Wk 10: Upper extremity nerve blocks Flashcards by Ashley Campbell

3 modes for monitoring nerve injury

Ultrasound
Injection pressure
Nerve stimulation

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Benefits of regional blocks (6)

Decreased N+V
Decreased postop pain
Decreased need for postop
analgesics
Better communication with
patient
Reduction in hospital stay
Increased patient satisfaction

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Which is LEAST cardiotoxic, bupivacaine or ropivacaine?

Ropivacaine

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How often should you aspirate to avoid intravascular injection?

Every 5 ml, or every time needle is moved

(to avoid intravascular injection)

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What sized needle should you use to best avoid nerve injury?

20-22g

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________ guidance and injection with______ ____ can help with safety in PNB’s

Ultrasound
pressure gauge

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On a pressure gauge needle, pressures of _____ psi may indicate intraneural/intrafascicular needle placement

> 15

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___ g, ______bevel, _____ tip needles cause less trauma

22g, short bevel, blunt tip

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Single-injection interscalene block has a ____ % incidence of peripheral nerve injury

1.7%

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Higher risk in PNB’s: (4)

Males
High BMI
> 60 years old
DM

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Highest incidence of lawsuits: Upper extremity block

Interscalene block (ISB)

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Highest incidence of lawsuits:
Lower extremity blocks

Femoral and sciatic

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Occurrence of permanent peripheral nerve injury

2-5/10,000 blocks

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Contributing factors to adverse events

Technical knowledge/performance
Pre-existing injury/radiculopathy

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Initial symptom of nerve injury

Paresthesia

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More than 95% of cases: nerve injury are ______, with full recovery over time

transient

(if delay in recovery occurs, its only a matter of time- several weeks- for full recovery)

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Risks to mention to patient for regional anesthesia (5)

Bleeding
Infection
Hematoma
LAST
Nerve damage (extremely rare)

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The “numbing injection” will last approximately ___ -____ hours

4-16

(depending on local anesthetic selection)

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PNB type of surgery

Interscalene block

Shoulder
Upper arm

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PNB type of surgery

Supraclavicular block

Entire upper extremity distal to shoulder

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PNB type of surgery

Infraclavicular block

Elbow and below

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PNB type of surgery

Axillary block

Distal to elbow

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PNB type of surgery

Elbow/wrist blocks

Wrist and hand

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PNB type of surgery

Intercostal block

Chest and upper abdominal wall

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PNB type of surgery TAP block

Anterior abdominal wall

PNB type of surgery Psoas compartment

Entire hip Thigh Medial lower leg

PNB type of surgery Femoral block

Anterior thigh and knee Medial lower leg

PNB type of surgery Fascia iliaca block

Hip Femoral shaft Knee

PNB type of surgery PENG block

Hip

PNB type of surgery Adductor canal block

Knee

PNB type of surgery Sciatic block

Below knee sparing medial lower leg

PNB type of surgery Popliteal

Below the knee sparing medial lower leg

PNB type of surgery Ankle

Foot Distal ankle

Absolute contraindications for PNB

Patient refusal Infection AT injection site Coagulopathy or other bleeding diathesis

Relative contraindications

Uncooperative patient Psychiatric disease Preexisting neurologic damage/ disease

Drugs that enhance block quality and duration (5)

Buprenorphine Epinephrine (1:200,000) Clonidine Dexmedetomidine Dexamethasone

Complications of PNB (10)

LAST Direct + indirect nerve injuries Vascular injury/hematoma Phrenic nerve paralysis Horner's syndrome Hypotensive bradycardic episode Total spine Recurrent laryngeal nerve damage Pneumothorax Infection

A total spinal would present at (2)

Bradycardia, LOC

Recurrent laryngeal nerve damage would present as

hoarseness

Phrenic nerve paralysis can be d/t ____ volume

Horner's syndrome is d/t LA spread to

cervical

Elements of a time out (5)

Patient ID (Name, DOB) Allergies Type of surgery and surgery side (marked) Type of block and block side (left or right) Monitors and equipment

Must haves for ALL patients (6)

Patient consent IV access Block cart (supplies, airway equipmemt, drugs) Lipid emulsion Monitoring (pulse ox, EKG, BP monitor) Light sedation (short acting benzos, opioids)

Minimum monitoring necessary (ASA standard)

Pulse ox EKG BP monitor

What nerves does the axillary block target?

Terminal branches Median, Radial, Ulnar, Musculocutaneous (all but Axillary)

Axillary block Where is musculocutaneous nerve located

coracobrachialis muscle

Why is axillary block unsuitable for proximal humerus or shoulder surgery?

Because the patient must be able to abduct the arm to perform

Level of blockade of axillary block

Terminal branches

Level of blockade infraclavicular block

Cords

Nerves blocked infraclavicular block

Radial, ulnar, median, axillary, musculocutaneous

Why is infraclavicular block a good alternative to a supraclavicular block?

Decreased risk of phrenic nerve blockade; good for patients with respiratory insufficiency Catheter site easy to maintain; no risk of hemo-, pneumothorax

Why infraclavicular block good alternative to axillary block?

For patients with limited upper extremity mobility if unable to abduct arm (as is required for axillary block)

Level of blockade supraclavicular. block

Trunks

Nerves blocked supraclavicular block

Radial, ulnar, median, musculocutaneous, axillary

Supraclavicular block has a high risk for what?

Pneumothorax

What type of procuedure is a supraclavicular block unsuitable for?

Outpatient procedures

Supraclavicular block causes what in 30% of cases?

Phrenic nerve paralysis

Interscalene block level of blockade

Roots or upper and middle trunks

Nerves blocked interscalene block

Radial, ulnar, median, musculocutaneous, axillary

In interscalene block, which nerve is not blocked 15-20% of cases?

Ulnar

Which patient population is interscalene block unsuitable for? Why?

Patients unable to tolerate 25% reduction in pulmonary function Phrenic nerve paresis in 100% of patients

How many Roots Trunks Divisions Cords Branches

5 3 6 3 5

Sensory test Pinch lateral aspect of shoulder

Axillary

Sensory test Pinch lateral aspect of forearm

Musculocutaneous

Sensory test Pinch index finger

Median

Sensory test Pinch web space between thumb and index finger

Radial

Sensory test Pinch pinky finger

Motor test Arm abduction (Deltoid contraction)

Axillary

Motor test Elbow flexion (biceps contraction)

Musculocutaneous

Motor test Thumb opposition

Median

Motor test Elbow extension (triceps contraction) Wrist and finger extension

Radial

Motor test Pinky finger abduction

Ulnar

Blocks above the clavicle

Interscalene Supraclavicular

Blocks below the clavicle

Infraclavicular Axillary

How long does Exparel work?

72 hours

What types of blocks is Exparel approved for?

Interscalene Sciatic in popliteal fossa Adductor canal Field blocks (TAP/Rectus sheath, PECS, ESP)

Avoid additional use of local anesthetics within _____ hours following administration of Exparel

Recommended dose of Exparel for local infiltration in adults is up to a maximum dose of ______

266 mg (20mL vial)

For Exparel, for interscalene block, adductor canal block, sciatic/popliteal block, max dose is: _____mg (10ml) + Bupivicaine 0.5% (10ml) = 20ml total

133

Exparel is approved for > ___ years of age

Interscalene block indications

Shoulder and upper arm surgery Surgery of clavicle (combined with cervical plexus block)

Interscalene block transducer position

Transverse on the neck, 3-4 cm superior to clavicle, over external jugular vein

Interscalene block injection location

In the interscalene groove, between anterior scalene muscle (ASM) and middle scalene muscle (MSM), when you see "stoplight/snowmen" = brachial plexus (C5, C6, C7)

How much LA do you inject for interscalene block

7-15 mL

What are the landmarks for an interscalene block?

Interscalene groove at level of Cricoid cartilage C6 Chassaignac's tubercle

Patient position for interscalene block

HOB up 45 degrees Head turned to opposite side

For nerve stimulator technique for an interscalene block, you would observe for twitches in which 4 muscles?

Deltoid Biceps Triceps Pectoralis major

For nerve stimulator technique for an interscalene block, once twitches are observed at ___ mA, the stimulation intensity is reduced to ____ mA; twitch should be maintained here

1 0.5

For nerve stimulator technique for an interscalene block, if twitches observed at < ____ mA, STOP - this is intraneural

0.2

For nerve stimulator technique for an interscalene block, if paresthesia or pain occurs, what do you do?

stop the injection needle position can be reevaluated prior to further injection

Which two blocks have a high incidence of phrenic nerve blockade?

Interscalene block Supraclavicular block

What does blockage of the phrenic nerve result in?

Paralysis of the ipsilateral diaphragm

Blockade of the phrenic nerve results in paralysis of the ipsilateral diaphragm, causing ____% reduction in forced vital capacity (FVC)

25%

Phrenic nerve blockade may not be tolerated in which types of patients?

Patients with severe or symptomatic COPD, particularly if the larger right lung is affected

Phrenic nerve blockade may not be tolerated in patients with severe COPD, especially if the ______, larger lung is affected

right

Phrenic nerve is blocked 100% of the time if what?

Large LA volumes (30-40mL) are used

Horner's syndrome results from _______ ________ blockade at ____

stellate ganglion C7 (cervical sympathetic chain)

Horner's syndrome s/s

Ptosis (eye drooping) Miosis (pinpoint pupil) Anhidrosis (inability to sweat)

As little at ___mL LA into ________ artery can cause seizure

1 vertebral

Needle enters nerve bundle, crampy sensation type of injury

Direct nerve injury

LA toxicity, large amounts surround nerve bundle Type of injury

Indirect nerve injury

Recurrent laryngeal nerve injury presents as

hoarseness, stridor

Recurrent laryngeal nerve injury is the result of what?

Injection of large volumes of LA

Hypotensive Bradycardic Episodes associated with ______ ______reflex and __________ surgery and ________ block

Bezold-Jarisch reflex Shoulder surgery in sitting position Interscalene block

Hypotensive Bradycardic Episode leads to __________, ___________ ,________

Bradycardia Hypotension Syncope

Supraclavicular block landmarks

Clavicle Subclavian artery ("Corner pocket" where first rib meets subclavian artery)

Supraclavicular block complications (3)

Pneumothorax Subclavian artery puncture Horner's syndrome

Supraclavicular probe placement

Supraclavicular fossa

MOST SERIOUS complication of supraclavicular block

Pneumothorax

What percent risk for a pneumothrax in a supraclavicular block?

Infraclavicular block preferred when?

Patient unable to abduct arm for axillary block

How is needle inserted for an infraclavicular block?

Vertically in a location 2cm medial and 2cm caudad to tip of the coracoid process

Most painful upper extremity nerve block? why?

Infraclavicular Pt discomfort as needle pierces pectoralis major and pectoralis minor muscles

Infraclavicular complications ________ is a possible complication with left-sided blocks

Chylothorax (Thoracic duct on left, and if damaged, lymph fluid can accumulate in pleural cavity)

Complications of intraclavicular block Hematoma: ________artery/vein puncture

Axillary artery/vein

Which block anesthetizes the nerves of the brachial plexus at the level of the individual nerves (median, radial, and ulnar), where they surround the axillary artery + MCN

Axillary block

Arm position for axillary block

Abduct arm 90 degrees

Axillary block: block _____ nerve first, ___ -___mL LA for each nerve

Radial 3-5 mL

The old method/transarterial procedure for axillary block involves LA injected posteriorly and anteriorly to the _________ artery to surround the median, ulnar, and radial nerves ____mL of LA will be injected posteriorly and anteriorly in ____mL increments with negative aspiration in between

axillary 15mL 5mL

To independently block the musculocutaneous nerve in an axillary block, 3-5mL of LA should be injected into the ________________ muscle

coracobrachialis

Artery at risk for being punctured in Interscalene block

Vertebral artery

Artery at risk for being punctured in Supraclavicular block

Subclavian artery

Artery at risk for being punctured in Infraclavicular block

Subclavian artery or axillary artery (Depends on block level)

Artery at risk for being punctured in Axillary block

Axillary artery

Indications for IV Bier block

Short procedures of upper and lower extremities Most common: Carpel tunnel, hand

Bier blocks are limited to ___ _____ (time)

1 hour

Bier block _________ _________ alternates inflation to decrease tourniquet pain, which limits the duration of surgical anesthesia

Double tourniquet

What do you need for a Bier block? (4)

Double tournaquet Esmarch wrap 2 IVs (1 for main, 22G iv in operative hand) LA (0.5% lidocaine, 50 mL)

Bier block No _____ added to LA

Epi

Bier block May add __________

Ketorolac

Bier block What LA used? How much?

30-50mL 0.5% Lidocaine 3mL/kg is sufficient

Most serious risk of Bier block

LAST d/t cuff failure

Bier block Never deflate tourniquet less than ______minutes after injection

Bier block Do NOT use ________ or __________

Ropivacaine or bupivacaine

Wrist block indication

Hand and finger surgery

Wrist block transducer position

Transverse at wrist crease or distal third of forearm

Wrist block target

LA injection next to radial, ulnar, median nerve

Wrist block LA amount

4-5mL per nerve

Do NOT use ____________ in the digits

epinephrine (vasoconstriction, ischemia)

Sciatic nerve block indication

Foot and ankle surgery Below-knee amputation Analgesia following knee surgery involving posterior compartment

Sciatic nerve block volume

10-20mL

Sciatic nerve block type of probe

curved

Femoral nerve block indications

Anterior thigh and knee Femur Medial lower leg

Femoral nerve block volume

15-20mL

Femoral nerve is __ cm lateral to femoral artery

1 cm

Femoral triangle acronym

"NAV" Nerve Artery Vein (from lateral to medial)

Muscle response to nerve stimulator for femoral nerve block

Quadriceps femoris contraction or Patellar twitch/snap

Which lower extremity nerve block is associated with quadriceps weakness and an increased rate of falls

Femoral nerve block

Fascia-Iliaca block indications

Hip fractures Hip arthroplasty

Fascia-Iliaca block volume

30-40mL Large volume block

3 nerves covered by Fascia-Iliaca block

Femoral nerve Genitofemoral nerve Lateral femoral cutaneous

Fascia-Iliaca block landmarks

1. Anterior superior iliac spine (ASIS) 2. Pubic tubercle

3 in 1 block indications

Hip Femur

3 in 1 block nerves blocked

Femoral nerve Lateral femoral cutaneous nerve Obturator nerve

PENG block stands for

Pericapsular nerve group

PENG block indications

Hip fracture Hip arthroplasty

PENG block nerves blocked

Femoral nerve Obturator nerve Accessory obturator nerve

PENG block = NO ___________ weakness, spares motor

quadriceps

PENG block type of transducer

Low frequency (2-5MHz) Curvilinear array transducer

PENG block landmarks

Anterior inferior iliac spine Psoas tendon (needle should be under this)

Adductor canal block indications

Post-op pain control for TKA

Adductor canal block nerve blocked

saphenous nerve

Adductor canal block limits _________ weakness

quadriceps

Adductor canal block volume

10-20 mL

LAST treatment

Intralipid 20% <70 kg: 100mL 2-3 min(bolus) 200-250mL 15-20 min (infusion) >70kg: 1.5ml/kg 2-3 min (bolus) 0.25ml/kg/min (infusion)