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N931 Advanced Principles > Lower Extremity Blocks > Flashcards

Lower Extremity Blocks Flashcards

1
Q

What are the indications for regional anesthesia? (5)

A 
primary anesthetic
PONV management
History of MH or PONV
Patient is too ill for general
Physician surgeon preference
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2
Q

Absolute contraindications to regional anesthesia (4)

A

Patient Refusal
Infection at Site
Anticoagulant therapy with active bleeding
Proven allergy to local anesthetic

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3
Q

Relative contraindications to regional anesthesia (5)

A

uncooperative patient/neurological disease/psychiatric disease
an anesthetized patient
bleeding diathesis secondary to an anticoagulant or genetic disorder
Blood stream infection
pre-existing peripheral neuropathy

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4
Q

Complications of regional anesthesia (6_

A 
intravascular injection/ LAST
Intraneural injection
High spinal (intra-thecal)
vascular injury (hematoma)
Infection
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5
Q

Benefits of Regional anesthesia (10)

A 
Decreased PONV
Decreased LOS
Decreased opioid requirements
decreased Post op pain
Decreased surgical stress
decreased blood loss
Increased patient satisfaction
Maintained upper airway and pharyngeal reflexes
increased gastric mobility
ability to titrate analgesia/ place catheter
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6
Q

Benefits of US vs. Landmark technique

A 
Visualization
improvement of block quality
Lower doses of anesthesia
less painful administration
improved patient satisifaction
safer?
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7
Q

What can you visualize better with US during a regional block?

A

anatomic structures
real-time needle movements
spread of LA

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8
Q

Pre-Procedure Checklist (8)

A 
Verify correct patient
Obtain consent
Verify correct procedure
Verify correct extremity
Gather all necessary equipment
Place patient on monitors/ supplemental O2/ EtCO2 monitor (if sedating)
Obtain baseline VS and monitor throughout procedure
Administer proper/adequate sedation
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9
Q

Supplies for Regional Anesthesia

A 
US Machine
Sterile Gloves
Probe cover
Drapes
CHG
Appropriate Needle with connection to nerve stimulator
Peripheral Nerve Stimulator for Needle Device (sorry don't know what that is called)
LA for block
LA for skin wheal if warranted
SW for hydrodissection
decadron?
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10
Q

What compromises the lumbar plexus? (ventral rami and nerves)

A 
L1-L4
Femoral Nerve
Obturator Nerve
Lateral femoral cutaneous Nerve
Also- ilioiguinal nerve
iliohypogastric nerve
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11
Q

What compromises the lumbar plexus? (ventral rami and nerves)

A

L4-5 through S1-5
Tibial nerve
peroneal nerve
nerves of ankle and foot

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12
Q

What are the blocks of the lumbar plexus?

A 
femoral
fascia iliaca
adductor canal
saphenous
PENG
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13
Q

What are the blocks of the lumbosacral plexus

A

sciatic (subgluteal)
sciatic (popliteal)
IPACK
Ankle block

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14
Q

What does the lumbar plexus provide innervation too? What innervation?

A

sensory and motor innervation to thigh, anterolateral knee

sensory innervation to medial aspect of lower extremity below the knee

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15
Q

Where is the femoral nerve located?

A

Lateral to the artery
Deep to the fascia lata and fascia iliaca
Superior to the iliopsoas muscle

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16
Q

What is the target of the femoral nerve block?

A

major branches of lumbar plexus

femoral nerve

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17
Q

Where does the femoral nerve block provide anesthesia too?

A

anterior to thigh, knee, and medial aspect of lower leg

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18
Q

What muscle group does the femoral nerve innervate?

A

quadraceips

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19
Q

What are the indications for femoral nerve block?

A

surgery on the anterior aspect of the thigh

superficial surgery on medial aspect of leg below the knee

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20
Q

What are surgical examples that require a femoral block?

A

quadriceps tendon repair, long saphenous vein stripping, postoperative pain femur/ knee surgery
TKA

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21
Q

Can a catheter be placed in a femoral nerve block for anaglesia?

A

yes for major knee and femur surgery

Just be careful and remove ASAP because femur is a dirty site- high risk for infection

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22
Q

Relative contraindications for femoral nerve block

A 
previous ilioinguinal surgery
large inguinal lymph node/tumor
infection
peritoneal infection
femoral neuropathy
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23
Q

Describe the anatomy of the femoral nerve

A

largest branch in the lumbar plexus
dorsal division of the anterior rami L2-L4
emerges from the lateral border of the psoas muscle and remains deep to the fasica iliaca
Anterior division innervates the sartorius and pectineus muscle

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24
Q

Describe Landmark Technique for Femoral Nerve Block

A

Patient is supine with leg slight external rotated
In the femoral crease, Find the femoral artery (we know the nerve is lateral to the artery)
Therefore, go 1 cm lateral to to the pulsating artery
Insert needle at a 45 degree angle towards head
Using nerve stimulator look for quadracieps/ patellar twitches. If still twitching at 0.3mA retract needle til twitches are absent.
Aspirate.
Small increments of LA injected

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25
Q

What is the surgical anesthesia LA choice for femoral nerve blocks?

A

mepivacaine or lidocaine 1.5-2%

Ropivacaine 0.5-0.75%

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26
Q

What is the postoperative anesthesia LA choice for femoral nerve blocks?

A

Ropivacaine or bupivacaine 0.2-0.25%

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27
Q

Discuss the USG technique for FNB?

A

Patient is supine with external rotation of extremity
Transducer is placed at inguinal crease
Identify femoral artery at level of femoral crease
If femoral artery and deep artery of thigh are both seen, scan proximal until fem artery seen
Femoral nerve is lateral to artery and covered by fascia iliaca and 2-4cm deep
Needle inserted lateral to medial
20ml local anesthetic
Goal for the LA to push the Femoral nerve lower can re-enter under nerve trying to get donut around it

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28
Q

Pearls of FNB (5)

A

Doppler needs to be utilized to check for absence or presence of vessels
If LA is placed below fascia iliaca and lateral to artery, successful blocks occur despite the lack of twitches
Watch your needle tip- can easily puncture vascular or inject local
Lymph nodes are not continuous, make sure to be scanning up and down to distinguish between lymph and nerves
No ambulation for 24 hours

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29
Q

Describe the anatomy of the fascia iliaca

A

Located anterior to the iliacus muscle
Deep to sartorius muscle and fascia lata
Superior to iliopsoas muscle

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30
Q

Indications for the Fascia iliaca Block

A 
Hip
Anterior thigh
Knee
Femur fracture
Alternatives to the femoral block/ ie lumbar plexus block
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31
Q

What are the targets for the fascia iliaca block?

A

Femoral nerve
Obtrurator nerve
lateral femoral cutaneous

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32
Q

Where does the lateral femoral cutaneous nerve stem from? what does it innervate?

A

(sensory) L2 and L3

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33
Q

Where does the obutrator nerve stem from? What does it innervate?

A

L2-L4 roots

Innervates portion of distal and medial thigh

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34
Q

Where is the obturator nerve anatomically?

A

Cross iliacus muscle,

Deep to fascia to medial thigh

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35
Q

What surgery needs to have the obturator nerve blocked?

A

IMPORTANT TO BLOCK WITH THA (ACETABULAR COMPONENT)

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36
Q

What volume of LA is required for a FIB?

A

40mls to block all three nerves

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37
Q

What volume of LA is required for FNB?

A

20ml

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38
Q

What is the goal of the FIB?

A

inject LA under fascia in a large volume that will spread broadly to reach nerves
Want to spread LA cephalad to hit the higher nerve roots

39
Q

What are major landmarks for FIB?

A

deep Circumferential iliac artery

40
Q

USG technique for FIB

A

Patient is supine, transducer placed parasagittal orientation (head to toe) just medial to anterior spinal IS then moved few cm caudad to see pelvis. Needle is placed towards cephalad inplane. Landmark: is deep circumferical iliac artery. Needle is directed to underside of fascia while being on pelvis side. Unzippering inidcates successful block. Circumferical artery should be superior to LA, if artery deep, block will be too superifical and will not work.

41
Q

What are the CKAs to FIB

A

none

42
Q

What are relative CKA to FIB?

A

uncooperative patient/ surgeon

infection at site

43
Q

What are complications of FIB?

A 
block failure
intraperitoneal injection(bowel perf)
femoral nerve palsy
quadriceps weakness
infection (increased with catheter)
44
Q

Describe the adductor canal anatomy/ Landmarks

A

Saphenous nerve is branch of femoral nerve
Medial side of knee and ankle
Saphenous nerve is below sartorius muscle, lateral to superficial femoral artery and femoral vein
Key: Mid-thigh with femoral artery in middle of sartorius muscle

45
Q

Indications for an adductor canal nerve block

A

TKA
ACL reconstruction
Anterior knee surgery
If used with sciatic nerve block: analgesia below the knee

46
Q

Contraindications of ACB

A

patient refusal
Infection at site
Allergy to LA
Anticoagulant therapy/coagulopathy

47
Q

What is the triangle of the ACB

A

medial aspect of adductor longus, medial aspect of sartorius and the point of the femoral triangle

48
Q

What does the ACB block?

A

Sensory nerve block with minimal motor involvement

Medial aspect of the leg

49
Q

What is the target of the ACB block?

A

Saphenous nerve that has branched from femoral nerve

effective for pain relief

50
Q

What is the risk of a ACB?

A

risk of falls secondary to quadriceps weakness

51
Q

USG ACB Technique

A

Patient Supine with slight rotation of extremity
Stand on operative side (scan at mid-thigh)
Transducer placed mid to distal third of thigh, high frequency array transducer
Short axis image, in plane needle insertion
LA deposited in fascial plane separating sartorius and vastus medialis lateral to femoral vessels
Hydro-dissection
Inject incrementally up to 20ml LA

52
Q

How much LA is needed for a ACB block?

A

20ml

53
Q

Pearls of ACB (4)

A

Nerve branches may be located on both sides of superficial femoral artery, pre-procedure scan may be helpful
Myotoxicity can occur if LA deposited in muscle
If Vastus medialis blocked well, may provide greater innervation to the knee then thought
Ie better sensory block then anticipated
Medial Knee is twitched

54
Q

Anatomy of the Saphenous Nerve (5)

A

Terminal branch of femoral nerve
Travels superficially in the distal thigh

Infrapatellar branches to knee joint
Sartorius muscle descends across anterior thigh and forms roof over adductor canal in lower half of thigh- trapezoid shape
Sides of triangle canal formed by vastus medialis laterally and adductor longus or magnus medially depending on how proximal/distal scan is

55
Q

Describe the saphenous nerve

A

Saphenous nerve is small, round, hyperechoic structure anterior to the femoral artery at the depth of 2-3cm

56
Q

What does the saphenous nerve innervate?

A

Sensory innervation to medial aspect of lower extremity below the knee

57
Q

Saphenous Block is useful for

A

Can be used with other blocks for surgery of ankle/foot

58
Q

Saphenous Block USG technique

A

Supine slightly external rotation of leg
Transducer is placed at distal thigh
High Frequency array transducer
Short-axis image, in plane technique
Saphenous nerve can be found between the sartorius muscle and vastus medialis muscle, anterolateral to the femoral artery and vein
LA deposited in fascial plane separating the adductor longus and vastus medialis below the sQ tissue
5-10mL

59
Q

How much LA is utilized for saphenous nerve blocks

A

5-10ml LA

60
Q

Does the quadriceps stay intact in a saphenous nerve block?

A

yes

61
Q

Where is the direction of the needle going in a saphenous nerve block?

A

below the satorius muscle

62
Q

What does the lumbosacral plexus supply innervation to?

A

sensory and motor innervation to posterior thigh, lower extremity below the knee

63
Q

What does the sciatic nerve run deep to?

A

gluteous maximus between ischial tuberosity and greater trochanter

64
Q

Where does the sciatic nerve stem from?

A

L4-L5 and then S1 to S2

65
Q

What does the sciatic nerve supply innervation to?

A

Sensory and motor block of entire lower extremity below the knee (- medial lowe extremity below knee ie saphenous)

66
Q

What does a sciatic nerve block miss?

A

Posterior Thigh is innervated by femoral cutaneous nerve, which may by missed with sciatic nerve block

67
Q

Sciatic (Subgluteal) USG technique

A
  1. Patient can be prone or lateral
  2. Low frequency curvilinear transducer placed to distal gluteal crease
  3. Short axis, in plane needle insertion
  4. Place needle tip adjacent to sciatic nerve, between adductor magnus and biceps femoris
  5. LA deposited in fascial plane between gluteus maximum and adductor magnus muscles
    Inject 20ml LA
68
Q

How much LA is utilized in a sciatic nerve block (subgluteal)

A

20 ml

69
Q

Where does the sciatic nerve spilt into the tibial and common peroneal nerve?

A

10cm above popliteal fossa

70
Q

What is the sciatic nerve bordered by in the popliteal fossa?

A

superiorly and medially by semitendinosus and semimembranosus muscles and superiorly and laterally by biceps femoris muscle

71
Q

Indications for a Popliteal Nerve Block (3)

A

Foot, ankle, achilles tendon surgery

72
Q

CKA to the Popliteal nerve block

A

patient refusal, LA allergy, infection at site, coagulopathy with active bleeding

73
Q

What will occur with the popliteal nerve block?

A

Foot drop

74
Q

Describe USG Technique for Popliteal Nerve Block

A

Supine with operative leg elevated
High frequency transducer placed in popliteal crease
Tibial nerve is superior and proximal to vein and artery
Scan proximal to locate bifurcation with peroneal nerve
Short axis image distal to tibial and peroneal bifurcation
24g 4in B bevel needle inserted in the plane lateral to medial at lateral thigh
Circumferential spread around each nerve
Transducer may have to angles toward the foot to obtain a better image of nerve (anisotropy) because the nerve may be superficial
Circumferential spread around each nerve ensures a dense block

75
Q

Complications of Popliteal nerve block

A

IV or intraneural injection
Easy to cause peroneal nerve injury as may not be seen on US
Peroneal nerve is prone to injury due to location

76
Q

What four nerves are covered in a Popliteal nerve block?

A

posterior tibial nerve
deep peroneal nerve
superficial peroneal nerve
sural nerve

77
Q

Goal of an IPACK Nerve Block/ What does it mean?

A

To place LA Infiltration between popliteal artery and posterior capsule of knee to block the terminal branches innervating knee joint, sparing distal innervation of tibial and peroneal branches

78
Q

What is an IPACK nerve block an alternative too

A

Alterative to sciatic nerve block

79
Q

What is the result of an IPACK block?

A

Provides analgesia following knee arthroplasty and facilitates ambulation

80
Q

Indications for an IPACK block?

A

Posterior knee pain control for TKA

81
Q

Describe the USG technique for a IPACK block?

A

Position: lateral decubitus position
Transducer placed in transverse plane above popliteal crease to visualize tibial nerve, common peroneal nerve, popliteal artery and femoral condyles
Transversely over medial aspect of knee 2-3cm above patella
Slide transducer to identify distal femoral shaft and popliteal artery
If femoral condyles is visualized, slide proximal until condyles disappear and femoral shaft is identified
Use color doppler
Identify space between popliteal artery and intercondylar notch
Needle inserted lateral to medial
In plane from antero-medial aspect of knee towards space between popliteal artery and femur
15-20ml injected slowly while withdrawing needle
Fills posterior capsule of knee with LA

82
Q

How much LA is injected for a IPACK block?

A

15-20ml

83
Q

What are the five nerves that supply innervation to the foot?

A 
Sural
Deep peroneal Nerve
Superficial peroneal nerve
Tibial nerve
Saphenous nerve
84
Q

Describe the tibial nerve innveration and stem

A

nerve roots at 4-5 lumbar roots along with 1-3 sacral roots
Larger of two branches is the sciatic nerve which lies on medial side of achilles tendon
Nerve is covered by flexor retinaculum
Sensory innervation of foot

85
Q

Describe the Saphenous nerve innveration and stem

A

Terminal branch of femoral nerve and travels subcutaneously from the lateral side of the knee joint

86
Q

Describe the sural nerve innveration and stem

A

Union of a branch of the tibial nerve and common peroneal nerve
Sensory innervation to the posterior portion of the sole of the foot and posterior portion of the heel and portion of achilles tendon immediately above ankle

87
Q

Describe the Superficial peroneal nerve innveration and stem

A

Roots of 4 and 5th lumbar roots

1st and 2nd sacral nerve roots

88
Q

Describe the deep peroneal nerve innveration and stem

A

Muscle of the great toe as transverses the leg and into ankle
Innervation to short extensors of the toes and provides sensory innervation to the skin on the lateral side of the hallux and on the medial side of the second digit
Nerve and artery cross each other, nerve lies laterally to the artery and medial to the long extensor muscle of the great toe and ankle

89
Q

Indications for ankle blocks

A

surgical anesthesia and postoperative analgesia for surgery of the foot

90
Q

What patients are appropriate for ankle blocks

A

Good for patients with gangrene of the foot or those with diabetes who have foot ulcers

91
Q

How much LA is used at each nerve for ankle blocks?

A

3-5ml

92
Q

What are the two deep nerves of the ankle?

A

tibial nerve and deep peroneal

93
Q

What are the three superficial nerves of the ankle?

A

superficial peroneal nerve, sural nerve and saphenous nerve

94
Q

Complications of ankle blocks (6)

A 
LAST
Paresthesia (should be temporary)
Nerve injury
Bleeding
Infection
Intravascular puncture/injection

N931 Advanced Principles (14 decks)

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