Peripheral Nerve Blocks Part 3

Question 1

Indications for a fascia iliaca block

Answer 1

anesthesia to hip, anterolateral thigh, and anterior knee to provide analgesia for hip fractures, THR, and hip scope

Question 2

What does the lumbar plexus branch into in the lower extremity?

Answer 2

lateral femoral cutaneous, femoral, and obturator

Question 3

What is not reliably blocked in a fascia iliaca block?

Answer 3

obturator nerve (located along medial border of psoas)

Question 4

Describe how to perform a fascia iliaca block

Answer 4

supine, transducer placed in parasagittal plane over ASIS, slide transducer medial along inguinal ligament to identify inferior border of IOM and superior border of SM (iliacus muscle is deep to them), insert needle in-plane until is passes through fascia iliaca (feel pop), and inject LA after negative aspiration- iliacus should separate from fascia iliaca

Question 5

How much volume of LA do you use with a fascia iliaca block?

Answer 5

40-60 mL

Question 6

Indications for a transversalis fascia plane block

Answer 6

anesthesia of anterolateral abdominal wall at L1 (ideal for inguinal hernia repair, iliac crest bone graft)- does NOT prevent visceral pain

Question 7

What nerves are blocked with a transversalis fascia plane block?

Answer 7

ilioinguinal and ilihypogastric nerves

Question 8

Describe how to perform a transversalis fascia plane block

Answer 8

pt lateral or supine, transducer placed transverse between costal margin and iliac crest along mid-axillary line, slide transducer posterior until TAM tapers off, insert needle 2-3 cm anterior to transducer and advance in posterior direction until tip lies within plane between deep fascia of the TAM and transversalis fascia, inject LA after negative aspiration to dissect plane between TAM and trasnversalis fascia

Question 9

Volume used for a transversalis fascia plane block

Answer 9

20 mL (per side if doing bilaterally)

Question 10

Indications for a femoral nerve block

Answer 10

surgery of anterior thigh and knee

Question 11

Landmarks for a femoral nerve block

Answer 11

femoral (inguinal) crease, femoral artery pulse

Question 12

Desired response to nerve stimulation for femoral nerve block

Answer 12

twitch of patella/quadriceps

Question 13

Volume used for femoral nerve block

Answer 13

15-20 mL

Question 14

Describe where the femoral nerve is in relation to the femoral artery

Answer 14

Immediately lateral to the vessel (and deep to the fascia iliaca)

Question 15

Describe how to perform a femoral nerve block

Answer 15

pt supine, ID femoral artery on US with transducer in femoral crease (nerve should be lateral to it), guide needle tip immediately adjacent to lateral aspect of femoral nerve into the wedge-shaped tissue space- inject LA after negative aspiration (femoral nerve should be lifted off surface of iliopsoas m)

Question 16

Indications for saphenous nerve block

Answer 16

medial ankle, foot surgery, saphenous vein stripping/harvesting

Question 17

What are the two approaches for a saphenous nerve block?

Answer 17

infiltrate medial aspect of knee at level of tibial tuberosity or adductor canal block

Question 18

Volume of LA used for a saphenous nerve block

Answer 18

5-10 mL

Question 19

What is different about a saphenous nerve block when using US?

Answer 19

visualization of the nerve is not necessary- it is not always well imaged (injecting 5-10 mL of LA next to the artery should suffice)

Question 20

Indications for adductor canal block

Answer 20

lower limb, foot and ankle surgery (usually in combo with popliteal bock)

Question 21

Where is the LA injected for an adductor canal block?

Answer 21

into the adductor canal deep to the sartorius muscle

Question 22

How much LA volume is used for a low volume adductor canal block? What is a low volume block used for?

Answer 22

5-10 mL; knee scope, ACL reconstruction, lower leg, foot and ankle surgery

Question 23

How much LA volume is used for a high volume adductor canal block? What is it used for

Answer 23

20-30 mL; total and uni-compartmental knee replacement

Question 24

Describe how to perform an adductor canal block

Answer 24

US probe on anterior aspect of patient’s thigh, mid-point between inguinal crease and medial condyle; identify femur and move probe medially until traspezoid shaped sartorius muscle is visualized and the femoral artery is in the middle of it; insert needle and inject next to the artery

Question 25

What area does an iPACK provide anesthesia to?

Answer 25

posterior knee joint

Question 26

What area does a local infiltration anterior (LIA) provide anesthesia to?

Answer 26

anterior knee

Question 27

What does an iPACK/LIA avoid blockade of?

Answer 27

common peroneal nerve

Question 28

Describe how to perform an iPACK

Answer 28

position patient with leg externally rotated and slightly flexed, place transducer in transverse position along medial thigh just above medial condyle of femur, ID popliteal artery, insert needle 2-3 cm medial to transducer until tip extends 3 cm beyond lateral border of the artery and inject after negative aspiration

Question 29

How much LA is used in an iPACK?

Answer 29

up to 30 mL

Question 30

Describe how to perform a LIA

Answer 30

transducer positioned over anterior distal thigh, insert needle 2-3 cm medial to transducer, advance needle over top of femur deep within muscle, administer 20 mL as needle is slowly withdrawn, reposition needle superficially and inject additional 20 mL (??)