Mod IV: Regional Anesthesia Part 1

Question 1

_{Regional Anesthesia}

The first local anesthetic

Answer 1

Cocaine

Spanish Jesuit, Father Burnabe Cobo

1653 Wrote about chewing the leaves of the coca plant to relieve a toothache

Question 2

_{Regional Anesthesia}

Sigmund Freud (1883-1887) wrote many articles detailing the virtues of cocaine:

Answer 2

Stimulant

Analgesic

Addiction treatment?

It has been argued that much of his early works on psychoanalysis were influenced by his cocaine use

Question 3

_{Regional Anesthesia}

Karl Kollar, college and friend of Freud, in 1884 demonstrated the local anesthetic properties of cocaine allowing him to perform

Answer 3

“painless” surgery on the eye

This is the first documented application of a drug to produce localized anesthesia

Question 4

_{Regional Anesthesia}

William Halsted & Alfred Hall, only 8 weeks after Kollar’s announcement they began experimenting with injecting nerves with cocaine, in December 1884 published injecting cocaine SQ into forearm and were able to produce:

Answer 4

Analgesia

Injected directly into Ulnar N. and produced complete anesthesia to its distal distribution

Question 5

_{Regional Anesthesia}

William Halsted & Alfred Hall, only 8 weeks after Kollar’s announcement they began experimenting with injecting nerves with cocaine, in December 1884 published injecting cocaine directly into Ulnar N. and produced:

Answer 5

Complete anesthesia to its distal distribution

Question 6

_{Regional Anesthesia}

Brachial plexus blocks were performed by Halsted using a cut-down technique and injecting cocaine directly into:

Answer 6

each nerve root

Question 7

_{Regional Anesthesia}

1st Percutaneous Blockade performed by G. Hirschel in 1911 was:

Answer 7

Axillary brachial plexus block

Question 8

_{Regional Anesthesia}

Selective anesthesia and analgesia that is achieved by exposing selected nerves to LA is also known as:

Answer 8

Regional Anesthesia

Question 9

_{Regional Anesthesia}

Which discipline tells us where nerves travel and what they do?

Answer 9

Applied Anatomy

Question 10

_{Regional Anesthesia}

We can choose how dense and how long the block will last by using which scientific discipline?

Answer 10

Applied Pharmacology

Question 11

_{Regional Anesthesia}

What are the different types of Regional Anesthesia?

Answer 11

Topical

Local infiltration

Field Block

Intravenous Regional – Bier block

Peripheral nerve block

Neuraxial

Question 12

_{Regional Anesthesia}

What are the possible uses of topical anesthesia?

Answer 12

IV placement

Eye procedures

ENT procedures

Awake fiber optic intubations

Dental pain

Surgical wound closure

Acute/chronic pain management

Question 13

_{Regional Anesthesia}

Which agents are used for topical anesthesia?

Answer 13

EMLA cream/patch

^{Eutectic Mixture of Local Anesthetics}

^{Mixture of 2.5%Lidocaine and 2.5%Prilocaine}

Cocaine, Tetracaine, Proparacaine (Alcaine)

Benzocaine spray

^{Methhemaglobinemia}

Lidocaine jelly/ointment

Skin refrigerant spray

Question 14

_{Regional Anesthesia}

What the composition of EMLA cream/patch?

Answer 14

Eutectic Mixture of Local Anesthetics

Mixture of 2.5%Lidocaine and 2.5%Prilocaine

Question 15

_{Regional Anesthesia}

Possible complication a/w the use of Benzocaine spray

Answer 15

Methhemaglobinemia

Question 16

_{Regional Anesthesia}

What are advantages of Topical anesthesia?

Answer 16

Extremely Easy

Low skill

Low risk

Great for mucous membranes

Question 17

_{Regional Anesthesia}

What are disadvantages of Topical anesthesia?

Answer 17

Short duration 1-4 hours

Slow onset over skin (Needs soak time!!!)

Doesn’t work well or at all on inflamed or infected tissues

Question 18

_{Regional Anesthesia}

Type of regional anesthesia where a LA is injected directly into a tissue:

Answer 18

Local infiltration

Question 19

_{Regional Anesthesia - Local Infiltration}

What the uses for Local Infiltration?

Answer 19

Traumatic Wound closure

^{Laceration closure in ER}

Surgical Wound closure

^{Injected as wound is closed}

Pre-emptive analgesia

^{Trocar sites - Joint injection}

Question 20

_{Regional Anesthesia - Local Infiltration}

Advantages

Answer 20

Fast and Easy

Low skill

Lower risk

Question 21

_{Regional Anesthesia - Local Infiltration}

Disadvantages

Answer 21

Short duration 1-6 hours

Doesn’t work well or at all on inflamed or infected tissues

Requires provider to place injections systematically to ensure good coverage

^{Patchy coverage can be commonplace}

Question 22

_{Regional Anesthesia}

Infiltration of LA around an area you wish to anesthetize:

Answer 22

Field blocks

Question 23

_{Regional Anesthesia - Field blocks}

Uses:

Answer 23

Carotid endarterectomy

^{Superficial cervical plexus}

I&D of wounds

Intercostobrachial and medial brachial cutaneous nerves

Dentistry

Plastic surgery

Question 24

_{Regional Anesthesia - Field blocks}

Advantages:

Answer 24

Fast and Easy to perform

Low risk procedure

Multiple LA options

Can be used to supplement patchy peripheral or neuraxial blocks

Question 25

_{Regional Anesthesia - Field blocks}

Disadvantages:

Answer 25

Inconsistent coverage

Only covers superficial structures

Relatively short duration of action

Question 26

_{Regional Anesthesia}

Injection of LA into the venous system of an exsanguinated extremity to produce surgical anesthesia for short procedure:

Answer 26

IV Regional Anesthesia or Bier Block

Question 27

_{IV Regional Anesthesia or Bier Block}

Uses:

Answer 27

Best suited for short soft tissue upper extremity procedures

Can be used for lower extremity

Question 28

_{IV Regional Anesthesia or Bier Block}

Advantages:

Answer 28

Relatively easy to perform

Provides surgical anesthesia quickly

Question 29

_{IV Regional Anesthesia or Bier Block}

Disadvantages:

Answer 29

Tourniquet pain limits useful duration

Tourniquet must be inflated for at least 20 minutes

Must be able to obtain IV access on operative limb

Pt habitus must be suitable for proper tourniquet fit

Question 30

_{IV Regional Anesthesia or Bier Block}

Pt habitus must be suitable for proper tourniquet fit. Failed tourniquets risk:

Answer 30

Acute LA Toxicity

Large volume LA immediately entering central circulation

Question 31

_{Bier Block - Procedure}

IV Heplock established; where?

Answer 31

Hand preferably

Question 32

_{Bier Block - Procedure}

Double Pneumatic tourniquet to upper arm. What should you do with the arm prior to protect it?

Answer 32

Pad with cotton

Question 33

_{Bier Block - Procedure}

How do Exsanguinate Arm/leg prior to Bier block?

Answer 33

Raise arm/leg up

Apply Esmarch bandage in a spiral from hand/leg to proximal cuff of tourniquet

Question 34

_{Bier Block - Procedure}

Tourniquet pressure to:

Answer 34

50-100mmHg above SBP

Question 35

_{Bier Block - Procedure}

Tourniquet cuff Sequence:

Answer 35

1 – Inflate Distal cuff

2 – Inflate Proximal cuff

3 – Deflate Distal cuff

Question 36

_{Bier Block - Procedure}

Injection of LA:

Answer 36

30-50ml 0.5% Lidocaine

3mg/kg MAX

Use NO OTHER LA!!

Question 37

_{Bier Block - Procedure}

When should you remove Heplock?

Answer 37

After you have injected LA

Question 38

_{Bier Block - Procedure}

After injection of LA, how long till onset?

Answer 38

< 5 minutes

Question 39

_{Bier Block - Procedure}

What should you do when tourniquet pain starts?

Answer 39

Inflate distal cuff, then

Deflate proximal

Question 40

_{Bier Block - Procedure}

From injection, never deflate cuff less than

Answer 40

20 minutes

Question 41

_{Bier Block - Procedure}

When would you use Two stage tourniquet deflation?

Answer 41

For short procedures (<30-45minutes)

Question 42

_{Bier Block - Procedure}

What happens during Two stage tourniquet deflation?

Answer 42

Deflate for 10 seconds

Inflate for 1 minute

Question 43

_{Bier Block - Procedure}

What’s the result of Two stage tourniquet deflation?

Answer 43

more gradual LA washout

Question 44

_{Regional anesthesia}

When is Peripheral Nerve Block indicated?

Answer 44

Surgical anesthesia

Post-op pain control

Vascular dilation

Chronic pain

Question 45

_{Regional Anesthesia - Peripheral Nerve Block}

What are some applications Peripheral Nerve Blockade?

Answer 45

Podiatry

^{Hammer toe, bunion, etc}

Hand and wrist

^{Trigger finger, carpal tunnel}

Hernia

^{Inguinal hernia repair}

Chronic pain

^Trigeminal

Airway blocks

Eye blocks

etc.

Question 46

_{Regional Anesthesia - Peripheral Nerve Block}

Advantages:

Answer 46

Specific control of what is being blocked

^{And possibly more import what is not blocked}

^{Requires working knowledge of fine anatomic detail}

Can avoid systemic side effects of neuraxial techniques

Continuous Perineural catheters can be used

Question 47

_{Regional Anesthesia - Peripheral Nerve Block}

Disadvantages:

Answer 47

Anatomical variability and technical difficulty can lead to failure

^{Especially in landmark techniques}

Inadvertent blockade of nerves due to proximity

^{Phrenic nerve block}

Question 48

_{Regional Anesthesia - Peripheral Nerve Block}

Which nerve should you be concerned about inadvertently blocking with a Peripheral Nerve Blockade approach?

Answer 48

Phrenic nerve

“C3, C4, C5 Keep the diaphragm alive”

Question 49

_{Regional Anesthesia}

Neuraxial approaches include:

Answer 49

Epidural, Spinal, Caudal

Question 50

_{Regional Anesthesia - Neuraxial}

Indicated for pain control when?

Answer 50

Surgical and Post-op pain control

Question 51

_{Regional Anesthesia - Neuraxial}

Uses:

Answer 51

OB

Hip and lower extremity

Multiple Thoracic, Abdominal, and pelvic surgeries

^{Esophagectomy}

^Lobectomy

^Prostate

^etc

Question 52

_{Regional Anesthesia - Neuraxial}

Advantages:

Answer 52

Provide coverage to large sections of the body

Catheter placement allows for analgesic control

Question 53

_{Regional Anesthesia - Neuraxial}

Disadvantages:

Answer 53

Can be technically difficult

Sympathectomy

Contraindicated for many comorbidities and pt specific factors

Question 54

_{Regional Anesthesia - Neuraxial}

Contraindicated for many comorbidities and pt specific factors, including:

Answer 54

Coagulopathy/anticoagulation

Uncooperative pt

Stenotic heart valve lesions

etc.