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Regional Anaesthesia Regional Anaesthesia Dr Reema Ayyash ST7 James Cook University Hospital Overview • Past SAQs • Anatomy and techniques for common blocks • MCQ & SBA session • Hot topics • For nerve bloc videos: http://www.nysora.com For any nerve block question Preparation • Pre-operative assessment and consent • Aseptic technique • Full monitoring as per AAGBI guidelines • IV access • Resuscitation equipment available • Trained assistant • Correct equipment available: needle, PNS, US • Calculated dose of local anaesthetic September 2014 a) Outline the basic principles of ultrasound signal and image generation. (6 marks) b) How may physical factors influence the image quality of an ultrasound device? (6 marks) c) Which two needling techniques are commonly used in ultrasound guided nerve blocks and what are the advantages and disadvantages of each? (8 marks) Pass Rate 5.7% “The very poor scores for this question were surprising given the widespread use of ultrasound imaging in current clinical practice” “ Eight marks were attainable for discussing two types of needling technique, hence this question was deemed to be moderately difficult and not hard. Despite this, many candidates failed to score more than five marks.” “ A “black box” approach was evident in the written answers and examiners questioned whether the candidates had any knowledge of the factors which affect the generation of a good quality ultrasound image.” “Previous reports from the SAQ Group Chair have emphasised that knowledge acquired in preparation for the Primary FRCA examination can be tested in any element of the Final FRCA process. This advice seems to have been largely ignored. The question was of moderate discriminatory value as ignorance of the topic was widespread within the candidate cohort.” a) Outline the basic principles of ultrasound signal and image generation. (6 marks) • Based on sound waves that are transmitted from, and received by, an US transducer • The transducer utilises frequencies of 2– 15 MHz • Transducers use artificial polycrystalline ferroelectric materials (ceramics) which have piezoelectric properties • Relies on piezo-electric effect: based on the conversion of sound to electrical energy • This allows the transducer to act as both a sound transmitter and receiver • Ultrasound waves are generated by a piezoelectric crystal transducer encased in the probe a) Outline the basic principles of ultrasound signal and image generation. (6 marks) • A high frequency alternate voltage is applied to the crystal • This changes the shape of the crystals generating oscillations • The generated sound waves are propagated into the tissues and are either reflected or scattered at the tissue interface • The reflected portion returns to the probe where it distorts the transducer material • This creates an electrical charge which is then amplified and displayed on a monitor to produce an image • Hyperechogenic: Highly reflective tissue e.g. bone – appear white • Hypoechogenic: Poorly reflective tissue e.g. muscle – appear grey • Anechogenic: Do not reflect at all e.g. blood/air – appear black a) Outline the basic principles of ultrasound signal and image generation. (6 marks) Amplitude mode (A mode): displays a single echo signal against time to measure depth Brightness modulation (B mode): A 2D image using multiple beam positions and a series of reflected echoes, producing a black and white image similar to an anatomical slice a) Outline the basic principles of ultrasound signal and image generation. (6 marks) Motion mode (M mode): M- line ensonified repeatedly to examine a moving structure. Plots how the structure moves with time b) How may physical factors influence the image quality of an ultrasound device? (6 marks) Tissue interaction • Ultrasound images produced depend on: • Density of tissue imaged • Echogenicity • Axial resolution: refers to the ability to distinguish two structures that lie along the axis (i.e. parallel) of the ultrasound beam as separate and distinct. • High frequency = low pulse duration thus better axial resolution • Acoustic impedance: determines the amount of ultrasound reflected in the media/tissue b) How may physical factors influence the image quality of an ultrasound device? (6 marks) Tissue interaction Attenuation b) How may physical factors influence the image quality of an ultrasound device? (6 marks) Tissue interaction Refraction Scattering b) How may physical factors influence the image quality of an ultrasound device? (6 marks) Tissue interaction Speckle Diffraction b) How may physical factors influence the image quality of an ultrasound device? (6 marks) Phenomena Anisotropy Acoustic enhancement b) How may physical factors influence the image quality of an ultrasound device? (6 marks) Phenomena Artifact Acoustic Shadowing b) How may physical factors influence the image quality of an ultrasound device? (6 marks) Phenomena Reverberation c) Which two needling techniques are commonly used in ultrasound guided nerve blocks and what are the advantages and disadvantages of each? (8 marks) Out of plane technique • Needle insertion perpendicular to transducer with the needle being identified as a hyperechoic dot on the screen as it crosses the beam Advantages: • Used when a short needle to nerve distance exists as this may minimize patient discomfort c) Which two needling techniques are commonly used in ultrasound guided nerve blocks and what are the advantages and disadvantages of each? (8 marks) Disadvantages: • Accurate identification of needle tip challenging increasing risk of misplacement c) Which two needling techniques are commonly used in ultrasound guided nerve blocks and what are the advantages and disadvantages of each? (8 marks) In-plane technique • Preferred technique • Needle inserted parallel to the transducer and ultrasound beam allowing visualization of the needle shaft and tip throughout the procedure Advantages: • Insertion angle of needle relative to probe is fairly superficial making it very useful for superficial nerve blocks c) Which two needling techniques are commonly used in ultrasound guided nerve blocks and what are the advantages and disadvantages of each? (8 marks) Advantages: • Needle visualization is better with accurate needle tip placement thus increasing potential for block success and limiting complications Disadvantages: • At steep angles identification of needle tip can be difficult with increased refraction/decreased reflection of ultrasound waves • Increased needle to nerve distance may result in increased patient discomfort September 2010 What are the a) cardiovascular (25%), b) respiratory (20%), c) gastrointestinal (20%) and d) haematological (25%) potential benefits of local anaesthetic neuraxial blockade? Pass Rate 21% “Neuraxial blockade is a foundation of anaesthetic practice and the poor performance in this question was surprising.” “Feedback from examiners suggests that the main reason for the poor performance in this question was not considering the potential benefits of neuraxial blockade through the entire perioperative period. “ Cardiovascular • Improved coronary blood flow - reduced risk of myocardial ischaemia • Myocardial oxygen supply:demand ratio is improved by reduction of sympathetic activity and reduced thrombotic tendency • Patients with underlying cardiac disease appear to have a better cardiac outcome with lower catecholamine levels and reduced cardiac workload Respiratory • Improved pulmonary function particularly in patients with a poor pre-op pulmonary function • Improved lung mechanics • Reduced incidence of post-op atelectasis and therefore pulmonary infection • Reduced side effects of opioid analgesia – respiratory depression • Allows patients to comply with physio – deep breathing and coughing Gastrointestinal • Improved intestinal motility • Blocking of nociceptive and sympathetic reflexes • Limiting use of opioids and therefore post-op ileus • Reduced side effects of opioids – nausea/vomiting/ileus • Reduced hyperglycaemic response to surgery Haematological • Decreased incidence of post-op DVT by: • Improved systemic blood flow • Decreased platelet stickiness • Decreased inhibition of fibrinolysis • Increased mobility post-op • Improved graft survival in vascular patients • Reduced intra-operative blood loss and therefore blood transfusions April 2002 a) Draw a diagram of the lumbar plexus. b) Outline the anatomical basis of a ‘3 in 1’ block c) Explain why the block may fail to provide reliable analgesia for hip surgery? a) Draw a diagram of the lumbar plexus. Anterior and Posterior Cutaneous Innervation of Lumbar Plexus Lumbar Plexus Block Patient Position • Lateral decubitus position • Side to be blocked uppermost Landmark • Posterior superior iliac crest • Spinous process (midline) • Posterior superior iliac spine • 50-100mm needle insertion site is 3-5 cm lateral intercristal line Lumbar Plexus Block Technique • Needle inserted perpendicular to skin • Nerve stimulator set initially to 1.5 mA • Needle advanced until twitches of quadriceps muscle is obtained (depth 6-8cm) • Current then decreased to 0.5- 1.0mA to produced stimulation • After negative aspiration, inject LA Lumbar Plexus Block: Complications • Infection: psoas abscess • Vascular puncture • Retro-peritoneal haematoma formation • Damage to abdominal viscera • Nerve injury and intra-neural injection • Haemodynamic consequences: spinal/epidural spread • Local anaesthetic toxicity b) Outline the anatomical basis of a ‘3 in 1’ block • 3 in 1 = Single injection which aims to block • Femoral nerve
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