Regional Anaesthesia

Question 1

In what order are the following modalities affected by local anaesthesia?

• Motor function
• Fine touch
• Proprioception
• Sympathetic tone
• Temperature

Answer 1

Sympathetic is first
Pain and temperature are second
Then proprioception and fine touch
Then motor function

Amount of blockade depends on dose of anaesthetic given and therefore concentration

A-gamma efferents and A-delta nociceptive afferent fibres are the most sensitive

C-fibres (dull pain afferents) are least sensitive

Question 2

What are the complications of a stellate ganglion block?

Answer 2

Pneumothorax
Mediastinitis
Oesophageal perforation
Intercostal neuralgia
Bleeding
Infection

Question 3

What is the sign of a successful stellate ganglion block?

Answer 3

Mueller’s syndrome

Warm ipsilateral face and injection of tympanic membrane

Question 4

What are the complications following an interscalene block?

Answer 4

Vertebral artery injection
Subarachnoid injection
Recurrent laryngeal nerve block
Neuropathy
Phrenic nerve block
Horner’s syndrome

Question 5

According to NAP3 what is the incidence of vertebral canal haematoma after neuraxial blockade?

Answer 5

0.85 per 100 000

Question 6

How long after rivaroxaban can you perform a spinal anaesthetic?

Answer 6

18 hours after last dose, if creatinine clearance is greater than 30ml/min

Question 7

How long after subcutaneous unfractionated heparin can you safely perform a spinal?

Answer 7

4 hours

Question 8

How long after subcutaneous LMWH can you safely perform a spinal?

Answer 8

12 hours

Question 9

How long after thrombolysis must you wait to perform a spinal?

Answer 9

10 days

Question 10

What are the complications of Erector Spinae Plane Block?

Answer 10

Failure
Infection
Bleeding
Local anaesthetic toxicity
Allergic reaction
Pneumothorax

Question 11

What are the contraindications for Erector Spinae Plane Block?

Answer 11

As always, divide your answer into absolute and relative contraindications.

Absolute

Patient refusal
Allergy to local anaesthetic
Infection at the site of injection

Relative

Anticoagulation is contentious - severe bleeding or wildly deranged clotting results should probably be discussed with haematology or at least a senior first - but the whole point of ESPB is that it can be used when neuraxial blockade is contraindicated by anticoagulation.

Question 12

What are the indications for Erector Spinae Plane Block?

Answer 12

Analgesia for rib fractures and metastasis
Nuss procedure
Thoracotomy
Percutaneous nephrolithotomy
Ventral hernia repair
Lumbar fusion

Question 13

What drug and concentration would you use for Erector Spinae Plane Block?

Answer 13

Levobupivacaine 0.25%
Ropivacaine 0.375%
20-30 ml is the generally accepted volume
As always your trust will likely have their own protocol or SOP - so check this first!

Question 14

Explain how you would prepare to perform an Erector Spinae Plane Block

Answer 14

Informed consent
Stop before you block, with confirmation of site and side
Trained assistant
‘AAGBI’ or Association of Anaesthetists minimum required monitoring - ECG, NIBP, Pulse oximetry
IV access
Emergency drugs and resuscitation equipment including airway equipment and intralipid available