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Sciatic Nerve Block
Transcript of Sciatic Nerve Block
Motor and sensory nerve Largest nerve of the body (1.5 to 2 cm wide and 0.3 to 0.5 cm thick) Comprises the anterior branches of the ventral rami of the L4, L5 nerves as well as S1-S4 sacral roots Enclosed in a common sheath, tibial nerve medially and posteriorly and the common peroneal nerve laterally and anteriorly Analgesia +/- anesthesia for posterior thigh, lower leg & foot (except the area innervated by saphenous nerve) Thigh tourniquet requires 3-in-1 block (femoral, obturator and lateral femoral cutaneous) to cover the anterior and medial thigh At Sunnybrook, sciatic nerve block (single injection) is used together with continuous femoral nerve block for postop analgesia in TKA Vitals monitoring i.e. ECG, SpO2, NIBP Supplemental oxygen Judicious use of anxiolytics (e.g. midazolam 2mg) and analgesia (e.g. fentanyl 25-50ug) Posterior Approach Labat Line drawn from PSIS to greater trochanter Perpendicular line from mid-point, 4cm 80-100mm 22G insulated needle Needle perpendicular to all planes Average depth 7cm Adjust needle position until motor response (plantar flexion or dorsiflexion) is elicited at around 0.4mA Hamstring contraction needle too medial; some authors accepts this as end-point though Winnie Line from PSIS to greater trochanter
Line from coccyx to greater trochanter Intercepting point with perpendicular bisector Gluteal midpoint of the line drawn between the ischeal tuberosity and the greater trochanter. Depth 5 to 7 cm. Sub-gluteal a line is drawn joining the greater trochanter and the ischeal tuberosity From the midpoint of this line, a perpendicular line is extended caudally for 4 cm Anterior Approaches When patients have difficulty turning
But nerve is deep and difficult to locate the nerve Beck's Chelly's Raj's Risks/benefits explained Consent obtained IV secured Resuscitation equipment and drugs readily available in case of LA toxicity Site prepared with antiseptics Anterior Approach with Ultrasound For the In Plane approach, use a 8-12 cm, 22G insulated block needle
Advance the needle in a medial to lateral direction as well as an anterior to posterior direction when the thigh is externally rotated Ultrasound Subgluteal Slow onset (up to 30min for surgical anesthesia) and long lasting
0.5% Bupivacaine: anesthesia 8-16hr; analgesia 10-48hr
0.5% Ropivacaine: anesthesia 6-12hr; 6-24hr
2% Lidocaine: anesthesia 5-6hr; analgesia 5-8hr
At TWH, 30mL 0.2% Ropivacaine w/ Epi
Sunnybrook, 20ml 0.5% Ropivacaine
Avoid the use of epinephrine during sciatic nerve blockade because of the peculiar blood supply to the sciatic nerve, the possibility of additional ischemia due to stretching or sitting on the anesthetized nerve, and the long duration Popliteal Nerve Block 5cm 22G insulated short bevel needle
Common peroneal nerve stimulation results in dorsiflexion and eversion. Stimulation of the tibial nerve results in plantar flexion and inversion
35-40ml of LA
Block dynamics is similar to sciatic nerve block Ultrasound Popliteal Nerve Block Seesaw sign with foot dorsi and plantar flexion Contraindications Patient refusal
Allergy to LA
Anticoagulated (not absolute)
Infection over injection site
Progressive neurological diseases