Equipment for Regional

Question 1

Provision for proper

Answer 1

monitoring, oxygen, equipment for emergency airway management and positive-pressure ventilation, and

Question 2

is of paramount importance

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access to emergency drugs

Question 3

The anesthesia cart

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should also be well stocked with all equipment necessary to perform

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PNBs effectively, safely, and efficiently. Supplies such as needles and catheters of

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various sizes, local anesthetics, and emergency airway and resuscitation equipment should also be included

Question 5

Local anesthetic toxicity due to intravascular injection or rapid absorption into systemic circulation is a

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relatively uncommon but potentially life-threatening complication of regional anesthesia.

Question 6

Premedication often necessary before many regional anesthesia procedures, may result in

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respiratory depression, hypoventilation, and hypoxia

Question 7

The risk of the local anesthetic

toxicity has a biphasic pattern and should be anticipated

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(1) during and immediately after the injection and (2) 10 to 30 minutes after the injection.

Question 8

Signs and symptoms of toxicity occurring during or shortly after the completion of the injection are due to an

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intravascular injection or channeling of local anesthetics to the systemic circulation (1–2 minutes).

Question 9

In the absence of an intravascular injection, the typical absorption rate of local anesthetics after injection peaks at approximately

Answer 9

10 to 30 minutes

after performance of a PNB;

Question 10

local anesthetics after injection peaks at approximately 30 mns , therefore patients should be

Answer 10

continuously and closely monitored for at least 30 minutes for signs of local anesthetic toxicity

Question 11

Routine monitoring during administration of nerve blocks:

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 Mental Status (Of the patient!)
 Pulse Oximetry
 Non-Invasive Blood Pressure
 Electrocardiogram
 Respiratory Rate
 Set-up should be clean and comfortable for all, including the anesthesia provider.

Question 12

Choice of needle depends on

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the block being performed, the size of the

patient, and preference of the clinician.

Question 13

Long needles have a greater risk of causing injury

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due to increased difficulty in their handling and possibility of being inserted too deeply.

Question 14

Have greater risk of injury

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Long needles

Question 15

US and needle

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needle length is often longer by 2 to 3 cm for ultrasound guided blocks because needles are inserted further from the target to visualize the course of the needle on the image.

Question 16

Needles should have

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depth markings on their shaft to allow monitoring for the depth of placement at all times.

Question 17

Cervical plexus block needle size

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2 in (50mm)

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Interscalene brachial pl block needle size

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1-2in (25-50mm)

Question 19

Infraclavicular brachial plexus block needle size

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100mm (4in)

Question 20

Axillay nerve block needle size

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1-2in (25-50mm)

Question 21

Thoracic paravertebral block needle size

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90mm (3.5-4in)

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Lumbar paravertebral, and lumbar plxus block needle size

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100mm (4in)

Question 23

Sciatic block posterior approach needle size

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100mm (4in)

Question 24

Sciatic block anterior approach needle size

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150mm

Question 25

Femoral block needle size

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50 (mm)

Question 26

Popliteal block posterior approach needle size

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50 mm

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Popliteal block anterior approach needle size

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150mm

Question 28

Atropine dose

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0.2-0.4

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Ephedrine dose

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5-10mg

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Phenylephedrine

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50-200mcg

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Epinephrine

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10-100mcg

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Midazolam

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2.0-10mg

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Propofol

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30-200mg

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Succ

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20-80mg IV

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Intralipid Emulsion

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105ml IV F/b 0.25ml/kg/min infusion at 400ml ovr 10min

Question 36

Studies have recently demonstrated the correlation between larger needle gauge and

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increasing levels of nerve damage after intentional nerve perforation in a porcine model.

Question 37

The needles of smaller caliber however, may also be more likely

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to penetrate the fascicles.

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In addition, needles of smaller gauges have more internal | resistance,

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making it more difficult to gauge injection resistance and aspirate blood.

Question 39

Long vs Short needles injection internal resistance

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smaller needles

Question 40

Needles of very small size (25 and 26 gauge) are most commonly used for

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superficial and field blocks.

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Larger gauge needles (20–22 gauge) may be used in

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deeper blocks to avoid bending of the shaft and to maintain better control over the needle path.

Question 42

17-19 gauge Toughy needles are most commonly used with | an 18- gauge catheter for

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continuous catheters

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is one of the more challenging aspects of | performing an ultrasound-guided PNB.

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Visualization of the needle tip

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Nerve stimulation has been a cornerstone of

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peripheral nerve blocks for decades.

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Understanding how nerve stimulators and why it works will probably

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increase your success rates and decrease complications.

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DUAL technique

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Nerve stimulation should always be used in conjunction with ultrasoundfor best results!

Question 47

HYPERECHOIC NEEDLE

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Dimples tip for visibility

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DUAL TECHNIQUE: Not simply from a nerve localization perspective, but as a means of

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affording one medical legal protection, and more effectively describing the needle to nerve distance at the time of injection.

Question 49

The current intensity used is usually from | The duration of the current is usually

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``` 0.2- 1 mA (milliam 100 msec (milliseconds)p). ```

Question 50

Normally, we try to elicit a nerve response at higher intensities, then dial-down to maintain the twitch. If we loose the twitch at higher amperage,

Answer 50

we are not in the correct place. Manipulation of the needle tip is needed to redirect to closer to the target.

Question 51

(c-fibers), and therefore require

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less current to stimulate them.

Question 52

As a clear, accurate image of the target is acquired via ultrasound,

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A stimulating needle is placed and viewed approaching the target. It is at this point we begin to see the benefits of the dual technique.

Question 53

If the current is too high, a

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“muscle twitch” may be elicited. This is different | than a “nerve twitch”

Question 54

Dual technique summary

Answer 54

As a clear, accurate image of the target is acquired via ultrasound, a stimulating needle is placed and viewed approaching the target. It is at this point we begin to see the benefits of the dual technique. If the current is too high, a “muscle twitch” may be elicited. This is different than a “nerve twitch”. Large alpha (motor) fibers have lower chronaxies than do sensory fibers (c-fibers), and therefore require less current to stimulate them. This means that a motor response can be elicited without the transmission of pain. Also this means that its important to keep initial power intensities low when performing stimulator techniques.

Question 55

Femoral block

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Patellar twitch

Question 56

Interscalene block you look for

Answer 56

deltoid switch