peripheral nerve block DHARMARAJ 123.pdf
DharmarajNBadyankal
140 views
58 slides
May 25, 2024
Slide 1 of 58
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
About This Presentation
Add vich gf says he ids dh h KB f SS huh good idea TDY ujj gf sa add tc v job HC re suc hok KB te read chho UT re wah GH I on c re a TT gf hok of rw th duh jk ok GD ee watch ko pi UT re SS y GH o of death jio ka gf sa w ad fgj ok GD redd SF h KB VC dagu DD FC j kV v DD cbl ohh gf s DC vj KB c SS f h...
Slide Content
Peripheral Nerve Blocks
CHAIRPERSON:DR H V AIRANI
MODERATOR:DR RAMNATH
PRESENTER:DR DHARMARAJ
CHAIRPERSON:DR H V AIRANI
MODERATOR:DR RAMNATH
PRESENTER:DR DHARMARAJ
Introduction
Peripheral nerve blocks are gaining widespread popularity for perioperative pain management because:
Pain relief with PNB avoids side effects such as nausea and vomiting, hemodynamic instability avoiding complications of
general and central neuraxial anesthesia.
Patients with unstable cardiovascular disease can undergo surgery under PNB without significant hemodynamic
changes.
Patients who have abnormalities in hemostasis or infection which contraindicate use of central neuraxial block can be
candidates for surgery under PNB.
A substantial savings in operating room turnover time can occur if PNB is done outside the operating room. Patients with
a PNB can frequently position themselves.
When used as part of a combined general regional technique, PNB facilitates lighter planes of anesthesia, avoiding the
use of opioids and allowing a quick emergence and recovery.
Peripheral nerve blocks are gaining widespread popularity for perioperative pain management because:
Pain relief with PNB avoids side effects such as nausea and vomiting, hemodynamic instability avoiding complications of
general and central neuraxial anesthesia.
Patients with unstable cardiovascular disease can undergo surgery under PNB without significant hemodynamic
changes.
Patients who have abnormalities in hemostasis or infection which contraindicate use of central neuraxial block can be
candidates for surgery under PNB.
A substantial savings in operating room turnover time can occur if PNB is done outside the operating room. Patients with
a PNB can frequently position themselves.
When used as part of a combined general regional technique, PNB facilitates lighter planes of anesthesia, avoiding the
use of opioids and allowing a quick emergence and recovery.
Advantages
Advantages
Disadvantages
EQUIPMENT AND DRUGS
Fully prepare the equipment and patient, including consent. Ensure
intravenous access, monitoring and full resuscitation facilities.
A linear ultrasound probe (Frequency 10-15 MHz) is used with the depth
setting of 2-4 cm. A 50mm length insulated nerve stimulator needle is used
to perform the block using Peripheral nerve stimulation.
Initial settings should be 0.5 mA for current , frequency of 2Hz and pulse
width of 0.1 msec. Higher currents may result in muscle contractions which
cause the arm to move and make it difficult to maintain a stable ultrasound
image.
Fully prepare the equipment and patient, including consent. Ensure
intravenous access, monitoring and full resuscitation facilities.
A linear ultrasound probe (Frequency 10-15 MHz) is used with the depth
setting of 2-4 cm. A 50mm length insulated nerve stimulator needle is used
to perform the block using Peripheral nerve stimulation.
Initial settings should be 0.5 mA for current , frequency of 2Hz and pulse
width of 0.1 msec. Higher currents may result in muscle contractions which
cause the arm to move and make it difficult to maintain a stable ultrasound
image.
Mechanism of action
Local anaesthetics in PNB
Local anaesthetics in PNB
Upper Extremity blocks
The brachial plexus is formed by the ventral rami of the lower
cervical and upper thoracic nerve roots (C5-T1).
The trunks pass laterally and lies around the subclavian artery
while passing over the first rib to enter the axilla, between the
clavicle and the scapula.
Behind the clavicle, each trunk splits into anterior and posterior
divisions. These recombine to form the posterior , lateral and
medial cords around the axillary artery.
The upper roots (C5–7) tend to stay lateral, the lower roots
(C8,T1) tend to stay medial and all roots contribute to the
posterior cord, and therefore also to the radial nerve.
ANATOMY
cervical and upper thoracic nerve roots (C5-T1).
The trunks pass laterally and lies around the subclavian artery
while passing over the first rib to enter the axilla, between the
clavicle and the scapula.
Behind the clavicle, each trunk splits into anterior and posterior
divisions. These recombine to form the posterior , lateral and
medial cords around the axillary artery.
The upper roots (C5–7) tend to stay lateral, the lower roots
(C8,T1) tend to stay medial and all roots contribute to the
posterior cord, and therefore also to the radial nerve.
ANATOMY
FORMATION OF THE BRACHIAL PLEXUS
Upper limb dermatomes
Usg
Interscalene
Supraclavicular
Infraclavicular
Axillary
BRACHIAL PLEXUS BLOCK -
Supraclavicular
Infraclavicular
Axillary
BRACHIAL PLEXUS BLOCK -
Indications
operations on the elbow, forearm, and hand. Blockade
occurs at the distal trunk–proximal division level.
Location-
The three trunks are clustered vertically over the first
rib cephaloposterior to the subclavian artery. The
neurovascular bundle lies inferior to the clavicle at
about its midpoint.
Supraclavicular block
operations on the elbow, forearm, and hand. Blockade
occurs at the distal trunk–proximal division level.
Location-
The three trunks are clustered vertically over the first
rib cephaloposterior to the subclavian artery. The
neurovascular bundle lies inferior to the clavicle at
about its midpoint.
Supraclavicular block
Technique-
In the classic technique, the
midpoint of the clavicle is
identified . The posterior border
of the sternocleidomastoid is
felt. The palpating fingers can
then roll over the belly of the
anterior scalene muscle into the
interscalene groove, where a
mark should be made
approximately 1.5 to 2.0cm
posterior to the midpoint of the
clavicle. Palpation of the
subclavian artery at this site
confirms the landmark
In the classic technique, the
midpoint of the clavicle is
identified . The posterior border
of the sternocleidomastoid is
felt. The palpating fingers can
then roll over the belly of the
anterior scalene muscle into the
interscalene groove, where a
mark should be made
approximately 1.5 to 2.0cm
posterior to the midpoint of the
clavicle. Palpation of the
subclavian artery at this site
confirms the landmark
A 22-gauge, 4-cm needle is directed in a caudad, slightly
medial, and posterior direction until a paresthesia is elicited
or the first rib is encountered.
If a syringe is attached, this orientation causes the needle
shaft and syringe to lie almost parallel to a line joining the
skin entry site and the patient's ear.
If the first rib is encountered without elicitation of a
paresthesia, the needle can be systematically walked
anteriorly and posteriorly along the rib until the plexus or
the subclavian artery is located .
The needle can be withdrawn and reinserted in a more
posterolateral direction, which generally results in a
paresthesia or motor response. 20 to 30mL of solution is
injected in incremental pattern.
medial, and posterior direction until a paresthesia is elicited
or the first rib is encountered.
If a syringe is attached, this orientation causes the needle
shaft and syringe to lie almost parallel to a line joining the
skin entry site and the patient's ear.
If the first rib is encountered without elicitation of a
paresthesia, the needle can be systematically walked
anteriorly and posteriorly along the rib until the plexus or
the subclavian artery is located .
The needle can be withdrawn and reinserted in a more
posterolateral direction, which generally results in a
paresthesia or motor response. 20 to 30mL of solution is
injected in incremental pattern.
Pneumothorax
Phrenic nerve block
Horner's syndrome
Neuropathy.
Complications
Phrenic nerve block
Horner's syndrome
Neuropathy.
Complications
Landmarks
There is no proper landmark, besides the clavicle, which in most patients is easily
felt.
The subclavian pulse might be palpated above the clavicle, but that is not
indispensable.
The ultrasound probe is positioned in the supraclavicular fossa, pointing caudad,
and moved laterally and medially, as well as in a rocking fashion, in order to locate
the subclavian artery
USG GUIDED SUPRACLAVICULAR BLOCK
There is no proper landmark, besides the clavicle, which in most patients is easily
felt.
The subclavian pulse might be palpated above the clavicle, but that is not
indispensable.
The ultrasound probe is positioned in the supraclavicular fossa, pointing caudad,
and moved laterally and medially, as well as in a rocking fashion, in order to locate
the subclavian artery
USG GUIDED SUPRACLAVICULAR BLOCK
Position of probe and
needle:-
-Probe is positioned just above
the clavicle.
It can be moved laterally or
medially, and rocked back and
forth until a good quality picture
is obtained.
-The needle is inserted from the
lateral side of the probe, as the
plexus lies lateral to the
subclavian artery.
It has to be exactly in the long
axis of the probe.
This is especially important for
this block, in which the needle
can easily cause a pneumothorax
if not fully visible at all times.
needle:-
-Probe is positioned just above
the clavicle.
It can be moved laterally or
medially, and rocked back and
forth until a good quality picture
is obtained.
-The needle is inserted from the
lateral side of the probe, as the
plexus lies lateral to the
subclavian artery.
It has to be exactly in the long
axis of the probe.
This is especially important for
this block, in which the needle
can easily cause a pneumothorax
if not fully visible at all times.
Technique
Once the subclavian artery is visualized, the
area lateral and superficial to it is explored
until the plexus is seen, with a characteristic
“honeycomb” appearance.
Multiple nerves can be seen, or as few as
two, depending on the level and the patient.
A caudad-cephalad rocking motion is then
used to find the plane where the nerves are
best seen.
Once the subclavian artery is visualized, the
area lateral and superficial to it is explored
until the plexus is seen, with a characteristic
“honeycomb” appearance.
Multiple nerves can be seen, or as few as
two, depending on the level and the patient.
A caudad-cephalad rocking motion is then
used to find the plane where the nerves are
best seen.
Figure 1: Left subclavian
artery and nerves of the
brachial plexus.
The subclavian artery is seen
beating at the center of the
field.
Underlying it is the first rib,
with a bright cortical bone
and a posterior shadow.
The pleura are seen on each
side of the rib, somewhat
deeper, and moving with the
patient’s respiration.
The nerves of the brachial
plexus can be seen lateral
and a little superficial to the
artery.
The distribution is variable,
with as little as two or as
many as 10 nerves seen.
artery and nerves of the
brachial plexus.
The subclavian artery is seen
beating at the center of the
field.
Underlying it is the first rib,
with a bright cortical bone
and a posterior shadow.
The pleura are seen on each
side of the rib, somewhat
deeper, and moving with the
patient’s respiration.
The nerves of the brachial
plexus can be seen lateral
and a little superficial to the
artery.
The distribution is variable,
with as little as two or as
many as 10 nerves seen.
Indications-Hand, wrist, elbow and distal arm surgery
Blockade occurs at the level of the cords of the
musculocutaneous and axillary nerves.
Anatomical landmarks: The boundaries of the infraclavicular
fossaare
pectoralis minor and major muscles anteriorly,
ribs medially ,
clavicle and the coracoid process superiorly,
and humerus laterally.
Infraclavicular block
Blockade occurs at the level of the cords of the
musculocutaneous and axillary nerves.
Anatomical landmarks: The boundaries of the infraclavicular
fossaare
pectoralis minor and major muscles anteriorly,
ribs medially ,
clavicle and the coracoid process superiorly,
and humerus laterally.
Infraclavicular block
Technique-
Classic approach
The needle is inserted 2cm below the midpoint of the
inferior clavicular border, advanced laterally and
directed toward the axillary artery
A coracoid technique consisting of insertion of the needle
2cm medial and 2cm caudal to the coracoid process
has also been described
Classic approach
The needle is inserted 2cm below the midpoint of the
inferior clavicular border, advanced laterally and
directed toward the axillary artery
A coracoid technique consisting of insertion of the needle
2cm medial and 2cm caudal to the coracoid process
has also been described
Infraclavicular approach
Described by winnie in 1970.
Indications-
Surgery in shoulder ,upper arm and forearm.
Post operative analgesia for total shoulder arthroplasty
Blockade occurs at the level of the upper and middle
trunks.
Interscalene block
Indications-
Surgery in shoulder ,upper arm and forearm.
Post operative analgesia for total shoulder arthroplasty
Blockade occurs at the level of the upper and middle
trunks.
Interscalene block
Anatomy
TECHNIQUE-
Under sterile precautions and development of a skin wheal, a 22-
to 25-gauge, 4-cm needle is inserted perpendicular to the skin at
a 45-degree caudad and slightly posterior angle. The needle is
advanced until paresthesia is elicited.
If bone is encountered within 2cm of the skin, it is likely to be a
transverse process, and the needle may be “walked” across this
structure to locate the nerve.
After negative aspiration, 10 to 40mL of solution is injected
incrementally, depending on the desired extent of blockade.
contraction of the diaphragm indicates phrenic nerve stimulation
and anterior needle placement; the needle should be redirected
posteriorly to locate the brachial plexus.
Under sterile precautions and development of a skin wheal, a 22-
to 25-gauge, 4-cm needle is inserted perpendicular to the skin at
a 45-degree caudad and slightly posterior angle. The needle is
advanced until paresthesia is elicited.
If bone is encountered within 2cm of the skin, it is likely to be a
transverse process, and the needle may be “walked” across this
structure to locate the nerve.
After negative aspiration, 10 to 40mL of solution is injected
incrementally, depending on the desired extent of blockade.
contraction of the diaphragm indicates phrenic nerve stimulation
and anterior needle placement; the needle should be redirected
posteriorly to locate the brachial plexus.
Complications
Ipsilateral diaphragmatic paresis
Inadvertent epidural or spinal block
Nerve damage or neuritis
intravascular injection with Seizure activity
Horner’s syndrome with dyspnea and hoarseness of
voice.
Puncture of the pleura may cause Pneumothorax.
Hemothorax.
Hematoma and Infection.
Ipsilateral diaphragmatic paresis
Inadvertent epidural or spinal block
Nerve damage or neuritis
intravascular injection with Seizure activity
Horner’s syndrome with dyspnea and hoarseness of
voice.
Puncture of the pleura may cause Pneumothorax.
Hemothorax.
Hematoma and Infection.
Indications –
include surgery on the forearm and hand. Elbow
procedures are also successfully performed with the
axillary approach.
Blockade occurs at the level of the terminal nerves.
blockade of the musculocutaneous nerve is not always
produced with this approach.
Axillary approach
include surgery on the forearm and hand. Elbow
procedures are also successfully performed with the
axillary approach.
Blockade occurs at the level of the terminal nerves.
blockade of the musculocutaneous nerve is not always
produced with this approach.
Axillary approach
Landmark-
•The axillary artery is the most important
landmark
•The median nerve is found superior to the
artery, the ulnar nerve is inferior, and the
radial nerve is posterior and somewhat lateral
•At this level, the musculocutaneous nerve
has already left the sheath and lies in the
substance of the coracobrachialis muscle.
•The axillary artery is the most important
landmark
•The median nerve is found superior to the
artery, the ulnar nerve is inferior, and the
radial nerve is posterior and somewhat lateral
•At this level, the musculocutaneous nerve
has already left the sheath and lies in the
substance of the coracobrachialis muscle.
A transarterial
technique can be used
whereby the needle
pierces the artery and 40
to 50mL of solution is
injected posterior to the
artery; alternatively, half
of the solution can be
injected posterior and half
injected anterior to the
artery.
Technique-
technique can be used
whereby the needle
pierces the artery and 40
to 50mL of solution is
injected posterior to the
artery; alternatively, half
of the solution can be
injected posterior and half
injected anterior to the
artery.
Technique-
Complications-
Nerve injury and systemic toxicity
intravascular injection
Hematoma and infection are rare complications.
Nerve injury and systemic toxicity
intravascular injection
Hematoma and infection are rare complications.
Lower Extremity blocks
Anatomy
Sacral
plexus
plexus
Dermatomes
Femoral nerve block
Anesthesia for knee arthroscopy in
combination with intraarticular local
anesthesia and analgesia for femoral shaft
fractures
anterior cruciate ligament reconstruction
total knee arthroplasty as a part of
multimodal regimens.
Indications
combination with intraarticular local
anesthesia and analgesia for femoral shaft
fractures
anterior cruciate ligament reconstruction
total knee arthroplasty as a part of
multimodal regimens.
Indications
Usg guided femoral block
Popliteal Fossa block
Anatomy
This block is chiefly used for foot and ankle
surgery.
Popliteal fossa block is preferable to ankle
block for surgical procedures requiring the
use of a calf tourniquet.
Indications
surgery.
Popliteal fossa block is preferable to ankle
block for surgical procedures requiring the
use of a calf tourniquet.
Indications
1.Posterior approach
2.Lateral approach
Approach
2.Lateral approach
Approach
Usg
Ankle block
Anatomy
Ankle blocks are simple to perform and offer
adequate anesthesia for surgical procedures
of the foot not requiring a tourniquet above
the ankle
Indications
adequate anesthesia for surgical procedures
of the foot not requiring a tourniquet above
the ankle
Indications
1.posterior tibial
2.sural
3.superficial peroneal
4.deep peroneal
5.saphenous
Nerves blocked
2.sural
3.superficial peroneal
4.deep peroneal
5.saphenous
Nerves blocked
Technique
REFERENCES
1.MILLERS ANAESTHESIA
2.COLLINS ANAESTHESIA
3.NYSORA WEBSITE
1.MILLERS ANAESTHESIA
2.COLLINS ANAESTHESIA
3.NYSORA WEBSITE
Tags
Categories
GeneralDownload
Download Slideshow Get the original presentation fileQuick Actions
Statistics
- Views 140
- Slides 58
- Age 555 days
Related Slideshows
22
Pray For The Peace Of Jerusalem and You Will Prosper
RodolfoMoralesMarcuc
30 views
26
Don_t_Waste_Your_Life_God.....powerpoint
chalobrido8
32 views
31
VILLASUR_FACTORS_TO_CONSIDER_IN_PLATING_SALAD_10-13.pdf
JaiJai148317
30 views
14
Fertility awareness methods for women in the society
Isaiah47
29 views
35
Chapter 5 Arithmetic Functions Computer Organisation and Architecture
RitikSharma297999
26 views
5
syakira bhasa inggris (1) (1).pptx.......
ourcommunity56
28 views