OF PNS
Desired initial---USUALLY
• current (1 - 2mA),
• pulse duration (0.1ms) and
• frequency (2hz).
A threshold current of less than 0.5ma usually results in a
successful block
current less than 0.2ma, increased resistance on injection
or pain on injection may suggest intraneural needle
placement
54

STIMULATION AND
INJECTION TECNIQUE
55

TOUHY SET FOR
CATHETERIZATION
57

TOUHAY SET FOR PERIPHERAL
NERVE CATHETERIZATION
60
Stimulating
catheter

CURRENT ADJUSTABLE
INSULATED NEEDLE SET
61

MEDIAN NERVE
CATHETER
64
postoperative pain relief after hand surgery. Continuous
infusion of levo-bupivacaine 0,125% - 2-5 ml/h

Direct visualization of nerves & other
structures
Visualization of LA spread
Re-position of needle in case of
misdistribution of LA
Avoidance of side effect- due to
excess dose of LA
ADVANTAGES OF USG67

Avoidance of painful muscle
contractions due to PNS
Faster onset
Longer duration of blocks
Improved quality
Blocks under GA
68

Short Axis (SAX) –
• probe is aligned perpendicular to the axis of the nerve, the
nerve is seen in cross section
Long Axis (LAX) –
• probe is aligned parallel to the axis of the nerve
Short Axis View is preferred due to easy identification of
nerves, more stable view & allows to visualize circumferential
spread of LA------ “Doughnut” sign
BASIC VIEWS ON USG69

TRANSDUCER MANIPULATION72
SLIDING (A), TILTING (B), COMPRESSION (C), ROCKING (D), ROTATION (E)

In plane (IP) – long axis of the needle is
oriented to the long axis of the probe
• Entire needle can be seen
Out of plane (OP) – the long axis of the
needle is the oriented perpendicular to
long axis of the probe
• Only part of the needle is seen
NEEDLE APPROACHES73

76
Schematic representation of the views and needle approaches for
nerve blocks with ultrasound imaging. A. Short axis view of a nerve
with an out-of-plane needle approach. B. Short axis view of a nerve
with an in-plane needle approach. C. Long axis view of a nerve with
an out-of-plane needle approach. D. Long axis view of a nerve with
an in-plane needle approach. Modified6.

77
Picture showing the orientation of the ultrasound probe
and the needle for placement of an interscalene block with
the in-plane needle approach
VIEW
SHORT /
LONG ?

TECHNIQUES
Single injection
Multiple injections---axillary block
Using catheters
• Intermittent dose
• Continuous
Field block---superficial cervical plexus block
• Large vol of LA in general location of cutaneous N
• Minor/superficial surgery
• Supplement to PNB & Neuraxial blocks
78

FEMORAL NERVE
CATHETERIZATION
79

CHOICE OF LOCAL
ANAESTHETICS
Purpose of block
• Anaesthesia or analgesia
Onset
Duration of block
Site & area of block—vol
Degree of sensory Vs motor block
Maximum toxic dose
80

LA DRUG IN MAJOR
NERVE BLOCK
82

83
LA DRUG IN MINOR
NERVE BLOCK

CONCENTRATION
ANALGESIC BLOCK
• 0.125% Bupivacaine, 0.2% Ropivacaine,
• Opiods, Clonidine.
86

PNB PLACEMENT
TECHNIQUES
Anatomy
Loss of
resistance and
tactile feedback
Evoked
paraesthesia
Nerve stimulator
(goal 0.2-0.5 mA)
Ultrasound
guided
Percutaneous
electrical
guidance
1
2
3
4
5
6
87
OTHERS
1.Droppler
2.CT
LA-- in
Perineural
area

CONCLUSION
Centralize your equipment
Select proper block
Good knowledge of anatomy
Know about potential complications and
treatment
88

Select right site of right patient
Be confident about your block
But still if you fail--Failures are the
stepping stones for success
89

SCALP BLOCK : AWAKE
CRANIOTOMY

SCALP BLOCK : AWAKE
CRANIOTOMY
SUPRAORBITAL NERVE
needle at a perpendicular
angle immediately
superior to the
supraorbital notch

SCALP BLOCK : AWAKE
CRANIOTOMY
SUPRATROCHLEAR NERVE
target area for insertion is on
the supraorbital ridge
approximately 1cm medial to
the supraobital notch,
between the notch and the
bridge of the nose

SCALP BLOCK : AWAKE
CRANIOTOMY
TEMPORAL BRANCH OF THE AURICULOTEMPORAL NERVE
Immediately posterior to the
superficial temporal artery at the
level of the auditory meatus.
Injection is superficial and
subcutaneous

ZYGOMATICOTEMPORAL NERVE
SCALP BLOCK : AWAKE
CRANIOTOMY
emerges from the temporalis
fascia near the lateral border of the
orbit
Field infiltration above the zygoma
through the temporalis muscle and
almost down to the periosteum of
the temporal bone

GREATER & LESSER OCCIPITAL NERVE
LESSER OCCIPITAL -- deep or
superficial to the fascia at
the upper, posterior border
of sternocleidomastoid
GREATER OCCIPITAL – middle
third of a line between the
mastoid process and the
external occipital
protuberance along the
superior nuchal ridge
SCALP BLOCK : AWAKE
CRANIOTOMY

SCALP BLOCK : AWAKE
CRANIOTOMY
GREATER AURICULAR NERVE
involved blockade of the
entire superficial cervical
plexus at the border of the
sternocleidomastoid muscle
USG guided GAN block
(superficial location on the
anterior surface of the
sternocleidomastoid muscle)

maxillary nerve eventually
enters the face through
the infraorbital canal,
where it ends as the
infraorbital nerve. The
infraorbital nerve supplies
SENSORY BRANCHES TO
THE LOWER EYELID, THE
SIDE OF THE NOSE, AND
THE UPPER LIP.
INFRAORBITAL NERVE
BLOCK : UPPER LIP
SURGERY

INFRAORBITAL NERVE
BLOCK : UPPER LIP
SURGERY
easily blocked by a facial
approach
Locate infraorbital foramina
with respect to supraorbital
foramina or upper teeth
Needle Placed through the
skin and aimed at the
foramen in a perpendicular
direction

EAR BLOCK
POSTERIOR Br. GREAT AURICULAR
NERVE
LESSER OCCIPITAL NERVE
ANTERIOR Br. GREAT AURICULAR
NERVE
AURICULOTEMPORAL NERVE
Blocking the
entire ear
(with the
exception of
the area
supplied by
the vagus
nerve)

EAR BLOCK
inserting the needle at the black dots and infiltrating along the dotted lines
TEMPORAL Br.
AURICULO
TEMPORAL nv.
LESSER
OCCIPITAL
nv.
GREAT
AURICULAR
nv.

OTHER NERVE BLOCK OVER
AROUND FACE : IN BRIEF
104

TRIGEMINAL (GASSERIAN
GANGLION) BLOCK
105

NASOCILIARY AND ANTERIOR
ETHMOIDAL NERVE BLOCKS
106

NASAL BLOCK108
SUPPLIMENTED WITH INFRAORBITAL NERVE BLOCK

POSTERIOR SUPERIOR
ALVEOLAR NERVE BLOCK
109

MIDDLE SUPERIOR ALVEOLAR
NERVE BLOCK
110

ANTERIOR SUPERIOR
ALVEOLAR NERVE BLOCK
111

GREATER PALATINE NERVE
BLOCK
113

MANDIBULAR NERVE
BLOCKS
114
below the zygomatic arch at the
midpoint of the notch of the mandible
until the pterygoid plate is felt
Another type -- AKINOSI closed-mouth Mandibular block

INFERIOR ALVEOLAR NERVE
BLOCK
115
2 inches deep, 1 inch superior and just medial to the 3rd Mandibular molar

MENTAL NERVE BLOCK116
Mental and incisive nerves are the
terminal branches for the inferior
alveolar nerve
Sensory - lower lip skin
mucobuccal fold at or anterior to the
mental foramen. This lies between the
Mandibular premolars

INDICATION
Vocal cord surgery - medialization thyroplasty
Cervicogenic headache
Carotid endarterectomy
Zenker diverticulum excision in a patient with ankylosing
spondylitis
Drainage of dental abscess in adults with difficult airways
Drainage of submandibular and submental abscesses

INDICATION
Minimally invasive parathyroidectomy
Carotid body tumor excision in a patient with Eisenmenger
syndrome
Postoperative analgesia after clavicle surgery
Thyroid surgery under general anesthesia
Management of neuropathic cancer pain

BLOCKADE
BOTH SUPERFICIAL & DEEP CERVICAL PLEXUS BLOCK -- skin of the
anterolateral NECK and the ante- and RETROAURICULAR areas.
In addition, the DEEP CERVICAL BLOCK anesthetizes
three of the four strap muscles of the neck, geniohyoid
the prevertebral muscles
Sternocleidomastoid
levator scapulae
the scalenes
Trapezius
and the diaphragm

TECHNIQUE : SUPERFICIAL
CERVICAL PLEXUS
SUPINE OR SEMI-SITTING POSITION WITH THE HEAD FACING AWAY
Landmark & needle insertion point
Fanning of drug

TECHNIQUE : DEEP
CERVICAL PLEXUS
DEEP CERVICAL PLEXUS BLOCK IS A PARAVERTEBRAL BLOCK OF THE C2 TO C4 SPINAL NERVES
C2 transverse process lies 1 to
2 cm caudal to the mastoid
process --- 1.5-cm intervals
C3, C4
Drug delivered by
paravertebral block technique
by guided over transverse
process
single injection of 10 to 12 mL
at the C4 transverse process

COMPLICATION : CERVICAL
PLEXUS BLOCK

NERVE BLOCK FOR AWAKE
INTUBATION
ophthalmic and
maxillary divisions of
the TRIGEMINAL
NERVE supply the
nasal cavity and
turbinates
oropharynx and posterior
third of the tongue are
supplied by the
GLOSSOPHARYNGEAL
NERVE
VAGUS NERVE innervate
the epiglottis and more
distal airway structures

NERVE BLOCK FOR AWAKE
INTUBATION
PREPARATION FOR AWAKE
INTUBATION
Premedication
Topical anesthesia by
spraying LA drug
LA soaked cotton pledgets
or swabs
Inhalation of Aerosolized
(Atomized) LA
Vasoconstrictor can be used
to reduce mucosal bleeding

BLOCKADE OF THE
TRIGEMINAL NERVE
NASAL
INTUBATION
PALATINE NERVE
ANTERIOR ETHMOIDAL
NERVE
greater and lesser palatine
nerves --- the nasal
turbinates and the
posterior two thirds of the
nasal septum
TOPICAL APPLICATION OF LA
PTERYGOPALATINE
GANGLION block
remaining portions of
the nasal passages
INHALATIONAL OR
SPRAY TOPICALIZATION

BLOCKADE OF THE
GLOSSOPHARYNGEAL NERVE
oropharynx, soft palate, posterior portion of the tongue, and the pharyngeal surface
of the epiglottis
INTRA-ORAL APPROACH

BLOCKADE OF THE VAGUS
NERVE
SUPERIOR LARYNGEAL NERVE sensory
innervation to the base of the tongue,
posterior surface of the epiglottis,
aryepiglottic fold, and the arytenoids
RECURRENT LARYNGEAL
NERVE sensory innervation
to the vocal folds and the
trachea
INNERVATION
the epiglottis
and more
distal airway
structures

patient is placed supine with the
head extended
greater cornu is encountered --
pulsation of the carotid artery
inserted in an anteroinferomedial
direction until the lateral aspect
of the greater cornu
walked downward toward the
midline
thyrohyoid membrane is pierced
internal branch alone is blocked

TRANSTRACHEAL BLOCK
the cricothyroid membrane is
located in the midline of the
neck
Needle is passed perpendicular
to the axis of the trachea and
pierces the membrane
advanced until air is freely
aspirated
Instillation of local anesthetic -
-- results in coughing
local anesthetic is dispersed
diffusely

INTERCOSTAL BLOCK &
INTERPLURAL CATHETER

INTERCOSTAL BLOCK :
TECHNIQUE
Patient is placed in the PRONE POSITION WITH A PILLOW PLACED UNDER THE ABDOMEN to
reduce the lumbar curve
primary rami of T1
through T11. T12 is a
subcostal nerve
At the posterior
angle of the rib, the
nerve lies in the
costal groove
accompanied by the
intercostal vein and
artery

INTERCOSTAL BLOCK :
TECHNIQUE
12th rib (last rib palpable inferiorly)
7th rib (lowest rib covered
by the angle of the scapula)
Spinous process C7 (the most
prominent spinous process in
the cervical region when the
neck is flexed)

INTERCOSTAL BLOCK :
TECHNIQUE
Determining midline and spinous processes
Insertion point is marked at 6-8 cm lateral to
midline and inferior edge of each rib is
palpated at desired level of block
Needle is inserted at the tip of the finger until
it rests on the rib
walks the needle 3 to 5 mm off the lower rib
edge
can be performed in the supine patient at the
midaxillary line
A perpendicular or
caudal angulation of
the needle can cause
the block failure;
maintenance of the 20°
cephalic angle

INTERPLURAL CATHETER :
TECHNIQUE
6th or 7th
intercostal space is
identified
Mark 10 cm
lateral from the
posterior midline
epidural needle tip is advanced
until it rests on the cephalad edge
of the rib below the intercostal
space
syringe filled with
saline or air
attached
advanced slowly
over the superior
edge of the rib
parietal pleura --- -
ve intrathoracic
pressure
catheter is then inserted
approximately 5 to 8 cm into the
interpleural space
catheter placement for
management of postoperative
pain
results with cholecystectomy
have been most favorable

INTERCOSTAL BLOCK &
INTERPLURAL CATHETER :
COMPLICATION

PARAVERTEBRAL BLOCK :
THORACIC & THORACO-
LUMBAR

ANATOMY & LANDMARKS
12th rib (last rib
palpable inferiorly)
7th rib (lowest rib
covered by the
angle of the
scapula)
Spinous process C7
(the most
prominent spinous
process in the
cervical region
when the neck is
flexed)Iliac crest
(corresponds to L3-
4 or L2-3)
1
2
3
4
1
2
3
4

INDICATION :THORACIC
Pain relief for thoracotomy
Major breast surgery
Implantable cardioverter defibrillator and laser lead extraction
Right lobe hepatectomy
Postoperative analgesia after robotic-assisted coronary artery bypass graft
Open cholecystectomy
Abdominoplasty
Submuscular breast augmentation

Radiofrequency ablation of a metastatic carcinoid liver lesion
Single-injection/continuous block technique for major renal surgery in children
Thymectomy performed with a bilateral thoracoscopic approach
Video-assisted thoracic surgery procedures
Percutaneous transhepatic biliary drainage
Thoracoabdominal esophageal surgery
Conventional on-pump cardiac surgery

Multiple rib fracture
Minimally invasive direct coronary artery bypass surgery
Pleuritic pain
Esophagogastrectomy

INDICATION :THORACO-
LUMBAR
Outpatient lithotripsy
Inguinal hernia repair
Ventral hernia repair
Hip arthroscopy
Femoral-popliteal bypass in high-risk patient
Labor analgesia

TECHNIQUE
Spinous process of desired level
marked
Another mark at 2.5 cm lateral to it
Needle inserted at this point until it
contact transverse process (depth of
3 to 5 cm)
needle is then redirected to walk off
the caudad edge of the transverse
process
1 to 2 cm (the thickness of the
transverse process) beyond this
point local anesthetic is injected
patient is positioned in the sitting or lateral
decubitus position and supported by an
attendant

TECHNIQUE
The fingers of the palpating hand should straddle the paramedian
line and fix the skin to avoid medial-lateral skin movement

TRANSVERSUS
ABDOMINUS PLANE (TAP)
BLOCK

ANATOMY & LANDMARK
TRIANGLE OF PETIT

INDICATION
expect analgesia between T10 and L1 with a single injection
postoperative analgesia for laparotomy
Appendectomy
laparoscopic surgery
Abdominoplasty
cesarean delivery, abdominal hysterectomy
Appendectomy, hernia repair
Bilateral blocks can be used for midline incisions or laparoscopic procedures
as an alternative to epidural anesthesia for operations on the abdominal wall

TECHNIQUE &
COMPLICATION
• ENTRY POINT – LUMBAR
TRAINGLE OF PETITY
• feeling double “pops” as the
needle traverses the external
oblique and internal oblique
muscles
LOSS OF
RESISTANCE
(BLIND
INJECTION)
• probe is placed several
centimeters superior and
parallel to the iliac crest
• in-plane approach
ULTRASOUND
-GUIDED
Peritoneal
puncture
liver
hematoma

ILIOINGUINAL AND
ILIOHYPOGASTRIC
BLOCKS

ANATOMY & LANDMARK
arise from the L1 spinal root
pierce the transversus abdominus cephalad and
medial to the ASIS
lie between the transversus abdominus and
internal oblique muscles
caudal and medially - pierce the
internal oblique muscle – branches
pierce the external oblique and provide sensory
fibers to the skin

ANATOMY & LANDMARK
• Anterior and inferiorly to the inguinal ring
• exits to supply the skin on the proximal,
medial portion of the thigh
ILLIOINGUINAL
NERVE
• nerve supplies the skin in the inguinal
region
ILLIOHYPOGASTRI
C NERVE

INDICATION
Analgesia following INGUINAL HERNIA REPAIR
Lower abdominal procedures
Analgesia following suprapubic incision

TECHNIQUE &
COMPLICATION
Mark is made 2 cm cephalad
and 2 cm medial to ASIS
Needle inserted
perpendicular to the skin
Passes through EOM – IOM
by Loss of resistance
Drug injected EOM-IOM
plane & IOM-TAM plane
Repeat the same in fanning
Perforation of
large & small bowel
Pelvic hematoma
Lower limb
weakness

needle is inserted in-
plane in a medial to lateral
orientation.
Double pop – needle at
IOM-TAM plane
TECHNIQUE
The nerves should appear as
hypoechoic ovals between the
IOM and TAM muscles

RECTUS SHEATH BLOCK
INDICATION
postoperative
analgesia for
umbilical hernia
repair
other umbilical
& para-umbilical
surgery

TECHNIQUE
transducer placed at the level
of the umbilicus immediately
lateral
Color Doppler – epigastric
artery
needle is inserted in-plane in a
medial to lateral orientation.
(obese – out plane)
pearce through the anterior
rectus sheath upto posterior
sheath
Perforation of
large & small bowel
Pelvic hematoma

Peripheral Nerve Block Part 1

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

Similaire à Peripheral Nerve Block Part 1

Similaire à Peripheral Nerve Block Part 1 (20)

Dernier

Dernier (20)

Peripheral Nerve Block Part 1