Upper Regional Flashcards
Advantages: can avoid __ __ if used as primary anesthetic. Reduced opiates (imp for __ and __ __ pts). Avoiding general/intubate imp for pts with __ to __ __ disease and __ disease)
General anesthesia
Copd and morbidly obese
Moderate to severe cardiac, pulmonary
Biggest advantage of blocks
Other advantages: reduced __. Improved __ __
Reduced post op pain
PONV, PT
Disadvantages
Risk for __ and __ damage, risk for __, risk of __ __ __
Nerve and vessel, infection, local anesthetic toxicity
Contraindications: __ __ most imp. Inability to __ __. Inability to __. __ complications, need to __
Pt refusal
Follow directions
Coagulate
Neurologic, document
Contraindications
__ at site
___
Lack of __, __, and __
Infection
Septicemia
Time, prep, experience
MS MAIDS stands for in preparation
Means of PPV Suction Monitors Airway IV access Drugs Special equipment
Drugs needed
Emergency drugs, lipid rescue, sedation drugs
Lipid rescue initial focus:
__ management
___ suppression. __ preferred, avoid __ if having CV instability
Alert nearest facility having __ __ capability
Airway
Seizure, benzos, Propofol
Cardiopulmonary bypass
Lipid rescue: management of cardiac arrhythmias
__ and __
Avoid __, __ __ __, __ __, or __ __
Reduce individual __ doses to
Bls and acls
Vaso, ca channel blockers, beta blockers, local anesthetic
1
Lipid rescue: lipid emulsion 20% therapy
Bonus __ml/kg over __ __ about __ mls
Continuous at __ml/kg/min about __ml/min
Repeat bolus once or twice for consistent __ __
Increase infusion to __ml/kg/min if __ remains low
Continue infusion for at least __ minutes before attaining cv stability
Recommended upper limit: __ml/kg over first __ minutes
1.5, 1 minute, 100
0.25, 18
Cardiovascular collapse
0.5, BP
10
10, 30
Steps: gather __, __, and __ check
Draw up __ __, __ and __
Meet pt, ___ discussed, __ __, and __
Verify __ and __
Supplies, equipment, safety
Local anesthetic, adjuncts, anxiolytics
RBA, consent signed, IV
Site and initial
Next steps: \_\_ and \_\_ on pt \_\_ \_\_ performed \_\_ Perform \_\_ and \_\_ \_\_ pt until \_\_ to \_\_
O2 and monitors Time out Sedate Block, document Monitor, roll back, or
Procedure varies with
Location
Usual settings nerve stim
Decrease to __ma after nerve response localized
Nerve response
1 ma, 0.1 ms, 2 hz
- 5, withdraw
- 3-0.5
Local that is long and most common Local that is long acting Local that is short acting Shortest acting local Very long local
Ropivicaine 0.5% Bupivicaine 0.5-0.75% Mepivicaine 1.5% Lidocaine 1-2% Liposomal bupivicaine
Epi mainly used as a __ __. Epi will increase HR > __bpm
Concentrations of epi in local
Vascular marker, 10
1: 200,000
1: 400,000
Clonidine: __ __.
Use __-__ mcg/30 ml of local. What it does
Alpha agonist, 75-100, prolongs block for hours
Buprenorphine: __ __ __-__
Added to local for what
Mixed opioid agonist antagonist
Prolongs duration of action of local
Decadron. Add __mg to 30 ml of local. What it does
4, can prolong block for up to 10 hours
Linear probe shows __ structures
Curved probe has __ penetration
Hypoechoic= \_\_ and examples Hyperechoic= \_\_ and examples
Shallow
Deeper
Black. Nerves, blood, fluid, air
White. Bone, nerves, vascular walls, connective tissue
Ultrasound can reduce __ to perform block, may use less __ of local anesthetic
Ultrasound vs nerve stim overall
Time, volume
No clear advantage in block effectiveness of either
What is raj test
Injecting 1 ml of local, should terminate muscle twitch
Repeat aspiration how often
Every 5 ml
What is the best monitor while injecting LA
Patient
Musculocutaneous reached which branches
C5,6,7
Axillary reaches which branches
C5,6
Radial reaches which branches
C6,7,8, T1
Median reaches which branches
C7,8,T1
Ulnar reaches which branches
C8,T1
Musculocutaneous nerve
Where it exits sheath: __ in the __, __ muscle
Motor for 3 to __ forearm
Sensory __ from __ to __
High in axillary, coracobrachialis
Biceps, brachial is, coracobrachialis
Flex
Lateral from elbow to wrist
Which nerve spared with an axillary nerve block
Musculocutaneous nerve
Axillary nerve
Leaves plexus at __ __ of __ muscle
Motor: 2 muscles
Sensory: __ __ and __ __ arm
Lower border of pectoralis
Deltoid and teres minor
Inferior shoulder, upper lateral
Radial nerve
Motor to 3
Sensory to __ arm and __. __ border of the __. __ and __ surface of the __
Posterior, forearm
Lateral, elbow
Thumb and dorsal, hand
Median nerve
Motor: __ and __ muscles of __ and wrist __
Sensory: __ surface of __, __, and __ fingers
__ of thumb, index, and __ fingers
Flexor and pronation, forearm and flexion
Palmar, hand, index, middle. Tips, middle
Ulnar nerve
Motor: this muscle which __ __
Sensory: __ __ and __ __ fingers
Flexor carpi ulnaris, abduct fingers
Little finger and medial ring
Less common blocks 3
Bier block, wrist block, and touch up blocks
Inter scalene block
Ideal for surgery of __ and __ __
___ sparing. Don’t use for procedures __ __
Shoulder, upper arm
Ulnar, below elbow
Inter scalene contraindications
Absolute 2
Relative 2
Contra lateral recurrent laryngeal nerve palsy, phrenic nerve palsy
Brachial plexus pathology, impaired pulmonary function
Inter scalene approach
Palpate__ border of SCM at level of __
Roll fingers __ palpated groove between __ and __ scalene
Posterior, c6
Posterior, anterior and middle
Inter scalene nerve stim Insert needle in \_\_ direction Twitch of \_\_ or \_\_ \_\_ How many ml LA How deep
Caudad
Bicep, distal hand
30
1-2 cm
Phrenic nerve often blocked with which block, what it leads to
Interscalene, hemidiaphragm paralysis
Ultrasound inter scalene Look for \_\_ nerve and \_\_ \_\_ sign Needle inserted \_\_ and \_\_ \_\_ Aim between \_\_ and \_\_ trunks \_\_ml inject
Hypoechoic, stop light
Lateral, in plane
Superior and middle
20
Interscalene complications \_\_ \_\_ most common. 3 signs \_\_ \_\_ \_\_ common \_\_ \_\_ \_\_ block, rare, leads to \_\_ \_\_ injection rare \_\_/\_\_ injection and \_\_ rare
Horners syndrome: ptosis, anhydrosis, mitosis Phrenic nerve block Recurrent laryngeal nerve, hoarseness IV Subarachnoid, epidural Pneumothorax
Supra clavicular block
Blocks __, __, and __ __
Carried out at __/__ level of brachial plexus
Can cover __ and __ nerves if done properly
Hand, forearm, upper arm
Trunk/division
Ulnar and radial (inferior trunk)
Contraindications supra clavicular block
__ __ pathology
__
__
Brachial plexus
Pneumothorax
Coagulopathy
Suprascapular with nerve stim Look for \_\_ border of \_\_ head of SCM Identify groove between \_\_ muscles Needle inserted \_\_cm from \_\_-\_\_ Needle directed towards\_\_ away from \_\_
Lateral, clavicular
Scalene
1, mid clavicle
Axillary, midline
Supra clavicular nerve stim
Motor response in __ or __. More distal response =
Depth
Motor response still at __ or less, inject
Volume
Hand, arm. More reliable block
2-4 cm
0.5 ma
30-40 ml
Supra clavicular ultrasound
Probe over __ __
Visualize __ artery and plexus __ and __
Probe __ __
Supra clavicular fossa
Subclavian, lateral, superior
In plane
Complications supra clavicular \_\_ most associated with this block Sudden \_\_ and \_\_ \_\_ puncture \_\_ of \_\_ \_\_\_ \_\_
Pneumothorax Cough and sob Vascular Hemiparesis of diaphragm Horners syndrome
Phrenic nerve c__-__
3-5
Infraclavicular Used for procedures \_\_ to \_\_ Block is at level of \_\_ Nerves not as compact, increased \_\_ \_\_ risk of pneumo Blocks all \_\_ \_\_
Distal, elbow Cords Time to onset Decreased Terminal branches
Infra clavicular w nerve stim \_\_ \_\_ and \_\_ arm \_\_ cm \_\_ and \_\_ cm \_\_ from \_\_ process Needle direction is toward \_\_ pulse Needle: \_\_, \_\_ bevel, \_\_cm
Externally rotate, abduct
2 medial, 2 caudad, coracoid
Axillary
Insulated, b, 10
Infra clavicular w nerve stim
Look for __/__ __ or __
If __ stim, needle too lateral
Volume
Finger or thumb extension or flexion
Bicep
30-40 ml
Infra clavicular ultrasound \_\_-\_\_mhz, \_\_ frequency Place probe \_\_ to clavicle Visualize \_\_ artery Observe \_\_ and \_\_ cords, \_\_ if possible Direct needle to \_\_ cord
5-12, high Inferior Axillary Lateral and posterior, inferior Posterior
Infra clavicular ultrasound
Needle angle is __
Target __ cord first then __ cord
How much volume
Steep
Posterior, medial
15 at post 15 at medial
Infra clavicular ultrasound
__ __ maneuver- disappears clavicle from ultrasound window
Leads to more __ angle of needle
Houdini clavicle
Shallow
Infra clavicular complications
Puncture of __ __ and __. __-__ region
Risk of __ low
Axillary artery and vein. Non compressible
Pneumo
Axillary block _ \_\_ of plexus blocks Ideal for \_\_ or \_\_ surgery. Distal to \_\_ Blocks \_\_, \_\_, and \_\_ nerves \_\_ nerve requires separate block
Least risk
Hand or forearm, elbow
Ulnar, radial, median
Musculocutaneous
Nerve stim axillary block Arm \_\_ and \_\_ rotated Palpate \_\_ \_\_ Needle \_\_g, \_\_cm, \_\_ bevel Volume
Abducted and externally
Axillary artery
22, 4, b
30
Axillary nerve stim
Insert __ or __ artery at __ degree angle
Observe for __ or __ __
Decrease to __ma or __
Above or below, 45
Finger or thumb flexion
0.5 or less
Mcn block
Pull ___ __
Set to __ ma
Advance needle into __ until rigorous __ contraction
Biceps laterally
2
Coracobrachialis, bicep
Transarterial axillary block
Needle __ g __ cm __ bevel or __g __in
22, 4, b, 26, 1/2
Transarterial axillary block
- Palpate __ and maintain __ pressure
- Insert needle into artery, aspirate blood
- Advance needle until __ __
- Inject __-__ ml
- __ needle
- Maintain pressure for __ min
Artery, distal, flow stops
30-40, withdraw, 5
Axillary ultrasound Probe: \_\_ frequency, \_\_ 1. \_\_, arm \_\_ to \_\_ degrees 2. Visualize \_\_ and \_\_ nerves 3. Insert needle in plane 4. Can use \_\_ \_\_ at same time 5. Deposit \_\_ ml on \_\_ \_\_ or \_\_ ml in one injection 6. Visualize \_\_, deposit \_\_ ml
High, linear
- Supine, abducted, 90
- Artery, hypoechoic
- Nerve stimulator
- 10, each nerve, 30
- Mcn, 10
Axillary complications \_\_\_ \_\_ \_\_ \_\_ injection If arterial puncture:
Vascular puncture
Hematoma
IV injection
Convert to transarterial approach
Bier block
Advantages: ideal for __ or __ cases that are under __ minutes
How it’s performed
Hand or forearm, 60
Without ultrasound or nerve stim
Bier block disadvantage Doesn't work if \_\_ \_\_ Limited block \_\_\_ Tourniquet \_\_ \_\_ \_\_ \_\_ risk
Obese arms
Duration
Pain
Local anesthetic toxicity
Bier block
- __ placed in hand
- Arm is ___
- Inflate __ tourniquet
- __ __
Distal IV
Exsanguinated (elevated and wrap in esmarch bandage)
Proximal
Unwrap esmarch
Bier block
- Verify no __ __ via __ __
- Inject __-__ ml of __% __ with no __ into IV
- Onset __-__ min
- Hold tourniquet for __ min to prevent toxicity
- Slowly deflate cuff
Arterial flow, pulse ox
25-50, 0.5% lidocaine, epi
5-10
30 min
How to make 0.5% lidocaine
Inflate tourniquet above
Mix 25 ml of lidocaine 1% with 25 ml nacl to yield 50 mls
Arterial blood pressure
Block eval
How to test: radial nerve
Push, arm extension
How to test mcn nerve
Pull, arm flexion
How to test median nerve
Pinch index finger
How to test ulnar nerve
Pinch little finger
Sympathectomy leads to vein __
Dilation
Superficial cervical plexus block
Used for __ procedures of the __ and for __ __
Unilateral, neck,
Carotid endarterectomy
Suprascapular nerve block
Used for what
Posterior shoulder pain
Inter scalene block Part of plexus Volume Indications \_\_ sparing, \_\_
Roots/trunks
20-30
Shoulder
Ulnar sparing and shallow
Supra clavicular block Brachial plexus Volume Indications Notes
Trunks/divisions
20-30
Upper, lower arm and hand
Ultrasound best, pneumo risk
Infra clavicular block Brachial plexus Volume Indications Notes
Cords
30 ml
Upper, lower arm and hand
Houdini clavicle
Axillary block Brachial plexus Volume Indications Notes
Branches
30 ml
Forearm and hand
Transarterial
Bier block Brachial plexus Volume Indications Notes
Branches
50 ml
Forearm and hand
Failure rate and LA toxicity
