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87 Cards in this Set
- Front
- Back
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ADVANTAGES of LE regional [6]
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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 |
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DISADVANTAGES of LE regional [3]
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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 |
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Indications for LE regional
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Total knee arthroplasty (TKA)
Below knee amputation (BKA) ACL (anterior cruciate ligament) repair ORIF (open reduction internal fixation) ankle or foot Podiatric surgery |
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both______ and ______ nerves are required to cover the whole knee
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Both fem and sciatic are required to get the whole knee
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contraindications of LE regional
absolute [3] relative [2] |
Absolute
PATIENT REFUSAL Infection at site Coagulopathy *** Relative Sepsis Pre-existing neurological condition |
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COMBINED BLOCK/GENERAL
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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. |
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ANATOMY of LUMBAR PLEXUS-facts
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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 |
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ANATOMY of LUMBAR PLEXUS-facts
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“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 |
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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. |
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ANATOMY of LUMBAR PLEXUS
Obturator Nerve |
L2-L4 origin
Primarily motor, some mixed sensory |
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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 |
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ANATOMY OF LUMBOSACRAL PLEXUS - L4-S3(4)
Sciatic Nerve |
Combination of 2 major nerve trunks; Tibial & Common Peroneal
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ANATOMY OF LUMBOSACRAL PLEXUS - L4-S3(4)
Tibial Nerve(anterior) |
Derived from anterior branches of L4,5-S1,2,3
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ANATOMY OF LUMBOSACRAL PLEXUS - L4-S3(4)
Common Peroneal Nerve |
(posterior)
Derived from dorsal branches of L4,5-S1,2,3 |
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ANATOMY OF LUMBOSACRAL PLEXUS - L4-S3(4) facts
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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 |
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PRE-OPERATIVE COUNSELING
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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 |
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PREPERATION for BLOCK
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Drugs
Supplemental O2 Sedatives/Narcotics/Amnestics (versed) Supplies Resuscitation Equipment Standards for monitoring Minimal = O2 sat, NIBP, ECG |
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STIMUPLEX NEEDLE
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Insulated needle
22 gauge B-bevel Usually 1 1/2 inches long, but longer for some blocks nerve stimulators are good!!. |
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LUMBAR PLEXUS BLOCKS
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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 |
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PERFORMING LUMBAR PLEXUS BLOCKS
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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. |
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LUMBAR PLEXUS – Special Considerations
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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) |
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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 |
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PERFORMING FEMORAL NERVE BLOCKS
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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 |
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FEMORAL NERVE – Special Considerations
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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 |
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SCIATIC NERVE BLOCKS
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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. |
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PERFORMING SCIATIC NERVE BLOCKS
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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…. |
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SCIATIC BLOCKS – Special Considerations
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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 |
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POPLITEAL FOSSA BLOCK
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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. |
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PERFORMING POPLITEAL FOSSA BLOCKS (+/- Saphenous)
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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. |
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POPLITEAL FOSSA – Special Considerations
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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 |
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ANKLE BLOCKS
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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. |
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PERFORMING ANKLE BLOCKS
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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. |
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ANKLE BLOCK – Special Considerations
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“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 |
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ASSESSING THE BLOCK
Femoral |
Inability to raise knee from bed or extend knee
Decreased sensation over superior aspect of thigh |
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ASSESSING THE BLOCK
Sciatic |
Unable to perform “gas-on/gas-off”
Decreased sensation over lateral half of leg and almost all of foot |
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ASSESSING THE BLOCK
Saphenous |
Decreased sensation over medial/anteromedial leg
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ASSESSING THE BLOCK
Common Peroneal |
Inability to extend toes/evert foot
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ASSESSING THE BLOCK
Lateral Femoral Cutaneous |
Decreased sensation over lateral thigh
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COMPLICATIONS
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Bleeding/Hematoma
Infection Nerve injury Neuraxial injection (Lumbar Plexus) |
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lumbar plexus formed from roots of ________ and is formed in front of the ________ abd behind the ________.
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L1-L4(T12)
quadratus luborum muscle psoas major |
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The lateral femoral cutaneous nerve is formed from the...
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2nd and 3rd lumbar nerves
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the first nerve to leave the lumbar compartment is the
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lateral femoral cutaneous
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The lateral femoral cutaneous nerve passes under the ______ and then provides sensory innervatin to the ______.
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lateral border of the inguinal ligament
lateral aspect of the thigh |
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The obturator nerve arises from the _____
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2nd, 3rd, and 4th lumbar nerves
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the obturator nerve emerges from the _______ border of the psoas and the level of the _____ and is covered by the ________.
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medial
sacroilliac joint external illiac artery and vein |
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Because of its proximity to the external illiac artery, _____ can be injured during surgical procedures.
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obturator nerve
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the _______ nerve is frequently injured in patients undergoin pelvic surgery.
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obturator
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the obturator nerve is primarily a ____ nerve that has some mixed sensory fibers to the _____[3].
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motor
hip, the medial aspect of the femur, and the skin and soft tissue of the lower portion of the thigh. |
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The femoral nerve is formed by the______ at the junction of the middle and lateral third of the _____.
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2nd, 3rd and 4th lumbar nerves
psoas major muscle |
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the femoral nerve lies _____ to the femoral artery
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lateral
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The femoral nerves 2 branches
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anterior, posterior
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The ______ branch of the ___ nerve provides innervation to the anterior surface of the thigh and sartorius muscle.
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anterior branch of femoral nerve
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The ______ branch of the ____ nerve provides innervation to the quadriceps muscle, the knee joint and its medial ligament.
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posterior branch of the femoral nerve
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waht is the origin of the saphenous nerve?
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posterior branch of the femoral nerve
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The femoral nerve is bound inferiorly by the...
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inguinal ligament
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Psoas compartment block (blockade of the lumbar plexus as a unit)
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lateral or sitting
120cm insulated block needle medial edge of illiac crest (L4) loss of resistance 8-12cm stimulatino of quads 30-40ml |
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Inguinal perivascular techique (3-in-one block)
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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 |
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The lumbar plexus is sandwiched amons the ____, _____ and the ____, and is enclosed by the fascia of theses muscles
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psoas major, quadratus laborum and iliacus
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Sciatic nerve blocks in combinatiion with _____ [3] provides complete anesthesia for lower extremity surgery
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lumbar plexus
femoral saphenous |
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largest nerve trunk in body
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sciatic
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sciatic innervation
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muscles of the back of the thigh, the skin of the leg, and the muscles of the lower leg and foot
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the _______ passes out through the great sacrosciatic foramen, below the piriform muscle
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sciatic nerve
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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 _____.
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internal and external popliteal nerves
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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. |
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sciatic dose, approach
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10cc at sciatic, then 10cc at peroneal (after lateral redirection)
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5 nerves at level of ankle
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tibial
sural superficial peroneal deep peroneal saphenous |
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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 |
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tibial nerve branches
_______ provides sensory innervatin to the foot |
leave at level of medial malleolus
medial and lateral plantar branches of the tibial nerve. |
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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 |
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superficial peroneal origin
branches just above the ankle (dorsum) |
L4-5, S1-2
same as deep peroneal |
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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 |
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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 |
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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 |
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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. |
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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 |
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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 |
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Anterior tibial
how injured? result of injury... |
plantar flexion of feet for extended periods of time
results... foot drop |
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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 |
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loss of dorsal extention of toes, what's damaged?
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common peroneal
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inability to adduct the leg, what's damaged?
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obturator
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decreased or absent knee jerk, what's damaged?
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Femoral nerve
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paresthesias alont the medial and anteromedial side of the calf, what's damaged?
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saphenous
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diminished sensation over the medial side of the thigh, what is damaged
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obturator
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foot drop, what is damaged
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sciatic, common peroneal, anterior tibial
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pain and dyesthesia over lateral thigh, what is damaged?
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lateral femoral cutaneous
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inability to evert the foot, what is damaged?
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common peroneal
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decreased sensatin over the superior aspect of thigh and medial and anetromedial side of leg, what is damaged?
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femoral
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