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931: Advanced Principles of Anesthesia I > Ultrasound guided lower extremity block > Flashcards

Ultrasound guided lower extremity block Flashcards

1
Q

A contraindication with the popliteal block is

A

fibula & tibia fracture because of the risk of compartment syndrome

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2
Q

Regional anesthesia has many indications including

A 
primary anesthetic
post-operative pain management
history of severe PONV or risk of MH
patient is too ill for general anesthesia
physician (surgeon) preference
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3
Q

Absolute contraindications for regional anesthesia include

A

patient refusal
active bleeding in an anticoagulated patient- not absolute for peripheral more so neuraxial
proven allergy to a local anesthetic
local infection at the site of the proposed block

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4
Q

Relative contraindications to peripheral blocks include

A

respiratory compromise
inability to cooperate/understand the procedure an anesthetized patient- generally accepted now
bleeding diathesis secondary to an anticoagulant or genetic disorder
bloodstream infection
preexisting peripheral neuropathy

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5
Q

Regional reduces

A

surgical stress (thus opioid consumption)
overall blood loss?- more so with neuraxial
risk of DVT- more so spinals/epidurals

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6
Q

Regional may be used because

A

provides anesthesia and/or analgesia (can be titrated)- ability to re-dose with catheter, convert from pain management to primary anesthetic
versatile- control extent of sensory & motor blockade, used with or without adjunct medications

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7
Q

In order for exparel to be effective for a procedure,

A

it needs to be mixed with regular bupivacaine so you can get short term coverage

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8
Q

Prior to beginning any procedure:

A 
verify the correct patient
obtain informed consent
verify the correct procedure
verify the correct extremity
gather all necessary equipment
place the patient on oxygen
obtain baseline VS and monitor during the procedure
administer proper/adequate sedation
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9
Q

Necessary block supplies include

A 
sterile gloves
4x4
nerve stimulator
anti-microbial 
stimulating needle
local of choice with possible additive
local for subcutaneous infection
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10
Q

For local anesthetics, most references recommend

A

20-40 mLs/block

some authors have demonstrated successful, complete blocks with much lower volume

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11
Q

Amount & type of local anesthetic depends on

A

patient factors-maybe they have an allergy?
timing of the procedure
procedure itself- maybe the procedure is really short and we don’t want them to have motor loss for 8 hours
purpose of the block- primary anesthetic vs. analgesia

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12
Q

The most commonly used amide is

A

bupivacaine because it is cheap

also most likely to cause last

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13
Q

The Lumbar/lubosacral plexi provides nerve innervation to

A

the lower extremity

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14
Q

The lumbar plexus arises from

A

nerve roots L1-4 and occasionally T12

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15
Q

The lumbar plexus includes the following nerves:

A

ilioinguinal, iliohypogastric, lateral femoral cutaneous, femoral (saphenous) and obturator nerves

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16
Q

The lumbosacral plexus arises ffrom

A

nerve roots L4-5 and S1-3

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17
Q

The lumbosacral plexus includes the

A

sciatic nerve (tibial, peroneal, and nerves of the ankle/foot)

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18
Q

The lateral femoral cutaneous nerve is

A

just sensory with no motor innervation

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19
Q

Lower extremity blocks that are considered lumbar plexus blocks include

A

femoral
fascia iliaca
adductor canal
saphenous (thigh & ankle)

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20
Q

Lower extremity blocks that are considered lumbosacral plexus blocks include

A

sciatic (subgluteal)
sciatic (popliteal level)
iPACK
ankle blocks

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21
Q

The lumbar plexus supplies

A

sensory and motor innervation to the thigh, anterolateral knee, and sensory innervation to the medial aspect of the lower extremity below the knee

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22
Q

The femoral nerve block targets

A

the major branch of the lumbar plexus

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23
Q

The femoral nerve block provides anesthesia to the

A

anterior thigh, knee, and medial aspect of lower leg

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24
Q

The femoral nerve can be found

A

lateral to the artery and deep to the fascia lata & iliaca, and superior to the iliopsoas muscle

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25
Q

The USG technique for the femoral nerve block includes

A

patient supine with slight external rotation of extremity
transducer placed over inguinal crease, over femoral pulse
high-frequency linear array transducer
short-axis image, in-plane needle insertion (lateral to medial)
nerve is a hyperechoic ovoid lateral to femoral artery, beneath fascia lata and iliaca
5 cm B-bevel needle
20 mLs of local anesthetic

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26
Q

If they want patient to walk then we would avoid

A

a femoral nerve block because we get quadriceps weakness

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27
Q

The needle approach for the femoral nerve block is

A

lateral to medial

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28
Q

____________ is elicited when nerve stimulation is used with ultrasound

A

Patellar snap

29
Q

Femoral nerve block pearls include

A

doppler can be used to verify flow in the femoral vessels
if two arteries are visible, scan cephalad until a single femoral artery is identified
local anesthetic placed below fascia lata and iliaca results in greatest efficacy
lymph nodes in the groin may appear as “nerves” a pre-procedure scan will help distinguish them

30
Q

Describe how to assess whether it is a nerve or lymph nodes.

A

lymph nodes are not continuous like nerves

lymph nodes are above the fascia plane

31
Q

The ultrasound guided fascia iliaca block is

A

similar to an USG 3 in 1 lumbar plexus block because it targets:
femoral nerve
obturator nerve
lateral femoral cutaneous nerve

32
Q

The USG fascia iliaca block uses (volume)

A 
increased volume (40 mL) to block all three nerves
it is considered a volume block
33
Q

The ultrasound imaging for the fascia iliaca block

A

is similar to that of the femoral nerve block

34
Q

A disadvantage of the fascia iliaca is

A

quadriceps weakness which limits ability to ambulate

35
Q

The adductor canal block is utilized for

A

total knee arthroplasty because it decreases hospitalization and narcotic administration while still allowing for ambulation

36
Q

The ________ has been the gold-standard for pain relief following TKA

A

femoral nerve block

- it is associated with risk of falls due to quadriceps weakness

37
Q

The adductor canal block was first used as

A

a means to identify the saphenous nerve using the superficial femoral artery/vein as landmarks

38
Q

The femoral triangle is considered to be

A

medial aspect of the sartorius
medial aspect of adductor longus
inguinal ligament

39
Q

The adductor canal describes an

A

intermuscular tunnel in the anteromedial thigh that lies posterior to the sartorius msucle

40
Q

The proximal origin of the adductor canal is the

A

femoral triangle and it terminates at the adductor hiatus

41
Q

Studies consistently demonstrate that _____________ pass through the canal in the adductor canal block

A

saphenous nerve and the nerve to the vastus medialis

42
Q

The USG technique for the adductor canal block is to

A

have the patient supine with slight external rotation of extremity
transducer placed mid to distal third of thigh
high-frequency linear array transducer
short-axis image, in plane needle insertion
LA deposited in the fascial plane separating the sartorius and vastus medialis lateral to the femoral vessels

43
Q

Adductor canal block pearls include

A

nerve branches may be located on both sides of the superficial femoral artery
a pre-procedure scan will detect any aberrancies and increase block efficacy
case reports demonstrate that if local anesthetic is deposited within the muscle, myotoxicity may occur

44
Q

The adductor canal block will not

A

cover any posterior nerve

45
Q

The saphenous nerve is the

A

terminal branch of the femoral nerve

46
Q

The saphenous nerve is

A

distal to the adductor canal

courses superficially in the distal thigh

47
Q

The saphenous nerve provides

A

sensory innervation to the medial aspect of lower extremity below the knee

48
Q

The saphenous nerve block is used

A

in conjunction with other blocks for surgical procedures involving the ankle & foot

49
Q

The USG technique for the saphenous nerve block is

A

patient supine with slight external rotation of extremity
transducer placed at distal thigh
high-frequency linear array transducer
short-axis image, in-plane needle insertion
LA deposited in the fascial plane separating the adductor longus and vastus medialis below the subcutaneous tissue
inject 5-10 mL of local anesthetic

50
Q

The lumbosacral plexus supplies

A

sensory and motor innervation to the posterior thigh, knee, and the lower extremity below the knee with exception to sensory innervation provided by the saphenous nerve

51
Q

The sciatic block is also known as

A

the subgluteal

52
Q

The sciatic nerve runs

A

deep to the gluteus maximus between ischial tuberosity and greater trochanter

53
Q

The sciatic block results in

A

sensory and motor blockade of the entire lower extremity below the knee except for sensory innervation of the medial lower extremity below the knee (saphenous)

54
Q

______ may be missed with the subgluteal approach

A

the posterior thigh which is innervated by femorocutaneous nerve

55
Q

Describe the technique for the sciatic block

A

patient prone or lateral
low-frequency curvilinear array transducer placed just distal to the gluteal crease
short-axis image, in-plane needle insertion
local anesthetic deposited in the fascial plane separating the adductor longus and vastus medialis below the subcutaneous tissue
inject 20 mL of local anesthetic

56
Q

The popliteal nerve block targets the

A

sciatic nerve slightly above the knee

57
Q

The sciatic branches into the

A

tibial (course medial) and common peroneal nerves (lateral)

58
Q

In the popliteal fossa, they are bordered superiorly and medially by the

A

semi-tendinosus and semi-membransosus muscles and superiorly and laterally by the biceps femoris muscle

59
Q

Describe the USG technique for the popliteal nerve block.

A

patient supine with operative leg elevated
high frequency linear array transducer
transducer is placed in the popliteal crease
short-axis image distal of the tibial and peroneal bifurcation
the tibial nerve is superior to the popliteal artery and vein, scan proximal to locate the bifurcation with the peroneal nerve

60
Q

With the popliteal nerve block, the needle is inserted

A

in-plane lateral to medial

61
Q

Popliteal block pearls include

A

scan the proximal and distal to appreciate the anatomy
the transducer may have to be angled toward the foot to better image the nerves
circumferential spread around each nerve ensures a dense block

62
Q

Describe an IPACK block

A

infiltration between the popliteal artery and posterior capsule of the knee to block terminal branches innervating the joint, sparing distal innervation of the tibial and peroneal branches

63
Q

The IPACK block is an alternative to

A

a sciatic block and selective tibial nerve block for controlling pain following knee arthroplasty
avoids blocking the motor nerve

64
Q

Indications for the IPACK block include

A

posterior knee pain control for total knee arthroplasty

-preserves or minimally reduces foot drop, facilitates post-op ambulation and rehabilitation

65
Q

The technique for the IPACK block is to

A

place patient in lateral decubitus position
transducer placed in transverse plane above the popliteal crease
identify space between- popliteal artery and vein & intercondylar notch
needle inserted lateral to medial
15-20 mL local anesthetic injected while slowly withdrawing needle

66
Q

The five nerves that supply innervation to the foot include

A 
tibial nerve
deep peroneal nerve
superficial peroneal nerve
saphenous nerve
sural nerve
67
Q

USG ankle blocks are routinely indicated for

A

surgical anesthesia & postoperative analgesia involving the foot

68
Q

Regional anesthesia complications include

A

LAST
paresthesia or nerve injury
bleeding & infection
intravascular puncture/injection

931: Advanced Principles of Anesthesia I (22 decks)

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