Regional- Technique

Question 1

Interscalene block with nerve stimulator

Answer 1

• Pt supine with head turned away from site
• palpate posterior border of sternocleidomastoid at level of C6
• roll fingers posterior to palpate grove btw anterior and middle scalene muscles
• Insert needle at C6 level slightly caudad, posterior direction
• starte nerve stimulator at 1.0 mA
  
  • look for twitch of bicep or distal hand between 0.5-0.3 mA
• Aspirate and inject 30 ml of LA
• depth 1-2 cm

Question 2

Interscalene ultrasound technique

Answer 2

• look for hypoechoic nerve trunks in “stop light” formation
• insert needle laterally, in plane
• aim between superior and middle trunks as shown
• aspirate and inject 20 ml

Question 3

Supraclavicular nerve stimulator technique

Answer 3

• lateral border of the clavicular head of SCM
• identify groove btw the scalene muscles
• insert needle 1 cm from med-clavicle
  
  • needle is directed toward the axilla, away from midline
• motor stimulation should happen immediately after needle has entered the interscalene groove
  
  • more distal response = a more reliable block
• Inject when motor response is still maintained at 0.5 mA
  
  • aspirate first, inject 30-40 ml

Question 4

Supraclavicular ultrasound technique

Answer 4

• Put probe over clavicle
  
  • Linear, high frequency probe
  • 5-12 Hz
• visualize subclavian artery and brachial plexus lateral and superior
  
  • visualize first rib and pleura
• Insert needle lateral and in plane
  
  • goal is to “corner pocket” between nerve bundle and subclavian artery
• aspirate and inject 20-30 ml in 5 ml increments

Question 5

Infraclavicular nerve stimulator technique

Answer 5

• externally rotate and abduct arm
• 2 cm medial and 2 cm caudad from coracoid process
• needle toward axillary pulse along delto-pectoral groove
  
  • needle is insulated B bevel 10 cm
• begin with 1 mA and observe for finger/thumb extension or flexion
  
  • if you have bicep/musculocutaneous stim, your needle is too lateral
  • maintain distal stimulation at 0.5-0.3 mA
• aspirate and inject 30-40 ml in 5 ml increments

Question 6

Infraclavicular ultrasound technique

Answer 6

• Probe: High frequency linear
  
  • 5-12 Hz
• place probe inferior to clavicle
• visualize axillary artery
  
  • observe lateral, posterior, and inferior cords if possible
• In-plane approach, directing needle toward posterior cord
• aspirate and inject 30 ml in 5 ml increments
  
  • 15 ml on posterior cord and 15 ml on medial cord
• ***steep angle makes needle visualization difficult
• ***can compress axillary artery with US probe, dont push too hard

Question 7

What is the Houdini clavicle maneuver?

Answer 7

• abduct arm (see photo)
• removes the clavicle from US view
• allows for more shallow angle of needle and better visualization
• needle is inserted 1-3 sm away from edge of probe and directed toward posterior cord below artery

Question 8

Axillary nerve stimulator technique.

MCN block

Answer 8

• arm abducted and externally rotated
• palpate axillary artery high in axilla
• Needle 22g, 4 cm B bevel
• insert above or below artery at 45 degree angle
  
  • observe for finger or thumb flexion
  • decrease to 0.5 mA or less
• aspirate and inject 30 ml
• MCN block:
  
  • pull biceps laterally
  • set to 1.0 mA
  • advance needle into coracobrachialis until vigorous bicep contraction
  • inject 10 ml of LA

Question 9

Axillary block transarterial approach technique

Answer 9

• Needle: 22 g 4 cm B bevel or 26g 1/2 in
• palpate artery, maintain distal pressure
• insert needle into artery, aspirate blood
• advance needle until flow stops
• inject 30-40 ml
• withdraw needle and maintain pressure for 5 min

Question 10

Axillary block ultrasound technique

Answer 10

• Probe: High frequency linear
• pt supine, arm abducted 90 degrees
• visualize artery and hypoechoic nerves
• insert needle in plane
• inject 10 ml on each nerve or 30 ml in one injection
• visualize MCN and deposit 5-10 ml

Question 11

Bier block technique

Answer 11

• have distal IV in hand
• elevate and wrap arm in esmarch bandage to exsanguinate arm
• inflate proximal tourniquet
• unwrap esmarch
• verify no arterial flow via pulse ox
• inject 25-50 ml of 0.5% lidocaine into IV (no epi)
• onset of block is within 5-10 min
• hold tourniquet for 30 minutes min to decrease LA toxicity risk
• slowly deflate cuff

Question 12

How do you make 0.5% lidocaine?

Answer 12

• mix 25 mL of 1% lidocaine with 25 ml of NS

Question 13

Subcostal TAP block technique

What is the target?

Answer 13

• Linear probe placedon medial to lower margin of rib cage
• Rectus abdominus is visualized
  
  • transverse abdominis muscle is deep to this sheath
• Target: fascial plane between the posterior rectus sheath and the transverse abdominis muscle
• Needle- medial to lateral to target (50-100 mm)
• inject 15-20 ml LA

Question 14

Lateral TAP block technique

target?

Answer 14

• Linear probe- placed at midaxillary line between subcostal margin and iliac crest
• visualize 3 muscles: external oblique, internal oblique, transverse abdominis
• Target: fascial plane between internal oblique and transverse abdominis
• Needle: insert anterior to midaxillary line, medial to lateral
• aspirate and inject 15-30 ml LA

Question 15

Femoral nerve block nerve stimulator technique

Answer 15

• Needle: 22g B bevel 5 cm
  
  • 1-2 mA
• insert 1-2 cm lateral to femoral artery, just below inquinal ligament directed cephalad at 30-45 degree angle
  
  • depth 1-3 cm
  • observe brisk “patellar snap” with current 0.5 mA or less
• aspirate and inject 20-30 ml LA

Question 16

Femoral nerve block ultrasound technique

Answer 16

• Prove: high frequency linear
  
  • 5-12 Hz
  • place in inguinal crease
• Nerve is hyper-echoic triangular shape lateral to femoral artery
• advance needle in plane lateral to medial
• penetrate fascia lata and fascia iliaca
• deposit 20-30 ml LA around entire nerve

Question 17

Adductor canal block ultrasound technique

Answer 17

• needle: 22g B bevel 5-8 cm
  
  • inserted in plane, lateral to medial
• Probe: high frequency linear
  
  • place probe on mid thigh
  • Place pt in supine position with external rotation of thigh
• Saphenous nerve is anterior and lateral to femoral artery and vein
• surrounded by:
  
  • sartorious
  • vastus medialis
  • adductor magnus
• aspirate and deposit 10-20 ml LA
  
  • surround the artery

Question 18

What are the anatomical landmarks for the sciatic nerve?

Answer 18

• using labats approach: (pt lateral with knee flexed)
• draw line from greater trochanter to posterior superior iliac spine
• draw second line from greater trochanter to sacral hiatus
• draw third line perpendicular from midpoint of first line to intersection with second line

Question 19

Sciatic nerve block nerve stimulator technique

Answer 19

• needle: 22g B bevel 10 cm
• set stimulator at 1-1.5 mA
• insert perpendicular to all planes
• advance through gluteus maximus stimulation
• observe plantar flexion (tibial nerve) or dorsi-flexion (common peroneal)
• Dial to 0.5 mA, aspirate, and slowly inject 20-30 ml LA
  
  • no epi

Question 20

Sciatic nerve block ultrasound technique.

Answer 20

• Probe: low frequency, curvilinear probe
  
  • 2-8 MHz
• place probe at midpoint between ischial tuberosity and greater trochanter
  
  • both bony structures will be visible with fascial layer deep to gludeal muscles
  • sciatic nerve is deep to this fascial layre
• advance needle in plane or out of plane with nerve stip

Question 21

Popliteal nerve block nerve stimulator technique:

Answer 21

• needle: 22g, B bevel, 5 cm needle
• place pt prone
  
  • have lower leg/foot elevated so you can see when it moves from stim
• identify the popliteal fossa crease, the biceps femoris tendon (lateral), and semitendinosus and semimembranosus tendon (medial)
• Insertion point is 7-10 cm proximal to crease, between two tendons
• Set stimulator for 1.5 mA
  
  • observe for plantar flexion or dorsiflexion at 2-3 cm depth
  • decrease to 0.2-0.5 mA
  • aspirate and inject 20-30 ml LA

Question 22

popliteal nerve block ultrasound technique

Answer 22

• Probe: High frequency linear probe
  
  • 8-12 mHz
• Pt can be prone supine or lateral
• place probe in popliteal fossa, ID popliteal artery
  
  • tibial nerve is superficial to artery
• advance probe proximal and observe where tibial and common peroneal come together to form sciatic
• insert needle in plane lateral to medial

Question 23

Ankle block technique

Answer 23

• Posterior tibial nerve
  
  • inject LA behind medial malleolus
  • deep to superficial fascia
  • contact bone then withdraw 1-2 mm, inject 3 ml
• Deep peroneal nerve
  
  • palpate groove just lateral to extensor hallucis longus (flexing big toe helps)
  • contact bone, withdraw 1-2 mm, inject 2-3 ml
• Saphenous nerve
  
  • at level of medial malleolus
  • inject “ring” of LA from:
    
    • injection site to achilles tendon
    • injection site to tibial ridge
  • 5 ml
  • 1.5 inch, 25 g needle
• Superficial peroneal
  
  • inject “ring” of LA from tibial ridge toward lateral malleolus
  • 5 ml LA
  • 1.5 in 25 g needle
• Sural nerve
  
  • at level of lateral malleolus
  • LA is injected towards the achilles tendon, subcutaneously, fan like spread
  • 5 ml

Question 24

Summary table of lower body blocks

Know: plexus, volume, indications, and notes for:

TAP

Femoral

Adductor canal

sciatic

popliteal

ankle

Answer 24