DR BARRY NICHOLLS
Consultant Anaesthetist
Taunton and Somerset Hospital
DR DAVID CONN
Consultant Anaesthetist
Royal Devon and Exeter Hospital
DR ALICE ROBERTS
Senior Teaching Fellow
Department of Anatomy University of Bristol
CONTENTS / 00
Contents
SECTION 1 - Introduction Golden rules of regional anaesthesia Local anaesthetics Physicochemical properties of local anaesthetics Local anaesthetic additives Complications of peripheral regional anaesthesia Treatment of toxicity Electrical stimulation of peripheral nerves SECTION 2 - Ophthalmic local anaesthesia Topical corneoconjunctival anaesthesia Peribulbar anaesthesia Sub-Tenons anaesthesia SECTION 3 - Upper limb blocks Elicited motor responses Brachial plexus - anatomy Cutaneous innervation chart Cervical plexus block Superficial Deep Interscalene block Winnie Meier Subclavian perivascular block Vertical infraclavicular block Subcoracoid infraclavicular block Suprascapular nerve block Axillary block Midhumeral block Elbow blocks Wrist blocks Digital nerve block Webspace block IVRA (Biers block) SECTION 4 - Trunk blocks Thoracic paravertebral block Intercostal nerve block Penile block Ilioinguinal/iliohypogastric block (hernia block) Caudal epidural - children 01 02 03 04 05 05 06 09 09 12 15 16 17 18 20 22 24 26 28 30 32 34 36 40 46 50 52 54 56 58 59 60 62
00 / CONTENTS
Contents
SECTION 5 - Lower limb blocks Elicited motor responses Lumbosacral plexus - anatomy Cutaneous innervation chart Lumbar plexus block Sacral plexus block (parasacral approach) Sciatic nerve block Labat (posterior approach) Beck (anterior approach) Lateral approach Raj (inferior approach) Femoral nerve block Lateral cutaneous nerve of thigh block Knee / popliteal blocks Lateral Prone Supine Intra-articular knee block Saphenous nerve block Ankle and foot blocks Ankle Midtarsal Digital SECTION 6 - Practical application of peripheral nerve blocks Shoulder Elbow Wrist Hand Hip Knee Ankle Foot Catheter techniques Infusion/bolus guidelines 65 66 67 68 70 72 74 76 78 80 82 84 86 87 88 89 90 96 96
KNOW THE ANATOMY & TECHNIQUE WELL. BE PREPARED TO FAIL HAVE A PLAN.
IMPORTANT: All blocks in this book are tried and tested by the clinical authors and are presented in good faith. This book is not intended as a stand-alone training in regional anaesthesia. We encourage all clinicians to get hands-on training. No responsibility can be accepted for complications arising from the use of the techniques described. In addition to the potential side effects of each block each anaesthetic agent has potential side effects. For details see summary of product characteristics of individual agent.
Local anaesthetics
Esters (COO-)
Procaine/Cocaine/Chloroprocaine/Amethocaine Relatively unstable Rapidly hydrolysed by plasma cholinesterase Para-amino benzoate associated with hypersensitivity & allergic reactions Lidocaine/Prilocaine/Bupivacaine/Levobupivacaine/Ropivacaine Stable in solution Usually weak acid pH 4-5.5 Slowly broken down by amidases in liver Hypersensitivity reactions low Reversible blockade of sodium channels in excitable/conducting neural tissue Administered as water-soluble hydrochlorides (B.HCL) After injection - base released by relative alkalinity of tissues (pH-pKa) B.HCL+HCO3B+H2CO3+CL Unionised base diffuses into nerve axoplasm, partially ionised again B+H+BH+ Ionised base BH+ enters sodium channel-from interior of nerve - preventing depolarisation
Amides (-NHCO-)
400
DURATION OF ACTION
Medium
Medium
150
Mode of action
PROTEIN BINDING
65%
55%
Long
POTENCY
Medium
95%
1000
150
High
ONSET
7.7
7.7
Duration of action
Protein binding at site of action Mass of drug and absorption from site Drugs inherent vasodilatation effect Vasodilator Lidocaine > Prilocaine increased absorption therefore shorter action Ropivacaine no vasodilatation - relative vasoconstrictor Lipid solubility Concentration of local anaesthetic Motor nerves have more myelin than sensory Ropivacaine low lipid sol, high pKa - sensory > motor
STEREO-ISOMER
Achiral
R&S
R&S
8.1
SRopivacaine
8.1
Potency
pKa
Slow
Slow
Fast
Fast
400
50
High
Low
94%
Long
200
Differential block
Levobupivacaine
Bupivacaine
Prilocaine
Lidocaine
Epinephrine (Adrenaline)
Decrease vascular reabsorption increasing duration more drug available Reduction of peak plasma levels (Lidocaine) Reduced benefit in long acting LA e.g. bupivacaine and Chirocaine Less effective in epidurals May have spinal effects via spinal alpha receptors Effective conc. 5mcg/ml = (1:200,000) Epinephrine (Adrenaline) max dose 200mcg Avoid in terminal extremity /digital blocks / sciatic nerve blocks Acts on spinal alpha 2 adrenergic receptors Prolongs duration of sensory and motor block Strengthens local anaesthetic effect Induces post block analgesia Reduce wide dynamic neurone (WDN) activity - inhibiting nociceptive transmission Effective in epidural/caudal/spinal analgesia Epidural/intrathecal use limited by hypotension and sedation Dosage 1mcg/kg in peripheral blocks Spinal/peripheral opiate receptors Proven synergism with local anaesthetic in epidurals/spinals All opioids have been used, debatable benefit in peripheral blocks Intra-articular morphine 2-5mg in knee surgery NMDA receptor/weak local anaesthetic properties Paediatric caudal epidurals PRESERVATIVE FREE DRUG ESSENTIAL Dose 0.5mg/kg in paediatric caudals
Technique related
Direct neural trauma Bleeding and haematoma Intravascular injection Pneumothorax Inadvertent epidural/intrathecal injection widespread block Toxicity Immediate- intravascular injection Delayed- absorption from vascular site/relative overdose Overdose Anaphylactoid reaction Methaemoglobinaemia (prilocaine)
Clonidine
Drug related
Treatment of toxicity
General
STOP INJECTION Airway, Breathing, Circulation
Opiates
CNS Toxicity
Administer oxygen Sedation midazolam, propofol If breathing inadequate or absent start manual ventilation & intubate if necessary Administer fluid replacement Vasopressor drugs as necessary Supplementary oxygen Intravenous fluid Bradycardia glycopyrrolate, atropine Hypotension ephedrine, metaraminol or epinephrine (adrenaline) Intubation and ventilation 100% oxygen Cardiopulmonary resuscitation (CPR) Bretylium for ventricular arrhythmias
Ketamine
Hyaluronidase
Only appears effective in peribulbar and retrobulbar blocks of the eye Aids in the onset of block by increased diffusion of LA through tissues
CVS Toxicity
Methaemoglobinaemia
Methylene blue 1mg/ kg
Peribulbar anaesthesia
Indications: Operations on the globe including cataract and retinal surgery Landmarks: Sclerocorneal junction (limbus), medial canthus, caruncle and inferior orbital rim Technique: Instill topical local anaesthetic drops Perform inferolateral injection +/- medial injection
Inferolateral injection:
Palpate the groove on the inferior orbital rim at the junction of the maxilla and zygoma, in line with the limbus. At a point 1mm above the rim of the orbit just lateral to this point - either transcutaneously (through lower lid) or transconjunctival Needle: 25G 25mm (bevel facing globe) Direction: Backwards, slightly inferiorly to contact bone. Redirect posteriorly under globe Depth: 20-25mm (hub level with iris) Volume: 4-6 mls (see Figures 1 & 2 ) LA: Lidocaine 2% with Hyaluronidase 10-30units/ml 1:1 mixture of Levobupivacaine 0.75% + Lidocaine 2% with Hyaluronidase 10-30units/ml
Medial injection:
At a point medial to the caruncle Needle: 25G 25mm (bevel facing globe) Direction: Directly backward, angled slightly medial to touch medial wall of orbit, then withdrawn and redirect posteriorly, parallel to the medial wall. Depth: 20-25mm Volume: 3-5mls (see Figures 3 & 4) Side effects: Conjunctival oedema/haemorrhage Proptosis Complications: Retrobulbar haemorrhage Subarachnoid injection Perforation of globe Extra-ocular muscle damage from intramuscular injection Clinical tips: Always know axial length (AL). Risk of globe perforation increases as AL increases. Extreme caution if AL >27mm, consider only a medial canthus injection or a sub-Tenons block
Sub-Tenons block
Indications: Operations on the globe including cataract and retinal surgery Landmarks: Sclerocorneal junction (limbus) Technique: (See Figures 5 & 6) Instill topical local anaesthetic drops Retract the eyelids with a speculum In the inferonasal quadrant, the conjunctiva is raised with Moorfields forceps At a point 5mm from the limbus a small incision in the conjunctiva is made using Westcott spring scissors. Dissection of this space inferonasally between the sclera (vascular) and Tenons capsule (white, avascular) Needle: Insert a blunt, curved sub-Tenon cannula backwards beyond the equator. Volume: 3-5 mls LA: Lidocaine 2% with Hyaluronidase 10-30units/ml 1:1 mixture of Levobupivacaine 0.75% + Lidocaine 2% with Hyaluronidase 10-30units/ml Complications: Bleeding Side effects: Chemosis (corneal oedema)/swelling Subconjunctival haemorrhage Proptosis Comparison with peribulbar: Lower risk of bleeding but poorer akinesia
SECTION THREE
Motor Response
Muscle Innervated
Nerve
C5 root Phrenic Dorsal scapular C5-6 root Upper trunk Middle trunk Lower trunk Lateral cord Posterior cord
Accept Comment
Acceptable for shoulder surgery Too anterior Too posterior Too superficial Caution too medial Medial cord Subscapular Musculocutaneous Median Ulnar Too deep, outside of plexus
SUBCLAVIAN PERIVASCULAR
Deltoid Diaphragm Levator scapulae/rhomboids Biceps Deltoid, Biceps, Brachialis, Coracobrachialis (BBC) & Triceps Primarily extensors flexors forearm/hand Flexors of forearm and fingers BBC flexors of the forearm and hand
INFRACLAVICULAR
Wrist and finger extension Finger and wrist flexion Flexion elbow, wrist and hand supination Wrist and fingers extension Wrist and fingers flexion, thumb adduction Scapula posterior adduction Elbow flexion Wrist flexion+ pronation. Finger flexion Thumb adduction, ring and little finger flexion Wrist and finger extension especially thumb
Extensors of forearm and hand Flexors of the forearm and small muscles of the hand Subscapularis Biceps, Brachialis, Coracobrachialis (BBC) Flexor digitorum superficialis and FCR Adductor pollicis/FDP Flexor carpi ulnaris Extensors elbow, wrist and fingers
Radial
r pe Up
C7
le dd Mi
2 3
4 5 6 7 8 9
La ter al
C8
r we Lo
r rio ste Po
4 5
11
T1 6 12
Me dia l
17 7 16 15 14 13 8 9 10 8 10
12 11 10
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)
Dorsal scapular nerve Nerve to subclavius Suprascapular nerve Lateral pectoral nerve Upper and lower subscapular nerves Axillary nerve Lateral root of median nerve Musculocutaneous nerve Radial nerve Ulnar nerve Median nerve Medial root of median nerve Medial cutaneous nerve of forearm Thoracodorsal nerve Medial cutaneous nerve of arm Medial pectoral nerve Long thoracic nerve
C5 C5,6 C5,6 C5,7 C5,6 C5,6 C6,7 C5,7 C5-T1 C7-T1 C6-T1 C8-T1 C8-T1 C6-8 C8,T1 C8,T1 C5-7
Branches of the cords Lateral cord 4,7,8 Medial cord 10,12,13,15,16 Posterior cord 5,6,9,14
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
Supraclavicular nerves Superior lateral cutaneous nerve of arm (axillary nerve) Intercostobrachial nerve Inferior lateral cutaneous nerve of arm Medial cutaneous nerve of arm (medial cord) Lateral cutaneous nerve of forearm (musculocutaneous nerve) Medial cutaneous nerve of arm (medial cord) Radial nerve Median nerve Ulnar nerve Posterior cutaneous nerve of arm (radial nerve) Posterior cutaneous nerve of forearm (radial nerve)
(1) Transverse cervical nerves (2) Supraclavicular nerves (3) Greater auricular nerve
1 2 5 3
2 3 4 5 1
FIGURE 12: Deep cervical plexus with sternocleidomastoid muscle cut and retracted
Interscalene block
Winnies approach
Indications: Shoulder & humerus surgery Landmarks: Cricoid cartilage (C6) Posterior border of Sternocleidomastoid muscle (SCM) Interscalene groove Technique: Identify posterior border of sternocleidomastoid muscle (SCM) at cricoid level (C6) Place finger beneath lateral border SCM onto belly of scalenus anterior Move fingers laterally feeling for groove separating scalenus anterior from scalenus medius
(See Figures 13 & 14)
Volume: LA:
25mm-50mm insulated Towards contra lateral elbow 10-20mm (very near the surface) Deltoid (shoulder surgery) Elbow flexion (humeral surgery) If the phrenic nerve is stimulated - needle too anterior If the dorsal scapular nerve is stimulated - needle too posterior 10-20mls upper roots/analgesia 20-40mls lower roots/anaesthesia 1% Lidocaine , 1% Prilocaine 0.25%-0.5% Levobupivacaine
Clavicle Phrenic nerve Subclavian artery Brachial plexus Dorsal scapular nerve
Side effects: Phrenic nerve block - 100% Recurrent laryngeal nerve block - 15% Stellate ganglion block - 20% Complications: Epidural/spinal injection Vertebral artery puncture Bilateral spread Spinal cord injury Pneumothorax Clinical tips: Never do block on anaesthetised patients Caution with patients with respiratory problems The plexus is rarely (if ever) more than 20mm deep to the skin Paraesthesia to the operative area is an acceptable alternative to electrical nerve stimulation
2 7 8 4 3
9 6
Interscalene block
Meiers approach
Indications: Shoulder and humeral surgery Difficult anatomy - poor identification of interscalene groove, short neck Continuous catheter techniques Landmarks: The posterior border sternocleidomastoid muscle (SCM) Thyroid cartilage prominence (C4) Subclavian artery - above the clavicle Technique: Mark the posterior border of sternocleidomastoid muscle at the level of the thyroid prominence Palpate the subclavian artery as it passes over the 1st rib behind the clavicle A line joining these two marks approximates to the interscalene groove
(See Figures 15 & 16)
Needle: Direction:
50mm insulated Caudally, passing along the long axis of the interscalene groove towards the subclavian artery Depth: 35-50mm Stimulation: Deltoid (shoulder surgery) Elbow flexion (humerus) Volume: 10-20mls upper roots/analgesia 20-40mls lower roots/anaesthesia LA: 1% Lidocaine , 1% Prilocaine 0.25%-0.5% Levobupivacaine Side effects: As with Winnies technique Complications: Inadvertent intravascular injection Pneumothorax - very low incidence Clinical Tips: Reduced risk of epidural/intrathecal injection Easier catheter placement because of angle of approach
1 2 3
50mm insulated Parallel to the floor, directly caudad (aiming at ipsilateral great toe). 1.5-4cm Flexion/extension wrist and fingers If no paraesthesiae or twitch found then redirect fractionally anterior/posteriorly in groove If accidental arterial puncture - move needle posteriorly If you contact 1st rib then walk antero-posteriorly along rib CAUTION: Absolutely no medial intent or medial angulation of the needle Volume: 0.5ml/kg up to 40mls LA: 1% Prilocaine, Lidocaine 0.25% - 0.5% Levobupivacaine Side effects: Horners syndrome/recurrent laryngeal nerve block Complications: Vascular puncture Inadvertent intravascular injection Pneumothorax - less than 1:1000 in experienced hands. Clinical Tips: Fast onset block, because of the narrowing of the perivascular sheath at this level. Ulnar border missed in approximately 5% of blocks.
FIGURE 17: Subclavian perivascular approach - Finger in the groove and/or subclavian artery
2 5 3
50mm insulated. 2-5 cm Absolutely vertical direction of needle. No medial angulation. Wrist / finger extension - accept, posterior cord. Pectoral muscle twitch - don't accept, needle too medial or superficial. Elbow flexion - don't accept, lateral cord, needle too lateral or superficial. No twitch - needle too lateral Caution: No medial angulation of needle, only move needle in horizontal plane medial / lateral Volume: 0.5ml/kg to 50ml LA: 1% Prilocaine, 1% Lignocaine 0.25% - 0.5% Levobupivacaine Side effects: Rarely recurrent laryngeal nerve block, stellate ganglion block Complications: Vascular puncture Inadvertent intravascular injection Pneumothorax - less than 1:1000 in experienced hands. Clinical Tips: Keep the needle as close to the inferior surface of the clavicle as possible. Move the needle medially or laterally but keep the needle absolutely vertical. Care with very thin patients as plexus may be less than 2cm deep (lung may be less than 5cm deep)
1 2 3
50-80mm insulated Perpendicular in all planes 3-8cm Wrist / finger extension - accept, posterior cord. Pectoral muscle twitch - don't accept, needle too medial or superficial. Elbow flexion - don't accept, lateral cord, needle too cephalad or superficial. Wrist flexion, thumb adduction - only accept if surgery is in ulnar distribution, medial cord. Posterior scapular movements - don't accept, too deep, outside plexus CAUTION - no medial angulation of needle/only move needle in sagittal plane (cephalad / caudad) Volume: 0.5 mls/kg to 50mls LA: 1% Prilocaine/Lidocaine Levobupivacaine 0.25%-0.5% Side effects: Nil of note Complications: Vascular puncture Inadvertent intravascular injection Clinical tips: 2cm & 1cm distances will need to be reduced proportionally in smaller patients
1cm
2cm
4 3
2cm
1cm
(1) Inferior angle of scapula (2) Spine of scapula (3) Suprascapular nerve
3 2
Axillary block
Indications: Elbow, forearm and hand surgery Landmarks: Axillary artery Insertion of pectoralis major muscle Technique: Identify the axillary artery with the arm abducted to 90 and the elbow flexed Draw a line down from the anterior axillary fold (insertion of pectoralis major) crossing the artery Fix the artery between index and middle finger and insert a needle to pass above or below the artery (See Figure 25 ) Above the artery - (median, musculo-cutaneous) Below the artery - (ulnar) Below / Behind the artery - (radial) (See Figure 26 ) Needle: 25-50mm insulated/uninsulated Direction: 45 to the skin, proximally Depth: 10-15mm Stimulation: Median index/middle finger - flexion Ulnar thumb adduction, little finger flexion Radial thumb extension Musculocutaneous elbow flexion Volume: Single injection: 0.5ml/kg up to 50mls Multiple-injection: Identify each individual nerve. 7-10mls each nerve. Intercostobrachial nerve subcutaneous infiltration across floor of the axilla decreases upper arm tourniquet pain. Alternative techniques Transarterial - deliberate transfixion of axillary artery Loss of resistance - click/pop on entering fascial sheath Subcutaneous infiltration - fanwise infiltration above/below artery Deliberately elicit paraesthesia in the nerve supplying target area Continuous axillary catheter- identify primary nerve supplying target, insert catheter either above (median) or below (ulnar/radial) artery LA: 1% Lidocaine, 1% Prilocaine 0.25% - 0.5% Levobupivacaine Side effects: Nil of note Complications: Inadvertent vascular injection Nerve damage Clinical Tips: Single shot almost always misses the musculo-cutaneous branch, also misses the radial in about 25%.
Musculocutaneous nerve Median nerve Medial cutaneous nerve of forearm Axillary artery Ulnar nerve
(6) Radial nerve (7) Medial cutaneous nerve of arm (8) Coracobrachialis/biceps muscle (9) Triceps muscle (10)Humerus
1 2 3 4 8
5 6 7 9 10
Midhumeral block
Indications: Elbow, forearm and hand surgery Landmarks: Insertion of deltoid muscle Brachial artery Technique: Mark the brachial artery in the bicipital groove Draw a line crossing the artery at the level of the insertion of deltoid This should be approximately three or four finger breadths below the axilla
(See Figures 27 & 28)
3 2 1
8 7
c/s
4 5 6
Needle: Direction:
50mm insulated Median - above (lateral) and parallel to the artery(See Figure 29) Musculocutaneous - 45 above the artery and lateral to humerus
(See Figure 32)
Radial- below (medial to) the artery and humerus. Pass needle to posterior border of humerus (nerve in spiral groove)(See Figure 31 ) Volume: 6-10mls on each nerve Stimulation: Median - index/middle finger - flexion Musculocutaneous - elbow flexion Ulnar - little finger flexion/thumb adduction Radial - thumb extension LA: 1-2% Lidocaine, 1% Prilocaine 0.5% Levobupivacaine Side effects: Nil of note Complications: Bleeding/bruising 5% Clinical Tips: Use long acting LA on nerve supplying area of operation and short acting LA on the rest. Additional subcutaneous infiltration 5 mls - medial cutaneous nerve of arm/forearm and intercostobrachial nerve to aid tourniquet comfort.
Ulnar nerve Median nerve Musculocutaneous nerve Medial cutaneous nerve of arm Medial cutaneous nerve of forearm
8 1 2 3 10 4 5 6 7
11 11 11
Medial cutaneous nerve of arm Musculocutaneous nerve Median nerve Brachial artery Ulnar nerve Medial cutaneous nerve of forearm
(7) Radial nerve (8) Biceps muscle (9) Deltoid muscle (10)Coracobrachialis muscle (11) Triceps muscle
Elbow blocks
Indications: Minor forearm surgery & hand surgery Top-up to augment or expedite brachial plexus blocks Landmarks: Elbow crease, brachial artery, tendon of biceps muscle LA: 1-2% Lidocaine , 1% Prilocaine 0.25%-0.5% Levobupivacaine Techniques:
Ulnar nerve (See Figures 33,34 & 37) Median nerve (See Figures 33,34 & 35)
Flex the elbow, mark the elbow crease Identify the brachial artery on this line and mark a point just medial to the artery Needle: Direction: Depth: Stimulation: Volume: 25-50mm insulated/uninsulated 45 to the skin/proximally 10-15mm, below bicipital aponeurosis (pop or click felt) Flexion of fingers accept. Pronation of wrist alone inadequate Paraesthesia into thumb index or middle finger accept 5mls slowly Palpate the ulnar sulcus (medial epicondyle). At a point 2cm proximal to the sulcus Needle: 50mm insulated Direction: 45 to the skin along a line joining the ulnar sulcus and axilla Depth: 1-3cms Stimulation: Flexion ring finger, adduction of thumb Volume: 5mls Side effects: Nil Complications: Nil of note Clinical Tips: Inject the LA slowly into tight tissues Avoid injection of ulnar nerve in ulnar sulcus Only accept distal finger movement and not forearm Inconsistent anatomy - causing varying nerve distribution with overlapping cutaneous innervation The major nerves at the elbow only have cutaneous innervation to the hand. Cutaneous innervation of the forearm comes from higher branches Paraesthesia is not routinely sought but if encountered then withdraw the needle by 1-2mm and slowly inject LA
Medial
Lateral
1
Medial
Lateral
2 2 5 6 4 3 3
1 C/S 4
Wrist block
Indications: Hand surgery Landmarks: Palmaris longus (PL), flexor carpi radialis (FCR), ulnar artery, flexor carpi ulnaris (FCU), radial styloid
(See Figures 38-41 )
3
Technique:
Median nerve
Make a fist. Identify the tendons of FCR & PL Mark a point 3-5cms proximal to the distal palmar crease between these tendons (if no PL present -1cm medial to FCR) (See Figure 42) Needle: 25G 25mm non-insulated Direction: 45 to the skin, towards the wrist Depth: 10-15mm Stimulation: Paraesthesia into thumb or index finger Volume: 3-5mls
Ulnar nerve
Make a fist. Identify the tendon of flexor carpi ulnaris (FCU) At a point 2cm proximal to the distal palmar crease beneath the medial border of the tendon (See Figure 43) Needle: 25G 25mm uninsulated Direction: Medially beneath tendon of FCU, towards radial border of wrist Depth: 10-15mm Stimulation: Paraesthesiae into little finger Volume: 3-5mls (1) Median nerve (2) Ulnar nerve (3) Radial nerve
(5) Ulnar artery (6) Ulnar nerve (7) Flexor carpi ulnaris
Side effects: Nil of note Complications: Possible vascular compromise from pressure Accidental vascular puncture / haematoma Clinical tips: Massage to aid spread NEVER use vasoconstrictors around end arteries
Webspace block
Indications: As for digital nerve block Landmarks: Metacarpophalangeal joints Technique: Insert the needle in the webspace till the tip of the needle is proximal to the MCP joint Needle: 23/25G 50mm uninsulated Depth: Just proximal to MCP joint Volume: 3-5mls in each space Clinical tips: Massage to aid spread NEVER use vasoconstrictors around end arteries
Technique: Patient sitting or lying with operative side up Palpate the spinous process and mark a point 2.5cms lateral to its most cephalad aspect Direction: Perpendicular to skin Needle: 22G 80mm spinal needle/ insulated needle Depth: Initially contact transverse process (2-5cm), reangle needle to pass above the TP advancing 1-1.5cm Stimulation/Endpoint: Loss of resistance or paraesthesiae (motor response - intercostal muscle twitch) Volume: 5mls per level or high volume 15mls* LA: 0.25% - 0.5% levobupivacaine Side effects: Epidural spread Contralateral spread Complications: Intravascular injection, intrathecal injection, pneumothorax Clinical tips: *Catheter/high volume techniques - work well in thoracic region (15mls -blocks 3-5 segments) Thoracic surgery T5/6 Fractured ribs variable level Cholecystectomy/Renal multiple levels T8-T12 Catheter T10 Avoid lateral angulation of needle - increased risk of pneumothorax
Lung 1 5
4 2 3
Penile block
Indication: Circumcision Technique: Palpate symphysis pubis (SP), above the root of penis Mark two points (0.5cm infant, 1.0cm child/adult) either side of the midline below the SP (See Figures 52 & 53) Needle: 22-25G short bevelled Direction: Posteriorly, medial and slightly caudally- until loss of resistance elastic recoil with penetration of Bucks fascia Depth: 8-30mm (correlates with age) Volume: 0.1ml/kg (max 5mls) per side (child) LA: 0.5% Levobupivacaine Infiltrate subcutaneously around root of penis onto the lateral side of scrotum, blocking branches from ilioinguinal and genitofemoral nerves (1-5mls depending on size of child - 0.25% Levobupivacaine) Never use epinephrine (adrenaline) containing solutions Complications: Intravascular injection Puncture corpus cavernosum/dorsal vessels (haematoma)
1 1
2 3 4
Iliohypogastric nerve
Following initial click (pop) as needle penetrates external oblique aponeurosis inject 8mls of LA to block the iliohypogastric nerve
Ilioinguinal nerve
Either insert the needle deeper till a second click, as internal oblique is penetrated and inject 8 mls to block the ilioinguinal nerve OR direct the needle posterolaterally to touch inner aspect of ileum and inject 8 ml of LA whist withdrawing blocking the ilioinguinal nerve
FIGURE 54: Hernia block
Intercostal nerves
Fan wise subcutaneous infiltration above the aponeurosis will block cutaneous supply from lower intercostal nerves and sub-costal nerve (T12) Fan wise subcutaneous infiltration from pubic tubercle superiorly & laterally will block contra lateral innervation
Rectus abdominis muscle External oblique muscle Iliohypogastric nerve Internal oblique muscle
Genitofemoral nerve
Palpate the deep ring, insert needle into inguinal canal to block the genitofemoral nerve - 5mls (can only reliable be performed at operation) Volume: 30mls LA: 0.25-0.5% Levobupivacaine Complications: Intravascular injection Intraperitoneal injection Femoral nerve block Clinical tips: In children limit volume 2.5mg/kg Levobupivacaine (0.25%-0.5%) Always warn the patient about the risk of femoral nerve block and subsequent inability to weight bear.
2 3 4 5
6 7
FIGURE 55: Cross section at the level of the anterior superior iliac spine
LA:
SECTION FIVE
Accept Comment
Too medial/too caudad Too deep
Too superficial
L1 1
L2
2 3
L3 1 4
L4
11
3 L5 4
5 S1
6 S2
8 S3
12
7 S4
13
10
14
Iliohypogastric nerve Ilioinguinal nerve Lateral femoral cutaneous nerve Genitofemoral nerve Femoral nerve Obturator nerve Sciatic nerve Pudendal nerve
(1) Lateral cutaneous branch of subcostal nerve (2) Femoral branch of genitofemoral nerve (3) Lateral femoral cutaneous nerve (4) Anterior femoral cutaneous nerves (5) Obturator nerve (6) Common fibular nerve
Saphenous nerve Superficial fibular nerve Sural nerve Deep fibular nerve Posterior cutaneous nerve of thigh Sural nerve Calcaneal branch of tibial nerve Plantar branches of tibial nerve
(1) Tuffiers line (2) Posterior Superior Iliac Spine (3) Lumbar plexus
Obturator nerve Genitofemoral nerve Femoral nerve Lateral femoral cutaneous nerve (5) Ilioinguinal/iliohypogastric nerves (6) Psoas muscle
2 3
FIGURE 62: Lumbar plexus anatomy FIGURE 60: Cross section through L4
2
6cm
6 cm
(1) Anterior Superior Iliac Spine (2) Femoral nerve (3) Pubic tubercle
1
1
3
1
3
1
3
3
4
High approach
At the level of the ischial tuberosity (IT)
Medial
1 2
Anterior Superior Iliac Spine Lateral cutaneous nerve of thigh Femoral nerve Femoral artery
1
3 4 5 6 7
2 3 4 5 6
2cm
2cm
(1) Anterior superior iliac spine (2) Lateral cutaneous nerve of thigh (3) Femoral nerve
2 cm 2 cm
3
Knee/popliteal blocks
Indications: Ankle and foot surgery
2 1 c/s
5
3
4
Lateral 1
2
6
3 4
6 7
(4) Popliteal artery (5) Tibial nerve (6) Common fibular nerve
Knee/popliteal blocks
Prone posterior approach
Landmarks: Semimembranosus, biceps femoris and the popliteal crease. Technique: With the patient prone and the leg resting on a pillow, flex the knee, mark the popliteal crease Palpate the apex of the fossa, marking the boundaries (lateral - biceps femoris, medial - semimembranosus) Draw a line from the apex to the middle of the popliteal crease Mark a point 6cm - 8cm proximal to the crease and 1cm lateral
(See Figure 78 & 81)
Needle: Direction:
Needle: Direction:
50-80mm insulated 45 proximal, moving laterally to identify tibial then common fibular (peroneal) Depth: 30-80mm Stimulation: Tibial - plantar flexion of foot Common fibular (peroneal) - dorsiflexion/eversion of foot Volume: 10-15 mls at each location LA: 1% Lidocaine, 1% Prilocaine 0.25%-0.5% Levobupivacaine Side effects: Nil of note Complications: Vascular puncture Clinical tip: 75% of sciatic nerves divide within 10cm of the popliteal crease. If fine movements of the needle cause both fibular and tibial nerves to be stimulated assume nerves are close enough together to use a single 20 - 30 ml injection of LA
50-80mm insulated Perpendicular to skin, moving laterally to identify tibial then common fibular (peroneal). Depth: 40-80mm Stimulation: Tibial - plantar flexion of foot Common fibular (peroneal) - dorsiflexion/eversion of foot Volume: 10-15 mls at each location LA: 1% Lidocaine, 1% Prilocaine 0.25%-0.5% Levobupivacaine Side effects: Nil of note Complications: Vascular puncture
FIGURE 83: Intra-articular knee block FIGURE 85: Saphenous nerve anatomy
2 6
Tibial nerve:
Draw a line joining the medial malleolus to the posterior inferior border of the calcaneum Mark a point just posterior to the posterior tibial pulse (half way) Needle: 25-50 mm Stimulation: Plantar-flexion toes, paraesthesia to the sole of foot/toes Volume: 5-8mls
3
1 1
Sural nerve:
Infiltrate subcutaneously from lateral malleolus to lateral border of Achilles tendon Volume: 5mls Clinical Tips: Use in conjunction with an ankle tourniquet for all minor foot surgery Painful block in non-anaesthetised patient - sedation advised.
FIGURE 86: Cutaneous innervation of foot and ankle
(1) Medial and lateral plantar (tibial) - sole of foot (2) Tibial nerve (calcaneal) - heel (3) Saphenous nerve (femoral) - medial side of foot variable innervation to head of 1st metatarsal (4) Sural (fibular) - lateral margin of foot and fifth digit (5) Superficial fibular (peroneal) nerve - dorsum of foot (6) Deep fibular nerve - web between 1st and 2nd toe
Lateral
1
2 1
(4) Tibia (5) Medial & lateral plantar nerves (6) Sural nerve
1 2 3
Superficial fibular nerve Saphenous nerve Extensor hallucis longus Deep fibular nerve Dorsalis pedis artery
4 5
Mid Tarsal
Indication: Post-op pain control. Minor surgery of the forefoot or toes. Use in conjunction with an ankle tourniquet Technique: (See Figures 94 & 95) Palpate the metatarsophalangeal joint (MTPJ). Mark a point 2cm proximal to the MTPJ Needle: Insert a 21-23G needle either side of the metatarsal to plantar aspect of foot. Inject 6-8mls while withdrawing needle LA: 1% Prilocaine, 1% Lignocaine 0.5% Levobupivacaine Side effects: Pain with injection Complications: Haematoma Clinical tips: There will be no appreciable motor block
1 1 1 1 1
Elbow
Cutaneous innervation Medial cutaneous nerve of arm /forearm (medial cord C8-T1) Posterior cutaneous nerves of arm / forearm (radial nerve -posterior cord C5-8 +T1) Lateral cutaneous nerve of forearm (lateral cord C5-7) Joint Primarily by the musculocutaneous (C5-7), radial (C5-8, T1) and ulnar nerve (C7,8,T1) Anaesthesia / analgesia - brachial plexus block (supra / infraclavicular, axillary and midhumeral) Catheter techniques for extended analgesia (supra / infraclavicular & axillary Clinical tips To ensure adequate cutaneous anaesthesia (axillary & midhumeral approaches) cutaneous infiltration of medial cutaneous nerve of arm needs to be added (nerve lies outside of sheath).
Wrist
Cutaneous innervation Medial cutaneous nerve of forearm Posterior cutaneous nerve of forearm Lateral cutaneous nerve of forearm Cutaneous branches of the median, ulnar and radial Joint Anterior interosseous nerve (median) Posterior interosseous nerve (radial) Dorsal and deep branches of the ulnar nerve Anaesthesia / analgesia Supraclavicular, Infraclavicular, axillary or midhumeral (interscalene - often misses lower roots, ulnar border wrist and hand) Clinical tips Biers block (IVRA) suitable for minor superficial operations or K wires.
Hand
2
Hip
Cutaneous innervation Lower intercostal nerves- subcostal (T12) ilio-hypogastric (L1) Lateral cutaneous nerve of thigh (lumbar plexus L2-3) Superior cluneal nerve (dorsal rami L1-3) Joint innervation Femoral nerve (L2-4 - branch to rectus femoris) Obturator nerve (L3-4 - anterior divisions) Sciatic nerve (L4-S3 - nerve to quadratus femoris) Superior gluteal nerve (L4-S1) Analgesia - Lumbar plexus block - posterior or anterior +/- parasacral block Anaesthesia - difficult to obtain complete surgical anaesthesia due to multiple innervations and varied surgical approaches Catheter techniques can be used for extended analgesia i.e lumbar plexus block for femoral shaft fractures Clinical tips Complete anaesthesia / analgesia is best obtained with either spinal or epidural techniques
2 5 3
Knee
Cutaneous innervation Femoral and saphenous nerve (L2-4) Posterior femoral cutaneous nerve (S2-3 - sacral plexus) Common fibular nerve (sural cutaneous nerve) Joint innervation Branches from femoral, obturator, tibial and common fibular nerves Analgesia - lumbar plexus block - posterior/anterior Anaesthesia - lumbar plexus + sciatic nerve +/- obturator Catheter techniques for extended analgesia Clinical tips Anaesthesia for arthroscopy can be achieved with intra-articular LA + infiltration of portals. For tourniquet add femoral nerve block. Sciatic and femoral blocks provide good analgesia but are not suitable as sole technique for knee replacement unless combined with light GA
Cutaneous innervation 1. Palmar cutaneous branch of the median nerve - skin lateral palm/thenar eminence 2. Medial/lateral branches of the median nerve - skin palmar surface, dorsum of terminal digits & nail beds of radial 31/2 digits. 3. Superficial branch ulnar nerve - skin of ulnar 11/2 digits. 4. Palmar cutaneous nerve of ulnar - skin over medial palm and hypothenar eminence 5. Superficial branch radial nerve - skin over dorsum of hand thumb and lateral aspect. Analgesia and analgesia Wrist blocks are sufficient with a wrist tourniquet for most minor surgery. Complete anaesthesia and immobility - midhumeral, axillary and infraclavicular approaches to the brachial plexus. Surgery isolated to digits - web space or digital nerve block Biers block sufficient for all minor hand surgery + minor bone work MUA + K wires. Clinical tips Palmar cutaneous branches of both ulnar and median leave their respective nerve proximal to the wrist - ulnar mid forearm, median proximal to flexor retinaculum passing superficial to it. Cutaneous innervation in the hand is very variable
Ankle
Cutaneous innervation Saphenous nerve Superficial fibular (peroneal) nerve Sural nerve (arises from both tibial and common fibular nerve) Tibial nerve Joint innervation Tibial nerve and deep fibular nerve Analgesia/anaesthesia - sciatic nerve block (above the knee) or tibial + common fibular nerve (popliteal approach). Clinical tips Saphenous nerve should be included for all medial ankle operations Thigh tourniquet required - proximal sciatic nerve and femoral nerve block
Foot
5 4
2 6 3 1 1 4
Cutaneous innervation 1) Medial and lateral plantar (tibial) - sole of foot 2) Tibial nerve (calcaneal) - heel 3) Saphenous nerve (femoral) - medial side of foot, variable innervation to head of the first metatarsal 4) Sural (fibular) - lateral margin of foot and fifth digit 5) Superficial & deep fibular nerves - dorsum of foot 6) Deep fibular nerve - web between 1st and 2nd toe Analgesia and analgesia Deep and superficial peroneal / fibular nerves + tibial nerve (behind medial malleoli) sufficient for most toe surgery/ except little toe (sural nerve)- use in conjunction with ANKLE tourniquet, Complete anaesthesia / immobile foot - tibial + common fibular (popliteal block) + saphenous nerve block If high tourniquet required - proximal sciatic nerve + femoral nerve block. Clinical tips The foot is not immobile following an ankle block Ankle blocks are uncomfortable to perform on awake patients - use sedation.
Catheter techniques
Advantages Extension of anaesthesia and analgesia into the post operative period - 24-72hrs Extended physiotherapy - frozen shoulder, complex regional pain syndromes (CRPS) 72hrs - 7days Disadvantages Technically more difficult to perform, larger needles, non standardisation of kit High failure rate - greater then 25% Labour intensive ie. Top ups, infusion pumps and nurse monitoring General principles Catheter needs to ideally lie parallel/alongside the nerve or plexus being blocked Therefore needle should be inserted as near to parallel to the nerve / plexus as possible to facilitate this Not so important when using Tuohy needle as catheter comes out at right angles to the needle direction- in theory (in practice 45) Prior to passing catheter, distend the space with 10-20mls of saline or local anaesthetic Only thread 3-5cms of catheter into space (unless using stimulating catheter then thread to target) Always flush the catheter after insertion - avoids blockage with blood Securely fix catheter (falling out! commonest cause of failure)
Stimulating catheter
Advantages Reliable placement of catheter stimulating chosen nerve or plexus. Confirm position of catheter prior to bolus of local anaesthetic i.e. stimulating C5/6 for shoulder replacement Check catheter position during post-operative period and reposition as necessary (withdraw slightly) Disadvantage Can be uncomfortable to place in awake patients, as saline must be used to distend space rather than LA Stimulating catheter is fairly stiff, can cause pain/paraesthesia on insertion Cost
Bolus top-ups
Brachial plexus / Lumbar plexus catheters Levobupivacaine 0.25% 20-30mls - 6-12hrs Bolus injections should always be carried out in a controlled environment with resuscitation equipment available
Continuous infusions
Brachial plexus / Lumbar plexus catheters Levobupivacaine 0.25% Levobupivacaine 0.1% +/- Fentanyl 2mcg/ml
108 / NOTES
NOTES
Adults
Epidural post-operative pain Epidural obstetrics Intrathecal Peripheral nerve block Ophthalmic blocks Local infiltration
150 mg
18.75 mg/hr
Children
2.5 mg/kg
N/A
Preparations available:
Chirocaine (Levobupivacaine Hydrochloride) Prescribing Information. Presentation: Three strengths are available, 2.5 mg/ml, 5.0 mg/ml and 7.5 mg/ml of levobupivacaine as levobupivacaine hydrochloride. Each strength is available in 10ml polypropylene ampoules in packs of 10. Indications: Adults: Surgical anaesthesia - Major, e.g. epidural (including for Caesarean section), intrathecal, peripheral nerve block - Minor, e.g. local infiltration, peribulbar block in ophthalmic surgery. Pain management - Continuous epidural infusion, single or multiple bolus epidural administration for the management of pain especially post-operative pain or labour analgesia. Children: analgesia (ilioinguinal/iliohypogastric blocks). Dose and Administration: The precise posology will depend upon the procedure and individual patient concerned. Careful aspiration before and during injection is recommended to prevent intravascular injection. When a large dose is to be injected, e.g. in epidural block, a test dose of 3-5 ml lidocaine (lignocaine) with adrenaline is recommended. An inadvertent intravascular injection may then be recognised by a temporary increase in heart rate and accidental intrathecal injection by signs of a spinal block. Aspiration should be repeated before and during administration of a bolus dose, which should be injected slowly and in incremental doses, at a rate of 7.5 30 mg/min, while closely observing the patients vital functions and maintaining verbal contact. The recommended maximum single dose is 150 mg. The maximum recommended dose during a 24 hour period is 400 mg. For Post-operative pain management, the dose should not exceed 18.75 mg/hour. For Caesarean section, higher concentrations than the 5.0 mg/ml solution should not be used. For labour analgesia by epidural infusion, the dose should not exceed 12.5 mg/hour. In children, the maximum recommended dose for analgesia (ilioinguinal/iliohypogastric blocks) is 1.25 mg/kg/side. Contra-indications: Patients with a known hypersensitivity to local anaesthetic agents of the amide type; intravenous regional anaesthesia (Biers block); patients with severe hypotension such as cardiogenic or hypovolaemic shock; and use in paracervical block in obstetrics. The 7.5 mg/ml solution is contra-indicated for obstetric use due to an enhanced risk for cardiotoxic events based on experience with bupivacaine. There is no experience of levobupivacaine 7.5 mg/ml in obstetric surgery. Precautions: Epidural anaesthesia with any local anaesthetic may cause hypotension and bradycardia. All patients must have intravenous access established. The availability of appropriate fluids, vasopressors, anaesthetics with anticonvulsant properties, myorelaxants, atropine, resuscitation equipment and expertise must be ensured. Levobupivacaine should be used with caution for regional anaesthesia in patients with impaired cardiovascular function e.g. serious cardiac arrhythmias and in patients with liver disease or with reduced liver blood flow e.g. alcoholics or cirrhotics. Interactions: Metabolism of levobupivacaine may be affected by CYP3A4 inhibitors eg: ketoconazole and CYP1A2 inhibitors eg: methylxanthines. Levobupivacaine should be used with caution in patients receiving anti-arrhythmic agents with local anaesthetic activity, e.g., mexiletine, or class III anti-arrhythmic agents since their toxic effects may be additive. No clinical studies have been completed to assess levobupivacaine in combination with adrenaline. Side-Effects: Adverse reactions with local anaesthetics of the amide type are rare, but they may occur as a result of overdosage or unintentional intravascular injection and may be serious. Accidental intrathecal injection of local anaesthetics can lead to very high spinal anaesthesia possibly with apnoea, severe hypotension and loss of consciousness. The most frequent adverse events reported in clinical trials irrespective of causality include hypotension (22%), nausea (13%), anaemia (11%), postoperative pain (8%), vomiting (8%), back pain (7%), fever (6%), dizziness (6%), foetal distress (6%) and headache (5%). Other side effects include: CNS effects: numbness of the tongue, light-headedness, dizziness, blurred vision and muscle twitch followed by drowsiness, convulsions, unconsciousness and possible respiratory arrest. CVS effects: decreased cardiac output, hypotension and ECG changes indicative of either heart block, bradycardia or ventricular tachyarrhythmias that may lead to cardiac arrest. Neurological damage is a rare but well recognised consequence of regional and particularly epidural and spinal anaesthesia. This may result in localised areas of paraesthesia or anaesthesia, motor weakness, loss of sphincter control and paraplegia. Rarely, these may be permanent. Use in Pregnancy and Lactation: Levobupivacaine should not be used during early pregnancy unless clearly necessary. The clinical experience of local anaesthetics of the amide type including bupivacaine for obstetrical surgery is extensive. The safety profile of such use is considered adequately known. There are no data available on excretion of levobupivacaine into human breast milk. However, levobupivacaine is likely to be transmitted in the mothers milk, but the risk of affecting the child at therapeutic doses is minimal. Overdose: Accidental intravascular injection of local anaesthetics may cause immediate toxic reactions. In the event of overdose, peak plasma concentrations may not be reached until 2 hours after administration depending upon the injection site and, therefore, signs of toxicity may be delayed. Systemic adverse reactions following overdose or accidental intravascular injection reported with long acting local anaesthetic agents involve both serious CNS and CVS effects. Special Storage Conditions: No special storage precautions for the closed ampoule. Once opened, use immediately. Legal Category: POM. Marketing Authorisation Number: PL 0037/0300-0302. Basic NHS Price: 2.5 mg/ml pack: 16.60, 5.0 mg/ml pack: 19.00, 7.5mg/ml pack: 28.50. Further information is available on request from Abbott Laboratories Ltd, Abbott House, Norden Road, Maidenhead, Berkshire SL6 4XE. PI/93/1/001. References: 1. Burke D, Bannister J. Current Anaesthesia and Critical Care 1999; 10:262-269. 2. Chirocaine Summary of Product Characteristics.