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Transcript of NYSORA - The New York School of Regional Anesthesia - Keys to Success With Peripheral Nerve Blocks
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Keys To Success With Peripheral Nerve
Blocks
By admin11/08/2014 18:13:00
Peripheral nerve block anesthesia offers many clinical advantages that contribute to both an
improved patient outcome and lower overall healthcare costs. Peripheral nerve blocks provide
excellent anesthesia and postoperative pain relief, fewer side effects than general anesthesia,
and facilitate early physical activity.
Peripheral nerve block anesthesia offers
many clinical advantages that contributeto both an improved patient outcome
and lower overall healthcare costs.
Peripheral nerve blocks provide
excellent anesthesia and postoperative
pain relief, fewer side effects than
general anesthesia, and facilitate early
physical activity. The use of nerve blocks
is also associated with reduced use of
opioids for postoperative pain, fewer
postoperative complications, and earlier
discharges. Regional anesthesia is
particularly desirable and effective in elderly and high-risk patients undergoing a wide variety of surgical procedures,
particularly on the upper and lower extremity. However, the success with peripheral nerve blocks is undoubtedly more
anesthesiologist-dependent than is the case with neuraxial and general anesthesia. The main determining factor for
success is the anesthesiologist's technical skills and determination, which are required for successful practice of
peripheral nerve blocks. To establish a regional anesthesia and peripheral nerve block program, a dedicated team of
well-trained anesthesiologists is a prerequisite to assure the consistent peripheral nerve block service.
Patient selection
To determine if a patient is a candidate for regional anesthesia, factors such as the primary indication for surgery, the
presence of coexisting diseases, potential contraindications, and the patient's psychological state should all be
considered. Regional anesthesia, alone or in combination with general anesthesia, is feasible and desirable in most
surgical patients, in almost any operative site. There are only a few absolute contraindications to regional anesthesia,
such as patient refusal, the presence of an active infection at the site of puncture, and, perhaps, true allergy to amide
local anesthetics. The contraindications for the use of regional anesthesia are so rare in our practice that we chose to
largely omit them in the description of the block techniques. Regional anesthesia is particularly advantageous in high-
risk surgical patients undergoing orthopedic, thoracic, abdominal, or vascular surgery. Patients with concomitant
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respiratory disease also benefit in that the endotracheal intubation and mechanical ventilation are avoided.
Patient education
Among the general public, there is a common lack of awareness regarding the potential uses and benefits of regional
anesthesia. Patients are commonly offered to choose between two overly simplistic descriptions of anesthesia
options: "a needle in the neck" or "go to sleep". However, neither of these accurately describes the nature of the
anesthetic care. Many patients, therefore, have a tendency to choose general ("asleep") anesthesia due to the lack of
their understanding of what regional anesthesia comprises and the anxiety related to the needle insertion during
block performance. In fact, most patients in our practice are appropriately sedated both during block performance and
during the actual surgery. Very few of these patients have an unpleasant recollection of their anesthesia experience.
Another common misconception is that nerve blocks are associated with an increased risk of nerve injury. In fact,
American Society of Anesthesiologists closed-claims studies suggest that the majority of reported neurologic
complications are actually associated with general anesthesia because of problems with patient positioning.
During the preoperative visit, the anesthesiologist should help the patient understand the basics of the anesthetic
management and establish a realistic expectations. Patients should be educated about the principal benefits of
regional anesthesia-avoidance of general anesthesia and airway management, improved pain control, and reduced
incidence of nausea and vomiting, all of which are evident immediately in the postoperative period. Patients should
be instructed on what to expect in the postoperative period. In particular, they should be informed about the duration
of the blockade, the need for analgesic therapy as the block is wearing off, and the care of the insensate extremity.
Surgeon
An insightful, and educated surgeon is often the greatest advocate of regional anesthesia. In our institution, nearly all
patients undergoing various orthopedic, vascular, hand, and podiatric surgical procedures are anesthetized using
regional anesthesia. While some new surgeons joining the staff have reservations about regional anesthesia, their
views are quickly changed once they realize that an increased operating room efficiency and favorable outcomes are
associated with expertly performed regional anesthesia procedures. However, the entire department of
anesthesiology must be adequately trained in peripheral nerve blocks to provide consistent service and continuity of
care. In such an environment, most of our surgeons routinely request regional anesthesia and many patients coming
for their procedures already have some basic information and expectations regarding the anesthetic plan. A
discussion with the surgeon prior to choosing a regional anesthetic technique is important. The discussion must
include considerations regarding the site, nature, extent, and duration of the planned surgical procedure. Discussion
of the use of a tourniquet is always necessary to make sure that the intended technique will be adequate for the
planned surgery.
Anesthesiologist
A confident, well trained, and charismatic anesthesiologist is perhaps the single most important factor for the success
of regional anesthetic. For patient's acceptance, and successful initiation and conductance of a regional anesthetic, it
is primarily the anesthesiologist's confidence and ability to establish a rapport with the patient that determines the
success. In our practice, we do not present the patient with a range of anesthetic options for the particular procedure,
which many patients find confusing. Instead, we propose to the patient a regional anesthesia plan that is deemed
optional based on the patient's physical status, planned procedure, surgical technique, and experience of the
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anesthesia team. As the number and complexity of regional anesthesia techniques keep increasing, it is clear that
regional anesthesia is a highly specialized subspecialty of anesthesiology. A thorough training during residency is
necessary to obtain consistent results and avoid complications. A well-structured regional anesthesia fellowship is by
far the best path toward success for those who chose to become regional anesthesiologists and acquire the skills
necessary to practice the full scope of regional anesthesia and become an effective instructor.
Technique
Selection
Technique selection is of vital importance for the success of nerve block anesthesia. Choosing, initiating, and
conducting regional anesthetic often requires more thought process than the conductance of a general anesthetic.
With general anesthesia, regardless of the technique, drugs, or ventilation modes chosen, adequate anesthesia is
almost assured because all patients are unconscious during the conductance of general anesthetic. In contrast,
otherwise successful regional blocks may fail to provide adequate operating conditions because the site and duration
of the surgery, the need for tourniquet application, or appropriate perioperative sedation were not considered.
General guidelines on selecting nerve block techniques for some specific surgical procedures are provided in the
appendix at the end of this chapter.
Premedication
Most patients are apprehensive about the pending anesthesia and surgery. Therefore, prior to placement of a
peripheral nerve block for surgery, premedication is essential to alleviate anxiety and prevent unnecessary
discomfort. Inadequately premedicated patients will move during the block placement, making it difficult to interpret
responses to nerve stimulation and possibly cause dislodgment of the needle from its intended position. In our
practice, we prefer using a combination of benzodiazepine and a short-acting narcotic (alfentanil). It should be noted
that different block procedures are associated with varying degrees of discomfort. Premedication is adjusted forindividual patients and the procedure. A narcotic analgesic is introduced only at the time of the needle placement.
The alfentanil provides intense analgesia of short duration and it is the most commonly used narcotic for this purpose
in our practice.
All peripheral nerve blocks can be divided into two major groups - blocks associated with minor patient discomfort
("superficial" blocks) and blocks associated with more patient discomfort ("deep" blocks). A sedation protocol should
be chosen according to the regional anesthesia technique planned and individual patient characteristics. For
instance, interscalene brachial plexus block can be administered to a minimally sedated, fully alert and awake
patient. On the other hand, an infraclavicular, sciatic, or lumbar plexus block necessitates, for most patients, a greater
degree of sedation and analgesia to ensure the patient's comfort and acceptance. Regardless of the sedation
technique chosen, the goal of sedation is to provide maximum patient comfort while maintaining a meaningful patient
contact throughout the procedure.
In the table below we suggest some premedication protocols. More information on the doses of sedatives and
analgesics are suggested in the chapter for each individual block procedure.
Block Placement Sedation
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logical needle redirection, and serve as an excellent educational tool for better understanding of the functional
anatomy. In our practice, we use nerve stimulators with a remote (foot) control, which allows quick and frequent
control of the current by a single anesthesiologist. A remote-controlled nerve stimulator is also ideal in teaching
programs because it allows the instructor to control the current while keeping the hands sterile on the patient during
resident training.
Local Anesthetic Selection
Selection of the type, dose, and volume of local anesthetic plays a major role in successful neuronal blockade. Local
anesthetics are discussed in detail in each chapter. Adequate volume and concentration are important to ensure fast
onset and complete blockade. However, unnecessarily high doses and concentrations should be avoided, particularly
in older and ill patients, in whom inadvertent intravascular injection of local anesthetic carries a much higher risk than
in the young and fit patient. High pressures and fast forceful injections should be avoided to decrease the risk of
massive inadvertent "channeling" of local anesthetic into the systemic circulation.
Intraoperative Management
Appropriate patient-comfort adjusted sedation is almost always beneficial and adds to the quality level of anesthesia
achieved with peripheral nerve blocks. Most surgeons prefer patients to be lightly asleep during surgery to better
concentrate on the technical aspects of the operation. Similarly, the majority of patients also prefer not to be "aware"
of the activities in the operating room. For outpatients, after completion of the block, sedation is maintained
throughout the surgical procedure and adjusted to the patient's comfort. In outpatients, this is most often
accomplished using an intravenous infusion of propofol in a dose of 10-30 mcg/kg/min (20-30 mL/hr) while patients
are spontaneously breathing. A face mask is routinely applied and oxygen delivered (5-6 l/min). At the completion of
the procedure, the infusion is discontinued. After surgery, most patients are fully alert and able to meaningfully
discuss the findings with the surgeon in the operating room while the wound dressing is being applied. Upon arrival at
the recovery room, most ambulatory surgery patients are fast tracked to the post-anesthesia care unit and prepared
for discharge home.
For inpatients, a combination of small
boluses of midazolam and propofol are
good choices. We avoid the use of narcotics
at any point during the intraoperative
management of patients receiving regional
anesthesia. A small proportion of regional
anesthetics will inevitably fail to provide
adequate operating conditions due to
inadequate anesthesia or difficulties with
achieving adequate sedation. When
anesthesia is deemed incomplete for the
planned surgery, our choice is often to
induce a light general anesthetic and control
the airway instead of resorting to over-
sedation and intravenous narcotics.
However, since anesthesia of the skin is often the last to onset, local infiltration by surgeon, when possible, and
deeper levels of sedation at the beginning of the procedure are often all that is required for the procedure to proceed
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while the block is "setting up".
Most operating rooms are kept cold and for this reason, all patients undergoing surgery under regional anesthesia
should be well warmed by using forced air or warm blankets. Failure to prevent shivering can result in uncontrolled
patient's movement, tremors, and a consequent failure of an otherwise successful regional anesthetic.
Significant noise levels are often present in operating amphitheatres due to discussion among the staff, handling of
instruments, or the use of various pneumatic instruments. In a study on noise levels during various orthopedic
surgery procedures, we recorded levels over 100 decibels when pneumatic drills and saws were used. Such noise isinvariably noxious to the patient and requires much higher doses of sedatives. Therefore, shielding the patient's ears
from the unwanted noise should be done routinely to help reduce the patient's anxiety.
During administration and conductance of regional
anesthesia, incremental doses (boluses) of sedatives,
narcotics, intravenous sedation, and antibiotics are
routinely administered and often there is a tendency to
over administer intravenous fluids. Overhydration
should be avoided because of the possibility of
difficulties intraoperatively when patients need to void.
For that reason, it is advisable to use an electronic
infusion pump or a micro drip intravenous infusion set.
We often use a combination of macro-micro drip IV set
(DualFlow) and set the infusion to a slow micro drip
rate. Then, we simply open and close the macro drip to
quickly flush the injected medications.
Such a practice is particularly useful when managing
patients with renal failure or a history of congestive
heart failure undergoing various procedures under
regional anesthesia. The micro drip is used to preventinadvertent fluid administration but the macro drip is
immediately available to allow flushing of the injected
medication or resuscitation. Common examples include
patients undergoing carotid endarterectomy or
arteriovenous graft insertions in the arm under cervical or brachial plexus blocks, respectively.
Postoperative Management
On completion of the surgical procedure is important to discuss with the surgeons, patient, and nursing staff the
expected duration of the motor and sensory blockade to prevent unnecessary concerns by anyone involved in the
patient management. In addition, a proper multi modal pain management protocol must be developed and discussed
thoroughly with the patient to avoid severe pain when the block(s) wears off. For inpatients, this is perhaps best
accomplished by prescribing intravenous patient-controlled analgesia (IV PCA) or oral analgesics. This applies even
for patients who may receive continuous nerve block infusion catheters. For outpatients, such a plan most often
consists of a combination of an oral non steroidal anti-inflammatory regimen and an oral acetaminophen-codeine
prescription.
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Clear instructions regarding the care of the insensate extremity should also be given to the patients to prevent
secondary injuries, which may occur when the anesthetized extremity is not handled with care.
Appendix
A confident, well trained, and charismatic anesthesiologist is perhaps the single most important factor for the success
of regional anesthetic. For patient's acceptance, and successful initiation and conductance of a regional anesthetic, it
is primarily the anesthesiologist's confidence and ability to establish a rapport with the patient that determines the
success. In our practice, we do not present the patient with a range of anesthetic options for the particular procedure,
which many patients find confusing. Instead, we propose to the patient a regional anesthesia plan that is deemed
optional based on the patient's physical status, planned procedure, surgical technique, and experience of the
anesthesia team. As the number and complexity of regional anesthesia techniques keep increasing, it is clear that
regional anesthesia is a highly specialized subspecialty of anesthesiology. A thorough training during residency is
necessary to obtain consistent results and avoid complications. A well-structured regional anesthesia fellowship is by
far the best path toward success for those who chose to become regional anesthesiologists and acquire the skills
necessary to practice the full scope of regional anesthesia and become an effective instructor.
NECK SURGERY
Surgical Procedure Peripheral Nerve Block
TechniqueComments
Neck lymph node
biopsy
Carotid
endarterectomy
Postoperative pain
management after
neck surgery (e.g.,
radical neck
dissection)
Superficial cervical
plexus block
Deep or superficial
cervical plexus
block
Since cervical plexus block is a "blind" technique,
the success rate can be significantly increased by
performing both superficial and deep cervical
plexus blocks routinely for carotid endarterectomy
It should be remembered that cervical plexus block
needs to be supplemented intraoperatively during
carotid endarterctomy because the carotid artery
receives neuronal input from glossopharyngeal
nerve this is best accomplished with a carotid
"sheath:" block
Cutaneous coverage from the opposite side is
blocked by a subcutaneous injection of local
anesthetic alongside the line connecting the thyroid
cartilage to just above the sternal notch
UPPER EXTREMITY SURGERY
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Surgical Procedure Peripheral Nerve Block
Technique
Comments
Shoulder
arthroscopy
Rotator cuff repair
Shoulder
arthroplasty
Shoulder
stabilization
Fracture of the
humerus neck repair
Classic interscalene
block
Low interscalene
block
Interscalene brachial plexus block provides
complete anesthesia of the shoulder joint
Cutaneous coverage of the area over the shoulder
varies and may require subcutaneous injection of
local anesthetic if cutaneous coverage proves
inadequate
Surgeons should be encouraged to routinely
infiltrate the site of the arthroscopic port insertion
with local anesthetic
Surgery on the
lower arm
Surgery on the
elbow
Forearm surgery
Hand surgery
Infraclavicular block
Infraclavicular/axillary
block
Both techniques are excellent choices for lower
arm, elbow, forearm, and hand surgery
Neither are optimal choices for shoulder surgery
The main advantages of both techniques over
axillary block are higher success rate and routine
block of the musculocutaneous nerve (better
tourniquet coverage)
The main disadvantage of the supraclavicular block
is the risk of pneumothorax. It is this reason that
classic supraclavicular block is rarely practiced inour institution
Hand surgery
Infraclavicular block
Axillary block
Intravenous regional
anesthesia (Bierblock)
When prolonged tourniquet application is not
required, axillary block is a simple and effective
technique to use for hand surgery
Double and multiple injection techniques have been
proposed to increase the success rate of axillary
blockade
When arterial puncture (axillary artery) is obtained
on needle advancement, injection of of the total
volume behind and in front of the artery increases
the success rate
Wrist block
Wrist and digital blocks are simple and highly
effective anesthetic techniques for surgery on the
digits and hands not requiring a tourniquet
A tourniquet on the forearm, when required, is very
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Hand surgery
Surgery on the digits
Digital block
Intravenous regional
anesthesia (Bier
block)
well tolerated and can be used to avoid the need for
more proximal neuronal blockade for short
procedures
Intravenous regional anesthesia (Bier block) should
be limited to surgery of short duration (30-45
minutes) because of the tourniquet pain that
becomes difficult to manage
SURGERY ON THE CHEST AND ABDOMINAL WALL
Surgical Procedure Peripheral Nerve Block
TechniqueComments
Thoracotomy
Mid-CABG surgery
Surgery on the
chest wall
Mastectomy
Reconstructive
breast surgery
Intercostal nerve
block
Paravertebral blocks
Paravertebral blocks can be used for any of the
listed surgical applications
Paravertebral blocks are much preferred over
intercostal blocks because of the lower risk of
systemic toxicity, higher success rate, and longer
duration of blockade
For breast surgery, levels T1-2 to T6 are necessary
when surgery extends to the clavicle, local
anesthetic infiltration or superficial cervical blockade
is also necessary
For axillary node surgery, T1 level is also required
surgical manipulation should be gentle to avoid
irritation of the brachial plexus in the axilla
Inguinal hernia
repair
Colostomy closure
Uncomplicated
appendectomy
Pain management
after hip surgery
Thoraco-lumbar Paravertebral Block
T9-L1 levels are necessary
Groin, part of the hip and knee, anterolateral and
medial thigh, and medial skin below knee is
anesthetized
Distribution of anesthesia is unilateral
15% epidural spread may occur, hemodynamics
should be monitored
LOWER EXTREMITY SURGERY
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Surgical Procedure Peripheral Nerve Block
TechniqueComments
Knee arthroscopy
Patella tendon and
ACL repair
Saphenous vein
stripping
Open reduction
internal fixation of
patella fracture
Pain managementafter hip and knee
surgery
Lumbar plexus
block
Femoral nerve block
Groin, portion of the hip and knee, anterolateral and
medial thigh, and medial skin below knee are
anesthetized
Femoral nerve block combined with a genitofemoral
nerve block is an excellent choice for saphenous
vein stripping
For complete anesthesia of the leg, femoral or
lumbar plexus blocks must be combined with sciatic
block
When choosing femoral vs lumbar plexus block - a
lumbar plexus block should be chosen when
anesthesia of the lumber plexus (lateral femoral
cutaneous nerve, obturator nerve) is sought
Femoral nerve block with large dose of local
anesthetic will not result in lumbar plexus blockade
regardless of volume used
Above and below
knee amputations
Any surgery on the
tibia and/or fibula
Achilles tendon
repair
Foot surgery
Pain management
after surgery on the
lower extremity
Sciatic nerve block
Combined with a lumbar plexus or femoral block
results in complete anesthesia of the lower
extremity
Can be combined with a saphenous block or
"low-volume" femoral block to achieve complete
anesthesia of the leg below the knee
Femoral nerve block is not an adequate supplement
for above the knee-surgery because the obturator
nerve and lateral femoral cutaneous nerve of the
thigh are not anesthetized and may be important for
complete anesthesia a lumbar plexus block is a
better choice
Ankle surgery
Foot
Achilles tendon
repair
Short saphenous
vein stripping
Popliteal nerve
block or ankle block
When surgery involves the medial aspect of the
lower leg, a saphenous nerve block is needed
Success rate is volume dependent
Popliteal block is chosen over ankle block for more
proximal, more extensive surgery and surgery
requiring the use of tourniquet.
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Dickerman D, Vloka JD, Koorn R, Hadzic A: Excessive noise levels during orthopedic surgery. Regional Anesthesia, 1997
22:97
Hadzic A, Vloka JD, Koenigsamen J: Training requirements for peripheral nerve blocks. Current Opinion in Anesthesiology
2002 15:669-73
Hadzic A, Vloka JD, Kuroda MM, et al: The practice of peripheral nerve blocks in the United States: a national survey. Reg
Anesth Pain Med 1998 23:241-6
http://www.NYSORA.com, October 18, 2001.
Karaca P, Hadzic A, Vloka, JD. Specific Nerve Blocks: An Update. Current Opinion in Anaesthesiology 2000 13:549-555.
Kopacz D, Neal J, Pollock J: The regional anesthesia "learning curve": What is the minimum number of epidural and spinal
blocks to reach consistency? Reg Anesth 1996 21:182-90
Kopacz DJ, Bridenbaugh LD. Are anesthesia residency programs failing regional anesthesia? The past, present, and future.
Reg Anesth 1993 18:84-7.
Vloka DJ, Hadzic A. A new intravenous infusion set for use in anesthesia practice. Anesth Analg 199886 S207.
Vloka, JD, Hadzic A, Santos A. Lower Extremity Nerve Blocks for Ambulatory Surgery. Current Anesthesiology Reports
2000, 2(4):327-332.
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DISCLAIMER:The material presented on this Web page has not been peer-reviewed. The indications, techniques
and dosages on this Web page have been recommended in the medical literature and/or conform to OUR clinicalpractice. The medications and equipment have not necessarily been approved by the Food and Drug Administration
(FDA) for use in the techniques and dosages for which they are recommended. The package insert for each drug
and/or equipment should be consulted for use and dosage as recommended by the FDA. Because standards,
practices and recommendations change, it is advisable to keep abreast of revised recommendations, particularly
those concerning new drugs and techniques. While the techniques and dosages described are successfully used in
our practice, they should be followed with a discretion since their complications may be dependent on the operator,
patient and/or other accompanying clinical circumstances. The development and maintenance of this web page has
not been supported by any pharmaceutical or medical manufacturing industry. The medications and/or equipment
discussed in the web page is shown solely for teaching purposes. Similar equipment or medications from other
manufacturers may produce similar clinical results to ours.
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