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.
18G (‘green’) needle & syringe
After insertion of epidural, withdrawn Thouhy by 1-2 cm so that it remains in patient but outside of epidural space
Small nick in skin adjacent to epidural needle, on side of which epidural catheter is to be tunnelled
Local anaesthetic using green needle in subcut plane laterally
Apply a slight curve in abbocath needle
Then local anaesthetic using abbocath
Exit at exit site of epidural catheter. Use plastic tube to apply tension to skin to help this. Do not exit too far away otherwise will struggle with dressing.
Cut off proximal wide part of abbocath
Pass epidural catheter through abbocath
Then remove abbocath
Pull back epidural to correct position
Then pull through tunnel
Glue the two skin incisions
Sensory block of medial knee and distally.Motor sparing.
Can combine with popliteal nerve block for distal leg
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
Compartment block, so volume important.
Provides post-op analgesia rather than surgical anaesthesia
For #NOF FICB>fem nerve block.
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
Observe cephalad spread.
Looks cool but it is useful? Difficult to aspirate imagine.
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
Probe in antecubital fossa
Identify nerve medial to brachial artery
‘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.
Radial and ulnar infiltration
Avoid median due to tight compartment
Finger (ring) block
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.
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
- 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
From Derby Upper Limb Regional Course & clinical training at RDH
Patient 30 degrees head-up
At edge of bed. Pillow pushed.
Neck rotated slightly away.
Can stand north or south.
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
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.
https://www.youtube.com/watch?v=CTJJdISVc24 (combined with saphenous n. block)
– how many ‘surgeons’ will be present e.g. the whole consultant firm?
– how much ‘teaching’ is involved?
– opioid? – to ‘inhibit autonomic response’? for post-op analgesia?
– post-op analgesia