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4th Quarter > US Regional Anesthesia Final Exam > Flashcards

US Regional Anesthesia Final Exam Flashcards

1
Q

What type of block is utilized for post-op Cesarean Section?

A

TAP block—>postoperative analgesia/not sole anesthetic

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2
Q

What structures need to be identified in a TAP block?

A 
SubQ(potential)
superior fascia of external oblique
External Oblique
inferior fascia of EOM/superior fascia of IOM
Internal Oblique
inferior fascia of IOM/superior fascia of TAM
Transversus Abdominus Muscle(TAM)
transversus fascia
Peritoneium
Intestines
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3
Q

Identify the proper positioning for a TAP block as related to the patient, transducer, depth, needling and approach.

A

POSITIONING:
Patient: Supine
Transducer: Linear
Depth: 3-4 cm
Needle: In-plane, long axis (out-of-plane for obese)
Approach: Transverse on the abdomen, at the anterior axillary line, between the costal margin and the iliac crest
(called the Triangle of Petit)

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4
Q

Identify the LA to use and the dose/amount to use with a TAP block was well as how to inject.

A

INJECTION:
1) Insert needle just slightly past the anterior fascia of TAM
2) Aspirate; then inject slowly retract needle as you inject
slowly
3) Once you see the two fascia layers separating, stop and
inject LA
20mL of 0.25% Ropivacaine (per side)
(0.4mL/kg per side for children)

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5
Q

Does a TAP block provide motor or sensory anesthesia?

A

Sensory only

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6
Q

What type of block is utilized to provide pain control for an Exploratory Laparotomy?

A

TAP block—–>postoperative analgesia only/not a sole anesthetic

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7
Q

What regional nerve blocks should be utilized for a Closed Reduction for Dislocated Right Shoulder?

A
  • Supraclavicular Block

- Interscalene Brachial Plexus Block

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8
Q

What are the structures to know when performing a Supraclavicular Block?

A

STRUCTURES TO KNOW:
• Clavicle (superior to)
• Prevertebral fascia (around the SA, MSM, & BP)
• Subclavian Artery (SA)
• Middle scalene muscle (MSM)
• Brachial plexus (between the SA & MSM)

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9
Q

What is the positioning as related to a Supraclavicular Block in regards to the patient, the transducer, the depth, needle and the approach.

A

POSITIONING:
Patient: Supine, semi-sitting
Transducer: Linear; transverse on neck, just superior to
the clavicle at midpoint
*** To achieve the best view, the transducer must be
tilted slightly inferiorly, rather than perpendicular to the
skin.
Depth: 2-4 cm(Brian 3cm)
Needle: In-plane, short axis
Approach: Lateral approach

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10
Q

Where LA should be used and how much should be used with a Supraclavicular Block? Where should the LA be deposited?

A
  • 15-30 mls of 0.5% Ropivacaine

- 2 injections(above and below the plexus)

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11
Q

What parts of the Brachial Plexus are anethesized by a Supraclavicular Block?

A
  • distal trunks

- proximal divisions

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12
Q

What are the structures to know when performing a Interscalene Brachial Plexus Block?

A

STRUCTURES TO KNOW:
• Sternocleidomastoid muscle (SCM)
• Prevertebral fascia (posterior to the SCM, covers the MSM and ASM)
• Middle scalene muscle (MSM)
• Brachial plexus (stoplight or honeycomb structure in the
interscalene groove between the MSM & ASM)
• Anterior scalene muscle (ASM)
• Carotid artery (CA)

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13
Q

What is the positioning as related to a Interscalene Block in regards to the patient, the transducer, the depth, needle and the approach.

A

POSITIONING:
Patient: Supine, semi-sitting, with head turned away
Transducer: transverse on neck, 3-4 cm superior to clavicle, over external jugular vein
Depth: 1-3 cm(Brian 3cm)
Needle: In-plane, short axis
Approach: Lateral approach; start in the “supraclavicular
approach” location and move cephalad until the scalene
muscles and BP is found

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14
Q

What LA should be used and how much should be used with a Interscalene Block? Where should the LA be deposited?

A
  • 15-30 mls of 0.5% Ropivacaine

- inject around the plexus

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15
Q

What parts of the Brachial Plexus are anethesized by a Interscalene Block?

A

PLEXUS &/or NERVE COVERAGE:
DISTAL ROOTS/ PROXIMAL TRUNKS
The interscalene approach to brachial plexus blockade results
in anesthesia of the shoulder and upper arm. Inferior trunk for
more distal anesthesia can also be blocked by additional,
selective injection, deeper in the plexus. This is accomplished
either by controlled needle redirection inferiorly or by
additional scanning to visualize the inferior trunk and another
needle insertion and targeted injection.

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16
Q

What blocks can be utilized to facilitate regional anesthesia for a Fractured Left Femur(mid shaft)?

A

o Fascia Iliaca Compartment Block

o Femoral Nerve Block

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17
Q

What are the structures to know when performing a Fascia Iliaca Block?

A
  • internal oblique
  • sartorius
  • fascia iliaca
  • iliopsoas Muscle
  • Ilium
  • bowel
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18
Q

What is the positioning as related to a Fascia Iliaca Block in regards to the patient, the transducer, the depth, needle and the approach.

A 
Patient: supine
Transducer: parasagittal 
Depth: 2-4 cm(Brian 4cm)
Approach: inferior to superior
Needle: in plane

palpate ASIS first—>place probe over ASIS—>ID ASIS spine then move superiorly and inferiorly to identify the “bow tie”

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19
Q

What LA should be used and how much should be used with a Fascia Iliaca Block? Where should the LA be deposited?

A

40-60 ml of 0.2 % Ropivacaine

Ideally the solution will lift the fascia iliac off the superficial layer and spread superior towards the lumbar plexus

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20
Q

What plexus is anethesized by the Fascia Iliaca Block?

A

Ideally the solution will lift the fascia iliac off the superficial layer and spread superior towards the lumbar plexus

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21
Q

What are the structures to know when performing a Femoral Block?

A
  • Illiopsoas muscle
  • Fascia lata
  • Fascia iliaca
  • Femoral artery
  • Femoral vein
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22
Q

What is the positioning as related to a Femoral Block in regards to the patient, the transducer, the depth, needle and the approach.

A 
Patient: supine
Transducer: transverse(near inguinal crease)
Depth: 2-4 cm
Approach: lateral to medial
Needle: in plane, short axis
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23
Q

What LA should be used and how much should be used with a Femoral Block? Where should the LA be deposited?

A

Ropivacaine 0.5% 20-30 ml

Must pierce both fascia lata and fascia iliac

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24
Q

What plexus is anethesized by the Femoral Block?

A

Lumbar plexus

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25
Q

What regional blockade is utilized for a Left Basilic Vein Transposition?

A

o Axillary Brachial Plexus Block
o Infraclavicular Brachial Plexus Block
o Supraclavicular Brachial Plexus Block

26
Q

What regional blockade is utilized for a Right Hip Pinning?

A

o Fascia Iliaca Compartment Block (adjunct not sole anesthetic)
o Lateral Femoral Cutaneous Nerve Block (postoperative analgesia/ not sole anesthetic)

27
Q

What blocks are utilized for a Left Total Knee Arthroplasty?

A

o Adductor Canal Block (saphenous nerve)
o Fascia Iliaca Compartment Block
o Femoral Nerve Block
o (+/ −) Sciatic Nerve Block

28
Q

What are the structures to know when performing a Saphenous Nerve Block?

A

STRUCTURES TO KNOW:
ABOVE THE KNEE (AK)
• mid-thigh
• Fascia lata
• Saphenous n. (SN)
o SN pierces the fascia lata between the tendons of the sartorius and gracilis muscle before becoming a subcutaneous n.
o May also surface between sartorius and vastus medialis muscles
• Vastus medialis muscle
• Femoral artery (FA)
BELOW THE KNEE (BK)
• Nerve passes along the tibial side of the leg, adjacent to the great saphenous vein subcutaneously
• At the ankle, a branch of the nerve is located medially next to the subQ positioned saph vein

29
Q

What is the positioning as related to a Saphenous Nerve Block in regards to the patient, the transducer, the depth, needle and the approach.

A

POSITIONING:
Patient: Supine position, with the thigh abducted and externally rotated to allow access to the medial thigh
Transducer: Linear; Transverse on anteromedial thigh approx. at the level of mid-thigh
Depth: 2-4 cm(Brian 4.5 cm)
Needle: In-plane, short axis
Approach: Lateral (AK); medial (BK)

Find femoral Artery—>lies under it*

30
Q

What LA should be used and how much should be used with a Saphenous Nerve Block? Where should the LA be deposited?

A

INJECTION:

1) After identification of the FA or SN; advance the needle in-plane toward FA
2) Place needle tip medial to artery in adductor canal, underneath sartorius muscle
3) Aspirate; inject 1-2mL of LA to confirm proper needle position
4) Inject a total of 10-20 mL of 0.5% Ropivacaine

31
Q

Whats to note about the plexus/nerve coverage of a Saphenous Nerve Block?

A

PLEXUS &/or NERVE COVERAGE:
Saphenous nerve block results in anesthesia of a variable strip of skin on the medial leg and foot. Of note, although saphenous nerve is a strictly sensory block, an injection of the local anesthetic in the adductor canal can result in the partial motor block of the vastus medialis. For this
reason, caution must be excercised when advising patients regarding the safety of unsupported ambulation after proximal saphenous block.

32
Q

What nerve blocks could be utilized for a ORIF for Right Trimalleolar Fracture?

A

o Popliteal Sciatic Block (+ either below)
o Femoral Nerve Block (adjunct not sole anesthetic)
o Saphenous Nerve Block (adjunct not sole anesthetic)

33
Q

What are the structures to know when performing a Popliteal Sciatic Nerve Block?

A
  • Biceps Femoris Tendon
  • Popliteal Artery
  • Popliteal Vein
  • Biceps Femoris muscle is lateral
  • Semi membranous and semi tendonosis are medial
  • Bifurcation of Tibial and Common Perineal Nerve(CPN more superficial and lateral)
34
Q

What is the positioning as related to a Popliteal Sciatic Nerve Block in regards to the patient, the transducer, the depth, needle and the approach.

A

Patient: lateral decubitus, pillow between knees-lower leg ben and upper leg straight in order to get probe in popliteal fossa
Transducre: transversely across the target popliteal fossa, just at the crease
Depth: 3-4 cm(Brian 4.5 cm)
Needle: in plane,

35
Q

What LA should be used and how much should be used with a Popliteal Sciatic Nerve Block? Where should the LA be deposited?

A

INJECTION: inject 5-10 cm above popliteal crease

Ropivicaine 0.5%, 20-30ml

36
Q

Whats to note about the plexus/nerve coverage of a Popliteal Sciatic Nerve Block?

A 
PLEXUS & NERVE INVOLVEMENT
Sacral Plexus (L4-S3)
Motor: preserves hamstring Fx
Sensory: covers all below knee
EXCEPT Saphenous
37
Q

What type of regional block would be appropriate for someone having a Right Mastectomy with Axillary Lymph Node Dissection?

A

o Thoracic Paravertebral Block

o PECs I/II Block

38
Q

What are the structures to know when performing a PECs Nerve Block?

A 
STRUCTURES TO KNOW:
Clavicle
Pectoralis major (pM)
Pectoralis minor (pm)
Serratus
Axillary artery (AA)
Axillary vein (AV)
2nd rib
4th rib
Pleura
39
Q

What is the positioning as related to a PECs Nerve Block in regards to the patient, the transducer, the depth, needle and the approach.

A 
POSITIONING:
Patient: Supine, arm abducted
Transducer: parasagittal then angled, in-plane
Depth: 3-5 cm
Needle: Medial to lateral (or posterior)
Approach: Cephalad to caudad
40
Q

What LA should be used and how much should be used with a PECs Nerve Block? Where should the LA be deposited?

A

INJECTION:
1) With the probe at the mid clavicular level and angled
inferolaterally, first locate the AA and AV
2) Next move the probe laterally until pm and serrates
anterior are identified
3) Locate the 2nd rib immediately under the AA, then count down to the 4th rib
4) With the image centered at the level of the 3rd rib,
advance the needle in plane til you touch the 4th rib
5) Retract slightly, aspirate, and inject 20 mL of LA (PEC II Block)
6) Retract needle until the your in between the pm and pM
7) Aspirate and inject 1-2 mL to confirm placement; inject the remaining 10 mL of LA 10 mL (PEC I) + 20 mL (PEC II) of 0.5% Ropivacaine

41
Q

Whats to note about the plexus/nerve coverage of a PECs Nerve Block?

A 
PLEXUS &/or NERVE COVERAGE:
C5-T6
Pectoral Nerves:
• Lateral pectoral n (C5-7)
• Medial pectoral n. (C8-T1)
T2-T6 Spinal Nerves:
• Lateral
• Anterior
Long Thoracic Nerve (C5-7)
Thoracodorsal Nerve (C5-8)
42
Q

What are the structures to know when performing a Axillary Brachial Plexus Nerve Block?

A 
STRUCTURES TO KNOW:
• Musculocutaneous nerve(MCN)
• Median n. (MN)
• Ulnar n. (UN)
• Radial n. (RN)
• Axillary artery (AA)
• Biceps
• Coracobrachialis muscle (CBM)
• Triceps
• Humerus
43
Q

What is the positioning as related to a Axillary Brachial Plexus Nerve Block in regards to the patient, the transducer, the depth, needle and the approach.

A

POSITIONING:
Patient: Supine, arm abducted 90° with head turned away
Transducer: Linear; short axis to arm, just distal to pectoralis major insertion
Depth: 1-3 cm
Needle: In-plane, short axis
Approach: Anterior. All needle redirections except occasionally for the MCN should be within the same needle insertion site.

44
Q

What LA should be used and how much should be used with a Axillary Brachial Plexus Nerve Block? Where should the LA be deposited?

A

INJECTION:
1) After identification of the AA; needle insertion is aimed at the RN.
2) 0.5 to 2 mL of LA is injected and the needle is advanced.
3) 5 to 10 mL of LA is injected around the RN and needle is pulled back and redirected to the MN and ulnar nerve
4) Needle is withdrawn an redirected to the MCN.
*** Can be performed in 3 to 4 injections.
20 – 25 mL (5 – 10mL per nerve) of 0.5% Ropivacaine

My Uncle Rapped w/ MC Hammer

45
Q

Whats to note about the plexus/nerve coverage of the Axillary Brachial Plexus Nerve Block?

A

PLEXUS &/or NERVE COVERAGE:
The axillary approach to brachial plexus blockade (including musculocutaneous nerve) results in anesthesia of the upper limb from the midarm down to and including the hand. The axillary nerve itself is not blocked because it departs from the posterior cord high up in the axilla. When required, the medial skin of the upper arm (intercostobrachial nerve, T2) can be blocked by an
additional subcutaneous injection just distal to the axilla, if
required.

46
Q

What is the max does of Ropivacaine that can be given safely?

A

3 mg/kg and with epi 3.5 mg/kg

47
Q

What is the dose of Mepivacaine if that is to be given and in what circumstance would you give it as opposed to Ropivacaine?

A
  • 1.5%

- Ropivacaine is more longer lasting

48
Q

What is the max dose of Mepivacaine?

A

4.5 mg/kg with Epi 7 mg/kg

49
Q

What regional blockade could be utilized for a Right Carotid Endartectomy?

A

o Superficial Cervical Plexus Block

50
Q

What are the structures to know when performing a Superficial Cervical Plexus Block?

A

STRUCTURES TO KNOW:
• Sternocleidomastoid muscle (SCM)
• Prevertebral fascia (posterior to the SCM, covers the
MSM and ASM)
• Middle scalene muscle (MSM)
• Brachial plexus (stoplight or honeycomb structure in
the interscalene groove between the MSM & ASM)
• Anterior scalene muscle (ASM)
• Phrenic nerve

51
Q

What is the positioning as related to a Superficial Cervical Plexus Block in regards to the patient, the transducer, the depth, needle and the approach.

A

POSITIONING:
Patient: Supine, semi-sitting, with head turned slightly away
Transducer: Linear; transverse on neck (approx. the level of the cricoid cartilage) (can be performed in the longitudinal view, not mentioned here)
Depth: 2-3 cm
Needle: In-plane, short axis
Approach: Lateral approach

52
Q

What LA should be used and how much should be used with a Superficial Cervical Plexus Block? Where should the LA be deposited?

A

INJECTION:
1) Block needle is inserted in-plane with the tip adjacent
to the BP and under the prevertebral fascia.
2) Aspirate; inject 1 – 2 mL of LA to check proper
placement.
3) After confirmation, inject the remainder (10 – 15mL) as
you are pulling the needle out.
10 – 20 mL of 0.5% Ropivacaine

53
Q

Whats to note about the plexus/nerve coverage of the Superficial Cervical Plexus Nerve Block?

A

PLEXUS &/or NERVE COVERAGE:
The superficial cervical plexus block results in anesthesia
of the skin of the anterolateral neck and the anteauricular
and retroauricular areas, as well as the skin overlying and
immediately inferior to the clavicle on the chest wall.

54
Q

What Regional Technique can be employed to provide regional anesthesia for a Left Anterior Cruciate Ligament Repair?

A

o Adductor Canal Block (Saphenous n.)
o Fascia Iliaca Nerve Block
o Femoral Nerve Block

55
Q

What regional technique can be employed to provide regional anesthesia for a Right total Elbow Replacement?

A

o Infraclavicular Brachial Plexus Block
o Supraclavicular Brachial Plexus Block
o Axillary Brachial Plexus Block
o Interscalene Brachial Plexus Block

56
Q

What are the structures to know when performing a Infraclavicular Brachial Plexus Block?

A 
STRUCTURES TO KNOW:
• Coracoid process
• Clavicle (inferior to)
• Pectoralis major muscle (PMaM)
• Pectoralis minor muscle (PMiM)
• Fascia of the PMiM
• Axillary Artery (AA)
• Lateral cord (LC) 9 o’clock
• Posterior cord (PC) 7 o’clock
• Medical cord (MC) 5 o’clock
57
Q

What is the positioning as related to a Infraclavicular Brachial Plexus Block in regards to the patient, the transducer, the depth, needle and the approach.

A

POSITIONING:
• Patient: Supine, head turned away, arm abducted 90 and the elbow flexed
• Transducer: approximately parasagittal, just medial to
coracoid process, inferior to clavicle L side of screen will be cephalad
• Depth: 3-5 cm(Brian 5 cm)
• Needle: In-plane, short axis
• Approach: In-plane from the cephalad aspect. Needle is
inserted inferior to the clavicle; aimed toward the posterior aspect of the AA

58
Q

What LA should be used and how much should be used with a Infraclavicular Brachial Plexus Block? Where should the LA be deposited?

A

INJECTION:
1) Insert needle inferior to the clavicle; aiming towards the
posterior aspect of the AA
2) If nerve stimulation is used, the 1st motor response is often from the lateral cord (either elbow or finger flexion)
3) Once the needle is between the AA and PC motor response may occur (finger and wrist extension)
4) Aspirate; inject 1-2 mL of LA to confirm proper placement and spread.
5) Aspirate: inject the rest of LA; should spread cephalad and caudad to cover LC and MC (with each heartbeat)
*** Additional injections may be necessary as opposed to
one large injection 20 – 30 mL of 0.5% Ropivacaine

59
Q

Whats to note about the plexus/nerve coverage of the Infraclavicular Brachial Plexus Nerve Block?

A

PLEXUS &/or NERVE COVERAGE:
Blocks BP at the CORDS
Results in anesthesia of upper limb below shoulder.
The medial skin of the upper arm (intercostobrachial nerve, T2) can be blocked by additional SubQ injection on the medial aspect of the arm just distal to the axilla.

60
Q

What is the treatment for LAST?

A

• 20% lipid emulsion:!
• 1.5 mL/kg as an initial bolus, followed by!
• 0.25 mL/kg/min for 30-60 minutes!
• Bolus could be repeated 1-2 times for persistent
asystole!
• Infusion rate could be increased if the BP declines

4th Quarter (11 decks)

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