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Basic Principles > 3 - Peripheral Nerve Anesthesia > Flashcards

3 - Peripheral Nerve Anesthesia Flashcards

1
Q

What is “soak time”

A

time it takes for local anesthetics to cross the cell membrane, block action potentials, and produce either analgesia or surgical anesthesia

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2
Q

What is LAST?

A

Local Anesthetic Systemic Toxicity

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3
Q

Why is interlipid used in LAST?

A

mitigates the toxic effects of local anesthetics and can reverse both neurologic and cardiac toxicity

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4
Q

What is the minimum required monitoring for a patient to get a block?

A

ECG, NIBP, Pulse Ox

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5
Q

The use of ________ is contraindicated in children receiving peripheral nerve blocks with NS guidance

A

muscle relaxants

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6
Q

What is the high range of a NS used for?

The low range?

A

Monitoring neuromuscular blockade

Localizing peripheral nerves

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7
Q

The general rule with NS is to use ________ currents of _________ for peripheral NS

A

short duration

No more than 100 microseconds

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8
Q

In NS, the needle is in proximity to the nerve when the threshold for motor response is between ________ mA

A

0.3-0.5 mA

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9
Q

What is the “pulse width”?

A

the length of time of each NS electrical pulse

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10
Q

What happens when you place a PNS needle in saline?

D5W?

A

Reduces the curent density at the needle tip

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11
Q

If you need to dilate the perineural space, what should be used?

A

D5W, so that you don’t alter the needle’s ability to stimulate the nerve

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12
Q

What is the definition of Ultrasound?

A

Any sound with above 20 kHz, but in medicine we use 5-15 kHz

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13
Q

On US, high impedance creates __________ images

Low impedance creates _________ images

A

light

dark

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14
Q

Higher U/S frequencies are useful for ____________

Lower U/S frequencies are useful for ____________

A

superficial locations (brachial plexus)

Deep locations (subgluetal region)

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15
Q

What is the most common reason for poor visualization with US?

A

not enough gel

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16
Q

Anatomic landmark for interscalene block

A

subclavian artery

scalene muscles

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17
Q

Anatomic landmark for supraclavicular block

A

subclavian artery

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18
Q

Anatomic landmark for infraclavicular block

A

subclavian/axillary artery and vein

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19
Q

Anatomic landmark for axillary block

A

axillary artery

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20
Q

Anatomic landmark for lumbar plexus block

A

lateral aspect of transverse process

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21
Q

Anatomic landmark for radial nerve at anterior elbow

A

humerus at spiral groove

deep brachial artery

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22
Q

anatomic landmark for median nerve at forearm

A

brachial artery

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23
Q

Anatomic landmark for ulnar nerve at forearm

A

ulnar artery

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24
Q

Anatomic Landmark for tibial block

A

posterior tibial artery

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25
Q

Anatomic landmark for deep peroneal block

A

anterior tibial artery

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26
Q

Anatomic Landmark for subgluetal block

A

greater trochanter and ischial tuberosity

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27
Q

When using US, once the needle is seen next to the nerve, what happens next?

A

a 1- to 2-mL test dose of D5W can be injected to visualize the spread

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28
Q

Describe a combined US/NS approach to PNS

A
  1. nerve stimulator set at 0.3 to 0.5 mA
  2. the nerve is sought primarily using visualization under US
  3. nerve stimulator serves as an alert when the insulated needle tip is too close to nerve (i.e., contacting or inside the nerve).
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29
Q

What type of needles are generally required for PNB?

A

22-24 gauge insulated short bevel needles

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30
Q

What is CAIT?

What does it prevent?

A

Compressed Air Injection Technique

Limits generation of excessive pressure during block administration

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31
Q

How is CAIT used?

A

air is drawn into the syringe and compressed by 50% during entire injection to maintain pressures @ 760 mmHg

well below the 1,300 mmHg threshold considered to be an associated risk factor for clinically significant nerve injury

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32
Q

What objective tools are available to assess ongoing PNB?

A

Infrared Thermal Imaging

Current perception threshold measurement

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33
Q

What is an objective measure of motor blockade in PNB?

A

strength testing using a force transducer

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34
Q

What subjective scale is used to assess motor blockade in PNB?

A

Bromage Scale

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35
Q

What is an absolute contraindication to regional anesthesia?

A

Refusal by the patient or parent/guardian

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36
Q

When should schizophrenic patients receive PNB?

A

Only when general anesthesia is also being performed

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37
Q

What are three relative contraindications to PNB?

A
  1. Local Infection
  2. Systemic anticoagulation
  3. Severe systemic coagulopathy
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38
Q

If you need to administer a large amount of volume of local, you should use __________ concentration

A

a lower

to prevent systemic toxicity

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39
Q

What is systemic toxicity with PNB usually attributed to?

A

Accidental intravascular injection

NOT to an excessive quantity of local anesthetic at an appropriate site

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40
Q

The highest blood levels of local anesthetic occur after:

A
  1. Intracostal
  2. Caudal
  3. Epidural
  4. Brachial
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41
Q

When is the use of epinephrine combined with local not appropriate?

A
  1. in the vicinity of “terminal” blood vessels, such as in the digits, penis, or ear
  2. intravenous regional technique
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42
Q

When do peak blood levels occur after PNB administration?

A

30 minutes

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43
Q

What two factors increase the risk of nerve damage r/t PNB?

A
  1. High pressure injection
  2. highly concentrated agents
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44
Q

How concerning is a hematoma in the epidural space?

In the peripheral nerve space?

A

Extremely

Not very

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45
Q

Sensory and motor innervation of the face are provided by the __________

A

CN 5 trigeminal nerve

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46
Q

What are the three main branches of the trigeminal nerve

A
  1. Opthalmic
  2. Maxillary
  3. Mandibular
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47
Q

What is the only branch of the trigeminal with motor fibers?

A

Mandibular

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48
Q

In the neck, the vagus nerve passes between which two anatomic landmarks?

A

The carotid artery and the IJ

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49
Q

What spinal nerve exits above the atlas?

A

C1

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50
Q

What spinal nerves exits below the atlas?

A

C2

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51
Q

Where does spinal nerve C8 exit the spinal cord?

A

Between C7 and T1

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52
Q

How many pairs of spinal nerves are there?

A

31 pairs

62 spinal nerves

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53
Q

The cervical plexus arises from which spinal nerves?

A

C1-C4

(a little bit of C5)

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54
Q

All blocks should be followed by _________

A

manual compression to prevent hematoma formation

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55
Q

When injecting the mandibular nerve, what should be a high priority?

A

Avoiding intravascular administration, because this area is highly vascular

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56
Q

Which muscle is a suitable US landmark for deep cervical plexus block?

A

Longus capitis

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57
Q

What are some life threatening complications that can arise from a deep cervical block?

A

Injection in vertebral artery

Subarachnoid or epidural injections

Phrenic nerve palsy

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58
Q

What is Horner syndrome?

A

Ipsilateral:

Ptosis

Miosis

Hyperemia

Nasal Congestion

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59
Q

The brachial plexus arises from which vertebral rami?

A

C5-T1

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60
Q

Brachial Plexus Roots

A

C5-T1

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61
Q

Brachial Plexus Trunks

A

Superior (C5 & C6)

Middle (C6 & C7)

Inferior (C8 & T1)

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62
Q

Brachial Plexus Divisions

A

Superior Ant & Post

Middle Ant & Post

Inferior Ant & Post

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63
Q

Brachial Plexus Cords

A

Lateral (from ant of superior and middle division)

Posterior (from post of all three division)

Medial (from anterior inferior division)

In that order

64
Q

What do interscalene blocks target?

A

Brachial plexus roots

65
Q

What do supraclavicular blocks target?

A

Trunks and divisions of the brachial plexus

66
Q

What do infraclavicular blocks target?

A

The cords of the brachial plexus

67
Q

What are the terminal branches of the brachial plexus?

A

Ulnar

Radial

Median

Musculocutaneous

68
Q

What does an axillary block target?

A

The terminal branches of the brachial plexus

69
Q

A patient with an interscalene block should be watched closely for what three things?

A

Horner Syndrome

RLN paralysis

Phrenic nerve paralysis

70
Q

An intrascalene block goes between which two muscles?

A

anterior and middle scalene

71
Q

What are three common surgeries that an intrascalene block is used for?

A

Shoulder surgery

Elbow Surgery

AV fistula formation

72
Q

Dyspnea with normal vital signs after an interscalene block is probably due to what?

A

Phrenic palsy

73
Q

How often does phrenic nerve palsy occur with interscalene blocks?

A

About 100% of the time, but only 10% are symptomatic

74
Q

What kind of patients should not receive an interscalene block?

A

Patients who can’t tolerate phrenic palsy:

COPD

Bronchospasm

Underlying Diaphragmatic Dysfunction

75
Q

What percentage of patients with interscalen blocks develop Horner Syndrome?

A

50-75%

76
Q

Three hallmarks of the Bezold-Jarisch Reflex

A
  1. Hypotension
  2. Bradycardia
  3. Syncope
77
Q

How can you decrease the likelihood of stimulating the Bezold Jarisch Reflex?

A

Prophylactic B blockers before an interscalene block

78
Q

What is an anechoic area?

A

An area that is completely black on the U/S (bone etc)

79
Q

What is a Bier Block?

A

arm anesthesia provided by the injection of local anesthetic into the venous system distal to an occluding tourniquet.

80
Q

What is the most popular anesthetic for a Bier Block?

A

Preservative 0.5% Lidocaine

30-50 ml

Max 3mg/kg

ANY ANESTHETIC USED MUST BE EPI FREE

81
Q

Which anesthetics are NOT recommended for Bier Block? Why?

A

Ropivicaine and Bupivicaine

Much higher toxicity if absorbed systemically

82
Q

If a patient with a Bier Block complains of pain from the tourniquet, what can be done?

A

Inflate distal cuff to 2.5x the SBP

Deflate the proximal cuff

provides relief for about 15-20 min

83
Q

US Axial resolution is determined by

A

pulse length

84
Q

US lateral resolution is determined by

A

transducer beam width

85
Q

Patients with pre-existing neuropathy are more at risk for: (2)

A

prolongation of the block

local anesthetic neurotoxicity

86
Q

Indication for an interscalene block

A

shoulder and upper arm

87
Q

Indication for a supraclavicular block

A

entire upper extremity distal to shoulder

88
Q

Indication for infraclavicular block

A

elbow and below

89
Q

Indication for axillary block

A

distal to the elbow

90
Q

Indication for intercostal block

A

chest and upper abdominal wall

91
Q

Indication for Transversus Abdominis Plane

A

anterior abdominal wall

92
Q

Indication for Psoas block

A

entire hip, thigh and medial aspect of lower leg

93
Q

Indication for femoral block

A

anterior thigh and knee

medial aspect of lower leg

94
Q

Indiciations for fasia iliaca block

A

hip, femoral shaft and knee

95
Q

Indication for sciatic block

A

below knee, sparing the medial lower leg

96
Q

Indication for popliteal block

A

below the knee sparing medial lower leg

97
Q

When using an electronic stimulator, which lead is attached to the patient? To the needle?

A

Negative lead to skin

Positive lead to needle

98
Q

When using nerve stimulators, when should the stimulator be turned on?

A

AFTER entering the skin

99
Q

In a short-axis view, nerves and vessels appear _______

In a long-axis view, they appear ________

A

round

linear

100
Q

What is short axis?

What is long axis?

A

transverse, cross-sectional

longitudinal, parallel

101
Q

What are the ART manuevers?

A

Alignment: sliding along the skin

Rotation: rotating the probe clockwise or counterclockwise

Tilting

102
Q

Where to the ventral rami roots of the brachial plexus reorganize into trunks?

A

As they pass the lateral border of the scalene muscles

103
Q

Where do the three trunks of the brachial plexus divide into vnetral and dorsal divisions?

A

lateral border of the first rib

Posterior to the clavicle

104
Q

The ventral divisions of the brachial plexus generally supply the __________

A

ventral (flexor) portion of the upper extremity

105
Q

The dorsal divisions of the brachial plexus generally supply ________

A

the dorsal (extensor) portions of the upper extremity

106
Q

In the brachial plexus, where do the ventral and dorsal divisions combine into cords?

A

Upon entering the axilla

107
Q

How are the cords of the brachial plexus named?

A

By their position relative to the axillary artery

Lateral to the artery

Medial to the artery

Posterior to the artery

108
Q

The lateral cord of the brachial plexus branches into:

A

musculocutaneous nerve

lateral root of the median nerve

109
Q

The medial cord of the brachial plexus branches into:

A

ulnar nerve

medial root of the median nerve

110
Q

The posterior cord of the brachial plexus branches into:

A

axillary and radial nerves

111
Q

Where do the cords divide into branch nerves?

A

lateral border of the pectoralis minor muscle

112
Q

What are the four primary approaches for anesthetizing the brachial plexus?

A

Interscalene

Supraclavicular

Infraclavicular

Axillary

113
Q

Which brachial block is best for shoulder surgery?

A

Interscalene

114
Q

Which brachial plexus block has the highest risk of LAST?

A

Axillary

115
Q

Immediately medial to the first rib is the __________

A

cupola of the lung

116
Q

Supraclavicular blocks have a high risk of ________

A

pneumothorax

117
Q

The cricoid cartilage corresponds with the vertebral body of _____ and ______

A

C6

Chassaignac’s Tubercle

118
Q

What can you ask the patient to do to make the scalene muscles easier to see?

A

Take a fast, deep breath through the nares

119
Q

If an axillary block is desired, but the patient can’t abduct the arm, which block can be used instead?

A

Infraclavicular

120
Q

What is a potential problem with infraclavicular blocks?

A

You can’t easily compress the axillary artery if it’s punctured

121
Q

Why are bier blocks usually only useful up to 1 hr?

A

Patient discomfort from the tourniquet

122
Q

What is the preferred size and location of an IV for an upper extremity bier block?

A

23-25 g IV

dorsum of the hand

123
Q

What are two difference between IVRA of the upper extremity and the lower extremity?

A

Lower extremity dose is about double

Tourniquet pressure has to be way higher, which increases likelihood of tourniquet pain

124
Q

When performing an intercostal nerve block the patient should be positioned

A

supine, with arms above the head

125
Q

When inserting the needle for an intercostal block, the needle should be placed:

A

perpendicular to the rib until it makes contact, then walked caudad off the rib

126
Q

The TAP block places local anesthetic between the _____ and ______

A

internal oblique

transversus abdominis

127
Q

The lumbar plexus is formed from the ______

A

L1-L4 ventral rami

128
Q

The lumbar plexus is formed between which two muscles?

A

in front of the quadratus lumborum

Behind the psoas

129
Q

Immediately after emerging from the _________ the nerve roots form the lumbar plexus

A

intervertebral foramina

130
Q

Femoral nerve blocks are not used as ________,

but rather ________

A

sole anesthetics

postop analgesia options after knee surgery

131
Q

If a patient is going with a peripheral catheter, what is an absolute requirement?

A

Must be able to get in contact with someone 24/7 until the catheter is removed

132
Q

Paralysis of ________ is common in shoulder surgeries

A

ipsilateral diaphragm

d/t interscalene block

133
Q

Which of the brachial plexus nerves is lease likely to be covered by an axillary block?

A

Musculocutaneous. It separates very high in the axilla and often needs to be blocked by itself

134
Q
A
135
Q

What is the max dose of bupivicaine and ropivicaine?

A

Bupivicaine 2 mg/kg

Ropivicaine 3 mg/kg

136
Q

All sensory fibers above the knee come from the _______

All sensory fibers below the knee come from the ________

A

Femoral plexus

Sciatic

137
Q

What is the terminal branch of the femoral nerve?

A

Saphenous nerve

138
Q

The injection of 3-5 mL of local anesthetic into the coracobrachialis muscle will anesthetize what nerve?

A

Musculocutaneous

139
Q

On the ultrasound monitor, the femoral nerve will appear:

A

hyperechoic, triangular, and lateral to the femoral artery

140
Q

What nerve roots contribute fibers to the ulnar nerve?

A

C8, T1

141
Q

What nerve roots contribute fibers to the radial nerve?

A

C7, C8

142
Q

What nerve roots contribute fibers to the musculocutaneous nerve?

A

C5, C6

143
Q

The popliteal fossa is bounded laterally by the _________ and medially by the__________

A

the biceps femoris tendon

semimembranosus and semitendinosis tendons

144
Q

From superior to inferior, the structures in the intercostal neurovascular bundle are positioned:

A

Vein

Artery

Nerve

145
Q

The musculocutaneous nerve is situated between what muscles?

A

pectoralis major

Coracobrachialis

146
Q

What volume of local anesthetic would you expect to use in an ultrasound-guided popliteal sciatic block?

A

20 ml

147
Q

What is the most common cause of hypotension in the postanesthesia care unit?

A

hypovolemia

148
Q

Where are the 3 trunks of the brachial plexus located in relation to the subclavian artery?

A

Lateral

149
Q

Which of the following is the most common event leading to an anesthesia malpractice claim?

A

Regional Blocks

150
Q

Which nerves are anesthetized during an ankle block?

A

deep peroneal

saphenous

posterior tibial

sural

superficial peroneal

151
Q

What two muscles form the crease in the axilla in which the ultrasound probe is placed during an ultrasound-guided axillary block?

A

Pectoralis major

bicep

152
Q

The largest identifiable and preventable cause of accidents is

A

fatigue

153
Q

When performing a brachial plexus block using the axillary approach, it is often necessary to perform separate blocks of which nerves?

Why?

A

medial brachial cutaneous and intercostobrachial nerves

medial brachial exits sheath below clavicle

intercostobrachial doesn’t travel in the sheath

154
Q

The injection of a 5-8 mL of local anesthetic subcutaneously near the inferior border of the medial malleolus would anesthetize which nerve?

A

Saphenous

155
Q

What is the only additive to the local anesthetic for a Bier block that has been proven effective?

A

Ketoralac

156
Q
A

Basic Principles (15 decks)

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