Regional Anesthesia - Principles

PFN:18DAAL05

Hours: 1.0
Updated: AUG 2012

JSOMTC, SWMG(A) Slide 1

 Regional Anesthesia - Principles

 Agenda
 Review physiology of nerve impulse conduction
 Identify equipment and preparation to provide
peripheral nerve blocks
 Identify types of local anesthetic agents,
characteristics, and risk factors
 Indentify techniques of risk mitigation in
performance of regional blocks
 Identify nerve stimulation theory

JSOMTC, SWMG(A) Slide 2

 Regional Anesthesia - Principles

 References
 Military Advanced Regional Anesthesia and
Analgesia Ch. 2 – 4, & 25
 Pathophysiology for the Health Professions 4th
Edition Ch. 6 p.126
 Basis Guide to Anesthesia for Developing
Countries, Volume 2, Daniel D. Moos
(International Federation of Nurse
Anesthetists, ifna-int.org)

JSOMTC, SWMG(A) Slide 3

 Regional Anesthesia - Principles

 Conduction of Nerve Impulse

 Depolarization

JSOMTC, SWMG(A) Slide 4

 Regional Anesthesia - Principles

 Conduction of Nerve Impulse

 Repolarization

JSOMTC, SWMG(A) Slide 5

 Regional Anesthesia - Principles

 Conduction of Nerve Impulse

 Blocking Impulse with Locals

JSOMTC, SWMG(A) Slide 6

 Regional Anesthesia - Principles

 The goal in regional anesthesia

 Target nerves proximal to source of pain
• Surround “targeted” nerve with agents thus
preventing depolarization prior to perception by
CNS
• Lowering or eliminating systemic pain medications
• Lowering or eliminating negative CNS side effects of
systemic medications

JSOMTC, SWMG(A) Slide 7

 Regional Anesthesia - Principles

 Methods of targeting proximal nerves

 Paraesthesia “Blind” or “anatomical”
• Less equipment
• More suitable for distal blocks
 Nerve Stimulation *
• Specialized equipment
• Allows very proximal blocks
 Ultrasound guided
• Specialized equipment
• Allows visualization of targeted nerves
JSOMTC, SWMG(A) Slide 8
 Regional Anesthesia - Principles
Methods of targeting proximal nerves

JSOMTC, SWMG(A) Slide 9

 Regional Anesthesia - Principles

"This technology can only confirm and

refine correct needle placement for
regional blocks; it should never be
considered a substitute for the
physician's understanding of the
anatomical basis for each block.”
Military Advanced Regional Anesthesia and Analgesia

JSOMTC, SWMG(A) Slide 10

 Regional Anesthesia - Principles
 Regional Block Contraindications
 Adamant refusal by the patient
 Infants, children, or the elderly
 Localized infection at the injection site
 Systemic anticoagulation / coagulopathy
 Obese patients
 Pre-existing neurological disease
 Inadequate communication capability
 History of traumatic injury at block site

JSOMTC, SWMG(A) Slide 11

 Regional Anesthesia - Principles
 Preparation (Patient consent and
education)
 Avoid using blocked extremity for 24 hours
 Protective reflexes and proprioception
decreased
 Location
• Calm/Quiet location
• Adequate “set up” time
 The most common cause of “failed” regional anesthesia is
impatience

JSOMTC, SWMG(A) Slide 12

 Regional Anesthesia - Principles
 Preparation (Specific Gear)
 Ruler and marking pen
 Lidocaine to anesthetize skin
 Chlorhexidine gluconate skin cleaner
 Local anesthetic for block
 Peripheral Nerve Stimulator
 Needle
• Stimulating
• Non-stimulating
 Sterile gloves
 Assistant

JSOMTC, SWMG(A) Slide 13

 Regional Anesthesia - Principles

 Stimulator and gear

JSOMTC, SWMG(A) Slide 14

 Regional Anesthesia - Principles

 Patient marking prior to block

 Provides memory cues, acts as a rehearsal, instills
confidence in the patient, focuses your attention

JSOMTC, SWMG(A) Slide 15

 Regional Anesthesia - Principles

 Local Anesthetics Blocking Considerations

 Nerve Composition
• Size
• Myelination
• Stimulation
 Agents
• Potency (lipid solubility)
• Duration

JSOMTC, SWMG(A) Slide 16

 Regional Anesthesia - Principles

 Local Anesthetics Agents

 Lidocaine (30-60 minute duration)
• Short to medium acting, most versatile, considered
too short acting for post operative pain
management
 Mepivacaine (45-90 minute duration)
• Medium acting, less neurotoxic and cardiotoxic
than lidocaine; very attractive agent due to low
toxicity, rapid onset, and a dense block

JSOMTC, SWMG(A) Slide 17

 Regional Anesthesia - Principles

 Local Anesthetics Agents

 Ropivacaine (120-360 minute duration)
• Considered the safest long acting agent, long acting
agent of choice at Walter Reed due to safety profile
and efficacy
 Bupivacaine (120-240 minute duration)
• Considered a long acting agent, longest latency to
onset time frame, low cost, propensity for sensory
versus motor blockade; cardiac toxicity high if
intravascular injection occurs

JSOMTC, SWMG(A) Slide 18

 Regional Anesthesia - Principles

 Preparation (Equipment)
 Basic Gear
• Monitor
• Oxygen
• Suction
• Airway adjunct capability
• Emergency hemodynamic equipment
 Advanced Gear
• ACLS (defibrillation)
• Intralipids
JSOMTC, SWMG(A) Slide 19
 Regional Anesthesia - Principles
 Local Anesthetics(Risk Factors)
 Neurotoxicity
 CNS Toxicity
 Cardiac Toxicity

 Stay out of vessels and keep the dosing in

prescribed ranges
 For every clinical situation, the use of regional
anesthesia must be carefully evaluated as a
matter of risk versus benefit
JSOMTC, SWMG(A) Slide 20
 Regional Anesthesia - Principles

 Neurotoxicity
 Evidence suggests that local anesthetics can be
myotoxic and neurotixic
 Usually associated with long term catheter
placement and infusion pumps
 Unintentional direct injection into the nerve
sheath can cause nerve damage.
 Unintentional direct needle penetration of the
nerve can cause damage
JSOMTC, SWMG(A) Slide 21
 Regional Anesthesia - Principles

 CNS Toxicity
 Muscle twitching
 Visual disturbances
 Tinnitus
 Light-headedness
 Tongue and lip numbness
 Extreme anxiety, screaming, and impending death
feelings

JSOMTC, SWMG(A) Slide 22

 Regional Anesthesia - Principles

 CNS Toxicity
 As blood concentrations increase S/SX progress
• Generalized tonic - clonic convulsions
• Coma
• Respiratory arrest
• Death

JSOMTC, SWMG(A) Slide 23

 Regional Anesthesia - Principles
 Cardiac Toxicity
 Arrhythmias and eventual collapse
 Agents with longer duration of action are the
culprit

JSOMTC, SWMG(A) Slide 24

 Regional Anesthesia - Principles

 Blocked Extremities (Risk Factors)

 Neurological Function
 Splinting
 Compartment Syndrome

JSOMTC, SWMG(A) Slide 25

 Regional Anesthesia - Principles

 Neurological Function Assessment

 Lower Extremities (Distal Checks)

JSOMTC, SWMG(A) Slide 26

 Regional Anesthesia - Principles

 Neurological Function Assessment

 Upper Extremity Neurological Check

 If you can’t remember anything, note sensory deficit

comparing good to bad and note prior to block

JSOMTC, SWMG(A) Slide 27

 Regional Anesthesia - Principles

 Local anesthetics(Risk mitigation)

 Standard monitoring with audible O₂ saturation
tone
 O₂ supplementation
 Slow, incremental injection(5ml every 10-15sec)
 Initial injection of local “test dose” observe HR >
10 beats/min, BP> 15mmHg, or T-wave
decrease
 Pretreatment with benzodiazepines increase
seizure threshold
JSOMTC, SWMG(A) Slide 28
 Regional Anesthesia - Principles
 Local anesthetics(Risk mitigation) cont.
 Patient either awake or sedated, but still able to
communicate
 Resuscitation equipment and drugs available
 If seizure occur, airway maintenance, O₂ and
seizure termination with propofol (25-50mg)
 If cardiovascular collapse, ACLS
 Intralipid 20% 1ml/kg every 3-5 minutes up to
3ml/kg in conjunction with ACLS treatments
Military Advanced Regional Anesthesia and Analgesia, TABLE 3-2

JSOMTC, SWMG(A) Slide 29

 Regional Anesthesia - Principles

 Local anesthetics(Risk mitigation) cont.

 “test dose” 10ml of regional agent with
epinephrine 1:400,000 (0.5ml 1:000 in 10ml)
• Aspirate for blood, inject 1ml
• If resistance felt, reposition repeat aspirate
 Inject 3-5ml of local with epinephrine
1:400,000
 Transfer to “clean” agent syringe
• Aspirate every 3-5ml

JSOMTC, SWMG(A) Slide 30

 Regional Anesthesia - Principles

 Conduction of Nerve Impulse

 Locating Nerves with Stimulation

JSOMTC, SWMG(A) Slide 31

 Regional Anesthesia - Principles

 Conduction of Nerve Impulse

 Locating Nerves with Stimulation
 Advancing needles (1.2mA to 0.5mA)

JSOMTC, SWMG(A) Slide 32

 Regional Anesthesia - Principles

 Putting it Together Nerve Stimulation

 Motor as a Proxy

JSOMTC, SWMG(A) Slide 33

 Regional Anesthesia - Principles

 Agenda
 Review physiology of nerve impulse conduction
 Identify equipment and preparation to provide
peripheral nerve blocks
 Identify types of local anesthetic agents,
characteristics, and risk factors
 Indentify techniques of risk mitigation in
performance of regional blocks
 Identify nerve stimulation theory

JSOMTC, SWMG(A) Slide 34

 Regional Anesthesia - Principles

 References
 Military Advanced Regional Anesthesia and
Analgesia Ch. 2 – 4
 Pathophysiology for the Health Professions 4th
Edition Ch. 6 p.126
 Basis Guide to Anesthesia for Developing
Countries, Volume 1, Daniel D. Moos
(International Federation of Nurse
Anesthetists, ifna-int.org)

JSOMTC, SWMG(A) Slide 35

 QUESTIONS ?

JSOMTC, SWMG(A) Slide 36