Understanding Peripheral Nerve Learn About These Techniques for Perioperative Anesthesia and Analgesia

Home , Femoral nerve block, Sciatic nerve block, Topical anesthetic

2.5 ANCC CONTACT HOURS Understanding peripheral nerve Learn about these techniques for perioperative anesthesia and analgesia.

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By Daniel D. Moos, MS, EdD, CRNA

Anesthesia and analgesia continue to evolve: nerve block didn’t occur until 1978.2 Since then, the Ancient civilizations used medicinal plants such as technology has become increasingly accepted among the poppy, coca leaves, and mandrake roots. In anesthesia providers. To briefly review, an ultrasound 1855, Alexander Wood invented a syringe with a transducer or probe creates sound waves through hollow needle, which allowed the administration piezoelectric crystals. These sound waves are pro- of medications by additional routes not previously jected into the tissue, bounce off the tissue or organ Aavailable. Cocaine was isolated from coca leaves the like an echo, and are reflected back to the ultra- same year. Karl Koller is credited with using cocaine sound transducer. Tissues vary in their ability to as a topical anesthetic in 1860 and William Halsted reflect sound waves back to the transducer, so anes- performed some of the first peripheral nerve blocks thesia providers may need to use different trans- in 1884.1 These humble beginnings have led to the ducers for different parts of the body. The depth of use of ultrasound-guided techniques for the admin- anatomic structures affects the overall quality of the istration of peripheral nerve blocks, the focus of this ultrasound image—the closer a structure is to the sur- article. Peripheral nerve blocks may be administered face, the better the image quality, and the deeper the without ultrasound guidance, but this technology is structure, the lower the image quality.3 becoming increasingly common. High-frequency linear array transducers (with a fre- This article describes some common peripheral quency of 10 to 12 MHz) are used for superficial nerve blocks that may be administered for anes- structures that are generally less than 4 cm (1.6 inch) thesia or postoperative analgesia, either as a single in depth, such as the brachial plexus and the femoral injection or through a continuous catheter. The nerve. A low-frequency curved array transducer (fre- blocks described are upper extremity blocks of the quency of 2 to 5 MHz) is used to identify anatomical brachial plexus, I.V. regional anesthesia, transver- structures that are deeper than 4 cm, such as the sciat- sus abdominis plane (TAP) block of the trunk, and ic nerve. Medium-frequency transducers generally lower extremity blocks of the femoral and sciatic have a frequency of 6 to 10 MHz, and aren’t com- nerves. monly used because low- and high-frequency transducers are adequate for most peripheral nerve blocks.4 About ultrasound Anesthesia providers exert a great deal of control Although ultrasound technology was first described in improving visualization of structures by manipulat- for medical uses in the 1940s, the first report of ultra- ing the transducer. When assisting with the place- sound being used in conjunction with a peripheral ment of a peripheral nerve block, the OR nurse may

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be asked to adjust some of the often place pressure on a trans- controls on the ultrasound ducer to identify vascular struc- machine to help improve the tures. Arteries will appear as overall image. A few basic con- round, pulsating structures that trols are frequency, gain, depth, aren’t easily compressed; veins and color Doppler. can be compressed by the • Frequency is primarily deter- application of pressure. A red mined by the anesthesia pro- image indicates that blood flow vider choosing the correct is traveling toward the trans- transducer. Finer adjustments ducer; blue indicates blood is may be made by manipulating traveling away from it.3 the frequency setting on the Ultrasound transducers The anesthesia provider ultrasound during the block to must be kept sterile during determines which approach improve resolution of the target the placement of peripheral to take based on the site structure. nerve blocks to avoid infec- of surgical intervention, • Adjusting gain will lighten or tion. For a single-injection individual expertise, and darken the image by changing block, the anesthesia provider patient-related factors. amplification of returning sound may choose to use sterile waves (also known as echoes). An increase in gain occlusive, transparent dressings. After the injection brightens the image and increases artifact; decreas- site has been prepared with antiseptic solution ing gain darkens the image. and draped with sterile drapes, the perioperative • Adjusting the depth adjusts the image on the nurse holds the transducer in an upright position screen so that the target anatomy is clearly seen. and applies transducer gel to the surface. The Depth is usually increased or decreased.4 The perianesthesia provider then places the sterile occlu- operative nurse should slowly adjust these settings sive transparent dressings on the transducer using to help optimize the image. sterile technique (see Preparing a transducer for a • The color Doppler function helps clinicians identify single-shot technique). Additional sterile transducer vascular structures such as the internal jugular artery gel will be applied to the injection site. (see Color Doppler image). Anesthesia providers will Alternatively, a sterile sleeve may be used over the transducer for either a single-shot injection or catheter insertion. The anesthesia provider prepares Color Doppler image the injection site with antiseptic solution and Red shows the carotid artery and the blue is the drapes it with a sterile barrier. The perioperative internal jugular vein. nurse holds the transducer in an upright position and applies transducer gel to the surface or within the sterile sleeve while the anesthesia provider holds the sleeve, maintaining sterility. The anesthesia provider prepares the sleeve for application over the transducer by grasping the transducer with the sleeve and pulling the sleeve over the probe while maintaining sterile technique. Sterile rubber or non-latex bands are applied to keep the sleeve tight around the transducer.

Peripheral nerve stimulators A peripheral nerve stimulator may be used during the placement of a single-shot injection or catheter for continuous analgesia in the postoperative period.

Photos courtesy of the author; used with permission. These devices may be used in conjunction with ultrasound or as a stand-alone technique. Nerve

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After the anesthesia site has been prepared, the perioperative nurse holds the transducer in an upright position (below left) and applies transducer gel to the surface. The anesthesia provider then places the sterile occlusive transparent dressings on the transducer using sterile technique (below right).

stimulators use low-intensity stimulation of the anesthesia provider sets the initial ms, Hz, and mA nerve and subsequent motor response of the mus- settings.5 The OR nurse may be asked to increase cles to aid in the placement of a peripheral nerve or decrease the intensity (mA) as the anesthesia block or catheter. Tell the patient that this tech- provider localizes the target nerve. nique generally isn’t uncomfortable, and that involuntary muscle movement is normal. Continuous catheters A stimulator has a positive lead (anode) that A number of continuous catheters are manufactured attaches to the ECG patch and a negative lead for administering postoperative analgesia. Stimulating (cathode) that attaches to the needle. Be sure that catheters are used in conjunction with peripheral the ECG patch is securely attached to the skin so nerve stimulators or ultrasound, or may be placed that it can maintain conductivity; interrupting the without peripheral nerve stimulation but with the current between the positive and negative elec- assistance of ultrasound. These catheters have centi- trodes could cause patient injury. meter markings similar to epidural catheters, and a Peripheral nerve stimulator configurations vary negative lead that attaches to the needle for initial by manufacturer, but have three basic parameters: localization. The negative lead is then attached to the milliseconds (ms), which determine the duration catheter as it’s inserted, and is attached to an injec- of stimulation; hertz (Hz), which determine the tion port for final confirmation of catheter place- frequency of stimulation; and milliamperes (mA), ment. Be sure the ECG patch (positive lead) is tightly which determine the intensity of stimulation. The connected to the nerve stimulator. www.ORNurseJournal.com September OR Nurse 2011 27

Peripheral nerve blocks: Upper extremity The anesthesia provider determines which A number of peripheral nerve blocks may be admin- approach to take based on the site of surgical inter- istered for upper extremity anesthesia or analgesia, vention, individual expertise, and patient-related and include nerves derived from the brachial plexus. factors.5 Peripheral nerve block is contraindicated Approaches to the brachial plexus include the use of in patients with a active infection at the site of the known anatomical landmarks, eliciting a paresthesia block, coagulation disorder, or those with neuropa- with a blunt needle, nerve stimulation, and ultrasound- thy. The duration of the block depends on a guided techniques. When eliciting a paresthesia, the variety of factors, including the type of local anesthesia provider will use a B-bevel needle to come anesthetic used. in close proximity to the nerve. The patient will feel a The brachial plexus is a relatively complicated ana- paresthesia in that nerve distribution. With the advent tomical structure formed by the ventral branches of of newer technology (and because of the risk of sharp cervical (C5-C8) and thoracic (T1) spinal nerves, needles injuring the nerve), this technique is no longer with some contributions from C4 and T2 (see common. Brachial plexus anatomy). These structures start as The overall success rate of the nerve block varies trunks as they leave cervical foramina and then come by approach and individual anesthesia provider expe- together and separate to form divisions, cords, and rience. Ultrasound has been found to have a greater eventually main branches. At the anterior and mid- rate of success and lead to a faster onset of sensory dle scalene muscles trunks are formed and course blockade when compared with other techniques.6 over the lateral border of the first rib and under the clavicle. Each trunk will separate into anterior and posteri- Brachial plexus anatomy or divisions. As the brachial The brachial plexus and its relationship to the structures in the upper plexus emerges under the chest, axilla, and shoulder. clavicle, the divisions form three cords. When the brachial plexus reaches the pectoralis minor muscle, each cord will divide into branches and end as individual nerves.5 Each of the following approaches can be used for single-shot or catheter techniques, and can be used with paresthesia, nerve stimulation, or ultrasound techniques. For a recap of the nurse’s role, see Summary of nursing actions for peripheral nerve block placement. • The interscalene approach for a peripheral nerve block in the upper extremity is indi- cated for surgical procedures involving the shoulder, arm, and forearm because local anesthetic is deposited primarily at the C5-C7 distribu- tions with a decreased block Source: Hickey JV. The Clinical Practice of Neurological and Neuroscience Nursing, 6th ed. at C8-T1 (see Interscalene Philadelphia: Wolters Kluwer Lippincott Williams & Wilkins; 2008; 489. ultrasound anatomy).

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Summary of nursing actions for peripheral nerve block placement3-5,7,8,13-16 • Follow the Universal Protocol and label medication • Assist the anesthesia provider in monitoring the preprocedure. patient during and after peripheral nerve blockade. • Follow standard precautions. • Avoid placing a pneumatic tourniquet directly • Have resuscitation equipment immediately over the sciatic nerve injection site. available. • Have a functioning and reliable double pneu- • Help the anesthesia provider position the patient. matic tourniquet available for I.V. regional anes- • Administer sedatives as directed by the anesthe- thesia. sia provider. • Monitor the patient recovering from a peripheral • Reassure the patient during administration of the nerve block as you would monitor any patient peripheral nerve block. recovering from anesthesia. • Help maintain sterility during preparation of the • Protect the insensate limb after block placement. injection site and the ultrasound transducer. • Monitor the patient for block-specific complica- • Adjust the ultrasound controls as needed to help tions. improve visualization. • Ensure that peripheral nerve catheters are con- • Ensure adequate ECG contact with the patient’s skin nected and secured. for positive lead and connection of negative lead to • Check the peripheral nerve catheter and inser- the needle when using peripheral nerve stimulator. tion site during routine nursing care. • Adjust the intensity of the peripheral nerve stim- • Ensure that sterile dressings are intact. ulator, if used, when identifying the nerve. • During patient transfers, avoid accidental dis- • Reassure the patient that involuntary muscle lodgement of the catheter. movement is normal when using a peripheral • Tailor patient teaching to the specific block and nerve stimulator during block placement. expected duration of blockade.

This approach isn’t used if the surgical procedure involves the ulnar nerve distribution.7 Because the Interscalene ultrasound anatomy local anesthetic is deposited close to the phrenic nerve, the interscalene approach shouldn’t be used in patients with pulmonary disease.5,7 Patients are positioned supine with their head turned to face away from the surgical side and the shoulder relaxed to improve access. Complications of the interscalene approach include local anesthetic toxicity; phrenic and recurrent laryngeal nerve blockade, which may lead to a hoarse voice and dyspnea; Horner syndrome (myosis, ptosis, and anhidrosis); neuraxial blockade; and pneumothorax. A hoarse voice and Horner syndrome are common but self-resolve as the local anesthetic wears off, so Photo courtesy of the author; used with permission. tell patients before the procedure. • The supraclavicular approach deposits local anesthetic in a more even distribution compared with the inter- include local anesthetic toxicity, pneumothorax, scalene approach, resulting in excellent anesthesia hemothorax, Horner syndrome, and phrenic nerve and analgesia of the upper arm, forearm, and hand. blockade.5,7 This approach isn’t a good choice for surgical proce- • The infraclavicular approach blocks the brachial plexus dures of the shoulder.7 at the level of the lateral, posterior, and medial cords Patients are positioned supine with their head formed when the brachial plexus travels past the first facing away from the surgical side at a 30-degree rib. This approach results in anesthesia of the upper angle. This approach should be avoided in patients arm, forearm, and hand, and isn’t a good choice for with severe pulmonary disease. Complications shoulder procedures.7 www.ORNurseJournal.com September OR Nurse 2011 29

Patients are positioned with their head turned When the procedure is completed and the cuff is slightly to the side away from the operative limb. deflated, monitor the patient for signs and symptoms The arm may be abducted or placed down at the of local anesthetic toxicity, which include lighthead- patient’s side. edness, tinnitus, paresthesia, seizure, cardiovascular Complications of this approach include local anes- depression with hypotension, bradycardia, ventricular thetic toxicity; pneumothorax and hemothorax, dysrhythmias, and respiratory arrest. The most com- which may occur at a higher incidence compared to mon complications of this block include local anes- the supraclavicular approach; and chylothorax, with thetic toxicity from early deflation of the tourniquet left-sided approaches.5,7 or tourniquet malfunction, and tourniquet pain. Once the tourniquet is deflated the patient will I.V. regional anesthesia regain sensation. Encourage the surgeon to infiltrate A technique first described in 1908, I.V. regional the operative area with local anesthetic, if appropri- anesthesia, also called a Bier block, doesn’t require ate, after closing the wound.5,7-8 modern technology such as ultrasound or peripheral nerve stimulators. Although it’s a simple block when Peripheral nerve blocks: Trunk performed properly, it can be dangerous if done The TAP block is a useful peripheral nerve block of improperly or with faulty equipment. In this block, the abdomen for postoperative analgesia of the an I.V. injection of preservative-free 0.5% lidocaine is lower anterior abdominal wall when an epidural isn’t used to anesthetize the hand and lower arm, rather desirable. A number of thoracolumbar nerves (T8- than blocking individual nerves. Using preservative- L1) can be blocked at the Petit triangle, which is free lidocaine suitable for I.V. regional anesthesia is located superior to the iliac crest and bordered by crucial—the use of any other local anesthetic solution the latissimus dorsi and external abdominal oblique could cause cardiac arrest. muscles. The thoracolumbar nerves are located This block is performed in the OR with the assis- between the transversus abdominis muscle and inter- tance of the OR nurse. The patient should have nal oblique.9,10 I.V. devices in the dorsum of the operative hand TAP blocks can be placed with or without ultra- and in the nonoperative hand. The patient’s opera- sound. Advantages of ultrasound over traditional tive arm is padded and a double pneumatic tourni- methods include being able to visualize anatomical quet is applied, and exsanguination occurs from structures at the Petit triangle, so the anesthesia pro- the hand to the tourniquet with an elastic bandage. vider can see the needle and avoid intraperitoneal The proximal cuff is inflated then the distal cuff (by placement, as well as confirm correct placement of the anesthesia provider, or according to the provid- local anesthetic.11 TAP blocks often are placed while er’s directions), followed by deflation of the proxi- the patient is anesthetized in the OR. mal cuff. The elastic bandage is removed from For this block, patients are positioned supine or in the patient’s arm. After confirmation of an absent a lateral decubitus position. Sterile towels, drapes, pulse, the I.V. catheter is injected with an appropri- and prep solution are needed. If the abdominal inci- ate dose and volume of 0.5% preservative-free sion is midline, a bilateral TAP block is performed. If lidocaine as determined by the anesthesia provider. the surgery affected only one side of the abdominal The catheter is then removed and the arm prepped wall, then a single injection may be performed. The for surgery. OR nurse may be asked to make fine adjustments The pneumatic tourniquet should be inflated for to the ultrasound machine and assist with injecting a minimum of 25 minutes so that the drug can be small amounts of local anesthetic as the anesthesia absorbed into the tissues and to prevent the local provider identifies each muscle plane for proper anesthetic from rushing into the circulation, causing placement of the local anesthetic. local anesthetic toxicity. If the patient complains of Complications of a TAP block include local anes- tourniquet pain during the procedure, the distal cuff thetic toxicity because of the volume and concentra- can be inflated and the proximal cuff deflated. tion of local anesthetic required for bilateral TAP blocks Because the patient can tolerate a tourniquet for a and the vascular structures located within the abdom- short period, I.V. regional anesthesia is limited to pro- inal wall; hematoma formation; and needle trauma cedures that take fewer than 60 minutes. or anesthetic injection into abdominal structures.9,10

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Peripheral nerve blocks: until the block wears off. Lower extremity Femoral nerve blocks have a Two types of lower extremity relatively low incidence of blocks, femoral and sciatic nerve complications. Complications blocks, can provide anesthesia include local anesthetic toxicity, and analgesia to the lower vascular puncture and hema- extremities. Most surgical proce- toma formation, and nerve dures require a combination of injury.5,7,13 nerve blocks to ensure surgical • A sciatic nerve block may be anesthesia. Because neuraxial combined with a femoral blockade offers reliable anesthe- nerve block for procedures of sia and is simple to administer, the knee. The sciatic nerve is Femoral nerve blocks peripheral nerve blocks of the formed by the nerve roots of weaken the patient’s lower extremity are often used L4, L5, S1, S2, and S3. This ability to contract the for postoperative analgesia. very large nerve provides sen- quadriceps, which Ultrasound lets the anesthesia sory input to the hip joint, knee, may predispose provider see anatomical struc- and below the knee (with the patients to falls. tures, needle placement, and exception of the medial aspect local anesthetic spread. As a of the ankle and foot). The sci- result, analgesia can take effect more quickly, with atic nerve also provides motor input to the hamstring less sensory and motor blockade, and less local anes- muscles in the upper leg and all of the muscles below thetic needed for femoral nerve blocks. Ultrasound the knee.7 Procedures below the knee can be easily guidance for sciatic nerve blocks also decreases local blocked with a sciatic nerve block; a supplemental anesthetic requirements and time to perform the saphenous nerve block will be required if surgery block, as well as providing for a faster onset and involves the medial aspect of the foot or ankle. improved success rate.12 A single-injection technique is often used, though • The femoral nerve innervates the anterior thigh peripheral nerve catheters may be placed. Sciatic and knee, making a femoral nerve block appropriate nerve blocks may be placed with peripheral nerve for any surgical procedure of the thigh and anterior stimulators or ultrasound. Approaches to the sciatic knee. The femoral nerve is formed from contribu- nerve are based on the anesthesia provider’s prefer- tions of L2, L3, and L4 and is the largest branch ence and may include a supine position for an ante- originating from the lumbar plexus. The femoral rior approach and a lithotomy or lateral decubitus nerve enters the thigh under the inguinal ligament, position for a posterior approach. The sciatic nerve between the psoas and iliacus muscle, and is located may be blocked above the popliteal fossa as it below the fascia iliaca.5,7,13 divides into the common peroneal and tibial nerves. Often, a femoral nerve block is combined with This is known as a popliteal block. additional nerve blocks to provide more complete Because of its anatomical position and relatively analgesia because the obturator and sciatic nerve poor blood supply, the sciatic nerve is prone to also innervate the lower extremities. Femoral nerve injury. Sciatic nerve blocks generally aren’t used blocks may be placed as a single injection or continu- in patients with a history of diabetes or peripheral ous infusion. When placing a pneumatic tourniquet, neuropathies. Epinephrine-containing solutions transferring a patient, or during sterile preparation of are avoided because they can exacerbate nerve the limb, be sure that the catheter is intact and won’t ischemia. be inadvertently dislodged. Place a knee immobilizer Avoid direct compression on the injection site on the operative limb before ambulation. when placing a pneumatic tourniquet or positioning Femoral nerve blocks weaken the patient’s ability a patient with a sciatic nerve block. Careful attention to contract the quadriceps, which may predispose to tourniquet inflation pressures and maximum patients to falls. Preoperatively, be sure to tell the inflation times are important to avoid potential com- patient about postoperative leg muscle weakness and plications. In addition to the risk of nerve trauma, the advise the patient to ambulate only with assistance patient is at risk for local anesthetic toxicity, especially www.ORNurseJournal.com September OR Nurse2011 31

if the sciatic nerve block was combined with other 8. Davis TC. Regional anesthesia. In: Perianesthesia Nursing: A Critical Care Approach. 5th ed. St. Louis: Saunders/Elsevier; 2009:350-351. peripheral nerve blocks.5,7,13 9. Sawardekar A, Kho M, Suresh S. Common peripheral nerve blocks By understanding the technology that may be in pediatric patients. Anesthesiology News. April 2010;1-8. involved during placement of a peripheral nerve 10. Scharine JD. Bilateral transversus abdominus plane nerve blocks for analgesia following cesarean delivery: report of 2 cases. AANA J. block, and the indications, complications, patient 2009;77(2):98-102. management, OR nurses can help patients have a 11. Abrahams MS, Horn JL, Noles LM, Aziz MF. Evidence based good surgical experience. OR medicine: ultrasound guidance for truncal blocks. Reg Anesth Pain Med. 2010;35(2 suppl):S36-S42. 12. Salinas FV. Ultrasound and review of evidence for lower extremity peripheral nerve blocks. Reg Anesth Pain Med. 2010;35(2 REFERENCES suppl):S16-S25. 1. Morgan GE, Mikhail MS, Murray MJ. The practice of anesthesiology. 13. Enneking FK, Chan V, Greger J, Hadzic A, Lang SA, Horlocker TT. In: Clinical Anesthesiology. 4th ed. New York: Lange Medical Books/ Lower-extremity peripheral nerve blockade: essentials of our current McGraw-Hill Medical Publishing Division; 2006:2-3. understanding. Reg Anesth Pain Med. 2005;30(1):4-35. 2. LaGrange P, Foster PA, Pretorius LK. Application of the Doppler 14. The Joint Commission. Accreditation program: hospital national ultrasound bloodflow detector in supraclavicular brachial plexus block. safety goals. http://www.jointcommission.org/patientsafety/national Br J Anaesth. 1978;50(9):965-967. patientsafetygoals. 3. Chan VWS, Abbas S, Brull R, Perlas A. Basic principles and physics 15. McCamant KL. Peripheral nerve blocks: understanding the nurse’s of ultrasound. In: Ultrasound Imaging for Regional Anesthesia, 2nd ed. role. J Perianesthesia Nurs. 2006;21(1):16-23. Toronto Printing Co.; 2008;6-15. 16. Fetzer SJ. Phase I discharge criteria. In Schick L, Windle PE, editors: 4. Brull R, Macfarlane AJR, Tse CC. Practical knobology for ultra- Perianesthesia Nursing Core Curriculum. 2nd ed. St. Louis, MO. Saunders/ sound-guided regional anesthesia. Reg Anesth Pain Med. 2010;35 Elsevier; 2010. (2 suppl):S68-S73. 5. Burkard J, Olson RL, Vacchiano CA. Regional anesthesia. In: Nurse Anesthesia. 3rd ed. St. Louis, MO: Elsevier Saunders; 2005:1008-1027. Daniel D. Moos is an adjunct faculty member of the Bryan/LGH College of Health Sciences in Lincoln, Neb., and a staff anesthetist with Kearney 6. McCartney CJ, Lin L, Shastri U. Evidence basis for the use of Anesthesia Associates of Kearney, Neb. ultrasound for upper extremity blocks. Reg Anesth Pain Med. 2010; 35(2 suppl):S10-S15. The author and planners have disclosed that they have no financial relation- 7. Morgan GE, Mikhail MS, Murray MJ. Peripheral nerve blocks. ships related to this article. In: Clinical Anesthesiology. 4th ed. New York: Lange Medical Books/ McGraw-Hill Medical Publishing Division; 2006:324-358. DOI-10.1097/01.ORN.0000403415.90130.ba

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