Regional Flashcards
From which spinal nerve roots does the brachial plexus originate
- C5-T1
List the dermatomes that a successful interscalene block will reliably anaesthetise
C5- posterolateral aspect of upper arm
C6 - upper arm, posterolateral aspect of forearm
C7 - posterior forearm, lateral aspect of hand
List four patient factors that increase the likelihood of development of nerve injury after peripheral nerve block
- Cigarette smoking
- Obesity
- Diabetes
- Hypertension
- Electrolyte abnormalities
List three mechanisms of injury that may cause nerve damage during peripheral nerve block
- Direct trauma
- Compression
- Local anaesthesia neurotoxicity
- Stretch
State what is meant by triple monitoring in the context of performing peripheral nerve blockade
- Use of ultrasound
- Peripheral nerve stimulator to ensure absence of motor response at 0.2mA
- In-line pressure monitoring to avoid injurtion pressure > 25 psi
Assuming appropriate patient selection, preparation, antisepsis and use of “Stop Before You Block,” list two other strategies that may help reduce the risk of nerve injury during peripheral nerve blockade.
- Awake patient
- Echogenic needle
- Short bevelled needle
- Tangential approach to nerve
- Needle repositioning if paraesthesia encountered
- Avoid intraneural injections
- Use of ultrasound
List six specific nerves that must be blocked to achieve effective local anaesthesia for shoulder surgery
- Supraclavicular nerve C3,4 - skin above clavicle, shoulder tibe and first two intercostal spaces anteriorly. For shoulder surgery, would need superficial cervical plexus block or to infiltrate around posterior port site
- Suprascapular nerve C4-6, acromioclavicular joint, capsule, glenohumeral joint
- Axillary nerve C5-6, inferior aspect of capsule, glenohumeral joint
- Upper lateral cutaneous nerve of the arm C5-6, skin over deltoid
- Musculocutaneous nerve C5-7, variable area
- Medial cutaneous nerve of the arm C8-T1, skin of medial arm and axilla
List six possible neurological complications of an interscalene block
- Phenic nerve block - hemidiaphragm palsy
- Stellate ganglion block - transient Horner’s syndrome
- Recurrent laryngeal nerve palsy - hoarse voice
- Inadvertent spinal
- Inadvertent epidural
- Syrinx formation from injection into cervical cord
State five anaesthetic measures that can help reduce all types of neurological damage during shoulder surgery
- Use of 0.5% chlorhexidine spray for nerve block, air dried to miniise infection and neurotoxicity
- Nerve block using techniques to minimise nerve damage including USS, awake patient, pressure monitoring, peripheral nerve stimulator
- Ensure adequate padding around bony prominences and eyes to prevent optic neuropathy
- Care with positioning on table to avoid stretch on brachial plexus
- If using GA, ensure adequate filling and appropriate use of vasopressors to avoid cerebral hypoperfusion
Give one surgical measure that can help reduce all types of neurological damage during shoulder surgery
- Careful technique to minimise risk of contusion or traction of nerves during surgery
Give two possible advantages of carrying out shoulder surgery in conscious patients using regional anaesthesia
- Reduced risk of hypotension and cerebral hypoperfusion
- Avoids risks of GA including PONV, more rapid return to normal diet and discharge
- Increased patient engagement in own care
- More efficient theatre utilisation if block room model followed
An 80-year-old woman is admitted to your hospital having sustained a proximal femoral (neck of femur) fracture in a fall.
List three pharmacological best practice elements of this patient’s pain management while awaiting surgery.
- Regular paracetamol unless contraindicated
- Opioids if required but aim to limit opioid intake, especially long-acting opioids
- NSAIDs not recommended.
You decide to perform a fascia iliaca block as part of her multimodal analgesia. Give the borders of fascia iliaca
- Anteriorly: fascia iliaca
- Posteriorly: iliacus and psoas major muscles
- Medially: origin of psoas major and vertebral column from which it originates
- Laterally: origin of iliacus muscle along the inner aspect of the iliac crest.
List the nerves blocked in a fascia iliaca block
- Femoral
- Lateral cutaneous nerve of the thigh
- Obturator
List two benefits of inclusion of a fascia iliaca compartment block in the pain management strategy for this patient.
- Contribute to better overall pain experience
- Avoidance of longer-acting opioids which may contribute to the risk of delirium
- May facilitate examination and radiological assessment on first presentation.
- May reduce the need for sedative or analgesic drugs for positioning for spinal anaesthesia, thus reducing the risk of delirium
- Are associated with a reduced time to remobilisation
State why a fascia iliaca block alone is insufficient for provision of anaesthesia for fractured neck of femur surgery.
Does not block innervation of posterior aspect of hip capsule and ischiocapsular ligaments which are innervated by sciatic nerve
State two specific complications of fascia iliaca block.
- Femoral nerve block causing quadriceps weakness, or femoral nerve damage
- Peritoneal puncture (suprainguinal technique)
- Bladder puncture (suprainguinal technique)
- Compartment block so reliant on large quantities of local anaesthetic, with risk of local anaesthetic toxicity
- Femoral artery and/or vein puncture with risk of vascular injection with local anaesthetic toxicity, pseudoaneurysm formation, or haematoma.
Give three alternative peripheral nerve blocks that may be used in the management of patients having proximal femoral fracture surgery.
- Femoral nerve block
- 3-in-1 block
- Lumbar plexus block
- Quadratus lumborum block
List five nerves that can be blocked at ankle level for foot surgery, describe their sensory distribtuion and give the anatomical landmarks
- Tibial-heel and plantar aspect of foot - midway between medial malleolus and tip of calcaneum, posterior to PT artery
- Deep peroneal - 1/2nd toe web space - 2-3cm distal to intermalleolar line lateral to extensor hallucis longus, inject either side of DP artery
- Superficial peroneal - dorsum of foot except 1/2nd toe web space - between tibial ridge and lateral malleolus
- Sural - plantar aspect 4/5th webspace+ lateral aspect foot - between lateral malleolus and Achilles tendon
- Saphenous - medial aspect of foot and ankle - posterior to saphenous vein from medial malleolus to Achille’s
Give five (total) pros and cons of an ankle block
Pros:
* Good post-operative analgesia
* Avoids GA in high risk patients
* Simple technique, low risk LA toxicity
* Minimal motor block
Cons:
* Can be uncomfortable to perform
* Risk of vascular puncture, particularly saphenous vein
* Does not alleviate tourniquet pain
Between which muscles do the berves that supply cutaneous innervation for the anterior abdominal wall lie
Internal oblique and transversus abdominis
State the nerves responsible for sensory innervation of the anterior abdominal wall
- Branches of anterior rami T7-T12
- Iliohypogastric nerve
- Ilioinguinal nerve
List three types of surgery in which TAP block coudl be used
- Abdominal hysterectomy
- Caesarean section
- Appendicectomy
- Lower abdominal open colorectal surgery
List three potential benefits of performing a TAP block for abdominal surgery
- Reduced opioid requirement, reduced related complications e.g. respiratory depression
- No associated motor block or urinary retention
- Alternative analgesic option in patients whom neuraxial block is contraindicated e.g. coagulopathy
- Offers pain relief after emergency caesarean where urgency has not permitted neuraxial
GIve two limitations of TAP block as part of an analgesic approach for abdominal surgery
- Does not offer visceral pain relief
- Short duration of analgesia
- Variable spread of local anaesthetic in facial plane so variable outcome
State the boundaries of the triangle of Petit
- Iliac crest inferiorly
- Anterior border latissimus dorsi posteriorly
- Posterior border of external oblique anteriorly
List two approaches to ultrasound guided TAP block
- Classial/lateral approach
- Subcostal approach
- Posterior approach
List two specific complications of TAP blocks
- Failure
- Local anaesthetic toxicity
- Transient femoral block
List the brachial plexus blocks
- Interscalene (roots)
- Supraclavicular
- Infraclavicular
- Axillary
Give regional techniques for mastectomy
- Serratus anterior
- Erector spinae
- Thoracic epidural
- Paravertebral
- Pectoral nerve block
