Category Archives: regional

Rectus Sheath Catheters

Equipment:

Catheter pack or Epidural pack

20ml of 0.25% l-bupivicaine for each side

 

Using US identify rectus muscle. Above umbilicus. Transverse plane if necessary.

Then view in longitudinal/sagittal plane

Enter as close to midline as possible, but alow enough clearance for dressing and wound.

Identify plane. Hydrodissect using saline and create space

Thread catheter as far as it goes

Then attach filter etc and inject remaining LA to see spread

Dressing pack – catheter to be exiting caudally. May use glue.

 

Attach infusion devise.

Link:

http://e-safe-anaesthesia.org/e_library/09/Ultrasound_guided_rectus-sheath_block_Update_2010.pdf

Saphenous nerve / adductor canal block

Indications:

Sensory block of medial knee and distally.Motor sparing.

Can combine with popliteal nerve block for distal leg

Method:

Follow femoral artery into adductor canal

Between vastus medialis (above femur) and sartorius (medially)

To lower 1/3rd of thigh

If the nerve is not identified then field block of 10-20 ml

Links:

http://www.nysora.com/techniques/ultrasound-guided-techniques/lower-extremity/3059-ultrasound-guided-saphenous-nerve-block.html

Fascia Iliaca Compartment Block

For:

#NOF

hip surgery

Principles:

Compartment block, so volume important.

Provides post-op analgesia rather than surgical anaesthesia

For #NOF FICB>fem nerve block.

Approaches:

Transverse or longitudinal approach. Needle in plane.

1cm inf and lateral to junction of medial and lateral 1/3 of line connecting ASIS and pubic tubercle

Two ‘pops’ – fascia lata, fascia iliaca

40ml.

Observe cephalad spread.

Links:

http://www.frca.co.uk/Documents/193%20Fascia%20Iliaca%20compartment%20block.pdf

http://www.nysora.com/updates/3107-ultrasound-guided-fascia-iliaca-block.html

http://www.ucl.ac.uk/anaesthesia/UCLHRegionalEducation/FemoralNerveEducation

http://neuraxiom.com/html/fascia_iliaca_block.html

 

Upper limb peripheral nerve blocks

Radial

Probe in antecubical fossa

Identify nerve laterally

Scan proximally and laterally to identify nerve above the elbow

It wraps around the humerus posteriorly in the spiral groove between triceps and humerus.

Inject at a level between elbow and when nerve is against bone i.e. inject when the nerve is ‘off the bone’ rather than in a tight compartment

Median

Probe in antecubital fossa

Identify nerve medial to brachial artery

Ulnar

Flex elbow

‘Plonck’ the probe in belly of flexor muscles. Identify nerve as it leaves cubital tunnel of medial epicondyle of elbow.

Proximally the ulnar artery is deeper than the nerve. Distally the ulnar nerve runs adjacent to ulnar artery.

Wrist block

Radial and ulnar infiltration

Avoid median due to tight compartment

Finger (ring) block

Useful!

General

For wrist/forarm surgery a heavy, number arm for 12+ hours is undesirable so use shorter acting e.g. prilocaine

Peripheral nerve blocks useful for post-op pain, however will be painful when block wears off so must get analgesia on board

Cutaneous nerves for skin incision e.g. at site of distal radial fracture, come off fairly proximally so peripheral block will cover bony pain but surgical infiltration required to cover incision.

Supraclavicular nerve block

Searle or Chang approach

Chang: parallel to clavicle, in dip of neck. Look for pleura (fuzzy parallel lines) & rib (single echogenic line with acoustic shadow). AVOID PLEURA! Nerve plexus -> artery -> vein (brachiocephalic valve may be present)

Searle: parasagital (at approx 60 degrees to Changs) in dip of neck

Clinical tips:

  • Do for deepest targets first
  • Up to 30ml of mix (1:1 of 1% prilocaine + 0.25% bupivicaine)
  • Supplement with peripheral nerve blocks 5ml of 0.5% bupivicaine

 

Links:

http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=542&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=53&isPDF=YES

http://www.cambridgeorthopaedics.com/cambridgeanaesthetics/advancednerveblocks/Supraclavicular%20block.htm

From Derby Upper Limb Regional Course & clinical training at RDH

Interscalene nerve block

Patient 30 degrees head-up

At edge of bed. Pillow pushed.

Neck rotated slightly away.

Can stand north or south.

SCAN

From supraclavicular region.

Identify subclavian artery pulsating. Identify brachial plexus nerves superior/lateral/posterior.

SCAN cephalad to identify roots (C5,6,7) between anterior and medial scalene

Approach from posteriorly. 50mm simplex needle

20ml of 0.375% for analgesia, 0.5% + lignocaine for anaesthesia

Popliteal nerve block

Lateral approach.

Patient supine with knee flexed, or tilted laterally to allow access with probe.

Probe proximal to popliteal fossa in transverse plane.

Popliteal artery at bottom of screen.

Nerve at 12 o’clock.

Scan caudal-cephelad to where common peroneal nerve and tibial nerves join to form sciatic. Injection just distal to bifurcation provides increased surface area.

Approprah from laterally, between semi-membranosis/tendenosis and femur, in plane parallel to skin/probe

Apply local anaesthetic circumferentially, starting in deep plane (between nerve and artery) then superficial plane.

Videos:

https://www.youtube.com/watch?v=CTJJdISVc24   (combined with saphenous n. block)

Anatomy:

http://www.neuraxiom.com/html/popliteal_block.php