Peripheral Nerve Block Part 1

A details about different types of peripheral nerve blocks , commonly use in regional anaesthesia......

1. 1

2. 2 SPEAKER Dr. DEBDIPTA DAS 1 ST Year PGT, Anesthesiology Medical College, Kolkata MODERATOR Dr. RITA HALDER Associate Professor, Anesthesiology Medical College, Kolkata PART 1

3. INTRODUCTION 3

4. History 4

5. 5 History

6. 6 History

7. Anatomy 7

8. Physiology 8

9. Physiology 9 A α MOTOR (A) largest diameter and highest degree of myelinization ----- highest speed of impulse propagation and a relatively low threshold level C PAIN (B) Smaller diameter and very little or absence of myelinization ---- lowest speed of impulse propagation and a relatively high threshold level A δ MOTOR Smaller diameter and smaller degree of myelinization than A α MOTOR

10. Physiology 10 MOTOR FIBRE PAIN FIBRE

11. Physiology 11 A certain minimum current intensity is necessary at a given pulse duration to reach the THRESHOLD LEVEL OF EXCITATION The lowest threshold current (at infinitely long pulse durations) is called RHEOBASE The pulse duration (pulse width) at double the rheobase current is called CHRONAXIE

12. Chronaxie of different nerves NERVE FEATURE CHRONAXIE-ms C Unmyelinated 0.40 A δ myelinated 0.17 A α myelinated 0.05 - 0.10 12

13. WHAT IS Hz ? 13 Cycles/second

14. Physiology 14

15. Physiology 15

16. CLASSIFICATION 16

17. ADVANTAGES 17

18. 18

19. 19

20. DISADVANTAGES 20

21. DISADVANTAGES 21

22. DISADVANTAGES 22

23. DISADVANTAGES 23

24. CONTRAINDICATIONS OF PNB 24

25. ABSOLUTE COTRAINDICATIONS 25

26. 26

27. RELATIVE COTRAINDICATIONS 27

28. COMPLICATIONS 28

29. 29

30. 1.LA TOXICITY 30

31. 31 1.LA TOXICITY

32. 32 Prevention ---always Maintain IV line before Have resuscitation equipments & drugs Always aspirate before injecting Inject slowly & aspirate after every 3-5 ml Stabilize needle ……short fine bore plastic tubing b/w needle & syringe (isolated needle technique) Observe pulse,ECG & sign of IV injection 1.LA TOXICITY

33. UNIPOLAR INSULATED NEEDLE 33

34. Protocol for treatment of la toxicity 34

35. 35

36. 36 Cont. observe Terminate neurological sym at once, control seizure

37. 37 Standard ACLS protocol, CPR in case of unconsciousness of cardiovascular collapse Start INTRALIPID

38. Immediate treatment of local anaesthetic toxicity 38 CALL FOR HELP Stop injecting ABC – 100% OXYGEN, INTUBATE, IV ACCESS. CONTROL SEIZURES. CPR IF INDICATED FOLLOWING STANDARD ALS PROTOCOLS CONSIDER TREATMENT WITH LIPID EMULSION (IV bolus 20%intralipid 1.5ml/kg over 1minute. Start an intravenous infusion of Intralipid® 20% at 0.25 ml/kg/min. Give two further boluses if necessary. Increase infusion rate of Intralipid® 20% to 0.5 ml/kg/min if necessary.)

39. 2.NERVE DAMAGE 39

40. recommendations to reduce risk of nerve damage 40

41. 3.VASOCONSTRICTOR PROBLEM 41

42. 42

43. 4.INFECTION 43

44. PREPARATION 44

45. PREMEDICATION 45

46. 46 EQUIPMENTS

47. EQUIPMENTS 47

48. BLOCK ROOM 48

49. 49

50. NERVE STIMULATOR 50 RED/+VE/ANODE CONNECTED TO PATIENT BLACK/-VE/CATHODE CONNECTED TO STIMULATING NEEDLE

51. NERVE STIMULATING NEEDLE 51

52. IDEAL ELECTRICAL CHARACTERISTICS OF A PNS 52

53. NERVE STIMULATOR 53

54. SETTINGS OF PNS 54

55. STIMULATION AND INJECTION TECNIQUE 55

56. 56

57. TOUHY SET FOR CATHETERIZATION 57

58. NEEDLE FOR USG GUIDED 58

59. 59 NEEDLE FOR USG GUIDED

60. TOUHAY SET FOR PERIPHERAL NERVE CATHETERIZATION 60 Stimulating catheter

61. CURRENT ADJUSTABLE INSULATED NEEDLE SET 61

62. CONTINUOUS PNB SYSTEM 62

63. 63 ELASTOMERIC BALOON PUMP

64. MEDIAN NERVE CATHETER 64 postoperative pain relief after hand surgery. Continuous infusion of levo-bupivacaine 0,125% - 2-5 ml/h

65. ULTRASOUND MACHINE 65

66. 66 LAPTOP ULTRASOUND MACHINE

67. ADVANTAGES OF USG 67

68. 68

69. BASIC VIEWS ON USG 69

70. 70

71. 71 Doughnut sign

72. Transducer manipulation 72 SLIDING (A), TILTING (B), COMPRESSION (C), ROCKING (D), ROTATION (E)

73. NEEDLE APPROACHES 73

74. 74

75. 75

76. 76

77. 77 VIEW SHORT / LONG ?

78. TECHNIQUES 78

79. FEMORAL NERVE CATHETERIZATION 79

80. CHOICE OF LOCAL ANAESTHETICS 80

81. 81 LA USED FOR PNB

82. LA DRUG IN MAJOR NERVE BLOCK 82

83. 83 LA DRUG IN MINOR NERVE BLOCK

84. 84 LA USED FOR PNB

85. 85 LA USED FOR PNB

86. CONCENTRATION 86

87. PNB PLACEMENT TECHNIQUES 1 2 3 4 5 6 87 OTHERS 1.Droppler 2.CT LA-- in Perineural area

88. CONCLUSION 88

89. 89

90. 90

91. 91

92. Tracheal block

93. SCALP BLOCK : AWAKE CRANIOTOMY

94. SCALP BLOCK : AWAKE CRANIOTOMY SUPRAORBITAL NERVE needle at a perpendicular angle immediately superior to the supraorbital notch

95. SCALP BLOCK : AWAKE CRANIOTOMY SUPRATROCHLEAR NERVE target area for insertion is on the supraorbital ridge approximately 1cm medial to the supraobital notch, between the notch and the bridge of the nose

96. SCALP BLOCK : AWAKE CRANIOTOMY TEMPORAL BRANCH OF THE AURICULOTEMPORAL NERVE Immediately posterior to the superficial temporal artery at the level of the auditory meatus. Injection is superficial and subcutaneous

97. ZYGOMATICOTEMPORAL NERVE SCALP BLOCK : AWAKE CRANIOTOMY emerges from the temporalis fascia near the lateral border of the orbit Field infiltration above the zygoma through the temporalis muscle and almost down to the periosteum of the temporal bone

98. GREATER & LESSER OCCIPITAL NERVE LESSER OCCIPITAL -- deep or superficial to the fascia at the upper, posterior border of sternocleidomastoid GREATER OCCIPITAL – middle third of a line between the mastoid process and the external occipital protuberance along the superior nuchal ridge SCALP BLOCK : AWAKE CRANIOTOMY

99. SCALP BLOCK : AWAKE CRANIOTOMY GREATER AURICULAR NERVE involved blockade of the entire superficial cervical plexus at the border of the sternocleidomastoid muscle USG guided GAN block (superficial location on the anterior surface of the sternocleidomastoid muscle)

100. maxillary nerve eventually enters the face through the infraorbital canal, where it ends as the infraorbital nerve. The infraorbital nerve supplies SENSORY BRANCHES TO THE LOWER EYELID, THE SIDE OF THE NOSE, AND THE UPPER LIP. INFRAORBITAL NERVE BLOCK : UPPER LIP SURGERY

101. INFRAORBITAL NERVE BLOCK : UPPER LIP SURGERY

102. EAR BLOCK POSTERIOR Br. GREAT AURICULAR NERVE LESSER OCCIPITAL NERVE ANTERIOR Br. GREAT AURICULAR NERVE AURICULOTEMPORAL NERVE Blocking the entire ear (with the exception of the area supplied by the vagus nerve)

103. EAR BLOCK inserting the needle at the black dots and infiltrating along the dotted lines TEMPORAL Br. AURICULO TEMPORAL nv. LESSER OCCIPITAL nv. GREAT AURICULAR nv.

104. OTHER NERVE BLOCK OVER AROUND FACE : IN BRIEF 104

105. TRIGEMINAL (Gasserian Ganglion) Block 105

106. Nasociliary and Anterior Ethmoidal Nerve Blocks 106

107. Maxillary Nerve Blocks 107

108. NASAL BLOCK 108 SUPPLIMENTED WITH INFRAORBITAL NERVE BLOCK

109. Posterior superior alveolar nerve block 109

110. Middle superior alveolar nerve block 110

111. Anterior superior alveolar nerve block 111

112. Nasopalatine nerve block 112

113. Greater palatine nerve block 113

114. Mandibular Nerve Blocks 114 below the zygomatic arch at the midpoint of the notch of the mandible until the pterygoid plate is felt Another type -- AKINOSI closed-mouth Mandibular block

115. Inferior Alveolar Nerve Block 115 2 inches deep, 1 inch superior and just medial to the 3rd Mandibular molar

116. Mental nerve block 116 Mental and incisive nerves are the terminal branches for the inferior alveolar nerve Sensory - lower lip skin mucobuccal fold at or anterior to the mental foramen . This lies between the Mandibular premolars

117. Tracheal block

118. Cervical plexus block

119. INDICATION Vocal cord surgery - medialization thyroplasty Cervicogenic headache Carotid endarterectomy Zenker diverticulum excision in a patient with ankylosing spondylitis Drainage of dental abscess in adults with difficult airways Drainage of submandibular and submental abscesses

120. INDICATION Minimally invasive parathyroidectomy Carotid body tumor excision in a patient with Eisenmenger syndrome Postoperative analgesia after clavicle surgery Thyroid surgery under general anesthesia Management of neuropathic cancer pain

121. Blockade BOTH SUPERFICIAL & DEEP CERVICAL PLEXUS BLOCK -- skin of the anterolateral NECK and the ante- and RETROAURICULAR areas. In addition, the DEEP CERVICAL BLOCK anesthetizes three of the four strap muscles of the neck, geniohyoid the prevertebral muscles Sternocleidomastoid levator scapulae the scalenes Trapezius and the diaphragm

122. Technique : superficial cervical plexus SUPINE OR SEMI-SITTING POSITION WITH THE HEAD FACING AWAY Landmark & needle insertion point Fanning of drug

123. Technique : deep cervical plexus DEEP CERVICAL PLEXUS BLOCK IS A PARAVERTEBRAL BLOCK OF THE C2 TO C4 SPINAL NERVES

124. Complication : cervical plexus block

125. Nerve block for awake intubation ophthalmic and maxillary divisions of the TRIGEMINAL NERVE supply the nasal cavity and turbinates oropharynx and posterior third of the tongue are supplied by the GLOSSOPHARYNGEAL NERVE VAGUS NERVE innervate the epiglottis and more distal airway structures

126. Nerve block for awake intubation PREPARATION FOR AWAKE INTUBATION

127. Blockade of the Trigeminal Nerve greater and lesser palatine nerves --- the nasal turbinates and the posterior two thirds of the nasal septum TOPICAL APPLICATION OF LA PTERYGOPALATINE GANGLION block remaining portions of the nasal passages INHALATIONAL OR SPRAY TOPICALIZATION

128. Blockade of the Glossopharyngeal Nerve oropharynx , soft palate, posterior portion of the tongue, and the pharyngeal surface of the epiglottis INTRA-ORAL APPROACH

129. PERI-STYLOID APPROACH

130. Blockade of the Vagus Nerve

131. TRANSTRACHEAL BLOCK

132. Tracheal block

133. Intercostal block & Interplural catheter

134. Landmark

135. Intercostal block : technique Patient is placed in the PRONE POSITION WITH A PILLOW PLACED UNDER THE ABDOMEN to reduce the lumbar curve primary rami of T1 through T11. T12 is a subcostal nerve At the posterior angle of the rib, the nerve lies in the costal groove accompanied by the intercostal vein and artery

136. Intercostal block : technique 12th rib (last rib palpable inferiorly) 7th rib (lowest rib covered by the angle of the scapula) Spinous process C7 (the most prominent spinous process in the cervical region when the neck is flexed)

137. Intercostal block : technique A perpendicular or caudal angulation of the needle can cause the block failure; maintenance of the 20° cephalic angle 

138. Intercostal block : technique

139. Interplural catheter : technique catheter placement for management of postoperative pain results with cholecystectomy have been most favorable

140. Intercostal block & Interplural catheter : complication

141. Paravertebral block : thoracic & thoraco-lumbar

142. Anatomy & landmarks

143. Anatomy & landmarks 1 2 3 4 1 2 3 4

144. Anatomy & landmarks

145. Indication :thoracic Pain relief for thoracotomy Major breast surgery Implantable cardioverter defibrillator and laser lead extraction Right lobe hepatectomy Postoperative analgesia after robotic-assisted coronary artery bypass graft Open cholecystectomy Abdominoplasty Submuscular breast augmentation

146. Radiofrequency ablation of a metastatic carcinoid liver lesion Single-injection/continuous block technique for major renal surgery in children Thymectomy performed with a bilateral thoracoscopic approach Video-assisted thoracic surgery procedures Percutaneous transhepatic biliary drainage Thoracoabdominal esophageal surgery Conventional on-pump cardiac surgery Indication :thoracic

147. Multiple rib fracture Minimally invasive direct coronary artery bypass surgery Pleuritic pain Esophagogastrectomy Indication :thoracic

148. Indication :thoraco-lumbar Outpatient lithotripsy Inguinal hernia repair Ventral hernia repair Hip arthroscopy Femoral- popliteal bypass in high-risk patient Labor analgesia

149. technique patient is positioned in the sitting or lateral decubitus position and supported by an attendant

150. technique The fingers of the palpating hand should straddle the paramedian line and fix the skin to avoid medial-lateral skin movement

151. complication

152. TRANSVERSUS ABDOMINUS PLANE (TAP) BLOCK

153. ANATOMY & LANDMARK TRIANGLE OF PETIT

154. indication expect analgesia between T10 and L1 with a single injection postoperative analgesia for laparotomy Appendectomy laparoscopic surgery Abdominoplasty cesarean delivery, abdominal hysterectomy Appendectomy, hernia repair Bilateral blocks can be used for midline incisions or laparoscopic procedures as an alternative to epidural anesthesia for operations on the abdominal wall

155. TECHNIQUE & COMPLICATION Peritoneal puncture liver hematoma

156. ILIOINGUINAL AND ILIOHYPOGASTRIC BLOCKS

157. ANATOMY & LANDMARK

158. ANATOMY & LANDMARK

159. INDICATION Analgesia following INGUINAL HERNIA REPAIR Lower abdominal procedures Analgesia following suprapubic incision

160. TECHNIQUE & COMPLICATION Perforation of large & small bowel Pelvic hematoma Lower limb weakness

161. needle is inserted in-plane in a medial to lateral orientation. Double pop – needle at IOM-TAM plane TECHNIQUE The nerves should appear as hypoechoic ovals between the IOM and TAM muscles

162. RECTUS SHEATH BLOCK INDICATION postoperative analgesia for umbilical hernia repair other umbilical & para-umbilical surgery

163. TECHNIQUE Perforation of large & small bowel Pelvic hematoma

164. 169

165. 170