Tag Archives: regional

Erector spinae plane (ESP) block

For abdominal e.g laparotomy or thoracic dermatomes e.g. thoracotomy, rib fractures

Alternative to epidural

Patient awake – sitting or prone

Identify midline (in transverse plane)

Block at level of:

  • T7 level for abdominal cover, even rooftop
  • T5 for thoracic cover (T2 – T9)

Scan laterally so transverse process (TP) in in middle of screen.

Rotate probe vertically to para-sagital plane

Identify layers of subcutaneous tissue, trapezius, (+/- rhomboid), erector spinae (ES)- with articulates with transverse processes

Local anaesthetic at superior entry point. Deep infiltration to level of muscle.

Use Tuohy needle or regional catheter pack needle, in plane approach

Access ESP below ES muscle, adjacent to TP. Can hit it (original description) but more painful. Create space with saline.

Then threat catheter. Leave at least 10cm in the space. Load with 20ml of 0.375% l-bupivicaine to each side.

Then run infusion 0.25% l-bupivicaine at 10ml per hour (split between both sides).

–  NG @ LGH



Rectus Sheath Catheters


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.



Tunnelled epidural catheter

Additional kit:



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After insertion of epidural, withdrawn Thouhy by 1-2 cm so that it remains in patient but outside of epidural space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

Apply dressing

Saphenous nerve / adductor canal block


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



Fascia Iliaca Compartment Block



hip surgery


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.







Upper limb peripheral nerve blocks


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


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



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





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.


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