Introduction to Regional Anesthesia
CA-1 Lecture
Meredith Kan, MD
9/26/17
What is Regional Anesthesia?
• Application of local anesthetic to nerves to
temporarily block sensation to a region of the
body (neuraxial and peripheral nerve blocks)
• What does it do?
• Reduces sensation – reduces need for other forms of anesthesia and analgesia, depending on type of block and type of local anesthetic
• in place of GA, supplement GA, and/or for post-op pain
• What purpose can they serve:
• Reduced the amount of other anesthetics, or completely eliminate need for GA
• Reduce the amount of post-op pain on POD 0 and beyond (if catheter is used)
•
• Components of regional anesthesia:
• -understanding when and how RA can help, patient selection
• -equipment – U/S
• -LA
•
•
• Types of blocks (full body diagram)
• Types of local anesthetics – what is a local anesthetic. Types. Properties. How do we choose between one and another
•
• Neuraxial blocks
• Spinal
• Epidural
•
• Peripheral Nerve blocks
• SS – short acting (3-6 hrs) long acting (8-18 hrs)
• Catheter (2-4 days)
Why Regional Anesthesia?
• Alternative to GA
• Reduce opioids
• Reduce PONV
• Improve pain control
• Facilitate readiness for discharge to home
Types of Regional Anesthesia
• Neuraxial blocks (spinal, epidural)
• Peripheral Nerve blocks
– Brachial Plexus blocks
– Femoral & Saphenous nerve blocks
– Sciatic Nerve blocks
– Truncal Blocks (TAP blocks, paravertebral blocks)
Spinal Block (SAB) vs. Epidural
Epidural Role in Surgery
Epidural Procedure
• Anatomic Landmarks
• Technique
Epidural Procedure
Epidural Procedure
Question Answers
Subcutaneous Supraspinous Interspinous Ligamentum
Skin
Fat ligament Ligament Flavum
Epidural - Steps
①Consent
②Positioning and Monitors
③Sterile Prep & Drape
④Skin Wheal
⑤Advance tuohy needle/attached LOR syringe until
loss of resistance is encountered
⑥Advance catheter through tuohy ~5 cm past tip
⑦Secure catheter
⑧Test dose
Epidural catheter placement
Spinal aka Subarachnoid Block (SAB)
Spinal vs Epidural
Spinal - steps
①Consent
②Positioning and Monitors
③Sterile Prep & Drape
④Skin Wheal
⑤Advance spinal needle until “pop” felt or if
appropriate depth achieved, check for CSF
⑥Administer local anesthetic dose
SAB/Epidural Risks
• Hypotension
• Infection (epidural abscess)
• Bleeding (epidural/subdural hematoma)
• Post-Dural Puncture Headache (PDPH)
• Unintentional intrathecal or intravascular injection
• Block failure
SAB/Epidural Contraindications
Risks and benefits must be considered on an individual patient basis.
Absolute Contraindications:
• Patient refusal
• Infection at site of injection
• Hypovolemia
• Coagulopathy
• Increased intracranial pressure
• Indeterminate neurological disease
• Severe spinal stenosis @ site of spinal injection (severe lumbar spinal stenosis)
Relative Contraindications:
• Infection distant from site of injection
• Unknown length of surgery (if spinal is primary anesthetic).
• Difficulty communicating with patient, patient unable to cooperate
• Cardiac disease that will not tolerate acute reduction of SVR (i.e. severe AS)
Peripheral nerve blocks
What are Nerve Blocks?
• Delivery of local anesthetic around specific nerve
or group of nerves to reduce sensation to desired
region of the body
• Motor and proprioception are also blocked
• Single shot (SS) or catheter
• Ultrasound-guided or nerve stimulation
• Follow-up
Nerve Blocks – overview
• Introduction to Regional Service @ Stanford
• Types of common Nerve blocks
• Indications/Contraindications
• Logistical issues
Regional Team
• Team approach to planning, nerve block
placement and follow-up
• Dedicated team outside of the OR to focus on
efficient, effective and appropriate block
placement
• Daily regional plan email – fellows
• Communication
• Busy AM – lend a hand when you can!
Regional Anesthesia Rotation
• Learn functional anatomy, sonoanatomy
• Appropriate patient selection
• Appropriate block type/local anesthetic selection
• Understanding perioperative management of pain
and the role of regional anesthesia
Upper Extremity Blocks
Interscalene Block
• Shoulder Surgery
• Proximal Humerus Surgery
• SS or catheter
Interscalene Block
Supraclavicular Block
• Elbow/forearm surgery
• Hand surgery
• Arteriovenous fistula placement/revision
• Not good location for catheter placement
Supraclavicular Block
Infraclavicular Block
Infraclavicular Block
• Elbow/forearm surgery
• Hand surgery
• Arteriovenous fistula placement/revision
• Good location for catheter placement
• Less likely phrenic involvement
Lower Extremity Blocks
• Femoral Block
• Adductor Canal (saphenous) block
• Sciatic (popliteal) block
Lower extremity sensory anatomy
Femoral Block
• Femur IM nail
• Patella ORIF
• Knee surgery
• Anterior Thigh Mass resection
Femoral Block
Saphenous Block
• Anterior knee
• Medial calf
• Medial component of ankle surgery
• “quadriceps sparing” – increased ambulation and
quad strength compared to femoral nerve block
Saphenous Nerve Block
Popliteal Block (Sciatic Nerve)
• Surgery below the knee
• Foot & ankle surgery
Popliteal block
Nerve Block Risks
• Bleeding
• Infection
• Nerve Injury
• Block Failure
Local Anesthetic Selection
• Duration
– Medium-acting (Mepivacaine, Lidocaine) – 3-8hrs
– Long-acting (Ropivacaine, Bupivacaine) acting – 8-18
hrs
Dosing
• volume
• concentration
Local Anesthetics
• Mechanism of action:
– Interrupt nerve conduction
– Bind to Na channels and block movement of ions
• Properties:
– Duration – lipid solubility
– Speed of onset – pKa (closer to pH, faster the onset)
Post-op Management
• Catheter follow-up on a daily basis
• Confirm resolution of block
• Monitor for complications
• Evaluate patient satisfaction
Thank you!
