CA1 Lecture Meredith Kan MD 92617 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 ID: 1035887
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1. Introduction to Regional AnesthesiaCA-1 LectureMeredith Kan, MD9/26/17
2. 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)
3. What does it do?Reduces sensation – reduces need for other forms of anesthesia and analgesia, depending on type of block and type of local anestheticin place of GA, supplement GA, and/or for post-op painWhat purpose can they serve:Reduced the amount of other anesthetics, or completely eliminate need for GAReduce 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 blocksSpinalEpidural Peripheral Nerve blocksSS – short acting (3-6 hrs) long acting (8-18 hrs)Catheter (2-4 days)
4. Why Regional Anesthesia? Alternative to GAReduce opioidsReduce PONVImprove pain controlFacilitate readiness for discharge to home
5. Types of Regional AnesthesiaNeuraxial blocks (spinal, epidural)Peripheral Nerve blocksBrachial Plexus blocksFemoral & Saphenous nerve blocksSciatic Nerve blocksTruncal Blocks (TAP blocks, paravertebral blocks)
6. Spinal Block (SAB) vs. Epidural
7. Epidural Role in Surgery
8. Epidural ProcedureAnatomic LandmarksTechnique
9. Epidural Procedure
10. Epidural Procedure
11. Question Answers
12. Epidural - StepsConsentPositioning and MonitorsSterile Prep & DrapeSkin WhealAdvance tuohy needle/attached LOR syringe until loss of resistance is encounteredAdvance catheter through tuohy ~5 cm past tipSecure catheterTest dose
13. Epidural catheter placement
14. Spinal aka Subarachnoid Block (SAB)
15. Spinal vs Epidural
16. Spinal - stepsConsentPositioning and MonitorsSterile Prep & DrapeSkin WhealAdvance spinal needle until “pop” felt or if appropriate depth achieved, check for CSFAdminister local anesthetic dose
17. SAB/Epidural RisksHypotensionInfection (epidural abscess)Bleeding (epidural/subdural hematoma)Post-Dural Puncture Headache (PDPH)Unintentional intrathecal or intravascular injectionBlock failure
18. SAB/Epidural ContraindicationsRisks and benefits must be considered on an individual patient basis. Absolute Contraindications:Patient refusalInfection at site of injectionHypovolemiaCoagulopathyIncreased intracranial pressureIndeterminate neurological diseaseSevere spinal stenosis @ site of spinal injection (severe lumbar spinal stenosis)Relative Contraindications:Infection distant from site of injectionUnknown length of surgery (if spinal is primary anesthetic).Difficulty communicating with patient, patient unable to cooperateCardiac disease that will not tolerate acute reduction of SVR (i.e. severe AS)
19. Peripheral nerve blocks
20. What are Nerve Blocks?Delivery of local anesthetic around specific nerve or group of nerves to reduce sensation to desired region of the bodyMotor and proprioception are also blockedSingle shot (SS) or catheterUltrasound-guided or nerve stimulationFollow-up
21. Nerve Blocks – overview Introduction to Regional Service @ StanfordTypes of common Nerve blocksIndications/ContraindicationsLogistical issues
22. Regional TeamTeam approach to planning, nerve block placement and follow-upDedicated team outside of the OR to focus on efficient, effective and appropriate block placementDaily regional plan email – fellowsCommunicationBusy AM – lend a hand when you can!
23. Regional Anesthesia RotationLearn functional anatomy, sonoanatomyAppropriate patient selectionAppropriate block type/local anesthetic selectionUnderstanding perioperative management of pain and the role of regional anesthesia
24. Upper Extremity Blocks
25. Interscalene BlockShoulder SurgeryProximal Humerus SurgerySS or catheter
26. Interscalene Block
27. Supraclavicular BlockElbow/forearm surgeryHand surgeryArteriovenous fistula placement/revisionNot good location for catheter placement
28. Supraclavicular Block
29. Infraclavicular Block
30. Infraclavicular BlockElbow/forearm surgeryHand surgeryArteriovenous fistula placement/revisionGood location for catheter placementLess likely phrenic involvement
31. Lower Extremity BlocksFemoral BlockAdductor Canal (saphenous) blockSciatic (popliteal) block
32. Lower extremity sensory anatomy
33. Femoral BlockFemur IM nailPatella ORIFKnee surgeryAnterior Thigh Mass resection
34. Femoral Block
35. Saphenous BlockAnterior kneeMedial calfMedial component of ankle surgery“quadriceps sparing” – increased ambulation and quad strength compared to femoral nerve block
36. Saphenous Nerve Block
37. Popliteal Block (Sciatic Nerve)Surgery below the kneeFoot & ankle surgery
38. Popliteal block
39. Nerve Block RisksBleedingInfectionNerve InjuryBlock Failure
40. Local Anesthetic SelectionDurationMedium-acting (Mepivacaine, Lidocaine) – 3-8hrsLong-acting (Ropivacaine, Bupivacaine) acting – 8-18 hrs
41. Dosingvolumeconcentration
42. Local AnestheticsMechanism of action:Interrupt nerve conductionBind to Na channels and block movement of ionsProperties:Duration – lipid solubilitySpeed of onset – pKa (closer to pH, faster the onset)
43. Post-op ManagementCatheter follow-up on a daily basisConfirm resolution of blockMonitor for complicationsEvaluate patient satisfaction
44. Thank you!