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87 Cards in this Set

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ADVANTAGES of LE regional [6]
Significant advantages compared with central neuraxial block in ambulatory setting
Reduced recovery room admission
Decreased PONV
Decreased urinary retention
Shortened hospital stay
Decreased hospital admission
DISADVANTAGES of LE regional [3]
Requires specific skill set from anesthetist

Time?

Most lower extremity blocks are better for analgesia than anesthesia; frequently more than one block is required

Need both lumbar and lumbosacral plexis
Indications for LE regional
Total knee arthroplasty (TKA)
Below knee amputation (BKA)
ACL (anterior cruciate ligament) repair
ORIF (open reduction internal fixation) ankle or foot
Podiatric surgery
both______ and ______ nerves are required to cover the whole knee
Both fem and sciatic are required to get the whole knee
contraindications of LE regional

absolute [3]

relative [2]
Absolute
PATIENT REFUSAL
Infection at site
Coagulopathy ***

Relative
Sepsis
Pre-existing neurological condition
COMBINED BLOCK/GENERAL
Good alternative for elderly or “squirmy” patient

Helpful when block is slow to set-up or “patchy”; may be necessary if only doing one block

Get benefits of both techniques with less side-effects of individual method.
ANATOMY of LUMBAR PLEXUS-facts
Remember the “minds-eye” picture

Formed from the roots of the L1/2-4
Contributions from T12 in 50% people

Located behind psoas muscle

Know which nerves come off first and what they innervate.

Either behind or in the belly of the psoas
ANATOMY of LUMBAR PLEXUS-facts
“Mixed sensory” to hip, medial aspect of femur, the skin and soft tissue of lower thigh
Anterior branch innervates anterior surface of thigh and sartorius muscle
Posterior branch innervates quads, knee joint, medial ligament and is origin of saphenous nerve (need for capsule)
Ternminal branch of femoral is saophenous
ANATOMY of LUMBAR PLEXUS

Femoral Nerve (most of sensation to knee and top of thigh)
L2-4 origin
Forms 2 branches; anterior and posterior bundles
Largest nerve branch in plexus.
ANATOMY of LUMBAR PLEXUS

Obturator Nerve
L2-L4 origin
Primarily motor, some mixed sensory
ANATOMY of LUMBAR PLEXUS

Lateral Femoral Cutaneous Nerve(1st off)(need for tourniquet)
L1/2-L3 origin
First to leave compartment
Provides sensation to lateral thigh
ANATOMY OF LUMBOSACRAL PLEXUS - L4-S3(4)

Sciatic Nerve
Combination of 2 major nerve trunks; Tibial & Common Peroneal
ANATOMY OF LUMBOSACRAL PLEXUS - L4-S3(4)

Tibial Nerve(anterior)
Derived from anterior branches of L4,5-S1,2,3
ANATOMY OF LUMBOSACRAL PLEXUS - L4-S3(4)

Common Peroneal Nerve
(posterior)
Derived from dorsal branches of L4,5-S1,2,3
ANATOMY OF LUMBOSACRAL PLEXUS - L4-S3(4) facts
Tibial/Common Peroneal Nerve pass as Sciatic through upper leg, divide at popliteal fossa into terminal branches

Tibial forms posterior tibial and sural nerves

Common Peroneal forms superficial and deep peroneal
PRE-OPERATIVE COUNSELING
Patient should be informed of all potential procedures available, potential risk, potential complications, then select technique

Informed Consent
Significant risks
Potential benefits
Advantages/Disadvantages
Answer patient questions
PREPERATION for BLOCK
Drugs
Supplemental O2
Sedatives/Narcotics/Amnestics (versed)
Supplies
Resuscitation Equipment
Standards for monitoring
Minimal = O2 sat, NIBP, ECG
STIMUPLEX NEEDLE
Insulated needle
22 gauge
B-bevel
Usually 1 1/2 inches long, but longer for some blocks

nerve stimulators are good!!.
LUMBAR PLEXUS BLOCKS
Produces block of all lumbar and some sacral nerves.
If anesthesia of lower leg is needed, must add sciatic block.
Useful in patient when neuraxial block should be avoided. (coagulopaty, scoliosis)
Use about 30cc of any amino amides is recommended.

Most of the LE blocks are volume blocks
PERFORMING LUMBAR PLEXUS BLOCKS
Set up equipment
Position patient
Lateral or sitting position
Identify landmarks
Draw line between iliac crests (Tuffier’s line)
Second line drawn 5cm lateral to midline parasagittally on side to be anesthetized
On second line make mark 3cm caudal to Tuffiers line for needle entry site
Cleanse patient skin
Intradermal anesthetic

Insert needle until hit transverse process L5, partially withdraw and redirect cephalad until slides past
Turn on nerve stimulator and elicit quadriceps twitch at 1.0 mA, maximize and inject 30-40 cc in divided doses after negative aspiration.
Patient should remain in position for about 5 minutes to prevent spread of drug.
LUMBAR PLEXUS – Special Considerations
Insertion of needle near the neuraxial structures makes epidural or subarachnoid injection possible

Pain from lumbar paravertebral muscle spasm can occur post-operatively (especially if using LOR technique)
FEMORAL NERVE BLOCK

Most common
Useful for procedures on anterior thigh, both superficial and deep.
Usually combined with another lower extremity block if anesthesia is needed on lower leg and foot
Can be used for analgesia to repair femoral fx. or continuous catheter analgesia after surgery on knee or femur.
20-30cc LA needed for good block; Bupivicaine/ Ropivcaine (0.5%),or lidocaine 1.5% commonly used
May need to use 0.25% LA if blocking sciatic nerve
PERFORMING FEMORAL NERVE BLOCKS
Set up equipment
Nerve stimulator
Syringe with LA/extension set
Identify landmarks
Draw line between ASIS and pubic tubercle
Cleanse pt. skin
Intradermal anesthetic
Stimuplex needle inserted just lateral to artery where palpated at line, advance perpendicularly
After twitch elicited at 1 mA, decrease to <0.5, then inject 1cc
Local anesthetic should be administered in 5cc increments while applying distal pressure

The higher you get the better chance of getting the lateral cutaneous.

Obturator brings legs together

You are looking far actual knee cap movememnt (quad twitch) try to get down to .38
FEMORAL NERVE – Special Considerations
For continuous catheter use, block is done as previously described, but after twitch is elicited:
Inject 20 cc preservative free saline
Insert catheter through needle, 10cm past tip
Secure with plastic occlusive dressing
Give initial bolus of drug (same amount needed for femoral nerve block), followed by infusion
SCIATIC NERVE BLOCKS
One of the largest nerve trunks in the body, but few surgical procedures can be performed with sciatic block alone.
Usually combined with femoral block for anesthesia of lower leg.
Effective for lower leg and may provide pain relief from ankle/tibial fx. prior to OR.
Useful if need to avoid neuraxial blockade, especially if combined w/ femoral block.
Also helpful for amputation of lower extremity for patient with diabetes or PVD.

Not done as frequently.

Decreases phantom leg pain

Also a volume block
\
Requires 25-30cc local anesthetic.

1.5% Mepivicaine/ Lidocaine, or 0.5%/ 0.25% Bupivicaine/Ropivicaine should be used for motor block.
PERFORMING SCIATIC NERVE BLOCKS
Set up equipment
Position patient
Sims position
Identify landmarks
Draw line from posterior superior iliac spine to greater trochanter
Draw line from sacral hiatus to greater trochanter
Third line drawn @ midpoint first line, perpendicular until intersects with second line
Cleanse patient skin
Intradermal anesthetic
Stimuplex inserted perpendicular to skin at “intersection” previously identified
After eliciting posterior tibial nerve distribution (gas-on-tibial more superficial) maximize and inject 10 cc LA incrementally after aspiration
Redirect needle laterally and advance until peroneal nerve twitch elicited (gas-off-peroneal) maximize and inject 10cc LA incrementally after aspiration

Twitch-maximize twitch, then 1cc, etc….
SCIATIC BLOCKS – Special Considerations
Position may be difficult for patient with lower extremity injury, or other traumatic injury
When this volume is added to that required by other blocks, may be close to max allowable dose.
Uptake of LA is low from lower extremity sites, so larger volume is acceptable
POPLITEAL FOSSA BLOCK
Tibial and peroneal nerves are extensions of the sciatic nerve and are blocked in the popliteal fossa nerve block.
Used for foot and ankle surgery.
Saphenous nerve block should be added if tourniquet will be used.
PERFORMING POPLITEAL FOSSA BLOCKS (+/- Saphenous)
Set up equipment
Position patient prone
Identify landmarks; popliteal crease,medial border of femoris biceps muscle laterally, tendon of semitendinous muscle medially
Draw line joining medial border of femoris biceps and lateral border of semitendinous muscle medially at popliteal crease
Draw perpendicular line from middle of this line extending 15 cm
Needle should be inserted 1cm laterally
Cleanse patient skin
Intradermal anesthetic

Needle should be inserted at 45-60 degree angle anterosuperiorly until twitch elicited
Tibial nerve – “gas-on”
Inject 30-40 cc LA incrementally after negative aspiration
If adding saphenous for foot or ankle surgery reposition patient supine, and inject 5-10 cc LA in superficial ring just distal to medial surface of tibial condyle.2.5 in, 2.5 out, same on the other side.

Put bolster under shin so you can visualize the twitch

Saphenous is a field block. Saph is sensory only, no motor

Anytime you don’t use a nerve stimulator, you are doing a field block.
POPLITEAL FOSSA – Special Considerations
Volume is the key to making this block work

If initially unsuccessful eliciting twitch, problem is usually d/t needle being directed too far medially. Try redirecting more laterally.

Commoon problem is that you are too deep
ANKLE BLOCKS
Used on procedures of the foot, especially if tourniquet will not be used.
Peripheral nerves being blocked are all terminal branches of sciatic except saphenous
Performed by blocking 5 nerves @ level of ankle
Tibial, sural, superficial peroneal, deep peroneal, and saphenous (terminal branches)
Infiltration block, so patient doesn’t need to be cooperative (i.e.. snow ‘em)
1% lidocaine, 1% mepivicaine, or 0.5% bupivicaine can all be used. Do not add epinephrine.
PERFORMING ANKLE BLOCKS
Set up equipment
Position patient
Block of posterior tibial and sural nerves is easier if patient is in prone position, but can be accomplished with roll under foot
Titrate sedation
Cleanse patient skin
Ask assistant to secure leg

Posterior Tibial Nerve
Palpate posterior tibial artery at superior portion medial malleolus, needle is inserted laterally to pulse until contact with malleolus
Inject 5-7 cc local after negative aspiration
Massage area
Sural Nerve
Needle is inserted anterolaterally immediately lateral to Achilles tendon at cephalad border of lateral malleolus, contact lateral malleolus and inject 5-7 cc while withdrawing needle

Deep Peroneal, Superficial Peroneal, and Saphenous Nerves (supine position)
Palpate anterior tibial artery pulse and insert 22g needle immediately laterally, inject 5cc
Advance needle subcutaneously laterally and medially to the malleoli, injecting 3-5 cc of LA in each direction.
ANKLE BLOCK – Special Considerations
“Volume Block”
Sedation will be necessary because this is generally very uncomfortable for the patient
Avoid epinephrine containing solutions
Patients can usually walk, but need to be warned to protect foot
ASSESSING THE BLOCK

Femoral
Inability to raise knee from bed or extend knee
Decreased sensation over superior aspect of thigh
ASSESSING THE BLOCK

Sciatic
Unable to perform “gas-on/gas-off”
Decreased sensation over lateral half of leg and almost all of foot
ASSESSING THE BLOCK

Saphenous
Decreased sensation over medial/anteromedial leg
ASSESSING THE BLOCK

Common Peroneal
Inability to extend toes/evert foot
ASSESSING THE BLOCK

Lateral Femoral Cutaneous
Decreased sensation over lateral thigh
COMPLICATIONS
Bleeding/Hematoma

Infection

Nerve injury

Neuraxial injection (Lumbar Plexus)
lumbar plexus formed from roots of ________ and is formed in front of the ________ abd behind the ________.
L1-L4(T12)

quadratus luborum muscle
psoas major
The lateral femoral cutaneous nerve is formed from the...
2nd and 3rd lumbar nerves
the first nerve to leave the lumbar compartment is the
lateral femoral cutaneous
The lateral femoral cutaneous nerve passes under the ______ and then provides sensory innervatin to the ______.
lateral border of the inguinal ligament

lateral aspect of the thigh
The obturator nerve arises from the _____
2nd, 3rd, and 4th lumbar nerves
the obturator nerve emerges from the _______ border of the psoas and the level of the _____ and is covered by the ________.
medial

sacroilliac joint

external illiac artery and vein
Because of its proximity to the external illiac artery, _____ can be injured during surgical procedures.
obturator nerve
the _______ nerve is frequently injured in patients undergoin pelvic surgery.
obturator
the obturator nerve is primarily a ____ nerve that has some mixed sensory fibers to the _____[3].
motor

hip, the medial aspect of the femur, and the skin and soft tissue of the lower portion of the thigh.
The femoral nerve is formed by the______ at the junction of the middle and lateral third of the _____.
2nd, 3rd and 4th lumbar nerves

psoas major muscle
the femoral nerve lies _____ to the femoral artery
lateral
The femoral nerves 2 branches
anterior, posterior
The ______ branch of the ___ nerve provides innervation to the anterior surface of the thigh and sartorius muscle.
anterior branch of femoral nerve
The ______ branch of the ____ nerve provides innervation to the quadriceps muscle, the knee joint and its medial ligament.
posterior branch of the femoral nerve
waht is the origin of the saphenous nerve?
posterior branch of the femoral nerve
The femoral nerve is bound inferiorly by the...
inguinal ligament
Psoas compartment block (blockade of the lumbar plexus as a unit)
lateral or sitting
120cm insulated block needle
medial edge of illiac crest (L4)
loss of resistance 8-12cm
stimulatino of quads
30-40ml
Inguinal perivascular techique (3-in-one block)
Winnie

injection site: 1cm inferior to inguinal ligament.

22g 4cm b-bevel

quad stimulation

20-30ml (30 ml is best)

pressure distal to injection 5-10 minutes(limits distal
spread)

No sciatic spread
The lumbar plexus is sandwiched amons the ____, _____ and the ____, and is enclosed by the fascia of theses muscles
psoas major, quadratus laborum and iliacus
Sciatic nerve blocks in combinatiion with _____ [3] provides complete anesthesia for lower extremity surgery
lumbar plexus
femoral
saphenous
largest nerve trunk in body
sciatic
sciatic innervation
muscles of the back of the thigh, the skin of the leg, and the muscles of the lower leg and foot
the _______ passes out through the great sacrosciatic foramen, below the piriform muscle
sciatic nerve
the sciatic descends between the major trochanter and the tuberosity of the ischium to the lower 3rd of the thigh where it divides into the _____ and _____.
internal and external popliteal nerves
sciatic block approach

line from __to __.
Sims position

line from posterior illiac spine to trochanter then 2nd line from sacral hiatis to trochanter, 3rd line perpendicular to and bisecting the first. the intersection of the 2nd and 3rd lines is the injection point.
sciatic dose, approach
10cc at sciatic, then 10cc at peroneal (after lateral redirection)
5 nerves at level of ankle
tibial
sural
superficial peroneal
deep peroneal
saphenous
tibial nerve origin

location
L4-L5, S1-3

largest of the 2 branches of the sciatic nerve

lies behind the posterior tibial artery and between the tendons of the long flexor muscles of the toes and the one of the great toe.

covered by the flexore retinaculum
tibial nerve branches

_______ provides sensory innervatin to the foot
leave at level of medial malleolus

medial and lateral plantar branches of the tibial nerve.
Sural nerve formed from the union of a branch of the _____ and the _____.

location

sensory innervation for...
branch of tibial nerve and common peroneal nerve


behind the lateral malleolus

posterior portion of the sole of the foot, heel and lower achilles
superficial peroneal origin

branches just above the ankle (dorsum)
L4-5, S1-2
same as deep peroneal
Deep peroneal Nerve origin

provides innervation to...
L4-5, S1-2
same as superficial peroneal

short extenors of toes and senory to the skin on the lateral side of the hallus and on the medial side o fthe 2nd toe.

FREQUENTLY MISSED
sciatic nerve

how injured?

result of injury...
in sitting-pressure on ischial tuberosities
in lithotomy-thigh and nerves are externally rotated and knees are extended
excessive hip flexion reulstin in nerve stretch
-intramuscular injections

results...
weankess of all skeletal muscles below the knee and diminshed senation over lateral half of the leg alnd almost all of the foot

foot drop

pain or numbness of lower leg, thigh or foot
Femoral nerve

how injured?

result of injury...
lithotomy-extreme abduction of the thights with external rotation of the hip
compression at pelvic brim by retractor or excessive angulation of the thigh

results...
decreased or absent knee jerk and loss of flexion of hip and extension of the knee
decreased sensation over superior oaspect of thigh and medial and anteromedial side of leg
saphenous

how injured?

result of injury...
lithotomy-damage occurs when medial aaspect of lower leg is supspended outside an unpadded support

result...paresthesia along the medial and anteromedial side of the calf.
common peroneal

how injured?

result of injury...
lithotomy-pressure of vertical support pole for the leg or inadequate padding of metal knee supports, whci impact the popliteal fossa
supine-prolonged pressure in popliteal fossa by pillows or leg

results...
Foot drop
loss of dorsal flexion of toes
inability to evert the foot
obturator

how injured?

result of injury...
damaged by difficult forceps dilivery or by extensive flexion fo the thigh to the groin

results...
inability to adduct the leg
diminished sensation over the medial side of the thigh
Anterior tibial

how injured?

result of injury...
plantar flexion of feet for extended periods of time

results...

foot drop
lateral femoral cutaneous

how injured?

result of injury...
nerve entrapment at inguinal ligament due to expanding abdominal girth

results...
pain and dyesthesia over lateral thigh
loss of dorsal extention of toes, what's damaged?
common peroneal
inability to adduct the leg, what's damaged?
obturator
decreased or absent knee jerk, what's damaged?
Femoral nerve
paresthesias alont the medial and anteromedial side of the calf, what's damaged?
saphenous
diminished sensation over the medial side of the thigh, what is damaged
obturator
foot drop, what is damaged
sciatic, common peroneal, anterior tibial
pain and dyesthesia over lateral thigh, what is damaged?
lateral femoral cutaneous
inability to evert the foot, what is damaged?
common peroneal
decreased sensatin over the superior aspect of thigh and medial and anetromedial side of leg, what is damaged?
femoral