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C O M M O N O P E R A T I V E R E G I O N A L B L O C K S : I n f e r i o r E x t r e m i t y
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Transcript of C O M M O N O P E R A T I V E R E G I O N A L B L O C K S : I n f e r i o r E x t r e m i t y
COMMON OPERATIVE REGIONAL BLOCKS:
Inferior Extremity
Dr. M. M. PANDITRAO
PROFESSOR/ HEAD & I/C SICU
DEAN of Faculty of MedicineDEPT.OF ANAESTHESILOGY & CRITICAL CARE
Pad. Dr. DY PATIL MEDICAL COLLEGE,HOSITAL & RESEARCH CENTER
Dr. DY PATIL UNIVERSITYPIMPRI, PUNE 411018
INTRODUCTION DEVELOPED EARLY IN HISTORY OF ANAESTHESIA
OPIUM / ALCOHOL etc. ACT BY CENTRAL DEPRESSION
IN 1884 “NEW ERA” : COCAINE COULD NUMB A BODY PART WITHOUT NUMBING THE BRAIN
THIS “PATH-BREAKING” CONCEPT EVOLVED AS INTERVENTIONAL MANAGEMENT viz.
“BLOCKS”
GOLDEN RULES RESUSCITATION DRUGS/ EQUIPT./ O2 / I.V. ACCESS
“XYLOCAINE SENSITIVITY” TEST IS A MISNOMER
ANAESTHESIOLOGISTS DO NOT CALCULATE AS mls.
CONSIDER DOSE,CONCENTRATION & VOLUME in toto
DOSE, MIDPOINT OF RANGE TO PERMIT “TOP-UPS”
WHEN COMBINATION IS TO BE USED : LOWEST OF DOSES(mg/kg) OF EACH TO REDUCE TOXICITY
GOLDEN RULES (continued)
MIX BUPIVACANE WITH XYLOCAINE+ ADRENALINE
ADJUVANTS: NaHCO3,OPIOIDS,KETAMINE,HYLASE
“BLOCK” ALWAYS UNDER SUPERVISION
“PRACTICE MAKES MAN PERFECT”
“BACK TO BASICS” BEFORE ATTEMPTING BLOCKS
“SEDATION” SHOULD NOT EVOKE “GUILT COMPLEX”
TYPES OF BLOCKS
HEAD, NECK AND FACE BLOCKS
UPPER EXTREMITY BLOCKS
LOWER EXTREMITY BLOCKS
ABDOMINAL FIELD BLOCKS
LOWER EXTREMITY BLOCKS
PROBLEMS ENCOUNTERED:
ANATOMICALLY DIFFICULT TO BLOCK NERVES WIDE-SPREAD DISTRIBUTION OF NERVES OVERLAPPING OF DISTRIBUTION MUSCULARITY OF LOWER EXTREMITY UNRELIABILITY & “MISSED SEGMENTS” MULTIPLE PUNCTURES / INJECTIONS
SPINAL AND EPIDURAL: EASIER, VERY RELIABLE
LOWER EXTREMITY BLOCKS:
INDICATED IF NEURAXIALS NOT FEASIBLE
ALTHOUGH COMMONLY PERFORMED IN DIABETICS, EXTRA CAUTION IS NEEDED
MULTIPLE PUNCTURES = PATIENT DISCOMFIRT
“RING / ANKLET” BLOCK IS ESSENTIAL
ANATOMY
LUMBAR PLEXUS:
Investment: L1 - L3 Ventral rami
Contribution From L4
From T12 In 50% patients
Distribution:Ventral Aspect of Inf.Extremity
T12, L1 : Superior; Ilio - inguinal,
Ilio - hypogastric
Inferior; Genito - Femoral
L 2-3-4 : Femoral, Obturator, Lat.Cut. Of Thigh
ANATOMY (Contd.)
Lumbo-sacral: Dorsal aspect of Inf. Extremity Investment: L
4-5, S1-2-3 Ventral Rami
Occasionally S4
Of Interest : Sciatic; Combination of Two
Tibial & Common Peroneal
Tibial; Ventral Branches of all 5
Common Peroneal; Dorsal Branches of all 5
Distribution: Leaves Pelvis Via Gr. Sc. Foramen
Enters thigh bet. Gr.Tr. & Isch. Tub.
INGUINAL PERI-VASCULAR BLOCK(3- IN- 1 BLOCK)
First described by Winnie 1973 Principle: At the level of Inguinal Ligament Femoral Nerve
“Wrapped Around” by
Fascia Iliacus on lateral border
Psoas Fascia on Medial Border
Transversalis Fascia as Anterior Wall
Drug Injected around the nerve ascends
up to “lumbar Plexus” near Psoas, blocking
“Femoral, Lateral Cutaneous Of Thigh, & Obturator
Viz: “Three-in –One” Block
TECHNIQUE (3- IN- 1 BLOCK)
Inguinal Ligament - ASIS to Pubic Symphisis Mid Point Femoral Arterial Pulsations 1cm. Below and lateral Insert Needle and direct cephalad at 60o angle If nerve-locator needle is used, at 0.5 mA current “
Patellar Dance” will be seen Minimum of 30 ml. of LAA to be injected If only medial side of thigh stimulated: go laterally
OBTURATOR BLOCK (Individually)
Supine Position Extremity to be blocked, Slightly abducted Pubic Tubercle 1.5 cm .Caudally, 1cm. Lateral to Tubercle (also
corresponds to midpoint between Pubic Tubercle and Femoral Arterial Pulsations
Spinal Needle, 22 Gz. And about 6-8 Inches long insert Perpendicular, till hits Pubic Ramus (1.5-4 cm.) Needle re-directed more laterally, 2-3 cms. more
deeper than Ramus (depth of First needle) Aspirate & inject 15 mls. in arrow-head manner
SCIATIC NERVE BLOCK (Classic)
Labat in1930 Lateral Position (Sim’s); affected side up Thigh Flexed completely and Knee flexed over Thigh Gr. Tr. and PSIS identified and Joined Perpendicular line from Midpoint on this line drawn Sacral Hiatus marked and line joined Gr. Tr. This line intersects Perpendicular At this point; Insert, 22 Gz. 6-8 inch long needle for about 4 inches/ if electrical stimulation possible then
movement in leg and foot 20-25 ml of LAA
SCIATIC NERVE BLOCK (Raj)
Raj in 1975 Patient Supine Leg is raised till Thigh is 900 to Trunk Knee is flexed at 900 to Thigh Gr. Tr. and Isch. Tuberosity marked Line joining them along with Gluteal Crease Midpoint Needle inserted perpendicular to skin and directed
cephalad 20-25 ml of LAA
ANKLE BLOCK
5 Nerves: Superficial Peroneal, Sural, Posterior Tibial, Saphenous, and Musculocutanous
Main 3: First Three.
1. Superficial Peroneal: Dorsalis Pedis Artery Pulsations, Between Tendons
of Ext. Hallucis longus & Ext. Digitorum longus 22 Gz. needle, perpendicular to skin, 1.5- 2cm.depth Hit the bone Withdraw, above Inf. Ext. Retinaculum Inject 6-8 ml. LAA Come upto Skin; Raise weal; “Anklet Block”
ANKLE BLOCK(Contd.)
2. Sural (Lateral Calcaneal & Lateral Dorsal Cutaneous) Just Behind Lateral Malleolus Hit the bone 7-8 ml. of LAA Anklet Block
3. Posterior Tibial Behind Medial Malleolus Posterior Tibial Artery Hit the bone Inject 7-8 ml LAA Anklet Block
HERNIA BLOCK
LOWER 3 – 6 INTER-COSTALS (IF REQUIRED) SUBCOSTAL ILIO-INGUINAL & ILIO- HYPOGASTRIC GENITAL branch of GENITO-FEMORAL
BEFORE ADVENT OF SAFER INHALATIOAL AGENTS / RELIABLE NMBDs / MONITORING / POST-OPERATIVE CRITICAL CARE, POPULAR
“SKILLED” ANAESTHESIOLOGISTS = SAFE G.A.
HERNIA BLOCK(CONTINUED)
“HYPOTHETICAL” MISSING OF LAT. CUTANEOUS BRANCH HAS BEEN PROVEN WRONG
“DREADED!” COMPLICATION OF PNEUMOTHORAX, FOUND TO BE NEGLIGIBLE (0.07% - 0.4%)
SERIES SHOWED SAFE SURGICAL CONDITIONS PRODUCED WITH SEDATION AND MONITORING
HERNIA BLOCKSubcostal : Mid- clavicular line, Subcostal Margin
Laterally and Medially
Infiltrate 7-8 mi.
Ilio-Inguinal & Ilio- Hypogastric:
1 finger breadth anterior to ASIS
Hit the Bone
Fan-shaped- “Arrow-head” Block
10-15 ml. of AA
Genital Branch of Genito - Femoral
Pubic Tubercle
Perpendicular to Skin
Hit the Bone
5-7 ml. of LAA
CONCLUSION
“SKILL & THRILL” OF ANAESTHESIOLOGIST
PROPER SELECTION, SAFE PRECAUTIONS
COST-EFFECTIVE & LESSER MORBIDITY
EXCELLENT “TOOL” OF TRAINING