Regional Flashcards
Superficial Cervical Plexus block
5 - 15 mL
Stellate Ganglion Block
5 mL
Interscalene Block
Supine, head turned contralateral
Depth 1 - 4 cm
22 G 50 mm needle
10 mL 0.2% for analgesia, 15 -20 mL 0.5% for anaesthesia
Ulnar sparing
Stellate Ganglion cross section
Supraclavicular BP
20 - 25 mL
Infraclav BP
Supine, head contralateral, Shoulder abduction elbow flexion
20 - 30 mL
Axillary BP
Supine, arm abducted + elbow flexed
22 G 50 - 100 mm needle
15 - 25 mL
ESPB
T5 for thoracic/breast surgery, T10 for abdominal, L3 for L-spine surgery
NB Lumbar level- much thicker ES muscle
30 mL ~8 thoracic or 4 lumbar levels
Midaxillary TAP
Block nerves prior to lateral cutaneous lateral cutaneous branch origin
Ensure LA reaches point where TA muscle ends
25 - 30 mL each side
SEnsory block below umbilicus to pubis
Subcostal TAP
Not very useful- doesn’t cover lateral cutaneous branches of intercostal nerves. Only get midline strip of anaesthesia- not useful e.g. Chevron, nephrectomy
PECS I and II
PECS 1: Muscle implants or tissue expanders, Pec muscle surgery, minimally invasive cardiac surgery
PECS II: breast surgery T2 -T6
Arm abducted 90 deg
Probe oblique parasaggital over 3rd and 4rth ribs
10 mL in PECS I, 20 mL PECS II. Do PECS II first
Serratus Anterior Plane
Block lateral cutanous branches T2-9 intercostal nerves, LTN (winged scapula), TDN, ICBN
Anterior cutaneous branches spared
Supine, shoulder abducted. Probe transverse, 5th and 6th ribs Mid axillary line at nipple level. Needle anterior to posterior, inject beetween LD and SA muscles (Shallow) or deep to serratus. No evidence for one vs other
Up to 40 mL LA
Paravertebral Block
Combined USS and LORS technique
Out of plane easier with hydrodissection
Breast surgical anaesthesia do every level T2-6 4 - 5 mL. Analgesia: T4 25 mL 0.5% ropi
Catheter 3 -4 cm max
Rectus Sheath block
avoid inferior and superior epigastric arteries. Posterior sheath
In plane lateral to medial
20 mL each side 2 at level of umbilicus, 2 at midpoint between umbilicus and xiphoid
Arcuate line- posterior rectus sheath terminates- . 1/3 below umbi.
Quadratus Lumborum Block
30 mL each side should block most of anterolateral abdominal wall
Curvilinear probe transverse just cephalad to iliac crest
Hip flexed
Needle medial to lateral
QL approaches
Lateral similar to TAP
Posterior: fascial plane posterior to QL (hope local spreads anteromedially)
Anterior: LA between QL and PM. Most effective/best spread cephalad
Lumbar plexus
Suprainguinal FIB
probe parasagital just medial to ASIS, slide inferomedially along ligamient
AIIS forms back ponbe of recturs fermoris- bow tie
avoid DCIA
Needle below Ingional ligmaent (IL)
FIB/FNB
Obturator block
Subgluteal Sciatic nerve
PCFN block not guaranteed but can block in same region
Inferior gluteal artery good landmark for plane
Hip flex
Popliteal Sciatic nerve
20 mL
Save 5 -10 for saphenous
Ankle block
PT- Posterior to MM, TDANH, inject from post to ant
Saphenous- field block above MM
SPN- Field block over dorsum of foot
DPN- Lateral to DPA
Sural- by short saphenous
Wrist block
- 25 G needle
- Median: mid forearm volar between deep and superficial flexors, trace down to wrist. 3 mL. Or needle 1 cm deep between FCR and PL
- Ulnar nerve: Mid forerarm where separates from Ulnar artery just medial to ulnar artery, 3 mL LA. Below FCU
- Superficial radial nerve- immediately superficial to styloid process (just lateral to radial artery) (NB deep branch motor). Radial styloid process palpated , 5 mL LA SC from dorsum of wrist
- Ulnar dorsal cutaneous branc- in SC tissue between Ulnar styloid and FCU- infiltrate SC on way out of ulnar. block
- Lateral cutaneous nerve of forearm- may cross into thenar emininece- SC infiltration across lateral wrist crease
Nerve injury - main concern
Motor blcok minimial as most muscles are innervated higher
Adductor canal
PENG
Interfascial plain block. Does not cover LFC
100 mm needle
20 mL LA
Abdominal wall innervation
L spine Transverse section
Deep blocks
Stellate ganglion/deep CP
Infraclavicular
Paravertebral
QL/Lumbar plexus,
PENG
Proximal sciatic block (above subgluteal!!)
NA
Superficial Blocks
Peribulbar/ST
SCP
ISB/Supraclav/axilla
SAP
ESB/intercostal
II/IH/TAP/Rectus sheath
Femora/FIB
Subgluteal or popliteal sciatic
Ankle
Breast Innervation
Lateral and anterior cutaneous branches of T2 - 6 intercostal nerves (including ICBN). Travel via paravertebral space
Supraclavicular nerve (SCP)
Bier’s block
Bilateral IV access
Double tourniquet, elevate/exsanguinate limb, tourniquet inflation 100 mmHg > SBP
Surgical procedure. Manage tourniquet pain by inflating distal cuff then deflate prox
Tourniquet time must be >20 min.
Gradual/cyclical deflation
Penile block
The technique involves inserting the needle until it
touches the pubic symphysis. This gives a guide to
depth. The needle is then withdrawn and redirected to
pass below the symphysis and 3-5 millimetres deeper
depending on the size of the patient. It is preferable
to direct it slightly laterally into the pear shaped space
and then to re-insert in on the other side depositing
equal volumes on each side. Avoiding the midline
injection reduces the chance of penetrating the dorsal
vessels of the penis and causing haematoma. If a
short beveled needle the fascia may be felt as a slight
resistance when it is penetrated, but in small children
this is not always felt as it is thin and may offer little
resistance
Ilioingional and iliohypogastric
probe oblique from line joining ASIS and umbilicus
10 - 20 mL
Intercostal blocks
3 -5 mL vol per level
between internal and innermost intercostal (can’t tell which plane actuall’y)
Posterior chest wall
Innermost and internal intecostal muscles disappear medial to scapula angle!. Only EIM and a membrane
Eye innervation
Sensory
- CNII- sensory to retina
-V1:
–Nasociliary- long and short - ciliary- sensation to cornea/limbus/superonasal- intraconal
–Lacrimal and frontal- remaining conjunctiva. Extraconal
Motor
- CN3: LPS, S/M/I rectus, IO
-CN6 abducens LR
-SO 4 trochlear
NA USS transverse interspinous/interlaminar
NA USS PSO
