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Peripheral Nerve Blocks Can Provide Surgical Anesthe- Ergonomics and Transducer Manipulation Sia and Postoperative Pain Relief (Table 18.1)

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Peripheral Nerve Blocks Can Provide Surgical Anesthe- Ergonomics and Transducer Manipulation Sia and Postoperative Pain Relief (Table 18.1) Chapter PERIPHERAL NERVE 18 BLOCKS Edward N. Yap and Andrew T. Gray INTRODUCTION The Role of Regional Anesthesia Preparation to Perform a Regional Nerve Block INTRODUCTION ULTRASOUND BASICS The Role of Regional Anesthesia Basic Ultrasound Physics Echogenic Properties of Nerves and Tissue Peripheral nerve blocks can provide surgical anesthe- Ergonomics and Transducer Manipulation sia and postoperative pain relief (Table 18.1). Paresthetic Regional Block Technique techniques and peripheral nerve blocks have been used for Peripheral Nerve Catheters decades. However, the main emphasis of this chapter will be on ultrasound guidance for peripheral nerve blocks. In CERVICAL PLEXUS BLOCK addition, ultrasound guidance and nerve stimulation tech- UPPER EXTREMITY BLOCKS nologies can be combined for some regional blocks. Brachial Plexus Intercostobrachial Nerve Block Preparation to Perform a Regional Nerve Block LOWER EXTREMITY BLOCKS Foundation of Knowledge Femoral Nerve To perform safe and effective peripheral nerve blocks, an Sciatic Nerve understanding of peripheral neuroanatomy, ultrasound Ankle Block technology, local anesthetic pharmacology, and risks CHEST AND ABDOMEN BLOCKS associated with peripheral nerve blocks is needed. Intercostal Nerve Block Transversus Abdominis Plane Block Patient and Surgeon Factors The willingness of the patient and the surgeon, as well as INTRAVENOUS REGIONAL ANESTHESIA the anatomic location of the surgery, must be taken into (BIER BLOCK) consideration when incorporating peripheral nerve blocks Selection of Local Anesthetic into an anesthetic plan. A thorough preoperative review of Characteristics of the Block the patient’s medical history, including any comorbid dis- Risks eases, allergies, prior neuropathy, and concurrent antico- agulation medications, must be performed to rule out any QUESTIONS OF THE DAY contraindications in providing a peripheral nerve block. Monitors and Equipment Peripheral nerve blocks may be performed preoperatively in a dedicated block area or in the operating room. The patient must have a functional peripheral intravenous line, and monitoring equipment including pulse oximetry, The editors and publisher would like to thank Dr. Adam B. Collins for contributing a chapter on this topic to the prior edition of this work. It has served as the foundation for the current chapter. 303 Downloaded for Wendy Nguyen ([email protected]) at University Of Minnesota - Twin Cities Campus from ClinicalKey.com by Elsevier on March 25, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. Section III PREOPERATIVE PREPARATION AND INTRAOPERATIVE MANAGEMENT electrocardiogram (ECG), and noninvasive blood pres- addition of epinephrine, 1:200,000 (5 μg/mL), can serve sure machine. Supplemental oxygen as well as emer- as a marker for intravascular injection and can increase gency medications and airway equipment must be readily the duration of a conduction block. In addition, through accessible. Sedation may be indicated, depending on the a decrease in the rate of systemic absorption, epinephrine patient’s anxiety and magnitude of pain. can reduce peak plasma levels of local anesthetic. Con- The patient, ultrasound machine, and anesthesia pro- siderations for the choice of local anesthetic solution for vider must be positioned in a way to optimize the nerve intravenous regional anesthesia are different from those block being performed. For most blocks, the provider is for peripheral nerve blocks (see the later discussion under positioned on the ipsilateral side and the ultrasound on “Intravenous Regional Anesthesia [Bier Block]”). the contralateral side of the block region. The choice of the ultrasound probe (Fig. 18.1) and needle is dependent Regional Block Checklist on the location of the peripheral nerve block as well, and A standardized regional block checklist should be the addition of placing a catheter will depend on the type reviewed prior to performing a peripheral nerve block of surgery being performed, the duration of hospital stay, to improve safety.1 The checklist should include surgi- and patient and surgeon preference. cal consent and site marking, allergies and anticoagu- lation status, proposed peripheral nerve block and local Choice of Local Anesthetic anesthetic dose, side of the block, monitors implemented, The choice of local anesthetic for peripheral nerve block- emergency equipment available, and sedation plan. ade depends on a number of factors, including the desired onset, duration, and degree of conduction block (see Chap- Risks and Prevention ter 10). Lidocaine and mepivacaine, 1% to 1.5%, produce Infection surgical anesthesia in 10 to 20 minutes that lasts 2 to 3 Infectious risk associated with a peripheral nerve block or hours. Ropivacaine, 0.5%, and bupivacaine, 0.375% to placement of a peripheral nerve catheter is rare.2 However, 0.5%, have a slower onset and produce less motor block- an infection can cause significant morbidity and may lead ade, but the effect lasts for at least 6 to 8 hours. The to permanent neurologic injury. By performing proper hand hygiene, using maximal barriers during nerve block and catheter placement, and providing antiseptic solution at the Table 18.1 Examples of Peripheral Nerve Blocks site of insertion, the rate of infection can be reduced. Origin Specific Block Hematoma Cervical plexus Superficial The risk of developing a hematoma depends on location Brachial plexus Interscalene of the peripheral nerve block being performed, the prox- Supraclavicular imity to vascular structures, and vascular compressibility. Infraclavicular With the use of ultrasound and proper aspiration tech- Axillary nique, vascular puncture can be reduced.3 A review of Lumbar plexus Lateral femoral cutaneousa the patient’s medical history with an emphasis on any Femoral anticoagulation medications is important. The American Adductor canal Society of Regional Anesthesia and Pain Medicine pro- Saphenous vides guidelines on anticoagulation management.4 Obturatora Sacral plexus Proximal sciatic Local Anesthetic Systemic Toxicity (Also See Chapter 10) Popliteal sciatic Local anesthetic systemic toxicity (LAST) secondary to local anesthetic absorption can range from mild symptoms to aNot covered. major neurologic and cardiovascular toxicity. A variety of Fig. 18.1 Ultrasound transducers for regional blocks. (From Gray AT. Atlas of Ultrasound-Guided Regional Anesthesia. 2nd ed. Philadelphia: Elsevier; 2013:22. 304 Downloaded for Wendy Nguyen ([email protected]) at University Of Minnesota - Twin Cities Campus from ClinicalKey.com by Elsevier on March 25, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. Chapter 18 Peripheral Nerve Blocks factors including patient risk factors, concurrent medica- convert electrical currents into mechanical pressure waves tions, total local anesthetic dose, and anatomic location of and vice versa, sending and receiving ultrasound echoes to the peripheral nerve block play a role in the risk of LAST. thereby generate images. There is no single measure to prevent LAST; however, using As ultrasound waves pass through different body the smallest effective dose, an incremental injection, aspi- tissues the resistance to the propagation of ultrasound ration prior to injection, an intravascular marker (i.e., epi- waves, or acoustic impedance, changes depending on the nephrine), and ultrasound guidance may decrease the risk density of the tissue. Solid tissues have denser particles of LAST. Lipid emulsion resuscitation remains the corner- that effectively reflect waves that will be received by the stone of therapy to treat patients with LAST.5 transducer, displayed as brighter or hyperechoic struc- tures. Less dense tissue does not reflect ultrasound waves Nerve Injury as effectively, displayed as darker or hypoechoic struc- Nerve injury may result from direct needle trauma, inad- tures. Tissues that do not reflect any ultrasound waves are vertent intraneural injection, or drug neurotoxicity. Seri- considered anechoic. ous neurologic injury from a peripheral nerve block is Improving image resolution, or the ability to dis- rare; however, the rate of transient paresthesia that tinguish one structure from another, will optimize per- resolves within days to weeks postoperatively is substan- formance of peripheral nerve blocks. Increasing the tially higher.6,7 The use of ultrasound to identify nerves, frequency of the ultrasound wave will improve reso- limiting the injection pressure, and patient feedback may lution of the image but will decrease the penetration help decrease the rate of nerve injury, although clinical of the ultrasound waves. Decreasing the frequency will outcome data are limited. lower the resolution but will improve the penetration to deeper tissue because there is less attenuation. Increas- III Wrong-Sided Block ing the receiver gain (i.e., amplification of the return- Wrong site, wrong procedure, and wrong patient periph- ing echo signal) can to some extent compensate for eral nerve blocks are potentially serious medical errors attenuation. that are inherent risks in performing any medical proce- dure.8 Although rare, this complication can be reduced Echogenic Properties of Nerves and Tissue by having a universal protocol that includes a checklist to ensure the correct patient, the proper surgery site, and Peripheral nerves can be recognized on ultrasound scans correct laterality (Table 18.2). by their fascicular
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