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931: Advanced Principles of Anesthesia I > Ultrasound-guided upper extremity blocks > Flashcards

Ultrasound-guided upper extremity blocks Flashcards

1
Q

The implications for regional anesthesia include

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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2
Q

Absolute contraindications include

A

patient refusal (make sure they’re saying no for the right reasons)
active bleeding in an anticoagulated patient
proven allergy to a local anesthetic
local infection at the site of proposed block

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3
Q

Relative contraindications include

A

respiratory compromise
inability to cooperate/understand the procedure
an anesthetized patient?–> more pediatric blocks are done under general anesthesia
bloodstream infection
bleeding diathesis secondary to an anticoagulant or genetic disorder
preexisting peripheral neuropathy

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4
Q

Describe the benefits that ultrasound offers over traditional landmark technique.

A

Visualization- anatomic structure, real-time needle movements, & spread of local anesthetic
safer-> yes but there is a learning curve

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5
Q

How much local anesthetic should be infused?

A

20-40 mLs/blocker

some authors have demonstrated successful, complete interscalene blocks with as little as 5 mL

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6
Q

Amount & type of local anesthetic depends on:

A

patient factors
timing of the procedure
procedure
purpose of block

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7
Q

Describe which esters have a fast onset and slow onset

A

procaine- slow
tetracaine-slow
chloroprocaine- fast

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8
Q

Describe which amides have a fast onset and slow onset

A

lidocaine- fast
mepivacaine- fast
ropivicaine- slow
bupivicaine- slow

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9
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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10
Q

Indications for a cervical plexus block include

A

carotid endarterectomy
superficial neck surgery
clavicle fractures

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11
Q

Cervical plexus block is performed at

A

branches of cervical nerve roots C2-C4

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12
Q

Major nerves of the cervical plexus include **

A 
transverse cervical nerve
greater auricular nerve
lessor occipital nerve
supraclavicular nerve
-phrenic nerve- maybe not full block but will get some sort of phrenic nerve involvement
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13
Q

Cervical plexus block provides anesthesia to

A

the anterolateral neck, the anterior and retro-auricular areas and the anterior chest just inferior to the clavicle

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14
Q

Describe the cervical plexus technique.

A

patient positioned with head turned to non-operative side
transducer placed at midpoint of SCM m. moved laterally until posterior edge is identified
identify brachial plexus between anterior and middle scalene m.
cervical plexus located in plane above prevertebral fascia
needle passed lateral to medial, in-plane to area between SCM and prevertebral fascia
following negative aspiration, inject 5-10 mL of LA

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15
Q

Cervical plexus pearls include

A

visualization of nerves in plexus is not necessary

since plexus nerves are purely sensory, low concentration LA used (0.25% is typically max)

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16
Q

Poor needle visualization when performing a cervical plexus block can result in

A

intrathecal injection due to close proximity of vertebral nerve roots
potential intravascular injection in vertebral artery

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17
Q

The brachial plexus consists of

A

ventral rami of the C5-T1 nerve roots

contribution from C4 & T2 are often minor or absent

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18
Q

Describe the path of the brachial plexus

A

roots–> trunks–> divisions–> cords–> branches–> nerve terminals

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19
Q

With a few exceptions, the brachial plexus supplies

A

sensory & motor innervation to the upper extremity

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20
Q

Describe the amount of roots, trunks, divisions, cords, & branches of the brachial plexus

A 
Five roots
three trunks
six divisions
three cords
five branches
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21
Q

The proximal branches of the brachial plexus include

A

dorsal scapular, phrenic, long thoracic

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22
Q

The lateral branches of the brachial plexus include

A

suprascapular, subclavius, lateral pectoral

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23
Q

The medial branches of the brachial plexus include

A

medial pectoral, medial cutaneous to arm and forearm

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24
Q

The posterior branches of the brachial plexus include

A

thoracondorsal

upper & lower subscapular

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25
Q

The posterior cord is responsible for

A

extensions

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26
Q

Describe the motor innervation that C5 provides

A

shoulder abduction

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27
Q

Describe the motor innervation that C6 provides

A

elbow flexion

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28
Q

Describe the motor innervation that C7 provides

A

elbow extension

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29
Q

Describe the motor innervation that C8 provides

A

finger flexion

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30
Q

Describe the motor innervation that T1 provides

A

finger abduction/adduction

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31
Q

The baseline block evaluation includes

A

have the patient “push, pull, pinch, pinch”

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32
Q

The post-procedure block evaluation includes

A

differential blockade

mantel effect

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33
Q

Describe the order in which nerves are blocked.

A

Sympathetic, sharp pain, proprioception, motor

Type B, Type C, Type A beta, gamma, & delta, & then Type A alpha

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34
Q

Describe the different types of brachial plexus blocks

A

supraclavicular
interscalene
infraclavicular
axillary

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35
Q

The supraclavicular block is a reliable upper extremity block for procedures involving the

A

upper arm & hand

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36
Q

The supraclavicular block is performed at the

A

trunk & division level

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37
Q

At this level, the brachial plexus is most compact

A

supraclavicular

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38
Q

Describe the SCB technique

A

transverse image using in-plane needle insertion
the trunks/divisions are found lateral to the pulsating subclavian artery & superior to the first rib
needle is inserted lateral to medial toward the inferior aspect of the plexus where the rib & artery meet (aka “the corner pocket”)
following negative aspiration, incremental injections of 5 mL is accomplished

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39
Q

Side effects and complications of the supraclavicular block include

A

increased risk of phrenic nerve paralysis & stellate ganglion block
pneumothorax is the most important complication
b/c of the proximity of the subclavian artery, there is the possibility for inadvertent arterial puncture

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40
Q

The interscalene block is a

A

root level block

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41
Q

The interscalene block is the primary brachial plexus block for procedures involving the

A

shoulder & proximal upper arm

-suprascapular nerve

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42
Q

Nerve roots C5-C7 are found in the interscalene groove between

A

the anterior & middle scalene muscles

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43
Q

Describe the interscalene block technique.

A

Supine position with head turned to non-operative side
high-frequency linear array transducer placed in the mid-clavicular fossa and moved cephalad
hypoechoic roots located between the ASM & MSM
6 cm, B bevel needle
incremental injection of 5 mL up to 20-30 mL

44
Q

If damaged, this nerve can cause winged scapula

A

long thoracic nerve

45
Q

Recent studies for the interscalene block demonstrate that the “stoplight” or “snowman” sign may result from

A

the branching of either C5 or C6

46
Q

For the interscalene block, a pre-procedure scan with

A

color Doppler should be performed prior to injection to limit potential inadvertent injections and identify anatomic variations

47
Q

Side-effects/complications of interscalene blocks include

A

Phrenic blockade occurs nearly 100% of the time
local anesthetic system toxicity (LAST)
high spinal
injury to the dorsal scapular and long thoracic nerves
Stellate ganglion block (aka Horner’s syndrome) is common- Ptosis, miosis, anhidrosis

48
Q

The infraclavicular block is a

A

cord level block

49
Q

The infraclavicular block is a good alternative to the

A

supraclavicular block, especially in patients with severe COPD or respiratory insufficiency

50
Q

The infraclavicular cords are labeled by

A

their relation to the axillary artery

lateral, posterior, & medial

51
Q

The infraclavicular block can be used for

A

lower upper arm (mid humeral shaft) and down

52
Q

Describe the infraclavicular block technique.

A

Patient placed in supine position with their head turned to the non-operative side
transducer is placed perpendicular to the clavicle just medial to the coracoid plexus
short-axis image
cords are arranged around the axillary artery
22 gauge, 8 cm needle inserted in-plane, cephalad to caudal
incremental injection of 20-30 mLs of local anesthetic around axillary artery

53
Q

For the infraclavicular block, depending on the patient’s body habitus,

A

a low-frequency transducer may be required

54
Q

For the infraclavicular block, sliding the needle medially increases the potential for

A

pneumothorax & hemothorax

55
Q

With the infraclavicular block, the _______ pass between the pectoral muscles so doppler may be used to prevent inadvertent puncture.

A

Thoraco-acromial artery & pectoral veins

56
Q

With the infraclavicular block, poor needle visualization may result in inadvertent

A

pneumothorax/hemothorax
vascular puncture
LAST event

57
Q

The axillary block is directed at the

A

terminal branches of the brachial plexus

58
Q

The axillary block anesthetized these nerves:

A

axillary nerves
radial nerves
ulnar nerves
& median nerves

59
Q

The axillary block is an excellent block for procedures

A

below the elbow

60
Q

Ultrasound has made the axillary block

A

less attractive because other blocks can be done as efficiently with minimal complications

61
Q

Describe the axillary block technique.

A

patient is placed in the supine position with head turned to the non-operative side, arm abducted & rotated externally
high-frequency linear array transducer is placed in the crease formed by the biceps muscle and pectoris major
22 gauge, 5 cm B bevel needle inserted in-plane
incremental injection of 20-40 mLs

62
Q

With the axillary block, the _____ nerve is missed

A

musculocutaneous

63
Q

With the axillary block, the _____ nerve is blocked first

A

radial nerve because of its deep location

64
Q

With the axillary block, compressing the veins may

A

decrease the risk of vascular puncture

65
Q

Complications of an axillary block include

A

uncommon but there is an increased risk of vascular puncture because the needle must be re-directed several times to achieve adequate LA distribution
-multiple veins located around the artery. be cautious

66
Q

Paresthesia from multiple needle punctures in the axillary block may result in

A

neuropathy

67
Q

Nerve blocks at the level of the elbow are performed as

A

a rescue for an incomplete block

68
Q

Nerve blocks at the elbow are

A 
localized procedures and address the
radial nerve
ulnar nerve
median nerve 
-median and ulnar nerves are blocked with the arm abducted
69
Q

Describe the technique used to anesthetize the median nerve.

A

courses alongside the brachial artery in the upper arm to the elbow- brachial artery can be verified using color doppler
needle inserted in-plane lateral to medial
following negative aspiration, inject 4-5 mL of LA
additional 2-3 mL can be injected if circumferential spread is not noted

70
Q

Describe the technique used to anesthetize the radial nerve

A

scan distally along the lateral humerus
identify the nerve as it takes a more anterior course along the humerus
needle inserted in-plane, lateral to medial
following negative aspiration, inject 4-5 mL of local anesthetic
an additional 2-3 mL may be injected if circumferential spread is not obstained

71
Q

Describe the technique used to anesthetize the ulnar nerve.

A

scan medially to identify the medial epicondyle
scan proximal & distal along the arm to identify where the nerve enters
needle inserted in-plane, medial to lateral
following negative aspiration, inject 4-5 mL of LA
an additional 2-3 mL may be injected if circumferential spread is not obtained

72
Q

The intravenous regional anesthesia is also known as

A

the Bier block

-may be used for upper or lower extremity procedures

73
Q

Describe the bier block.

A

A block in which local anesthetic is injected into the venous system of an extremity that has been exsanguinated by compression & isolated by a torniquet

74
Q

Describe the two mechanisms of anesthesia for the Bier block.

A

direct- local bathing nerve endings in the tissue

indirect- LA transported to the ‘substance’ of the nerves via the vasa nervorum

75
Q

The bier block can be used for

A

brief surgical procedures & manipulations such as ganglion cyst excision, carpal tunnel release, Duputyren’s contractures, & fracture reduction (mostly in pediatrics)

76
Q

The bier block may also be used as a treatment for

A

regional pain syndromes
-analgesia
reduce neurogenic inflammation

77
Q

Contraindications to the bier block include

A

patient refusal

78
Q

Relative contraindications to the bier block include

A 
injuries to the extremity (crush or open fractures)
inability to cannulate peripheral vein
local skin infection or cellulitis
true allergy to local anesthetics
preexisting arteriovenous fistula
sickle cell disease
surgery greater than one hour
79
Q

Describe the procedure for the bier block

A
  1. place IV catheter with as distal as possible in extremity
  2. apply a double pneumatic tourniquet on the proximal arm
  3. elevate the extremity and apply an Esmarch bandage
  4. occlude the axillary artery
  5. inflate the proximal cuff 50-100 mmHg above patient’s systolic BP
  6. remove Esmarch bandage
  7. inject 30-50 mL of 0.5-1% lidocaine
  8. if patient complains of tourniquet pain, inflate distal cuff first, then deflate proximal cuff
80
Q

With the bier block, the tourniquet must

A

remain inflated for at least 30 minutes following the injection of local anesthetic, regardless of surgery length

81
Q

Describe the deflation of the tourniquet for the bier block.

A

after 30 minutes, the cuff tourniquet deflation occurs in a cyclical fashion:
cuff deflated, then instantly reinflated
patient evaluated for signs of LAST or other complications
wait 1-2 minutes
repeat

82
Q

Side effects and complications of the Bier block includes

A 
if LE IVRA is performed, there will be 100% incidence of LA leakage under the tourniquet- observe for s/s of LAST
damage to radial, median, & ulnar nerves
compartment syndrome
arterial thrombosis
death or permanent brain damage
83
Q

Regional anesthesia can result in

A

local anesthetic systemic toxicity (LAST)
nerve injury
intravascular puncture/injection
death

84
Q

____ must be obtained prior to any regional block

A

informed consent

85
Q

LAST most commonly occurs from

A

an inadvertent intravascular injection

  • initial blocking of inhibitory neurons thought to cause seizures
  • blocking of cardiac ion channels results in bradycardia- Vfib is the most serious complication
86
Q

Shorter acting drugs are (related to LAST)

A

thought to be less cardiotoxic

  • chemical properties play a role
  • more potent agents higher lipid solubility & protein binding
87
Q

The classic clinical presentation of LAST is

A

rapid onset, usually within a minute

88
Q

The progression of subjective symptoms of last includes

A

agitation, tinnitus, circumoral numbness, blurred vision & metallic taste

89
Q

The subjective symptoms of LAST are followed by

A

muscle twitching, unconsciousness, and seizures

90
Q

Very high levels of intravascular LA can result in

A

cardiac & respiratory arrest

91
Q

LAST is most commonly seen with

A

epidural, axillary, & interscalene

92
Q

The incident rate of LAST is

A

0.4 per 10,000

93
Q

Prevention strategies of LAST include

A

test dosing
incremental injection with aspiration
use of pharmacologic markers
ultrasound

94
Q

Treatment of Last includes

A

prompt recognition & diagnosis
airway management priority
seizure suppression- benzodiazepines, succinylcholine
prevent hypoxia & acidosis
lipid emulsion therapy
vasopressors
do not give vasopressin; epinephrine <1 mg/kg

95
Q

The MOA of Lipid emulsion therapy is to

A

capture local anesthetic in blood (lipid sink)
increased fatty acid uptake by mitochondria
interference of Na+ channel binding
promotion of calcium entry
accelerated shunting

96
Q

Describe the max dose of lidocaine & mepivicaine

A

4 mg/kg & 7 mg/kg (with epi)

97
Q

Describe the max dose of bupivacaine, tetracaine, & ropivacaine

A

3 mg/kg

98
Q

Describe the max dose of prilocaine

A

7 mg/kg & 8.5 mg/kg (with epi)

99
Q

Describe the max dose of procaine

A

12 mg/kg

100
Q

Nerve injury can be either

A

direct needle trauma or local anesthetic toxicity

101
Q

The incidence of peripheral nerve injury varies with

A

location

102
Q

Pre-existing factors for the development of nerve injury is

A

diabetes, pre-existing neurologic disease, smoking, increased BMI, & male

103
Q

Local anesthetic neurotoxicity is the result of

A

dose & concentration of LA

additive agents, e.g. epinephrine

104
Q

Ultrasound allows the practitioner to identify important structures close to nerve injury including

A

dural
pleural
vasculature
& bowel

105
Q

Patient’s perception of postoperative nerve injury can be skewed by

A

“postoperative blur”

non-operative factors that coincide with the surgical site

106
Q

The nerve injury should be evaluated based on

A

presenting signs & symptoms as it could be surgical vs. insertion of block

931: Advanced Principles of Anesthesia I (22 decks)

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