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Anaesthesiology
Peripheral Nerve Blockade
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
14 sections · 181 slides
Overview
- Scope of this presentation
Why blocks are used
- Uses of peripheral nerve blockade
- Benefits and limitations of nerve blockade
- Key points and standardised nomenclature
Equipment and the block room
- The block room
- Block room equipment and drugs
- Monitoring and the timing of toxicity
- Discharge and paediatric considerations
- Premedication, sedation and documentation
Finding the nerve
- Principle of electrical nerve stimulation
- Nerve stimulation in practice
- Conducting versus nonconducting injectate
- What ultrasound shows and how the image forms
- Probe frequency, sterility and image quality
- In-plane and out-of-plane needle alignment
- Combining ultrasound with nerve stimulation
- Sequence of an ultrasound-guided block
- Block needles
- Limiting injection pressure
- Perineural catheters
After the block
- Assessing sensory block
- Motor block grading and discharge criteria
- Advice for a patient with a numb limb
- Reported complication rates
- Patient selection, contraindications and guidelines
- Concentration, duration and absorption
- Epinephrine as an additive
- Treatment of local anaesthetic systemic toxicity
- Nerve injury and recovery
- Injuries not caused by the block
- Pathway from intrafascicular injection to nerve injury
Clinical anatomy: head and neck
- Origin of the trigeminal nerve
- Major branches of the trigeminal nerve
- Ophthalmic and maxillary branches
- Infraorbital and mandibular terminal nerves
- Other mandibular terminal branches
- Formation of the cervical plexus
- Schematic of the cervical plexus
- Cervical transverse processes and plexus course
- Sensory branches of the cervical plexus
- Greater and lesser occipital nerves
- Blocking the occipital nerves
Clinical anatomy: spine
- Spinal nerves and their sympathetic links
- Numbering of spinal nerves
- Dermatomes of the body
- The thoracic paravertebral space
- Vertebral landmarks and process offsets
Clinical anatomy: upper limb
- Structure of the brachial plexus
- Schematic of the brachial plexus
- Roots, trunks and the plexus sheath
- Divisions, cords and the axillary artery
- Course of the phrenic nerve
- Courses of the terminal nerves of the upper extremity
- Course of the radial nerve
- Course of the median nerve
- Course of the musculocutaneous nerve
- Course of the ulnar nerve
- Cutaneous innervation of the upper extremity
- Variation in plexus roots and sheath
- Variation in trunks, cords and vessels
Clinical anatomy: trunk
- Course of the intercostal nerves
- Costovertebral and costotransverse joints
- Formation and compartment of the lumbar plexus
- Branches of the lumbar plexus
- Schematic of the lumbar and sacral plexuses
- Iliohypogastric and ilioinguinal nerves
- Formation and branches of the sacral plexus
Clinical anatomy: lower limb
- Cutaneous innervation of the lower extremity
- Course and territory of the genitofemoral nerve
- Lateral cutaneous nerve of the thigh
- Territory of the lateral cutaneous nerve of the thigh
- Course and relations of the femoral nerve
- Femoral branches and the saphenous nerve
- Course and branches of the obturator nerve
- Accessory obturator nerve
- Formation and course of the sciatic nerve
- Course of the common peroneal nerve
- Course and branches of the tibial nerve
- Saphenous nerve at the ankle
- Deep peroneal and tibial nerves at the ankle
- Superficial peroneal and sural nerves
Techniques: head and neck
- Head and neck regional anaesthesia in practice
- Semilunar (Gasserian) ganglion block
- Ultrasound of the facial foramina
- Superficial trigeminal branch block technique
- Infraorbital nerve block
- Mental nerve block
- Drug choice and practical points for facial blocks
- Scalp block and supraorbital variation
- Maxillary nerve block below the zygomatic arch
- Maxillary block: needle path and cautions
- Suprazygomatic maxillary nerve block
- Suprazygomatic block: technique and dosing
- Suprazygomatic block: imaging and confirmation
- Mandibular nerve block
- Mandibular block: technique and injection
- Alternatives and risks in mandibular block
- Indications for cervical plexus block
- Deep cervical plexus block technique
- Deep cervical plexus block: needling and dosing
- Complications of deep cervical plexus block
- Superficial cervical plexus block
- Cervical plexus block for neck surgery
- Complications of superficial cervical plexus block
- Occipital nerve block technique
- Occipital block: extension and safety
Techniques: brachial plexus
- Four classic sites for brachial plexus block
- Choosing a brachial plexus approach
- Block site and plexus level targeted
- Interscalene block: indications and positioning
- Interscalene block: landmarks and needle angle
- Interscalene block: stimulation and children
- Ultrasound-guided interscalene block
- Interscalene block: needling and spread
- Interscalene catheters and stimulation thresholds
- Complications of interscalene block
- C6 root neuropathy and the paravertebral alternative
- Supraclavicular block: indications and landmarks
- Supraclavicular block: needle angle and depth
- Nerve stimulation responses at the supraclavicular site
- Ultrasound-guided supraclavicular block
- Supraclavicular block: needling and pleural safety
- Supraclavicular block: imaging and complications
- Infraclavicular block: indications and positioning
- Infraclavicular block: landmarks and depth
- Infraclavicular block: cord responses and injection
- Ultrasound-guided infraclavicular block
- Identifying individual cords on ultrasound
- Infraclavicular block: needling and injection
- Infraclavicular block: advantages and catheters
- Axillary block: indications and nerve positions
- Axillary block: landmarks and needling
- Nerve localisation and dosing in axillary block
- Ultrasound-guided axillary block
- Axillary nerves: appearance and needle alignment
- Axillary block: injection quality and volume
- Axillary block: supplementation and complications
Terminal nerve blocks of the arm
- Terminal upper limb blocks and the wrist problem
- Useful anatomic landmarks for locating nerves during common ultrasound-guided peripheral nerve blocks
- Useful anatomic landmarks for locating nerves during common ultrasound-guided peripheral nerve blocks (continued)
- Useful anatomic landmarks for locating nerves during common ultrasound-guided peripheral nerve blocks (continued)
- Useful anatomic landmarks for locating nerves during common ultrasound-guided peripheral nerve blocks (continued)
- Territory of the radial nerve
- Radial nerve block at the elbow
- Ultrasound-guided radial nerve block
- Radial nerve: appearance and needling
- Radial nerve block at the wrist
- Median and ulnar nerves in the forearm
- Territory of the median nerve
- Median nerve block at the elbow
- Median nerve block in the forearm
- Ultrasound of the median and ulnar nerves
- Median nerve: appearance and needling
- Median nerve block: wrist caution and troubleshooting
- Territory and indications for ulnar nerve block
- Ulnar nerve block at forearm and elbow
- Ulnar nerve block in the forearm by stimulation
- Ulnar nerve: scanning and needling
- Ulnar block: injection and the wrist site
- Bier block: setup and exsanguination
- Injection for the Bier block
- Tourniquet management in the Bier block
- Bier block: limits and safe practice
Summary
- Core principles to remember
- Safety rules to remember
- Block-specific cautions to remember
- Source note on this presentation
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition