Femoral nerve block Dr. S. - PowerPoint Presentation

Slide1

Femoral nerve block

Dr. S.

Parthasarathy

MD., DA., DNB, MD (

Acu

), Dip.

Diab

. DCA, Dip. Software

statistics

PhD

(

physio

)

Mahatma Gandhi Medical college and research institute ,

puducherry

India

Slide2

Indications

procedures carried out on the anterior thigh

Combined with other blocks – lower leg and foot surgeries

femoral fracture analgesia

With catheter technique – post op analgesia of knee

Slide3

Anatomy

largest nerve of the lumbar plexus

( L2- L4)

supplies the muscles and the skin of the anterior compartment of the thigh

passes downwards in the groove between

psoas

and

iliacus

enters the thigh beneath the inguinal ligament

nerve lies on

iliacus

, a finger’s breadth lateral to the femoral artery

Slide4

Anatomy

Slide5

Technique

A line is drawn connecting the anterior superior iliac spine and the pubic tubercle.

The femoral artery is palpated on this line, and a 22-gauge, 4-cm needle is inserted

0.5 to 1 cm both below the inguinal ligament and lateral to the femoral artery.

The initial insertion should abut the femoral artery in a perpendicular fashion.

wall” of local

anaesthetic

is developed by redirecting the needle in a fanlike manner

Slide6

Line marked

Slide7

Needle insertion

Slide8

Injection of LA spanning out

Slide9

Drugs

20 

mL

of local

anaesthetic

0.25 to 0.5 %

bupivacaine

0.25%

bupivacaine

or 0.2%

ropivacaine

for catheter techniques

8- 10 ml / hour is enough

Slide10

Nerve stimulator

The femoral artery should be palpated and marked. The site of introduction of the needle is vertically, 0.5 to 1 cm both below the inguinal ligament and lateral to the femoral artery.

Set the nerve stimulator at a frequency of 2 Hz and a current of 2.5

mA

.

Go

anteroposterior

and get motor response of the femoral nerve (contraction of the quadriceps muscle with the phenomenon of the “dancing patella”).

Reduce to 1 Hz and 0.5

mA

- same response - and inject.

Slide11

technique

Needle positioned,

20 

mL

of preservative-free NS injected appropriate-size catheter is inserted approximately 10 cm past the needle tip.

Once the catheter has been secured with a plastic occlusive dressing, the initial bolus injection of drug is carried out and the infusion is started.

Slide12

Continuous catheter

Slide13

USG probe

Slide14

USG guided femoral nerve block

Slide15

Tips

The femoral artery and femoral nerve are

not

in the same anatomic compartment.

Therefore, if solution spreads

perivascularly

, the needle should be repositioned to produce local anesthetic spread below the fascia

iliaca

.

Slide16

Anatomy

The

obturator

nerve emerges from the medial border of the

psoas

muscle at the pelvic brim and travels along the lateral aspect of the pelvis anterior to the

obturator

internus

muscle and posterior to the iliac vessels and

ureter

. It enters the

obturator

canal

cephalad

and anterior to the

obturator

vessels, which are branches from the internal iliac vessels.

Slide17

Obturator nerve block

Slide18

adductor muscles, hip and knee joint

In the

obturator

canal, the

obturator

nerve divides into anterior and posterior branches The anterior branch supplies the anterior adductor muscles ,

articular

branch to the hip joint ,

cutaneous

area on the medial aspect of the thigh.

The posterior branch innervates the deep adductor muscles and sends an

articular

branch to the knee joint..

Slide19

Technique

The pubic tubercle should be located and an “X” marked 1.5 cm

caudad

and 1.5 cm lateral to the tubercle

The needle is inserted at this point, and at a depth of approximately 2 to 4 cm it contacts the horizontal

ramus

of the pubis.

The needle is then withdrawn, redirected laterally in a horizontal plane, and inserted 2 to 3 cm deeper than the depth of the initial contact with bone.

The needle tip now lies within the

obturator

canal

With the needle in this position, 10 to 15 

mL

of local anesthetic solution is injected

Slide20

Technique

Slide21

Complications

The

obturator

canal is a vascular location; thus, the potential exists for intravascular injection or hematoma formation,

more theoretical than clinical concerns.

Volume determines success.

Slide22

Probe position

Slide23

USG

Slide24

Lateral femoral cutaneous N blockwhy ?

Slide25

Technique

Slide26

Technique

The anterior superior iliac spine is marked in the supine patient,

and a 22-gauge, 4-cm needle is inserted at a site 2 cm medial and 2 cm caudal to the mark, the needle is advanced until a “pop” is felt as the needle passes through the fascia

lata

. Local anesthetic is then injected in a fanlike manner above and below the fascia

lata

, from medial to lateral.

Slide27

Technique

Slide28

Three in one block

The

perivascular

approach to the

psoas

compartment

is based on the premise that injection of a large volume of local anesthetic within the femoral canal while maintaining distal pressure will result in proximal spread

of the solution into the

psoas

compartment

and consequent lumbar plexus block

Slide29

Technique

The femoral artery is marked.

A 22- gauge, 5- cm needle is advanced lateral

to the artery in a

cephalad

direction

Paraesthesia – 30 ml given

Distal pressure applied

Success - ?

Slide30

Thank you all