Mod IV: Regional Anesthesia - Part 2

Question 1

_{Regional Anesthesia}

Choosing the right anesthetic: what’s the right way to do a case?

Answer 1

THERE IS NO ONE RIGHT WAY TO DO A CASE!!

Question 2

_{Regional Anesthesia}

Considerations when formulating an anesthetic plan

Answer 2

Surgical procedure

Patient

Anesthetist

Surgeon

Facility

Pre-op and PACU staff

Question 3

_{Regional Anesthesia}

Surgical procedure considerations when formulating an anesthetic plan:

Answer 3

Laparoscopic/open

Size of incision

Positioning

Length of procedure

Question 4

_{Regional Anesthesia}

Patient considerations when formulating an anesthetic plan: who makes the final determination?

Answer 4

The patient is the one who makes the final determination!!

They must consent to your plan

Question 5

_{Regional Anesthesia}

Patient considerations when formulating an anesthetic plan include:

Answer 5

Comorbidities

Demeanor

Habitus

Ability for self care

Cooperative

Question 6

_{Regional Anesthesia}

Patient considerations when formulating an anesthetic plan - Contraindications to RA include:

Answer 6

Contralateral paralyzed diaphragm

Severe aortic stenosis

Preexisting peripheral neuropathy

Question 7

_{Regional Anesthesia}

Anesthetist considerations when formulating an anesthetic plan:

Answer 7

Skill in performing GA, sedation, and blocks

Question 8

_{Regional Anesthesia}

Surgeon considerations when formulating an anesthetic plan:

Answer 8

Surgical skill

Comfort with the anesthetist

Comfort with the block

Question 9

_{Regional Anesthesia}

Facility considerations when formulating an anesthetic plan:

Answer 9

Rural 2 OR hospital

1000 bed tertiary like MUSC

Outpatient surgery center

US available

Drugs available

Do they have required monitors?

Question 10

_{Regional Anesthesia}

Pre-op and PACU staff considerations when formulating an anesthetic plan: what question to you want answered?

Answer 10

Do they have the ability to care for a pt with your anesthetic plan

Question 11

_{Regional Anesthesia}

Blocks you all Should Know:

Answer 11

Interscalene

Axillary

Femoral

Popliteal

_{<em>Can cover 90% of all peripheral blocks you will need to cover</em>}

Question 12

_{Regional Anesthesia}

There are so many choices of blocks, including:

Answer 12

Brachial Plexus (ISB, SCB, ICB, AX)

Radial, Ulnar, Median - Axillary Nerve

Intercostobrachial

Cervical plexus (Deep and Superficial)

Scalp Blocks (Occipital, Auricular)

Eye Blocks (RBB, PBB) - Airway Blocks

Facial Blocks (Trigeminal, Lingual)

TAP - Rectus Sheath - Illiohypogastric, illioinginal

Lateral femoral cutaneous - Paravertebral

Intercostal - PEC - Suprascapular

Median Branch blocks - Lumbar Plexus

Femoral (Adductor Canal) - Fascia iliaca - Obturator

Saphenous nerve

Sciatic (Trans/sub Gluteal, mid shaft - Popliteal)

Ankle Blocks - Digit blocks - Penile

Pudendal

Question 13

_{Regional Anesthesia}

Case Study:

68 yo Male 6’0” 250lbs

Crushed hand hooking up a trailer to farm tractor

Pt a/o x 3, pain 8/10

Hx: MI 2002 s/p 2 stents

Moderate Aortic stenosis

Pt has not seen cardiology in about 1 year

Last visit: Cardiac stable

DM2, HTN, ↑Lipids

Former smoker quit 2002

NPO status: 0700Full breakfast, Injury 1000

1600 Add on case

Hospital treatment - ER:

Morphine 10 mg

Zofran 4mg x 2

Fentanyl 100 mcg

Hospital treatment - Inpatient Floor:

Dilaudid 2 mg 1430

Phenergen 25mg

What would you do?

Answer 13

What I did:

Pre-op:

^{<strong>US guided Axillary block</strong>}

^{30 ml 0.5% Marcaine w/ EPI}

^{60 minute soak time}

OR:

^{IV versed 4 mg total}

^{1500 ml LR}

PACU:

^{Awake and comfortable}

Question 14

_{Regional Anesthesia}

Regional Anesthesia can be used alone or combined with other anesthetic techniques. What are possible Anesthetic combinations?

Answer 14

Sole anesthetic

Regional Anesthesia (RA) with a TIVA or MAC

GA with RA for post-op pain control

Combined RA techniques

Question 15

_{Regional Anesthesia - Anesthetic Options}

Examples of cases where Regional Anesthesia could be used as sole anesthetic:

Answer 15

SAB for C-section

Wrist block for carpal tunnel

Infraclavicular block for AV fistula

Intra-articular block for knee arthroscopy

Topical lidocaine for cataracts

Question 16

_{Regional Anesthesia - Anesthetic Options}

RA with a TIVA or MAC:

Answer 16

Rotator cuff repair

^{Interscalene block (ISB) with versed during case}

Carotid Endarterectomy

^{Superficial cervical plexus with surgeon supplement infiltration of LA}

Bier Block for carpal tunnel with propofol infusion

Question 17

_{Regional Anesthesia - Anesthetic Options}

GA with RA for post-op pain control:

Answer 17

Robotic hysterectomy with TAPs blocks

Rotator cuff repair with interscalene block (ISB) and continuous catheter

Question 18

_{Regional Anesthesia - Anesthetic Options}

Example of combined use of Spinal anesthesia and Adductor canal continuous catheter techniques:

Answer 18

Used in Uni-compartmental knee replacement

Spinal primary anesthetic, and

Adductor canal continuous catheter to go home with

Question 19

_{Regional Anesthesia - Local Anesthetic Choices}

Characteristics to consider when choosing a LA:

Answer 19

Onset

DOA

Depth of blockade desired

Question 20

_{Regional Anesthesia - Local Anesthetic Choices}

Why use “Additives” with LA?

Answer 20

As markers

Prolong duration

Speed onset

Question 21

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs:

Answer 21

Lidocaine

^{Fast onset, short duration - Dense block}

Mepivicaine

^{Fast onset, short duration - Dense block}

Bupivicaine

^{Slower onset, long duration - Dense block}

Exparel = Liposomal Bupivicaine

^{Very slow onset - Very long acting}

Ropivicaine

^{Slower onset, long duration - Less profound block}

Question 22

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with Fast onset:

Answer 22

Lidocaine

Mepivicaine

Question 23

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with Slow onset:

Answer 23

Bupivicaine

Ropivicaine

Question 24

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with Very slow onset:

Answer 24

Exparel = Liposomal Bupivicaine

Question 25

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with short duration:

Answer 25

Lidocaine

Mepivicaine

Question 26

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with long duration:

Answer 26

Bupivicaine

Ropivicaine

Question 27

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with very long duration:

Answer 27

Exparel = Liposomal Bupivicaine

Question 28

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with Dense block:

Answer 28

Lidocaine

Mepivicaine

Bupivicaine

Question 29

_{Regional Anesthesia - Local Anesthetic Choices}

Commonly seen LAs with less profound block:

Answer 29

Ropivicaine

Question 30

_{Regional Anesthesia - Local Anesthetic Choices}

Common “Additives” to LA:

Answer 30

Epinephrine

Phenylephrine

Dexamethasone

Clonidine

Bicarb

Question 31

_{Regional Anesthesia - Local Anesthetic Choices}

“Additive” to LA to acts as intravascular marker:

Answer 31

Epinephrine

Question 32

_{Regional Anesthesia - Local Anesthetic Choices}

“Additive” that prolong duration of LA by decreasing uptake:

Answer 32

Epinephrine

Phenylephrine

Question 33

_{Regional Anesthesia - Local Anesthetic Choices}

“Additives” that generally prolong duration of LA:

Answer 33

Epinephrine

Phenylephrine

Dexamethasone (Decadron)

Clonidine

Question 34

_{Regional Anesthesia - Local Anesthetic Choices}

“Additive” that Speed onset of LA:

Answer 34

Bicarb

Question 35

_{Regional Anesthesia}

Complications and Risks of Peripheral nerve blocks:

Answer 35

Infection

Hematoma

Incidental blockade

Pneumothorax

Nerve injury

Intravascular injection

LA Toxicity

Total spinal anesthesia

Question 36

_{Regional Anesthesia - Infection risk}

How is the risk of infection with Regional anesthesia?

Answer 36

Very low risk <1%

cPNB ↑ risk over single shot

↑ risk at Femoral and axillary sites

Question 37

_{Regional Anesthesia - Infection risk}

Localized infection has been noted to occur more frequently than full sepsis.

Answer 37

TRUE

Question 38

_{Regional Anesthesia - Infection risk}

How to lower infection risks?

Answer 38

Avoid puncture of infected tissue

Ensure good aseptic technique

Judicious Pt selection

Reduce trauma r/t block placement

Question 39

_{Regional Anesthesia - Infection risk}

Lowering infection risk by ensuring good aseptic technique; how?

Answer 39

Good skin prep

^{Betadine – vs – Chlorhexadine}

Sterile technique

Catheter dressed well

^{Biopatch, chlorhexadine dressing}

Question 40

_{Regional Anesthesia - Infection risk}

What if Already septic or infected surgical site?

Answer 40

No clear data for what to do

Some say no increased risk for SS

I would not place continuous catheter!!!

Question 41

_{Regional Anesthesia - Infection risk}

Factors that may ↑ infection risk:

Answer 41

Recent trauma

Recent ICU admission

Compromised immunity

^{Including Diabetes mellitus}

Catheter in place for >48hrs

Absence of ABX use

Question 42

_{Regional Anesthesia}

Risk of Hematoma increased with:

Answer 42

Prolonged needling

Larger needle size

Trans-arterial technique

Pt with coagulopathy (Rx and patho)

Question 43

_{Regional Anesthesia - Hematoma}

Current Neuraxial Anticoagulation guidelines apply to RA. What’s the Caveat?

Answer 43

It is commonly and well accepted to judiciously practice outside of guidelines

Different blocks carry different risks

Question 44

_{Regional Anesthesia}

What you can do to decrease the risk of Hematoma:

Answer 44

Consciously avoid vascular structures

_{Avoid both deep and superficial structures}

Question 45

_{Regional Anesthesia - Hematoma}

You my pierce a vein and not see it nor get bloody aspiration. How come?

Answer 45

Veins collapse easily

with minimal pressure from needle or US

Question 46

_{Regional Anesthesia - Hematoma}

How long should you hold pressure after inadvertent vascular puncture?

Answer 46

5 minutes or

Longer for arterial puncture

Question 47

_{Regional Anesthesia - Hematoma}

How can Hematoma cause nerve injury?

Answer 47

↑pressure on nerve