Ultrasound guided lower extremity block

Question 1

A contraindication with the popliteal block is

Answer 1

fibula & tibia fracture because of the risk of compartment syndrome

Question 2

Regional anesthesia has many indications including

Answer 2

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

Question 3

Absolute contraindications for regional anesthesia include

Answer 3

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

Question 4

Relative contraindications to peripheral blocks include

Answer 4

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

Question 5

Regional reduces

Answer 5

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

Question 6

Regional may be used because

Answer 6

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

Question 7

In order for exparel to be effective for a procedure,

Answer 7

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

Question 8

Prior to beginning any procedure:

Answer 8

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

Question 9

Necessary block supplies include

Answer 9

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

Question 10

For local anesthetics, most references recommend

Answer 10

20-40 mLs/block

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

Question 11

Amount & type of local anesthetic depends on

Answer 11

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

Question 12

The most commonly used amide is

Answer 12

bupivacaine because it is cheap

also most likely to cause last

Question 13

The Lumbar/lubosacral plexi provides nerve innervation to

Answer 13

the lower extremity

Question 14

The lumbar plexus arises from

Answer 14

nerve roots L1-4 and occasionally T12

Question 15

The lumbar plexus includes the following nerves:

Answer 15

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

Question 16

The lumbosacral plexus arises ffrom

Answer 16

nerve roots L4-5 and S1-3

Question 17

The lumbosacral plexus includes the

Answer 17

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

Question 18

The lateral femoral cutaneous nerve is

Answer 18

just sensory with no motor innervation

Question 19

Lower extremity blocks that are considered lumbar plexus blocks include

Answer 19

femoral
fascia iliaca
adductor canal
saphenous (thigh & ankle)

Question 20

Lower extremity blocks that are considered lumbosacral plexus blocks include

Answer 20

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

Question 21

The lumbar plexus supplies

Answer 21

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

Question 22

The femoral nerve block targets

Answer 22

the major branch of the lumbar plexus

Question 23

The femoral nerve block provides anesthesia to the

Answer 23

anterior thigh, knee, and medial aspect of lower leg

Question 24

The femoral nerve can be found

Answer 24

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

Question 25

The USG technique for the femoral nerve block includes

Answer 25

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

Question 26

If they want patient to walk then we would avoid

Answer 26

a femoral nerve block because we get quadriceps weakness

Question 27

The needle approach for the femoral nerve block is

Answer 27

lateral to medial

Question 28

____________ is elicited when nerve stimulation is used with ultrasound

Answer 28

Patellar snap

Question 29

Femoral nerve block pearls include

Answer 29

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

Question 30

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

Answer 30

lymph nodes are not continuous like nerves | lymph nodes are above the fascia plane

Question 31

The ultrasound guided fascia iliaca block is

Answer 31

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

Question 32

The USG fascia iliaca block uses (volume)

Answer 32

``` increased volume (40 mL) to block all three nerves it is considered a volume block ```

Question 33

The ultrasound imaging for the fascia iliaca block

Answer 33

is similar to that of the femoral nerve block

Question 34

A disadvantage of the fascia iliaca is

Answer 34

quadriceps weakness which limits ability to ambulate

Question 35

The adductor canal block is utilized for

Answer 35

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

Question 36

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

Answer 36

femoral nerve block | - it is associated with risk of falls due to quadriceps weakness

Question 37

The adductor canal block was first used as

Answer 37

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

Question 38

The femoral triangle is considered to be

Answer 38

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

Question 39

The adductor canal describes an

Answer 39

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

Question 40

The proximal origin of the adductor canal is the

Answer 40

femoral triangle and it terminates at the adductor hiatus

Question 41

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

Answer 41

saphenous nerve and the nerve to the vastus medialis

Question 42

The USG technique for the adductor canal block is to

Answer 42

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

Question 43

Adductor canal block pearls include

Answer 43

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

Question 44

The adductor canal block will not

Answer 44

cover any posterior nerve

Question 45

The saphenous nerve is the

Answer 45

terminal branch of the femoral nerve

Question 46

The saphenous nerve is

Answer 46

distal to the adductor canal | courses superficially in the distal thigh

Question 47

The saphenous nerve provides

Answer 47

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

Question 48

The saphenous nerve block is used

Answer 48

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

Question 49

The USG technique for the saphenous nerve block is

Answer 49

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

Question 50

The lumbosacral plexus supplies

Answer 50

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

Question 51

The sciatic block is also known as

Answer 51

the subgluteal

Question 52

The sciatic nerve runs

Answer 52

deep to the gluteus maximus between ischial tuberosity and greater trochanter

Question 53

The sciatic block results in

Answer 53

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)

Question 54

______ may be missed with the subgluteal approach

Answer 54

the posterior thigh which is innervated by femorocutaneous nerve

Question 55

Describe the technique for the sciatic block

Answer 55

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

Question 56

The popliteal nerve block targets the

Answer 56

sciatic nerve slightly above the knee

Question 57

The sciatic branches into the

Answer 57

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

Question 58

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

Answer 58

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

Question 59

Describe the USG technique for the popliteal nerve block.

Answer 59

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

Question 60

With the popliteal nerve block, the needle is inserted

Answer 60

in-plane lateral to medial

Question 61

Popliteal block pearls include

Answer 61

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

Question 62

Describe an IPACK block

Answer 62

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

Question 63

The IPACK block is an alternative to

Answer 63

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

Question 64

Indications for the IPACK block include

Answer 64

posterior knee pain control for total knee arthroplasty | -preserves or minimally reduces foot drop, facilitates post-op ambulation and rehabilitation

Question 65

The technique for the IPACK block is to

Answer 65

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

Question 66

The five nerves that supply innervation to the foot include

Answer 66

``` tibial nerve deep peroneal nerve superficial peroneal nerve saphenous nerve sural nerve ```

Question 67

USG ankle blocks are routinely indicated for

Answer 67

surgical anesthesia & postoperative analgesia involving the foot

Question 68

Regional anesthesia complications include

Answer 68

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