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Regional Anesthesia Regional Anesthesia for the Lower Limbsfor the Lower Limbs
Dr. Prakash Ambardekar SeniorAnaesthesiologist Dept of Anesthesia SL Raheja Hospital, Mumbai
Diabetes Mellitus is not a simple endocrine disorder 1] Cardio-vascular system - Angina pectoris, silent small to massive Myocardial Infarcts , varying degrees of cardiomyopathies, varying types of Conduction blocks etc may be accompanied with Hypertension
2] Reno-vascular system - Nephropathies leading to Chronic renal failure
3] Central nervous system –Secondary effects
4] Autonomic nervous system -Sympathetic & Parasympathetic systems causing Autonomic Imbalance
5]Immunological system – suppression, prone to infections
Contd…
Diabetes Mellitus is not a simple endocrine disorder
6] Septicaemia - following infection affecting various systems
7] Fluid & Electrolyte status altered.
8] Pulmonary system – alters ventilation and perfusion
9] G. I. system – slows gastric emptying - aspiration
10] Skeleto-muscular system - fusion of upper cervical vertebrae with limited neck movement, if accompanied with obesity & short neck
Thus, in Diabetes, the selection of Anesthesia becomes a tricky and highly skillful job.
Why regional anaesthesia ?
1] Ideal for day-care patients2] Safety in high risk patients3] No intra-op regurgitation & aspiration4] No PONV5] Minimal alteration in drug schedule -specially in diabetics
Why regional anaesthesia ? Continued….
6] Minimal effects on vital parameters7] Safer in emergency situations8] Can be repeated frequently9] Conscious & arousable patient at the end of the surgery10] Reduction in morbidity & mortality
Why not other modes of Anesthesia ??
General Anesthesia: [besides usual precautions]
a] Risk of Aspiration and PONV
b] Difficult intubations
c] Resistant hypotension which may last for longer time
d] Management of ischaemic changes and arrhythmias
e] Management of blood sugar
Why not other modes of Anesthesia ??
Spinal & Epidural Anesthesia
a] Prevention and management of hypotension
b] Cannot be repeated frequently [ except in continuous epidural analgesia ] especially for small but painful procedures.
Limitations
1] Surgical time limit is between1-3 hrs.
2] Patient’s co-operation is must3] Failure or partially acted block
Types of blocks
1] Sciatic & femoral nerve block2] Sciatic nerve block in lower thigh3] Leg block a] low b] mid c] high4] Field Block (small infected cysts, abscess,
carbuncles)
Pre-block preparation Besides usual instructions….
Application of elastocrepe bandage 2-3 days prior to surgery
Advantages :-• limb becomes soft & supple • reduced oedema , improved limb circulation • pH of tissue fluid alters
Success rate improves
Pre-block preparation
Counseling the patient regarding the procedureand the expectation from the patient(compliance and accurate replies regarding paresthesia)
Lower leg block or modified ankle block
Deep peroneal nerve – can be blocked by injecting subcutaneously 3-5 mm along the lat border of the shin with 2 ml 2% xylocaine with 24 g 1.5 inch needle
Lower leg block or modified ankle block
Post. Tibial nerve – Blocked by injecting 3-5 ml 2% xylocaine at the junction of proximal 1/3rd with distal 2/3rd of medial malleolus to calcaneum, where normally pulsations of post. Tibial artery is felt.
Sural nerve
Inject 2% xylocaine between the tendoachilles and the calcaneaum on the lateral aspect
Lower leg block or modified ankle block
Ring block – 0.5 % xylocaine around the leg to block cutaneous nerves
Lower leg block or modified ankle block
Calcaneal nerve block
2 Finger breadths proximal to the medial malleolus
Inject along the direction of the nerve
Lower leg block or modified ankle block
Mid leg block
Anterior Tibial nerve
Inject 2- 4 ml 2% xylocaine subcutaneously 5-7 mm alongthe lateral border of the shin
Mid leg block
Posterior Tibial NerveSpinal needle no 23 G is inserted from the lateral side of the leg over the ant. border of fibula going medially downwards just to slip the interosseous border of tibia , advance 1-2 mm & deposit 8-10 ml 2% xylocaine
Mid leg block
Sural nerve
Inject 2 – 3 ml 2% xylocaine along a line extended proximallytangential to the lateral border of the tendo achilles
Ring block
0.5 % xylocaine around the leg to block cutaneous nerves
Mid leg block
High leg block
Anterior Tibial nerve Inject 3-4 ml 2% xylocaine 5-10 mm deep lateral to theupper end of shin
High leg block
Posterior Tibial nerve
2-4cm below the neck of the fibula
Lateral approach –Spinal needle no 23 G is passed from the lateral side of the leg over the ant. border of fibula going medially downwards just to slip the interosseous border of tibia , advance 1-2 mm & deposit 8-10 ml 2% xylocaine
Lateral Popliteal Nerve
2- 4 ml 2% xylocaine injected around the neck of fibula
High leg block
Ring block
0.5 % xylocaine around the leg to block cutaneous nerves
High leg block
If patient has a pain-free leg, then one may give sciatic nerve
block in the lower third of thigh alongwith lat. Popliteal nerve block and ring block.
High leg block
An alternate technique -
Practice regularlyYour patienceThe surgeons’ patienceThe patients’ patience!
Steps to success with local blocks
Patients’ comfortThe surgeons comfortYour comfortAND SAFETY!!
In Diabetic Foot
Blocks are the way to go!!
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