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Regional Anesthesia (AA Student Lecture Series)

Ben Barfield AA-C, MMSc Anesthesiology Department | Children’s Hospital Colorado 13123 East 16th Avenue, Box 090 | Aurora, CO 80045 | Phone: (720) 777-4583 | Fax: (720) 777-7266 | benjamin.barfield@childrenscolora
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Ben Barfield

on 18 August 2015

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Transcript of Regional Anesthesia (AA Student Lecture Series)

Common Pediatric
Regional Anesthesia

Ben Barfield AA-C, MMSc
Anesthesiology Department | Children’s Hospital Colorado
13123 East 16th Avenue, Box 090 | Aurora, CO 80045 | Phone: (720) 777-4583 | Fax: (720) 777-7266 | benjamin.barfield@childrenscolorado.org
No disclosures associated with this presentation.
Infraorbital Block
Trigeminal Nerve (5)
CN V2
Maxillary Nerve Branch
Infraorbital Foramen
Mid-line with Pupil
Bruising at injection site
Local Anesthetics
Procaine, Cocaine, Chloroprocaine, Tetracaine

Ester linkage cleaved by plasma cholinesterases. The half-life of this process in circulation is about 1 minute.
Amides
Esters
References
1. Dunn, P. F. (2007). Local Anesthetics, Clinical Anesthesia Procedure of the Massachusetts General Hospital (7th. ed., pp. 238-246). NY:
Lippincott Williams & Wilkins.
2. Shlamovitz, MD, Gil Z. Medscape Reference. "Dorsal Penile Nerve Block". 2013. Web. 28 May 2013.
3. Molliex S Navez M, Baylot D et al: Regional Anesthesia for Outpatient Nasal Surgery. Br J Anaesth 1996; 76: 151-3
4. B.A.T.S, Research Group. "Interscalene Sonography". 2013. Photograph. Better Anesthesia Through Sonography. Web. 28 April 2013.
5. Prabhu KP, Wig J, Grewal S: Bilateral infraorbital nerve block is superior to peri incisional infiltration for analgesia after repair of cleft
lip. Scand.J.Plastic Reconst.Surg & Hand Surg 1999; 33: 83-7
6. "Continuous Femoral Nerve Block". NYSORA. 2012. Web. 1 May 2013.
7. "Popliteal Block: Intertendinous Apporach". NYSORA. 2012. Web. 1 May 2013.
8. "Supraclavicular Brachial Plexus Block". Neuraxiom Ultrasound Guided Regional Nerve Blocks. 2013. Web. 1 May 2013.
9. G. Ivani, E. Lampugnani, M. Torre, G. C. Maria, P. DeNegri, F. Borrometi, A. Messeri, M.Calamandrei, P. A. Lonnqvist, and N. S.
Morton. Comparison of ropivacaine with bupivacaine for paediatric caudal block. Br. J. Anaesth. 1998 81: 247-248.
10. IVANI, G. (2002), Ropivacaine: is it time for children?. Pediatric Anesthesia, 12:383–387. doi: 10.1046/j.1460-9592.2002.00859.
11. McLeod MD, Ian K. Medscape Reference. "Local Anesthestics". 2013. Web 15 May 2013.
12. "Local Anesthetic Cardiac Toxicity". Regional Anesthesia and Pain Medicine. Vol. 27 No. 6 November–December 2002
13. Bernard Dalens, MD, Guy Vanneuville, MD, and Pierre Dechelotte, MD. Penile Block via the Subpubic Space in 100 Children. Anes Anal 41
1989;69:41-5.
14. Tassone, DO, Heather. Medscape Reference. "Saphenous Nerve Block". 2013. Web. 28 May 2013.
15. "Saphenous Block". Neuraxiom Ultrasound Guided Regional Nerve Blocks. 2013. Web. 2 May 2013.
16. "Interscalene Block". Neuraxiom Ultrasound Guided Regional Nerve Blocks. 2013. Web. 28 April 2013.
17. "Supraclavicular Brachial Plexus Block". Neuraxiom Ultrasound Guided Regional Nerve Blocks. 2013. Web. 1 May 2013.
18. "The Axillary Brachial Plexus Block". Neuraxiom Ultrasound Guided Regional Nerve Blocks. 2013. Web. 28 April 2013.
19. "The Femoral Nerve Block". Neuraxiom Ultrasound Guided Regional Nerve Blocks. 2013. Web. 28 April 2013.
20. "Popliteal Block". Neuraxiom Ultrasound Guided Regional Nerve Blocks. 2013. Web. 28 May 2013.
Interscalene Block
Penile Block
Popliteal Nerve Blocks
Common for ankle surgery, achilles tendor repair, foot surgery, and reducing tourniquet pains.

Sciatic nerve enters the popliteal fossa and branches into the Tibial Nerve and Common Peroneal Nerve.
This will cover the leg
EXCEPT
the
medial
part of the leg.
Medial part of th leg is covered by the sa
phe
nous. (Part of
Femoral
Branch)
Layers of anatomy from the midline approach:

Skin
Subcutaneous fat
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Dura mater
Subdural space
Arachnoid mater
Subarachnoid space
1
Spinal Anesthesia
Layers of anatomy from the paramedian approach:

Skin
Subcutaneous fat
Ligamentum flavum
Dura mater
Subdural space
Arachnoid mater
Subarachnoid space
Spinal nerves that originate from the cervical region are named according to the upper cervical vertebral body from which they exit. The exception is the 8th cervical nerve exits below the 7th cervical vertebral body.
http://www.bats.ac.nz/resources/interscalene_image2.jpg
Interscalene Block
Technique:
Tilt head away from you
Identify the sternocleidomastoid muscle & anterior scalene muscle
There will be a groove between the two muscle
This groove and the level of the cricoid is the injection site
Insert needle towards caudal position

Nerve Stimulation of deltoid, bicep, or pectoris muscles shows plexus stimulation
Commonly used for shoulder, arm, or elbow surgery.
This approach blocks the cervical plexus and brachial plexus = blocks the skin over the shoulder.
The brachial plexus is formed by C5-C8 and T1
Some from C4 and T2
Roots are found between the anterior and middle scalene muscles.
Esters break down to metabolite p-aminobenzoic acid
This is also a cross reaction with sulfa drugs (sulfonamides, thiazide diuretics)


Procaine – rapid onset, sort duration
Chloroprocaine – very rapid onset, short duration
Tetracaine – slow onset, long duration
1
1
EMLA - Eutectic Mixture of Local Anesthetics
2.5% Liodcaine and 2.5% Prilocaine

Remember your "L's"
Mechanism of Local Anesthetics
Myelinated fibers are blocked easier than unmyelinated. This is because the myelinated fibers must only be blocked at the nodes of Ranvier.
Neural Blockade sequence:

1. Sympathetic block – vasodilation & skin temperature increase
2. Pain & Temperature sensation
3. Proprioception – “one’s own/individual touch”
4. Touch and pressure
5. Motor paralysis

Epinephrine added to LA speeds the onset of action.
Max Epi Dose:
10 mcg/kg in pediatrics (5-6 mcg/kg here at CHC)200-250 mcg in adults
Goal is to anesthetize the branch of the II division of the Trigeminal Nerve.
Maxillary Branch

Facial Branches of Maxillary Nerve (CN V2)
Inferior palebral = lower eyelid
External nasal = skin of nose (lateral)
Superior labial branch = upper lip, skin, & mucosa

Used in cleft lip surgery, nasal septal repair, and endoscopic sinus surgery.

Dosing:
Infants: 0.25-0.5 mL per side
Children: 0.5-1.5 mL per side
Infraorbital foramen usually located midline with pupil
3
Infraorbital Block
Randy Travis Drinks Cold Beer
Roots, Trunks, Divisions, Cords, Branches
Complications
Infection - aseptic technique

Vascular puncture - avoid multiple insertions

Hematoma - steady pressure on site

LA toxicity - inadvertant intravascular injection, multiple aspirations during injection, slow injections

Nerve injury - don't force injection

Horner's Syndrome - ipsilateral ptosis, hyperemia of the conjuctiva, and nasal congestion; tell patients it is possible before performing the block

Diaphragmic paralysis - smaller volumes of LA
Femoral Nerve Block
"Navel"
or "Van"
Popliteal Block
Spinal nerves that originate from the cervical region are named according to the upper cervical vertebral body from which they exit. The exception is the 8th cervical nerve exits below the 7th cervical vertebral body.
Contraindications:
Testicular torsion
Skin infection at injection site
No
Epinephrine
Here
Common block for TKA, quadricep muscle sx/bx, and knee arthroscopy.
Femoral nerve originates from lumbar plexus at L2-4. After the nerve passes the inguinal ligament it flattens out next to the artery and vein.
GOAL: Provide anesthesia to the anterior thigh, femur/knee joint, and skin of the medial leg below the knee joint.
6
Anatomy
1. Popliteal fossa crease
2. Tendon of biceps femoris (lateral)
3. Tendons of semitendinosus and semimembranosus muscles (medial)
GOAL with nerve stimulator - Common peroneal nerve stimulation results in dorsiflexion and eversion. Stimulation of the tibial nerve results in: plantar flexion and inversion
7
Caudal Block
Think of an inverted Triangle:

5 Fused sacral vertebra

Under 4th spinous tubercle is the sacral hiatus
Feels like a knuckle - opening of caudal canal
Sacrococcygeal ligament
Extension of ligamentum flavum

Sacral canal - epidural venous plexus
Generally terminates at S4
Caudal Technique
1. Lateral decubitus
Tuck the knees into the chest - assume the fetal position
2. Look at the butt
3. Palpate sacral cornua - 2 of them
4. Hollow space between the Sacral Cornua = Money shot
5. Insert needle, Aspirate, Inject
With needle insertion you don't feel a pop but an easier placement/advancement

When aspirating you should get nothing back. Blood or CSF means withdraw and redirect.

When injecting feel the skin after injection site. Swelling = not in correct spot
Biggest difference: perioperative pain control in kids and chronic pain management for adults.
Caudal Dosing

Ropivacaine 0.2% 1 mL/kg 8.4 min 271.9 min
Bupivacaine 0.25% 1 mL/kg 8.8 min 233.2 min
Ropivacaine has longer duration with less motor block than bupivacaine at these dosages.
9
LA
Dose
Onset
First
Analgesic
0.2–0.25% Ropivacaine 1 ml/kg is probably the best solution for a caudal block - perioperative pain control and a reduced incidence of motor blockade.
Continuous Infusion (0.1% Ropivacaine)
0.2 mg/kg/hr in infants
0.4 mg/kg/hr in older children is effective and safe
10
10
Ultrasound probe is held at the cricoid level over the SCM muscle.

Identifying the carotid, internal jugular and then the anterior scalene and middle scalene

Needle will "pop" through the middle scalene muscle. Inject LA between the middle and anterior scalene muscles.
Most of the nerves creating the brachial plexus are sitting above and behind the subclavian artery. The subclavian artery is above the 1st rib.
Think Sandwich

Local - Nevre Bundle - Local

The scalene muscle borders are pushed away from the bundle when local is injectet.
Supraclavicular Block
Place the probe above the clavical and tilt towards the chest/lungs.


The nerves will look like bubbles, empty circles, or a honeycomb. Inject local anesthetic into the sheath holding the nerves.


"Corner pocket" - the ulnar nerve is usually hidden in the pocket between the first rib and the subclavian artery.
Femoral Nerve
Femoral Nerve Block
Questions
Lateral
Medial
How these things work:

LA yield anesthesia by inhibiting nerve endings from becoming excited and block coduction to peripheral nerves.

Reversibly bind to sodium channels = inactivate the channel

Without sodium influx no depolarization can occur in the nerve cell membranes = no impulses along the nerve

Without impluses you get a loss of sensation in the area supplied by the nerve.
Amides are metabolized in the liver and very stable in solution.

Elimination half-life = 2-3 hrs
Drug
Onset
Max Dose
Duration
Lidocaine
Rapid
5 mg/kg 7mg/kg
2 hrs / 4 hrs
Bupivacaine
Slow
2.5 mg/kg
4 hrs / 8 hrs
Ropivacaine
Medium
2-3 mg/kg
3 hrs / 6hrs
11
If you don't remember anything remember this...
IV > tracheal > intercostal > caudal > paracervical > epidural > brachial > sciatic > subcutaneous
I

T I C

P E B S S

No, seriously this is a board question
Fixing an
Overdose
of LA

Airway Management - ACLS

Cardiac Management - ACLS
AVOID:
Calcium channel blockers, beta blockers, or LA - these all create an added depressant effect on myocardial contractility

Lipid Emulsion (20%) Therapy
1.5 mL/kg Bolus over 1 minute (may repeat bolus if cardiovascular collapse)
0.25 mL/kg/min infusion (if BP low increase to 0.5 mL/kg/min)
12
Higher concentrations
Lower concentrations
Early Signs:
Tinnitis
Dizziness
Metallic/funny taste
Late Signs:
Seizures
Respiratory Arrest
Cardiac depression/arrest
Penis is innervated by dorsal nerves (Left and Right). Part of the pudendal nerve.

The nerve lies at the layer of superficial fascia that supplies the skin and also gives a branch to the corpus cavernosus.

FYI: The Dorsal penile nerve block can miss the nerves to the frenulum = you need to inject local at the base of the ventral aspect of the penis.
10-15 minutes
to set up
Penile Block
Axillary block – 0.2-0.6 mL/kg

Interscalene block – 0.33 mL/kg

Femoral block – 0.5 mL/kg

Sciatic block – 0.15-0.2 mL/kg

Penile block - 0.2 mL/kg
Volume of local anesthetic for common blocks
Axillary Block of Brachial Plexus
Ideal block will provide anesthesia to:

Arm
Elbow
Forearm
Hand

0.1 mL/kg LA at each injection site
= 0.2 mL/kg total LA
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Volume of local anesthetic for common blocks
Axillary block – 0.2-0.6 mL/kg

Interscalene block – 0.33 mL/kg

Femoral block – 0.5 mL/kg

Sciatic block – 0.15-0.2 mL/kg

Penile block - 0.2 mL/kg

Axillary block – 0.2-0.6 mL/kg

Interscalene block – 0.33 mL/kg

Femoral block – 0.5 mL/kg

Sciatic block – 0.15-0.2 mL/kg

Penile block - 0.2 mL/kg
Volume of local anesthetic for common blocks
Needle inserted to 0.5 cm or until loss of resistance is felt = Buck fascia

Hit the 10 and 2 o'clock positions
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Saphenous Nerve Block
14
15
Identify the medial femoral condyle and the medial tibial condyle
Saphenous nerve Lies between the sartorius and gracilis muscle tendons
Saphenous nerve - trace branch of superficial femoral artery to a spot just above the knee where it is trapped in its path between muscle bodies
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