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AP II Test 2 > Peripheral Nerve Blocks > Flashcards

Peripheral Nerve Blocks Flashcards

1
Q

What determines our choice of anesthetic? (5)

A

time to onset
duration of action
degree of sensory block to motor block
risk of cardiac toxicity
how many areas need to be blocked

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2
Q

What is the dose and duration of bupivacaine?

A

3mg/kg

1.5 - 8 hours

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3
Q

What is the dose and duration of lidocaine?

A
  1. 5 mg/kg, 7 with epi
  2. 75 - 2 hours
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4
Q

What is the dose and duration of mepivicaine?

A

4.5 mg/kg, 7 with epi

1-2 hours

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5
Q

What is the dose and duration of ropivacaine?

A

3 mg/kg

1.5-8 hours

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6
Q

Name the amides: (5)

A

bupivacaine

lidocaine

mepivacaine

prilocaine (used for dental, PNB)

ropivacaine

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7
Q

Name the esters: (5)

A

benzocaine

chloroprocaine

cocaine

procaine

tetracaine

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8
Q

What are the concentrations of bupivicaine?

A
  1. 25%
  2. 5%
  3. 75%
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9
Q

What are the concentrations of lidocaine?

A

0.5-5%

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10
Q

What are the concentrations of mepivacaine?

A

1-3.5% in 0.5% increments

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11
Q

What are the concentrations of ropivacaine?

A

0.2, 0.5, 0.75, 1%

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12
Q

What is the max dose and duration of chloroprocaine?

A

12 mg/kg

All esters are 0.5 - 1 hr except tetracaine.

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13
Q

What is the max dose and duration of cocaine?

A

3mg/kg

All esters are 0.5 - 1 hr except tetracaine.

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14
Q

What is the max dose and duration of tetracaine?

A

3mg/kg

1.5-6 hours

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15
Q

What is the max dose and duration of procaine?

A

12 mg/kg

0.5-1 hr

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16
Q

Why do we use epinephrine? (4)

A

Intravascular marker: increase HR by 20%

Improves quality of block: increased neuronal uptake, and alpha2- adrenergic receptors

Decreases absorption: prolong action

Vasoconstriction on surgical field

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17
Q

What amount of epinephrine do we add to LA?

A

5 mcg/ml (1:200,000)
2.5 mcg/ml (1:400,000)

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18
Q

What are the major risks of nerve blocks?

A

Systemic toxicity, rare but fatal

Infection

Peripheral nerve damage

Note: Use B bevel needles (short bevel) to reduce risk of nerve damage.

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19
Q

What vascular areas are most to least prone to systemic toxicity? (8)

A

Tracheal
Intercostal
Caudal
Paracervical
Epidural
Brachial plexus
Sciatic
subcutaneous

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20
Q

What are the signs and symptoms of CNS excitation toxicity? (6)

A

Dizziness
Tinnitis
Circumoral numbness
Muscle twitches
Slurred speech
Seizures

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21
Q

What are the cardiovascular signs of toxicity? (5)

A

Depress myocardial conduction and contractility

Produce arterial vasodilatation, except cocaine

Hypotension

Bradycardia, PVCs, PACs

VT or VF

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22
Q

How do you prevent systemic toxicity?

A

Incremental injection
Frequent aspiration
Adding a marker
Limiting LA dose and concentration
Continual communication with patient

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23
Q

In a nerve block, proceed with caution in what patients?

A

Patients with cardiac conduction abnormalities

Kidney or liver disease

Acidosis

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24
Q

How do you treat seizures from systemic toxicity?

A

midazolam, propofol, thiopental

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25
How do you treat cardiac toxicity/respiratory depression during systemic toxicity?
Airway management ACLS/BLS: avoid calcium channel blockes, B-blockers and lidocaine IV lipid infusion Cardiopulmonary bypass
26
How do you provide LAST lipid treatment?
20% Intralipid 1. 5 mL/kg as an initial bolus, followed by 0. 25 mL/kg/min for 30-60 minutes Bolus could be repeated 1-2 times for persistent cardiac collapse Infusion rate could be increased if the BP declines.
27
What are the methods to place nerve blocks?
Ultrasound technique: direct visualization ## Footnote Peripheral nerve stimulator: motor response Paresthesia technique: sensory response
28
What nerves are included within the brachial plexus?
C5-C8, T1
29
What nerves can accidentally be blocked when blocking the brachial plexus?
Superficial cervical plexus: C3-C4 Phrenic nerve: C3, C4, C5 Intercostobrachial nerve: T2
30
Name the brachial plexus blocks: (4)
Interscalene Supraclavicular Infraclavicular Axillary
31
Name the block performed with the ultrasound positions indicated in the image:
1. Interscalene (roots/trunks) 2. Supraclavicular(divisions) 3. Infraclavicular(cords) 4. Axillary(branches) 5. Mid-humeral(branches)
32
What are the most commonly performed blocks for regional anesthesia?
Interscalene
33
What block provides anesthesia and analgesia for shoulder, humerus, and clavicle?
Interscalene
34
What block is performed at the level of the roots/trunks of BP, between the anterior & middle scalene muscle?
Interscalene
35
What block is traditionally unsuccessful for forearm and hand surgery because the ulnar nerve is often missed?
Interscalene
36
What are the adverse effects and possible complications of brachial plexus blocks?
* phrenic nerve palsy * Horner’s syndrome (stellate ganglion block) * Cervical plexus block (small pupil, drooped eyelid) * Recurrently laryngeal nerve palsy * Possible vertebral artery injection * Pneumothorax (PTX) * Epidural, subarachnoid injection
37
What anesthetic is often used for humeral fractures or shoulder surgery?
Ropivacaine 0.75%
38
What is also known as the spinal of the arm?
Supraclavicular block
39
What block is performed at the DIVISIONS of the brachial plexus and is used to perform surgery for the entire arm, below the shoulder?
Supraclavicular block
40
What are the risks of supraclavicular blocks?
pneumothorax 50% chance of phrenic nerve block recurrent laryngeal nerve block vascular puncture
41
What block is indicated for elbow, forearm, and hand surgery?
infraclavicular, aka axillary block least preferred
42
What block is performed at the level of the terminal branches: median, ulnar, radial, and musculocutaneous nerves?
axillary
43
Axillary block has a low complication rate and low rate of infection/hematoma. True or false?
false low complication high infection rate/hematoma
44
What position must the arm be in for an axillary block?
abducted
45
What nerve often gets overlooked in brachial plexus blocks?
musculocutaneous nerve
46
What block provides surgical anesthesia for short procedures (\<45-60 minutes) in the forearm, hand, or leg?
Bier block
47
What items do you need to perform a bier block?
IV inserted on the hand double pneumatic tourniquet eschmark elastic bandage 0.5% lidocaine (50ml)
48
What are the benefits of continuous peripheral nerve blocks?
Decreased sleep disturbances Increased patient satisfaction Possible improved early rehabilitation Decreased narcotic side effects: * Nausea/vomiting * Pruritis * Sedation
49
The lumbar plexus is comprised of the ventral rami of what nerves? Name them:
T12, L1-L4 Iliohypogastric/ilioinguinal Femoral Obturator Lateral femoral cutaneous
50
The sacral plexus is comprised of the ventral rami of what nerves? Name them:
L4-S4 Sciatic nerve Tibial Common peroneal
51
What are the most commonly blocked nerves in the lumbar plexus?
femoral sciatic obdurator
52
What type of block is good for providing analgesia for the hip, anterior thigh, and knee?
lumbar plexus block
53
What nerves does the lumbar plexus block cover?
LFCN femoral obturator
54
What is a lumbar plexus deep block's distance from skin to lumbar plexus?
5-10 cm
55
What are the complications of a lumbar plexus block?
renal puncture spinal or epidural injection hematoma LAST
56
What is the largest branch block of the lumbar plexus that arises from L2, L3, and L4?
femoral nerve block
57
What nerve emerges from the psoas muscle and gives off articulating branches to the hip?
femoral nerve
58
What nerve enters the leg under the inguinal ligament and then quickly divides?
femoral nerve
59
Is the femoral nerve located more medially or laterally?
laterally
60
What muscle is on the anterior division of the femoral nerve?
sartorius
61
What muscle is located on the posterior division of the femoral nerve?
Saphenous nerve (most medial) Muscular (quadriceps muscle) Articular branches ( knee) Femur
62
Where do we place the transducer for a femoral nerve block?
Over the femoral artery at the level of inguinal ligament
63
What is the needle approach to a femoral nerve block?
lateral to medial
64
What type of block do we use for: knee surgery: TKA, ACL reconstruction, patellar surgery femoral ORIF, skin grafting, muscle biopsy?
femoral
65
What block do we use for surgery involving the medial aspect of the leg?
femoral nerve block
66
What nerve tends to be overlooked in a femoral nerve block and may need to be blocked also?
saphenous nerve
67
What is the onset time for a femoral block using ultrasound with 20ml of buivacaine 0.5%?
about 15 minutes vs. about 30 minutes for an unguided block
68
For any surgery involving the medial aspect of the foot/ankle or a popliteal/sciatic nerve block. you must also have what nerve blocked?
saphenous nerve
69
What is the largest sensory branch of the femoral nerve?
saphenous nerve
70
What are the 4 main locations we can block the saphenous nerve?
femoral nerve adductor canal below the knee medial malleolus
71
What is the largest nerve in the human body?
sacral plexus, sciatic nerve L4-S3
72
What are the imaging areas for the sciatic nerve?
popliteal mid-thigh subgluteal transgluteal
73
What is the sensory nerve to the posterior hip and knee?
sciatic nerve
74
The sciatic nerve innervates what muscles? (motor function)
hamstrings and lower leg below the knee
75
When do we use a sciatic nerve block?
Knee surgery(TKA), foot and ankle surgery
76
What are the complications of a sciatic nerve block?
partial block, nerve injury
77
What are complications of popliteal fossa sciatic nerve blocks?
incomplete blocks due to anatomical variations sciatic nerve divides into the tibial nerve and common peroneal nerve at varying locations above the popliteal fossa
78
What is the main obstacle of subgluteal sciatic nerve blocks?
depth of nerve, especially in large pts
79
Sciatic nerve blockade in the subgluteal region is convenient and easily accessible. True or false?
true
80
Where do you insert for sciatic nerve block?
groove just lateral to the upper portion of the biceps femoris muscle
81
What are the indications for an ankle block?
foot and toe surgery good if no tourniquet is used above the calf
82
What nerves are blocked in an ankle block?
Deep peroneal Superficial peroneal Posterior tibial Sural saphenous
83
84
What is the concentration of benzocaine?
20% topical only
85
For lumbar plexus block, what type of probe do you need?
low frequency

AP II Test 2 (7 decks)

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