Thomas Drye, MD Madison Anesthesiology Consultants, LLP

Definition:

Local anesthetic induced blockade of peripheral or spinal nerve impulses from a targeted body part with preserved level of consciousness

 Categories:

Intravenous (Bier block) Neuraxial (spinal, epidural) Peripheral nerve blocks (PNB)
Truncal (e.g. paravertebral, TAP blocks) Plexus (e.g. brachial plexus, lumbar plexus) Distal (e.g. femoral, sciatic)

More hemodynamic stability c/w neuraxial Anticoagulation less of an issue Increasing popularity due to advances in ultrasound technology Introduction of perineural catheters prolongs post-operative pain control benefits

 Avoidance

of general anesthesia

Primary regional anesthetic vs. combination with light general anesthetic Most patients request intra-operative sedation Decreased PONV, sore throat, delirium, airway obstruction and respiratory depression Decreased time to discharge from PACU Increased patient satisfaction

 Post-operative

pain control

Decreased narcotic requirements and associated adverse side effects (e.g. nausea, pruritis, sedation, confusion, respiratory depression) Earlier recovery of bowel function Improved tolerance of physical therapy Improved pain scores, but not always in PACU Increased patient satisfaction

Infrastructure requirements and potential for surgeon delays Failed Blocks Intraoperative awareness and non-operative discomfort (e.g. positioning) Motor block Variable duration (approx. 4-40 hours) Rare serious complications (e.g. local anesthetic toxicity, nerve injury)

Needle phobia or otherwise uncooperative Excessive sedation (adults) Infection (local and untreated systemic) Anticoagulation? Pre-existing nerve injury? Surgery specific (e.g. motor block and postop neurological examination) Block specific (e.g. pulmonary disease and interscalene block)

Anatomy Loss of resistance and tactile feedback Evoked paresthesia Nerve stimulator (goal 0.3-0.5 mA) Ultrasound guided

Monitoring Availability of resuscitation equipment (suction, airway management) Availability of resuscitation drugs (induction agents, ACLS drugs, lipid emulsion) Pre-procedure confirmation (timeout) Aspiration before injection Incremental injection Do not inject when paresthesia present

Block voltage gated sodium channels on nerve cells preventing impulse conduction Two classes: amide and ester local anesthetics Rare allergic reactions Variable onset and duration
Quick onset, short acting (lidocaine, mepivacaine)

e.g. 1-2 hours following subcutaneous infiltration

Slow onset, long duration (bupivacaine, ropivacaine) e.g. 2-8 hours following subcutaneous infiltration

Intravascular injection (immediate onset) Systemic absorption (delayed onset) Central nervous system signs

Cardiovascular toxicity

1st excitation: perioral tingling, tinnitus, agitation 2nd depression: blurred vision, slurred speech, loss of consciousness Seizure Cardiac arrhythmia and/or circulatory collapse Requires ~ 3x blood concentration that causes seizures

For use in the treatment of life threatening local anesthetic toxicity Novel therapeutic indication for an old medication (component of TPN) First case reported in 2006, now with over a dozen reported cases Mechanism of action unknown (lipid sink?)

Local anesthetic toxicity Bleeding/hematoma Infection Nerve injury

Transient paresthesias 1-3% Permanent nerve injury ~1/10,000

Failed block

Brachial plexus
Interscalene block Supraclavicular block Infraclavicular block Axillary block

Lower extremity
Lumbar plexus block Femoral nerve block and saphenous nerve block Sciatic nerve blocks: anterior, gluteal, and popliteal

Truncal
Paravertebral block Transversus abdominis plane (TAP) block

Interscalene Supraclavicula r Infraclavicula r Axillary

Between the scalenes

Anterior scalene muscle Middle scalene muscle

IJ
CA

Primarily for shoulder or proximal humerus surgery - distal arm and hand are often sparred Multitude of unique complications because of location in neck:

Vertebral artery injection- seizure with only very small local anesthetic volume Accidental epidural or spinal injection Pneumothorax- pleural puncture, dome of lung

 Hemidiaphram paralysis (phrenic nerve blockade)

100% of interscalene blocks May cause dyspnea, even respiratory failure, depending on severity of underlying lung disease

Hoarseness (recurrent laryngeal nerve blockade) Horners syndrome (stellate ganglion blockade)
Myosis- constriction of the pupil Ptosis- drooping eyelid Anhidrosis- lack of sweating

Spinal of the arm- blocks shoulder, upper arm, forearm, and hand 50% incidence of phrenic nerve block with traditional technique, 0-20% with low volume US-guided technique Risk of pneumothorax Risk of bleeding: non-compressible site

AV

Effective for procedures of the elbow, forearm, and hand Safe alternative in patients with lung disease since phrenic nerve is sparred and no PTX risk Safe alternative in anticoagulated patients due to easy compressibility and no at risk adjacent structures Disadvantages: higher failure rate and tourniquet discomfort

Femoral nerve

Post-operative pain control for surgery of the thigh or knee, most commonly used for ACL repair and total knee arthroplasties (TKA) Only numbs the front- incomplete analgesia after knee surgery because sciatic nerve innervates posterior knee compartment

Tibial nerve

Peroneal nerve

Popliteal approach to the sciatic nerve Effective for procedures of the leg distal to the knee, particularly foot and ankle surgery Longer duration than ankle block or subcutaneous infiltration The terminal branch of the femoral nerve, the saphenous nerve (sensory only), innervates the medial ankle and requires separate block

Used increasing for breast surgery, either primary anesthetic or post-operative analgesic Surgical block requires injections at multiple levels Pneumothorax is most common serious complication

Paravertebra l space

Tranversus Abdominis Plane

Used for post-operative analgesia for lower abdominal surgery (e.g. inguinal hernia, abdominal hysterectomy, Caesarean section) Midline incisions require bilateral injections Serious complications are extremely rare, and this block can be safely performed in an anesthetized patient

Peripheral nerve blocks are increasing in frequency due to recent advances in ultrasound technology PNBs have many advantages including decreased narcotic requirements and increased patient satisfaction Serious complications are rare but do occur Choosing to perform PNB requires consideration of each patient and surgical procedure, as well as individual surgeon preferences