educational+material+ra+handbook+final

THE ABBOTT POCKET GUIDE

TO PRACTICAL PERIPHERAL NERVE BLOCKADE

DR BARRY NICHOLLSConsultant Anaesthetist

Taunton and Somerset Hospital

DR DAVID CONNConsultant Anaesthetist

Royal Devon and Exeter Hospital

DR ALICE ROBERTSSenior Teaching Fellow

Department of AnatomyUniversity of Bristol

Sponsored by Abbott Laboratories Ltd,Abbott House,

Norden Road,Maidenhead,Berkshire,SL6 4XE

Date of preparation:Oct 2003

Code No:HXCHI2003104

CONTENTS / 00

SECTION 1 - IntroductionGolden rules of regional anaesthesia 01Local anaesthetics 02Physicochemical properties of local anaesthetics 03Local anaesthetic additives 04Complications of peripheral regional anaesthesia 05Treatment of toxicity 05Electrical stimulation of peripheral nerves 06

SECTION 2 - Ophthalmic local anaesthesiaTopical corneoconjunctival anaesthesia 09Peribulbar anaesthesia 09Sub-Tenon’s anaesthesia 12

SECTION 3 - Upper limb blocksElicited motor responses 15Brachial plexus - anatomy 16Cutaneous innervation chart 17Cervical plexus block• Superficial 18• Deep 20Interscalene block • Winnie 22• Meier 24Subclavian perivascular block 26Vertical infraclavicular block 28Subcoracoid infraclavicular block 30Suprascapular nerve block 32Axillary block 34Midhumeral block 36Elbow blocks 40Wrist blocks 46Digital nerve block 50Webspace block 52IVRA (Bier’s block) 54

SECTION 4 - Trunk blocksThoracic paravertebral block 56Intercostal nerve block 58Penile block 59Ilioinguinal/iliohypogastric block (hernia block) 60Caudal epidural - children 62

Contents

SECTION ONE / INTRODUCTION / 0100 / CONTENTS

1. Always discuss the procedure with the patient, explaining benefits andrisks and obtaining consent.

2. Always discuss with the surgeon the procedure you intend to perform.

3. Always discuss potential complications and side effects, documentthese in the notes/anaesthetic chart.

4. Always perform the procedure in the patient’s best interest NOT theanaesthetist’s.

5. Always perform the technique in an appropriate setting withresuscitation equipment and drugs available.

6. Always have intravenous access and monitor to RCA standards.

7. Always fractionate doses greater than 5mls.

8. Always document procedure carried out, recording complicationsand/or problems e.g. pneumothorax, paraesthesia, bleeding.

KNOW THE ANATOMY & TECHNIQUE WELL.

BE PREPARED TO FAIL – HAVE A PLAN.

Golden Rules of Regional AnaesthesiaContents

SECTION 5 - Lower limb blocksElicited motor responses 65Lumbosacral plexus - anatomy 66Cutaneous innervation chart 67Lumbar plexus block 68Sacral plexus block (parasacral approach) 70Sciatic nerve block• Labat (posterior approach) 72• Beck (anterior approach) 74• Lateral approach 76• Raj (inferior approach) 78Femoral nerve block 80Lateral cutaneous nerve of thigh block 82Knee / popliteal blocks• Lateral 84• Prone 86• Supine 87Intra-articular knee block 88Saphenous nerve block 89Ankle and foot blocks• Ankle 90• Midtarsal 96• Digital 96

SECTION 6 - Practical application of peripheral nerve blocks

Shoulder 99Elbow 99Wrist 99Hand 100Hip 101Knee 101Ankle 101Foot 102Catheter techniques 104Infusion/bolus guidelines 106

IMPORTANT:All blocks in this book are “tried and tested” by the clinical authors and are presented in goodfaith. This book is not intended as a stand-alone training in regional anaesthesia. We encourageall clinicians to get hands-on training. No responsibility can be accepted for complications arisingfrom the use of the techniques described.

In addition to the potential side effects of each “block” each anaesthetic agent has potentialside effects. For details see summary of product characteristics of individual agent.

SECTION ONE / INTRODUCTION/ 0302 / SECTION ONE / INTRODUCTION

Local anaesthetics

Esters (COO-) • Procaine/Cocaine/Chloroprocaine/Amethocaine • Relatively unstable • Rapidly hydrolysed by plasma cholinesterase• Para-amino benzoate associated with hypersensitivity & allergic reactions

Amides (-NHCO-)• Lidocaine/Prilocaine/Bupivacaine/Levobupivacaine/Ropivacaine • Stable in solution • Usually weak acid pH 4-5.5 • Slowly broken down by amidases in liver • Hypersensitivity reactions low

Mode of action• Reversible blockade of sodium channels in excitable/conducting neural tissue• Administered as water-soluble hydrochlorides (B.HCL)• After injection - base released by relative alkalinity of tissues (pH-pKa)• B.HCL+HCO3↔B+H2CO3+CL• Unionised base diffuses into nerve axoplasm, partially ionised again• B+H+↔BH+

• Ionised base BH+ enters sodium channel-from interior of nerve - preventingdepolarisation

Properties relating to local anaestheticsOnset• Unionised base is lipid soluble - crosses into nerve. • pKa is the pH at which [base] = [charged cation]• The closer the pKa is to pH 7.4 the greater amount base, faster onset• !concentration of the drug (! conc. gradient), faster onset

Potency• Directly proportional to lipid solubility

Duration of action• Protein binding at site of action• Mass of drug and absorption from site• Drug’s inherent vasodilatation effect• Vasodilator Lidocaine > Prilocaine – increased absorption therefore shorter action• Ropivacaine no vasodilatation - relative vasoconstrictor

Differential block• Lipid solubility • Concentration of local anaesthetic• Motor nerves have more myelin than sensory• Ropivacaine low lipid sol, high pKa - sensory > motor

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SECTION ONE / INTRODUCTION / 0504 / SECTION ONE/ INTRODUCTION

Complications of peripheral regional anaesthesia

Definitions A side effect is a reversible, non-serious, unwanted effect of a block i.e. phrenic nerve palsy and diaphragmatic paralysis (temporary) after an interscalene block. A complication is a potentially serious, or irreversible unwanted effect i.e apneumothorax after a subclavian perivascular block, or an intravenous injection of LA, or permanent nerve damage after any block.

Technique related• Direct neural trauma• Bleeding and haematoma • Intravascular injection• Pneumothorax• Inadvertent epidural/intrathecal injection – widespread block

Drug related• Toxicity• Immediate- intravascular injection• Delayed- absorption from vascular site/relative overdose• Overdose• Anaphylactoid reaction• Methaemoglobinaemia (prilocaine)

Treatment of toxicityGeneral• STOP INJECTION• Airway, Breathing, Circulation

CNS Toxicity• Administer oxygen • Sedation – midazolam, propofol • If breathing inadequate or absent start manual ventilation & intubate if necessary• Administer fluid replacement• Vasopressor drugs as necessary

CVS Toxicity• Supplementary oxygen• Intravenous fluid• Bradycardia – glycopyrrolate, atropine• Hypotension – ephedrine, metaraminol or epinephrine (adrenaline)• Intubation and ventilation 100% oxygen• Cardiopulmonary resuscitation (CPR)• Bretylium for ventricular arrhythmias

Methaemoglobinaemia• Methylene blue 1mg/ kg

Bicarbonate• Added to increase pH of solution – increase unionised LA• May increase speed of onset• Risk of precipitation if > 1ml 8.4% NaHCO3 per 10mls LA

Epinephrine (Adrenaline)• Decrease vascular reabsorption – increasing duration – more drug available• Reduction of peak plasma levels (Lidocaine)• Reduced benefit in long acting LA e.g. bupivacaine and Chirocaine • Less effective in epidurals• May have spinal effects via spinal alpha receptors• Effective conc. 5mcg/ml = (1:200,000) Epinephrine (Adrenaline) max dose 200mcg• Avoid in terminal extremity /digital blocks / sciatic nerve blocks

Clonidine• Acts on spinal alpha 2 adrenergic receptors• Prolongs duration of sensory and motor block• “Strengthens” local anaesthetic effect• Induces post block analgesia• Reduce wide dynamic neurone (WDN) activity - inhibiting nociceptive transmission• Effective in epidural/caudal/spinal analgesia• Epidural/intrathecal use limited by hypotension and sedation• Dosage 1mcg/kg in peripheral blocks

Opiates• Spinal/peripheral opiate receptors• Proven synergism with local anaesthetic in epidurals/spinals• All opioids have been used, debatable benefit in peripheral blocks• Intra-articular morphine 2-5mg in knee surgery

Ketamine• NMDA receptor/weak local anaesthetic properties• Paediatric caudal epidurals• PRESERVATIVE FREE DRUG ESSENTIAL• Dose 0.5mg/kg in paediatric caudals

Hyaluronidase• Only appears effective in peribulbar and retrobulbar blocks of the eye• Aids in the onset of block by increased diffusion of LA through tissues

Local anaesthetic additives

06 / SECTION ONE / INTRODUCTION

Rheobase is the minimum current in milliamps required to create a nerve impulse.

Chronaxie is the minimum duration of stimulus, at twice the rheobase, that must beapplied to the nerve to initiate an impulse. Chronaxie varies depending on the type ofnerve; A alpha myelinated fibres (motor) 50-100msec, A delta myelinated fibres (sensory)150msec, C unmyelinated fibres (sensory) 400msec.

Using a peripheral nerve stimulator (PNS)

• Connect the stimulating needle to the cathode and ground electrode or ECG pad to anode. Negative to Needle (Black)Positive to Patient (Red).

• Flush the needle with local anaesthetic, puncture skin and then disconnect thesyringe to allow free flow of blood in case of inadvertent vascular puncture.

• Insert the insulated needle of your choice using a standard approach. Start withcurrent of 1mA, a frequency of 2Hz and a pulse width of 100msec. Maximizemotor response without paraesthesia and reduce current towards 0.5 mA.

• Reduce current to threshold (minimum current to obtain motor response) – if 0.2mAor less consider intraneural placement - reposition.

• Inject 1 ml of LA, motor response should disappear (nerve is displaced by solution –increasing needle-nerve distance). If motor response still presents suspectmisplacement of needle - start again.

• Increase current to again obtain desired motor response (Coulomb’s law - inversesquare law) confirming needle is still in correct location.

• Inject full volume after careful aspiration, fractionating dose if greater than 5mlsand aspirating regularly to check for intravascular placement. Any pain or increasedresistance to injection, stop immediately and reposition needle.

Electrical stimulation of peripheral nerves

SECTION TWO

Ophthalmic Local Anaesthesia

SECTION TWO / OPHTHALMIC ANAESTHESIA / 09

Topical corneoconjunctival anaesthesiaLevobupivacaine 0.75%,Amethocaine 1% (may sting/cloud cornea)Oxybuprocaine 0.4% (Benoxinate)Proxymetacaine 0.5% (least stingy and least toxic to the cornea)

Peribulbar anaesthesiaIndications:Operations on the globe including cataract and retinal surgeryLandmarks:Sclerocorneal junction (limbus), medial canthus, caruncle and inferior orbital rimTechnique:• Instill topical local anaesthetic drops • Perform inferolateral injection +/- medial injection

Inferolateral injection:Palpate the groove on the inferior orbital rim at the junction of the maxilla and zygoma,in line with the limbus. At a point 1mm above the rim of the orbit just lateral to thispoint - either transcutaneously (through lower lid) or transconjunctival Needle: 25G 25mm (bevel facing globe)Direction: Backwards, slightly inferiorly to contact bone. Redirect posteriorly under

globeDepth: 20-25mm (hub level with iris)Volume: 4-6 mls (see Figures 1 & 2 )

LA: Lidocaine 2% with Hyaluronidase 10-30units/ml1:1 mixture of Levobupivacaine 0.75% + Lidocaine 2% with Hyaluronidase 10-30units/ml

Medial injection:At a point medial to the caruncleNeedle: 25G 25mm (bevel facing globe)Direction: Directly backward, angled slightly medial to touch medial wall of orbit,

then withdrawn and redirect posteriorly, parallel to the medial wall.Depth: 20-25mmVolume: 3-5mls (see Figures 3 & 4)Side effects:Conjunctival oedema/haemorrhageProptosisComplications:Retrobulbar haemorrhageSubarachnoid injectionPerforation of globeExtra-ocular muscle damage from intramuscular injectionClinical tips: Always know axial length (AL). Risk of globe perforation increases as AL increases. Extremecaution if AL >27mm, consider only a medial canthus injection or a sub-Tenon’s block

Ophthalmic local anaesthesia

SECTION TWO / OPHTHALMIC ANAESTHESIA / 1110 / SECTION TWO / OPHTHALMIC ANAESTHESIA

FIGURE 4: Medial injection

FIGURE 1: Inferolateral injection

FIGURE 2: Inferolateral injection

FIGURE 3: Medial injection

SECTION TWO / OPHTHALMIC ANAESTHESIA / 1312 / SECTION TWO / OPHTHALMIC ANAESTHESIA

Sub-Tenon’s blockIndications:Operations on the globe including cataract and retinal surgeryLandmarks:Sclerocorneal junction (limbus) Technique: (See Figures 5 & 6)

• Instill topical local anaesthetic drops• Retract the eyelids with a speculum• In the inferonasal quadrant, the conjunctiva is raised with Moorfield’s forceps • At a point 5mm from the limbus a small incision in the conjunctiva is made using

Westcott spring scissors. Dissection of this space inferonasally between the sclera(vascular) and Tenon’s capsule (white, avascular)

Needle: Insert a blunt, curved sub-Tenon cannula backwards beyond the equator. Volume: 3-5 mlsLA: Lidocaine 2% with Hyaluronidase 10-30units/ml

1:1 mixture of Levobupivacaine 0.75% + Lidocaine 2% with Hyaluronidase 10-30units/ml

Complications: Bleeding Side effects:Chemosis (corneal oedema)/swellingSubconjunctival haemorrhageProptosisComparison with peribulbar:Lower risk of bleeding but poorer akinesia

FIGURE 5: Sub-Tenon dissection

FIGURE 6: Sub-Tenon injection

SECTION THREE / UPPER LIMB BLOCKS / 15SECTION THREE

Upper limb blocks

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FIGURE 7: Brachial plexus anatomy

Brachial plexus anatomy

16 / SECTION THREE / UPPER LIMB BLOCKS SECTION THREE / UPPER LIMB BLOCKS / 17

(1) Supraclavicular nerves(2) Superior lateral cutaneous nerve of arm (axillary nerve)(3) Intercostobrachial nerve(4) Inferior lateral cutaneous nerve of arm (5) Medial cutaneous nerve of arm (medial cord)(6) Lateral cutaneous nerve of forearm (musculocutaneous nerve)(7) Medial cutaneous nerve of arm (medial cord)(8) Radial nerve(9) Median nerve(10) Ulnar nerve(11) Posterior cutaneous nerve of arm (radial nerve)(12) Posterior cutaneous nerve of forearm (radial nerve)

(1) Dorsal scapular nerve C5(2) Nerve to subclavius C5,6(3) Suprascapular nerve C5,6(4) Lateral pectoral nerve C5,7(5) Upper and lower subscapular nerves C5,6(6) Axillary nerve C5,6(7) Lateral root of median nerve C6,7(8) Musculocutaneous nerve C5,7 (9) Radial nerve C5-T1(10) Ulnar nerve C7-T1(11) Median nerve C6-T1(12) Medial root of median nerve C8-T1(13) Medial cutaneous nerve of forearm C8-T1(14) Thoracodorsal nerve C6-8(15) Medial cutaneous nerve of arm C8,T1(16) Medial pectoral nerve C8,T1(17) Long thoracic nerve C5-7

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SECTION THREE / UPPER LIMB BLOCKS / 1918 / SECTION THREE / UPPER LIMB BLOCKS

Superficial cervical plexus block

Indication:Analgesia for neck line insertionCutaneous analgesia for shoulder surgeryIn combination with deep cervical plexus blocks for awake carotid artery surgeryBilateral for thyroid surgery analgesia

Landmarks:Mid-point of the posterior border of sternocleidomastoid muscle (SCM)

Technique: (See Figures 9 & 10)

• Insert needle along posterior border of SCM both caudad and cephalad. Needle must puncture first fascial layer

Needle: 21 - 23 g needleDirection: Cranial and caudal

Stimulation/endpoint:Puncture fascial layer. Local anaesthetic should form a “sausage” along the posteriorborder of SCM.

Volume: 10mlLA: 1% Prilocaine, 1% Lignocaine

0.25% Levobupivacaine

Side effects:None

Complications:Haematoma (rare)

FIGURE 9: Superficial cervical plexus block

FIGURE 10: Superficial cervical plexus anatomy

(1) Transverse cervical nerves(2) Supraclavicular nerves(3) Greater auricular nerve

(4) Lesser occipital nerves(5) Sternocleidomastoid muscle

1

2

3

4

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20 / SECTION THREE / UPPER LIMB BLOCKS

Deep cervical plexus block

Indications:Anaesthesia and analgesia for carotid surgery, cysts, lymph node biopsy, othersuperficial surgery to the neckLandmarks: Thyroid cartilage (C4)Posterior border of Sternocleidomastoid muscle (SCM)Interscalene grooveTechnique: (See Figures 11 & 12)

• Identify the posterior border of SCM at Thyroid cartilage level C4• Place a finger beneath the lateral border of SCM onto belly of scalenus anterior• Move finger laterally feeling for interscalene groveNeedle: 25mm - 50mm insulated/non-insulatedDirection: Towards contra-lateral elbow. Medially, caudally and dorsally.Depth: 10mm - 20mm. Insert until paraesthesia are felt or bone of C4

transverse process is contacted. After careful aspiration inject LA.Volume: 8mls - 10mlsLA: 1% Lidocaine, 1% Prilocaine

0.25% - 0.5% Levobupivacaine Side effects:Phenic nerve blockRecurrent laryngeal nerve block Stellate ganglion blockComplications:As with interscalene blockClinical tips:The single injection technique is as effective as the multiple injection technique.

SECTION THREE / UPPER LIMB BLOCKS / 21

FIGURE 11: Deep cervical plexus block

FIGURE 12: Deep cervical plexus with sternocleidomastoid muscle cut and retracted

(1) Sternocleidomastoid muscle(2) Phrenic nerve(3) Ansa Cervicalis

(4) Brachial plexus(5) Deep cervical plexus

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Indications:Shoulder & humerus surgeryLandmarks:Cricoid cartilage (C6)Posterior border of Sternocleidomastoid muscle (SCM)Interscalene grooveTechnique:• Identify posterior border of sternocleidomastoid muscle (SCM) at cricoid level (C6)• Place finger beneath lateral border SCM onto belly of scalenus anterior• Move fingers laterally feeling for groove – separating scalenus anterior

from scalenus medius(See Figures 13 & 14)

Needle: 25mm-50mm insulatedDirection: Towards contra lateral elbowDepth: 10-20mm (very near the surface)Stimulation: Deltoid (shoulder surgery)

Elbow flexion (humeral surgery)If the phrenic nerve is stimulated - needle too anteriorIf the dorsal scapular nerve is stimulated - needle too posterior

Volume: 10-20mls upper roots/analgesia20-40mls lower roots/anaesthesia

LA: 1% Lidocaine , 1% Prilocaine 0.25%-0.5% Levobupivacaine

Side effects:Phrenic nerve block - 100%Recurrent laryngeal nerve block - 15%Stellate ganglion block - 20%Complications:Epidural/spinal injectionVertebral artery punctureBilateral spreadSpinal cord injuryPneumothorax Clinical tips:Never do block on anaesthetised patientsCaution with patients with respiratory problemsThe plexus is rarely (if ever) more than 20mm deep to the skinParaesthesia to the operative area is an acceptable alternative to electrical nervestimulation

Interscalene blockWinnie’s approach

FIGURE 13: Winnie’s interscalene block

FIGURE 14: Interscalene anatomy

(1) Clavicle(2) Phrenic nerve(3) Subclavian artery(4) Brachial plexus(5) Dorsal scapular nerve

(6) First rib(7) Stellate ganglion(8) Scalenus anterior(9) Scalenus medius

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4

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Indications: Shoulder and humeral surgeryDifficult anatomy - poor identification of interscalene groove, short neckContinuous catheter techniques

Landmarks:The posterior border sternocleidomastoid muscle (SCM) Thyroid cartilage prominence (C4)Subclavian artery - above the clavicle

Technique:• Mark the posterior border of sternocleidomastoid muscle at the level of the thyroid

prominence

• Palpate the subclavian artery as it passes over the 1st rib behind the clavicle

• A line joining these two marks approximates to the interscalene groove(See Figures 15 & 16)

Needle: 50mm insulatedDirection: Caudally, passing along the long axis of the interscalene groove towards

the subclavian arteryDepth: 35-50mm Stimulation: Deltoid (shoulder surgery)

Elbow flexion (humerus) Volume: 10-20mls upper roots/analgesia

20-40mls lower roots/anaesthesiaLA: 1% Lidocaine , 1% Prilocaine

0.25%-0.5% Levobupivacaine Side effects:As with Winnie’s techniqueComplications:Inadvertent intravascular injectionPneumothorax - very low incidence

Clinical Tips:Reduced risk of epidural/intrathecal injectionEasier catheter placement because of angle of approach

Interscalene blockMeier’s approach

FIGURE 16: Interscalene anatomy

FIGURE 15: Meier’s interscalene block

(1) Thyroid cartilage(2) Subclavian artery(3) Brachial plexus

(4) Posterior border of sternocleidomastoid

1

4

2

1

2

3

4


Indication:Elbow, wrist and hand surgery

Landmarks:Interscalene groove, subclavian artery

Technique:

• Identify the interscalene groove

• Move finger inferiorly down the groove until pulsation of subclavian artery is felt (onlyfound in 50% of patients) or skin begins to flatten out over supraclavicular fossa

• With your finger in the groove, insert a needle in the posterior part of the grooveposterior to the artery(See Figures 17 & 18)

Needle: 50mm insulated Direction: Parallel to the floor, directly caudad (aiming at ipsilateral great toe).Depth: 1.5-4cmStimulation: Flexion/extension wrist and fingers

If no paraesthesiae or twitch found then redirect fractionally anterior/posteriorly in grooveIf accidental arterial puncture - move needle posteriorlyIf you contact 1st rib then “walk” antero-posteriorly along rib

CAUTION: Absolutely no medial intent or medial angulation of the needle

Volume: 0.5ml/kg up to 40mlsLA: 1% Prilocaine, Lidocaine

0.25% - 0.5% Levobupivacaine

Side effects: Horner’s syndrome/recurrent laryngeal nerve block

Complications:Vascular punctureInadvertent intravascular injection Pneumothorax - less than 1:1000 in experienced hands.

Clinical Tips:Fast onset block, because of the narrowing of the perivascular sheath at this level.

Ulnar border missed in approximately 5% of blocks.

Subclavian perivascular block (SPV)

FIGURE 18: Subclavian perivascular anatomy

FIGURE 17: Subclavian perivascular approach - Finger in the groove and/or subclavian artery

(1) Clavicle(2) Subclavian artery(3) Brachial plexus

(4) First rib(5) Scalenus anterior(6) Scalenus medius

2

3

1

5

6

4


Indications: Surgery of the elbow, forearm and hand.

Landmarks:Anterior process of the acromion, jugular notch, subclavian artery.Technique:• Lie the patient flat, with one pillow behind the head• Mark the mid-point between the anterior process of the acromion and the jugular

notch, below the clavicle • Note the position of the subclavian artery above the clavicle. The plexus will lie

lateral to this point, after passing below the clavicle(See Figures 19 & 20)

Needle: 50mm insulated.Depth: 2-5 cmDirection: Absolutely vertical direction of needle. No medial angulation.Stimulation: Wrist / finger extension - accept, posterior cord.

Pectoral muscle twitch - don't accept, needle too medial or superficial.Elbow flexion - don't accept, lateral cord, needle too lateral or superficial.No twitch - needle too lateral

Caution: No medial angulation of needle, only move needle in horizontal planemedial / lateralVolume: 0.5ml/kg to 50ml LA: 1% Prilocaine, 1% Lignocaine

0.25% - 0.5% LevobupivacaineSide effects:Rarely recurrent laryngeal nerve block, stellate ganglion block

Complications:Vascular punctureInadvertent intravascular injectionPneumothorax - less than 1:1000 in experienced hands.

Clinical Tips:Keep the needle as close to the inferior surface of the clavicle as possible.Move the needle medially or laterally but keep the needle absolutely vertical.Care with very thin patients as plexus may be less than 2cm deep (lung may be less than 5cm deep)

Vertical infraclavicular block (VIB)

FIGURE 20: Infraclavicular anatomy

FIGURE 19: Vertical infraclavicular block

(1) Anterior process of acromion(2) Jugular notch

(3) Subclavian artery

2

1

3

2

1


Indications:Elbow, wrist and hand surgery

Landmarks:Coracoid process

Technique:• Identify the coracoid process (shrug shoulder)• Mark the most anterior prominence• Mark a point 2cm inferior and 1-2 cm medial

(See Figures 21 & 22 )

Needle: 50-80mm insulatedDirection: Perpendicular in all planesDepth: 3-8cmStimulation: Wrist / finger extension - accept, posterior cord.

Pectoral muscle twitch - don't accept, needle too medial or superficial.Elbow flexion - don't accept, lateral cord, needle too cephalad or superficial.Wrist flexion, thumb adduction - only accept if surgery is in ulnar distribution, medial cord.Posterior scapular movements - don't accept, too deep, outside plexus

CAUTION - no medial angulation of needle/only move needle in sagittal plane(cephalad / caudad)

Volume: 0.5 mls/kg to 50mlsLA: 1% Prilocaine/Lidocaine

Levobupivacaine 0.25%-0.5%Side effects:Nil of note

Complications:Vascular punctureInadvertent intravascular injection

Clinical tips:2cm & 1cm distances will need to be reduced proportionally in smaller patients

Subcoracoid infraclavicular block

FIGURE 22: Subcoracoid infraclavicular block

FIGURE 21: Subcoracoid infraclavicular block

(1) Clavicle(2) Tip of coracoid process(3) Pectoralis minor

(4) Subclavian artery (5) Cords of brachial plexus

4

5

1

3

2

2cm

1cm

2cm

1cm

2

SECTION THREE / UPPER LIMB BLOCKS /3332 / SECTION THREE / UPPER LIMB BLOCKS

Indication:Analgesia for shoulder operations

Landmarks:Inferior angle of scapula, spine of scapulaTechnique:• With the patient sitting, or lying (operative side up)• Mark the mid-point of the scapular spine • Draw a line from the inferior angle of the scapula to this point • Move 1cm superiorly• Insert the needle 90º in all planes

Needle: 50mm insulated or uninsulatedDirection: Perpendicular to skin downwards onto bone

(suprascapular fossa)

Stimulation/endpoint: Move needle anteriorly until either, paraesthesiae (into shoulder), abduction/elevationarm (supra/infraspinatus) or needle passes into the suprascapular notch.

Volume: 10-15mlsLA: 0.5% Levobupivacaine

Side effects:Nil of note

Complications:Very rarely pneumothorax due to incorrect landmarks.

FIGURE 23: Suprascapular block

Suprascapular nerve block

1

2

(1) Inferior angle of scapula(2) Spine of scapula(3) Suprascapular nerve

FIGURE 24: Suprascapular nerve anatomy

2

3

1


Indications:Elbow, forearm and hand surgeryLandmarks:Axillary arteryInsertion of pectoralis major muscle Technique:• Identify the axillary artery with the arm abducted to 90º and the elbow flexed • Draw a line down from the anterior axillary fold (insertion of pectoralis major)

crossing the artery• Fix the artery between index and middle finger and insert a needle to pass above or

below the artery (See Figure 25 )

• Above the artery - (median, musculo-cutaneous)• Below the artery - (ulnar)• Below / Behind the artery - (radial) (See Figure 26 )

Needle: 25-50mm insulated/uninsulatedDirection: 45º to the skin, proximallyDepth: 10-15mmStimulation: Median – index/middle finger - flexion

Ulnar – thumb adduction, little finger flexionRadial – thumb extensionMusculocutaneous – elbow flexion

Volume: Single injection: 0.5ml/kg up to 50mls

Multiple-injection: Identify each individual nerve. 7-10mls each nerve.Intercostobrachial nerve – subcutaneous infiltration across floor of the axilla – decreasesupper arm tourniquet pain.

Alternative techniquesTransarterial - deliberate transfixion of axillary artery Loss of resistance - click/pop on entering fascial sheathSubcutaneous infiltration - fanwise infiltration above/below arteryDeliberately elicit paraesthesia in the nerve supplying target areaContinuous axillary catheter- identify primary nerve supplying target, insert cathetereither above (median) or below (ulnar/radial) arteryLA: 1% Lidocaine, 1% Prilocaine

0.25% - 0.5% Levobupivacaine


Complications:Inadvertent vascular injectionNerve damage

Clinical Tips:Single shot almost always misses the musculo-cutaneous branch, also misses the radialin about 25%.

Axillary block

FIGURE 25: Axillary block

FIGURE 26: Cross section at neck of humerus

(1) Musculocutaneous nerve(2) Median nerve(3) Medial cutaneous nerve of forearm(4) Axillary artery(5) Ulnar nerve

(6) Radial nerve(7) Medial cutaneous nerve of arm(8) Coracobrachialis/biceps muscle(9) Triceps muscle(10)Humerus

1

2

3

4

5

6

7

9

8

10


FIGURE 27: Midhumeral anatomy

FIGURE 28: Midhumeral anatomy at level of deltoid insertion

Indications:Elbow, forearm and hand surgery

Landmarks:Insertion of deltoid muscleBrachial arteryTechnique:• Mark the brachial artery in the bicipital groove • Draw a line crossing the artery at the level of the insertion of deltoid• This should be approximately three or four finger breadth’s below the axilla

(See Figures 27 & 28)

Needle: 50mm insulatedDirection: Median - above (lateral) and parallel to the artery(See Figure 29)

Musculocutaneous - 45º above the artery and lateral to humerus(See Figure 32)

Ulnar - below (medial to) the artery/superficial to triceps(See Figure 30)

Radial- below (medial to) the artery and humerus. Pass needle to posterior border of humerus (nerve in spiral groove)(See Figure 31 )

Volume: 6-10mls on each nerveStimulation: Median - index/middle finger - flexion

Musculocutaneous - elbow flexionUlnar - little finger flexion/thumb adductionRadial - thumb extension

LA: 1-2% Lidocaine, 1% Prilocaine0.5% Levobupivacaine


Complications:Bleeding/bruising 5%

Clinical Tips:Use long acting LA on nerve supplying area of operation and short acting LA on the rest.Additional subcutaneous infiltration 5 mls - medial cutaneous nerve of arm/forearm and intercostobrachial nerve to aid tourniquet comfort.

Midhumeral block

c/s

23

1

2

3

4

5

6

7

4 5 6

(1) Ulnar nerve(2) Median nerve(3) Musculocutaneous nerve(4) Medial cutaneous nerve of arm(5) Medial cutaneous nerve of forearm

(6) Brachial artery(7) Biceps / coracobrachialis muscle(8) Pectoralis major(9) Triceps muscle

(1) Medial cutaneous nerve of arm(2) Musculocutaneous nerve(3) Median nerve(4) Brachial artery(5) Ulnar nerve(6) Medial cutaneous nerve of forearm

(7) Radial nerve(8) Biceps muscle(9) Deltoid muscle(10)Coracobrachialis muscle(11) Triceps muscle

88

109

11

11

11

8

7

9

1


FIGURE 31: Midhumeral block. Approach to radial nerve

FIGURE 32: Midhumeral block. Approach to musculocutaneous nerve

FIGURE 29: Midhumeral block. Approach to median nerve

FIGURE 30: Midhumeral block. Approach to ulnar nerve


Indications:Minor forearm surgery & hand surgery‘Top-up’ to augment or expedite brachial plexus blocks

Landmarks:

Elbow crease, brachial artery, tendon of biceps muscleLA: 1-2% Lidocaine , 1% Prilocaine

0.25%-0.5% Levobupivacaine

Techniques:

Median nerve (See Figures 33,34 & 35)

• Flex the elbow, mark the elbow crease• Identify the brachial artery on this line and mark a point just medial to the artery

Needle: 25-50mm insulated/uninsulated Direction: 45º to the skin/proximallyDepth: 10-15mm, below bicipital aponeurosis (pop or click felt)Stimulation: Flexion of fingers accept. Pronation of wrist alone inadequate

Paraesthesia into thumb index or middle finger acceptVolume: 5mls slowly

Medial cutaneous nerve of the forearm• Subcutaneous infiltration along the medial border of biceps tendon 5-8mls

Radial nerve (See Figures 33,34 & 36)

• Palpate the groove between lateral border of biceps tendon & brachioradialis• Mark a point 1.5-2cm proximal to the elbow crease in this grooveNeedle: 50mm insulatedDirection: Towards the lateral epicondyle / slightly cephaladDepth: 2-4cmsStimulation: Extension of the thumb accept. Wrist extension alone inadequate.Volume: 5mls

Elbow blocks

Lateral cutaneous nerve of forearm• Subcutaneous infiltration along lateral border of biceps tendon 5-8 mls

Posterior cutaneous nerve of forearm• Subcutaneous infiltration between the lateral epicondyle and the olecranon 5-8mls

Ulnar nerve (See Figures 33,34 & 37)

• Palpate the ulnar sulcus (medial epicondyle). At a point 2cm proximal to the sulcusNeedle: 50mm insulatedDirection: 45º to the skin along a line joining the ulnar sulcus and axillaDepth: 1-3cmsStimulation: Flexion ring finger, adduction of thumbVolume: 5mlsSide effects: NilComplications: Nil of noteClinical Tips:Inject the LA slowly into tight tissuesAvoid injection of ulnar nerve in ulnar sulcusOnly accept distal finger movement and not forearmInconsistent anatomy - causing varying nerve distribution with overlapping cutaneousinnervationThe major nerves at the elbow only have cutaneous innervation to the hand. Cutaneousinnervation of the forearm comes from higher branchesParaesthesia is not routinely sought but if encountered then withdraw the needle by 1-2mm and slowly inject LA

SECTION THREE / UPPER LIMB BLOCKS / 43

FIGURE 33: Cubital fossa

(1) Ulnar nerve(2) Median nerve(3) Brachial artery(4) Radial nerve

(5) Biceps muscle(6) Brachialis muscle(7) Brachioradialis muscle(8) Triceps muscle

FIGURE 34: Cross section of arm at supracondylar level

Lateral LateralMedial Medial

1

2

3

4C/S

5

6

7

8

5


2

3

4

1


FIGURE 35: Median nerve block

FIGURE 36: Radial nerve block

1

2

1

2

FIGURE 37: Ulnar nerve block

(1) Brachial artery(2) Biceps tendon


Indications:Hand surgery

Landmarks:Palmaris longus (PL), flexor carpi radialis (FCR), ulnar artery, flexor carpi ulnaris(FCU), radial styloid (See Figures 38-41 )

Technique:

Median nerve• Make a fist. Identify the tendons of FCR & PL

• Mark a point 3-5cms proximal to the distal palmar crease between these tendons (if no PL present -1cm medial to FCR) (See Figure 42)

Needle: 25G 25mm non-insulated

Direction: 45º to the skin, towards the wristDepth: 10-15mmStimulation: Paraesthesia into thumb or index fingerVolume: 3-5mls

Palmar cutaneous branch (medial nerve)• Infiltrate superficially proximally to the flexor retinaculum 3-5mls

Ulnar nerve• Make a fist. Identify the tendon of flexor carpi ulnaris (FCU)

• At a point 2cm proximal to the distal palmar crease beneath the medial borderof the tendon (See Figure 43)

Needle: 25G 25mm uninsulated Direction: Medially beneath tendon of FCU, towards radial border of wristDepth: 10-15mmStimulation: Paraesthesiae into little fingerVolume: 3-5mls

Dorsal cutaneous branch (ulnar)• Subcutaneous infiltration over the ulnar aspect of the wrist at this level - 3mls

Superficial radial nerve• Palpate the styloid processes of the radius

• Infiltrate subcutaneously from this point over the posterior aspect of the wristto the mid-point of the dorsum of the wrist 5-8mls (See Figure 39)

Wrist block

FIGURE 38: Cutaneous innervation

FIGURE 39: Superficial radial nerve

(1) Median nerve(2) Ulnar nerve(3) Radial nerve

3

1 22

3

1

3


FIGURE 41: Cross section at level of distal radius

FIGURE 42: Median nerve block

FIGURE 43: Ulnar nerve block

(1) Radial artery(2) Flexor carpi radialis(3) Median nerve(4) Palmaris longis

(5) Ulnar artery(6) Ulnar nerve(7) Flexor carpi ulnaris

6 5 4 3 2 17

FIGURE 40: Wrist anatomy

1 2 3

7 6 5 4


Indication:Surgery distal to the base of the proximal phalanx

Landmarks:Base of proximal phalanx

Technique:• Dorsal injection• On the dorsolateral aspect of finger. At the base of the proximal phalanx

Needle: 25G 25mm uninsulatedDirection: Vertically to slide past base of phalanx. Medial and lateral

injections of each phalanx needed for complete anaesthesiaVolume: 2-3ml (injecting to palmar surface and on withdrawal)LA: 1% Lidocaine, Prilocaine

0.25% LevobupivacaineSide effects:Nil of noteComplications:Possible vascular compromise from pressureAccidental vascular puncture / haematomaClinical tips:Massage to aid spreadNEVER use vasoconstrictors around end arteries

FIGURE 45: Cross section at distal metacarpals

FIGURE 44: Digital nerve block

Digital nerve block

FIGURE 46 & 47: Webspace block

52 / SECTION THREE / UPPER LIMB BLOCKS SECTION THREE / UPPER LIMB BLOCKS / 53

Indications:As for digital nerve block

Landmarks:Metacarpophalangeal joints

Technique:• Insert the needle in the webspace till the tip of the needle is proximal to the

MCP jointNeedle: 23/25G 50mm uninsulatedDepth: Just proximal to MCP jointVolume: 3-5mls in each space

Clinical tips:Massage to aid spreadNEVER use vasoconstrictors around end arteries

Webspace block


Indication:Minor superficial surgery forearm & handReduction minor fractures +/- K wiring

Technique:• Apply double/single cuff to upper arm• Cannulate a suitable vein distal to the cuff• Insert a cannula (safety needle) in a different limb• Elevate or use an Esmark (or similar) bandage to exsanguinate the arm• Inflate lower cuff followed by upper cuff to 100mmHg above systolic BP- deflate

lower cuff inject local anaesthetic (can switch cuffs after 10mins)Volume: Small arm 40mls

Medium arm 50mlsLarge arm 60mls

LA: 0.5% Prilocaine (up to 300mgs) keep cuff inflated for 15mins minimum0.5% Lidocaine (max adult dose 250mg) keep cuff inflated for 20mins minimum.

Clinical tips:Contra-indicated in childrenNever use Bupivacaine / Levobupivacine / RopivacaineUnsatisfactory in fat arms & hypertensive patients (systolic BP greater than 200mmHg)Only use in short operations <30mins

Intravenous regional anaesthesia (IVRA)(Bier’s block)

FIGURE 48: Bier’s block

SECTION FOUR

Trunk blocks

SECTION FOUR / TRUNK BLOCK / 5756 / SECTION FOUR / TRUNK BLOCK

Indication:Analgesia for rib fractures, thoracic surgery, breast surgery, open cholecystectomy and renal surgery

Landmark:Spinous process and transverse process (TP) of corresponding vertebra (See Figures 49 & 50)

Technique:

• Patient sitting or lying with operative side up

• Palpate the spinous process and mark a point 2.5cms lateral to its most cephalad aspect

Direction: Perpendicular to skinNeedle: 22G 80mm spinal needle/ insulated needleDepth: Initially contact transverse process (2-5cm), reangle needle to pass

above the TP advancing 1-1.5cm

Stimulation/Endpoint:Loss of resistance or paraesthesiae (motor response - intercostal muscle twitch)

Volume: 5mls per level or high volume 15mls* LA: 0.25% - 0.5% levobupivacaine

Side effects:Epidural spreadContralateral spread

Complications:Intravascular injection, intrathecal injection, pneumothorax

Clinical tips:*Catheter/high volume techniques - work well in thoracic region (15mls -blocks 3-5 segments)

Thoracic surgery T5/6

Fractured ribs variable level

Cholecystectomy/Renal multiple levels T8-T12 Catheter T10

Avoid lateral angulation of needle - increased risk of pneumothorax

Thoracic paravertebral block

FIGURE 49: Thoracic paravertebral block

FIGURE 50: Cross section through thoracic vertebra

(1) Vertebral body(2) Transverse process(3) Rib

(4) Nerve root in paravertebral space(5) Pleura

1

24

3

5

Lung

58 / SECTION FOUR / TRUNK BLOCK

Indication:Analgesia for fractured ribs, open cholecystectomyLandmark:Angle of the ribTechnique:• With the patient lying affected side up, or sitting• Palpate the angle of the rib, (found immediately lateral to the border of erector

spinae muscle)• Holding the rib between two fingers, insert the needle to contact the inferior border• Redirect the needle to pass just below the rib (See Figure 51)

Needle: 22G uninsulated short bevelled/ 22g 50cm insulated needle connected to extension tubing

Direction: Perpendicular to skinDepth: 2-5mm deep to the inferior border of ribEnd point: Contact lower border rib, walk off rib, advance till loss of resistanceVolume: 5mls at each levelLA: 0.5% Levobupivacaine Complications:PneumothoraxAbsorption toxicityInadvertent intravascular injection

FIGURE 51: Intercostal nerves and vessels

Intercostal nerve block

SECTION FOUR / TRUNK BLOCK / 59

Penile block

Indication:CircumcisionTechnique:• Palpate symphysis pubis (SP), above the root of penis• Mark two points (0.5cm infant, 1.0cm child/adult) either side of the midline

below the SP (See Figures 52 & 53)

Needle: 22-25G short bevelled Direction: Posteriorly, medial and slightly caudally- until loss of resistance -

elastic recoil with penetration of Buck’s fasciaDepth: 8-30mm (correlates with age)Volume: 0.1ml/kg (max 5mls) per side (child)LA: 0.5% Levobupivacaine Infiltrate subcutaneously around root of penis onto the lateral side of scrotum,blocking branches from ilioinguinal and genitofemoral nerves (1-5mls depending on size of child - 0.25% Levobupivacaine) Never use epinephrine (adrenaline) containing solutionsComplications:Intravascular injectionPuncture corpus cavernosum/dorsal vessels (haematoma)

FIGURE 52: Penile block FIGURE 53: Cross-section through pubic bone

(1) Symphysis pubis(2) Membranous fascia (Scarpa’s)

(3) Penile fascia (Buck’s)(4) Subpubic space

(1) Rib(2) Intercostal vein(3) Intercostal artery(4) Intercostal nerve

3

4

2

2

3

4

1

1


FIGURE 55: Cross section at the level of the anterior superior iliac spine

Indications:Inguinal surgery, including orchidopexy

Landmarks:Anterior superior iliac spine (ASIS), deep inguinal ring (1-1.5cm above mid inguinal point)

Technique:

• Mark a point 2cm medial to ASIS in adults and 1cm in children

Needle: 22G 50mm short bevelled Direction: Perpendicular to skinDepth: 10-40 mm

Iliohypogastric nerve • Following initial click (pop) as needle penetrates external oblique aponeurosis inject

8mls of LA to block the iliohypogastric nerve

Ilioinguinal nerve • Either insert the needle deeper till a second click, as internal oblique is penetrated

and inject 8 mls to block the ilioinguinal nerve

• OR direct the needle posterolaterally to touch inner aspect of ileum and inject 8 mlof LA whist withdrawing blocking the ilioinguinal nerve

Intercostal nerves • Fan wise subcutaneous infiltration above the aponeurosis will block cutaneous

supply from lower intercostal nerves and sub-costal nerve (T12)

• Fan wise subcutaneous infiltration from pubic tubercle superiorly & laterally willblock contra lateral innervation

Genitofemoral nerve • Palpate the deep ring, insert needle into inguinal canal to block the genitofemoral

nerve - 5mls (can only reliable be performed at operation)

Volume: 30mlsLA: 0.25-0.5% Levobupivacaine

Complications:Intravascular injectionIntraperitoneal injectionFemoral nerve block

Clinical tips:In children limit volume 2.5mg/kg Levobupivacaine (0.25%-0.5%)

Always warn the patient about the risk of femoral nerve block and subsequent inabilityto weight bear.

Ilioinguinal / iliohypogastric nerve blocks(Hernia block)

(1) Rectus abdominis muscle(2) External oblique muscle(3) Iliohypogastric nerve(4) Internal oblique muscle

(5) Ilioinguinal nerve(6) Lateral femoral cutaneous nerve(7) Femoral nerve(8) Ilium

FIGURE 54: Hernia block

2

34

5

6

7

1

8

Indications:Circumcision, orchidopexy, herniotomy and analgesia and/or anaesthesia for lowerlimb surgery

Landmarks:Posterior superior iliac spines (PSIS), sacral cornua, sacral hiatus

Technique:• Either prone or on the side. Palpate PSIS’s, the sacral hiatus is at the apex of

an equilateral triangle whose base is formed by a line joining the PSIS’s

• OR palpate the sacral cornua, the depression between and immediately inferior to them is the sacral hiatus (See Figures 56 & 57)

Needle: 22G intravenous cannula Direction: Cephalad at 45º in the sagittal plane (15º in babies - sacrum flatter)Depth: 5-10mm (insert needle 3mm into canal) - advancing cannula 10 mm

off needleEnd point: ‘Pop’ felt – sacro-coccygeal membrane pierced

Volume: Segmental level of operation Dose (ml/kgs)

LA: 0.25% Levobupivacaine (volumes >20mls change to 0.125% )

0.2% Ropivacaine


Caudal epidural - children

FIGURE 57: Caudal injection

FIGURE 56: Caudal injectionLumbo-sacral 0.5Thoraco-lumbar 1.0Mid-thoracic 1.25

SECTION FIVE / LOWER LIMB BLOCKS / 65SECTION FIVE

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SECTION FIVE / LOWER LIMB BLOCKS / 67

FIGURE 59: Cutaneous innervation of the lower limbs

66 / SECTION FIVE / LOWER LIMB BLOCKS

FIGURE 58: Lumbosacral plexus

L1

L2

L3

L4

L5

S1

S2

S3

S4

2

3

4

7

8

(1) Iliohypogastric nerve L1(2) Ilioinguinal nerve L1(3) Lateral femoral cutaneous nerve L2-3(4) Genitofemoral nerve L1-2(5) Femoral nerve L2,3,4(6) Obturator nerve L2,3,4(7) Sciatic nerve L4-S2(8) Pudendal nerve S2,3,4

6

5

1

(1) Lateral cutaneous branch of subcostal nerve

(2) Femoral branch of genitofemoral nerve

(3) Lateral femoral cutaneous nerve(4) Anterior femoral cutaneous nerves(5) Obturator nerve(6) Common fibular nerve

(7) Saphenous nerve(8) Superficial fibular nerve(9) Sural nerve(10) Deep fibular nerve(11) Posterior cutaneous nerve of thigh(12) Sural nerve(13) Calcaneal branch of tibial nerve(14) Plantar branches of tibial nerve

1

2

3

4

5

6

7

8

9

10 14

13

12

11

Indications:Analgesia for fractured neck of femur and femoral shaftWith GA provides analgesia for hip, knee and femoral shaft surgeryWith sciatic nerve block - anaesthesia & analgesia for all leg & foot surgeryLandmarks:Posterior superior iliac spines (PSIS), line joining the iliac crests (Tuffier’s line)Technique: (See Figures 61 & 62)

• Patient lateral with operative side uppermost

• Draw line parallel to the spinous processes passing through the PSIS. Mark a pointwhere Tuffier’s line crosses

Needle: 100-150mm insulatedDirection: Perpendicular to skin, slight caudad angle, contact with transverse

process (TP) then re-angle to pass above or below TPDepth: 8-12cmStimulation: Quadriceps contraction

If hamstrings are stimulated needle is too medial or too caudad Volume: Approx 0.5 mls/kg - max 30mls LA: 1% Prilocaine , 1% Lidocaine

0.25% - 0.5% LevobupivacaineComplications:Accidental epidural spread leading to bilateral sympathetic, motor and sensory block.Intravascular injectionClinical tips:Avoid medial angulation as paravertebral injection has a high incidence of epiduralspreadPrimarily intramuscular injection - caution high doses of LA can lead to absorptiontoxicityWhen combining sciatic nerve blocks with lumbar plexus or femoral nerve blocks - a large combined volume of LA is used, care that the max recommended dose is not exceeded


FIGURE 60: Cross section through L4

Lumbar plexus block


(1) Obturator nerve(2) Genitofemoral nerve(3) Femoral nerve(4) Lateral femoral

cutaneous nerve(5) Ilioinguinal/iliohypogastric

nerves(6) Psoas muscle

FIGURE 62: Lumbar plexus anatomy

FIGURE 61: Lumbar plexus block

(1) Tuffiers line(2) Posterior Superior Iliac Spine(3) Lumbar plexus

3

1

2

L4 6

5

1

2

3

4

SECTION FIVE / LOWER LIMB BLOCKS / 7170 / SECTION FIVE / LOWER LIMB BLOCKS

Indications:Post operative analgesia for hip surgery / post amputation, also see indications forsciatic blockLandmarks:

PSIS, Ischial tuberosity (IT)Technique: (See Figures 63 & 64)

• In lateral recumbent position, draw a line connecting the PSIS and IT, at a point 6cm(three fingers breadth) distal to the PSIS

Needle: 100mm insulated needleDirection: Perpendicular to skin, to contact bone (sacral ala or ileum) -

superior aspect of greater sciatic notch, (note depth), redirect needle caudally advancing no more than a further 2cms.

Depth: 60-80mmStimulation: Plantar flexion of the foot/toes (tibial nerve) - accept

Dorsiflexion/eversion of the foot (common fibular/peroneal nerve) - move needle medially

Volume: 10-20mlsLA: 0.25-0.5% levobupivacaineSide effects:Blockade of other components of sacral plexus, including posterior cutaneous nerve ofthigh, obturator, gluteal nerves and the nerve to quadratus femoris (supplying the hipjoint). The sacral parasympathetics, perineal and pudendal nerves may be blocked -causing urinary retention (uncommon). Complications:Intravascular injection (internal iliac vessels), perforation pelvic viscera (sigmoid colon)

Caution:Avoid adrenaline containing solutions near the sciatic nerve. Blood supply may be damaged. When combining sciatic nerve blocks with lumbar plexus or femoralnerve blocks - a large combined volume of LA is used, care that the maxrecommended dose is not exceeded

Sacral plexus block (parasacral approach)

FIGURE 64: Parasacral anatomy

(1) Posterior superior iliac spine(2) Ischial tuberosity

(3) Sacral plexus

FIGURE 63: Parasacral block

1

2

12

6 cm

3

6cm


FIGURE 66: Labat’s approach to sciatic nerve

FIGURE 65: Labat’s approach to sciatic nerve

Indications:Solely - ankle and foot surgery. Post-operative analgesia for lower limb amputation.In combination with femoral nerve block for all surgery of the knee and lower legincluding amputations

Posterior Approach (Labat)Landmarks:Posterior Superior Iliac Spine (PSIS), Greater Trochanter (GT), Ischial Tuberosity (IT),Sacral Hiatus (SH)

Technique:• With the patient in Sim’s position, operative leg uppermost

• Draw a line connecting the PSIS to the GT, dropping a perpendicular from its mid-point

• Mark where this crosses a line joining the sacral hiatus and GT

Needle: 100mm insulated needleDirection: Perpendicular to the skinDepth: 50-100mmStimulation: Plantar flexion of the foot/toes (tibial nerve) - accept

Dorsiflexion/eversion of the foot (common fibular/peroneal nerve)- move needle medially

Volume: 10-20mlsLA: 1% Prilocaine , 1% Lidocaine

0.25% -0.5% Levobupivacaine

Caution: Avoid adrenaline containing solutions near the sciatic nerve. Bloodsupply may be damaged. When combining sciatic nerve blocks with lumbarplexus or femoral nerve blocks - a large combined volume of LA is used, carethat the max recommended dose is not exceeded.

Clinical tips: Place knee in line with PSIS and GT.

If unable to stimulate nerve move needle along the perpendicular line (sciatic nervemust cross this line).

(1) PSIS(2) Greater trochanter

(3) Sacral hiatus

1

2

Sciatic nerve block

1

2

3


Sciatic nerve block

FIGURE 67: Anterior approach to sciatic nerve

(1) Anterior Superior Iliac Spine(2) Femoral nerve(3) Pubic tubercle

(4) Sciatic nerve(5) Greater trochanter(6) Femoral artery

6

1

5

FIGURE 68: Anterior approach to sciatic nerve

1⁄3

1⁄3

4

2

1

3

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1⁄3

Anterior approach (Beck)Indications:As with other approaches

Landmarks:Anterior superior iliac spine (ASIS), pubic tubercle(PT), greater trochanter (GT)


• Draw a line connecting the ASIS to the pubic tubercle

• Draw a further parallel line from the greater trochanter

• Drop a perpendicular line from the junction of the middle and medial thirds

• Mark where the second and third lines cross

Needle: 100mm insulatedDirection: Directly posteriorly with slight lateral intent - touch the medial

aspect of femur - redirect to pass medially - a further 2-3 cms. (See figs 70 page 77 anterior and lateral approaches)

Depth: 80-100mmStimulation: As with other approachesVolume: 10 - 20mlsLA: 1% Lidocaine, 1% Prilocaine

0.25% -0.5% Levobupivacaine


Complications:Femoral vessel damage, accidental intravascular injection, nerve damage

Clinical tips:The sciatic nerve is two distinct nerves, tibial and common peroneal (fibular) they candivide anywhere in the thigh, but always bear the same relationship, tibial- medial,fibular (peroneal) -lateral

The more distal the sciatic block the more likely the risk of missing the posteriorcutaneous nerve of thigh.

Put non dominant hand under the buttock with a finger on the ischial tuberosity. Aimthe stimulating needle 1-2 cm lateral to this finger.

Caution: Avoid adrenaline containing solutions near the sciatic nerve.Blood supply may be damaged. When combining sciatic nerve blocks withlumbar plexus or femoral nerve blocks - a large combined volume of LA isused, care that the max recommended dose is not exceeded


Lateral approachThe sciatic nerve can also be approached laterally at more than one level as itpasses through the thigh

Technique:• Marking the posterior border of the greater trochanter, drawing a line parallel to

the femur distally

High approach • At the level of the ischial tuberosity (IT)

Mid-thigh approach (See Figures 69 & 70)• Half way between knee and greater trochanterNeedle: 100-150mm insulated needleDirection: Horizontally, if femur is contacted, either redirect posteriorly or move

insertion point slightly more posteriorly. High approach - aim for IT.Low approach - rotation of thigh to neutral helps location of tibial component.Depth: 8-12cm (high approach), 5-10cm (mid-thigh)Stimulation: as previous pageVolume: 10-20 mlsLA: 0.25-0.5% LevobupivacaineClinical tips:The sciatic nerve is two distinct nerves, tibial and peroneal (fibular), they can divideanywhere in the thigh, but always bear the same internal relationship, tibial- medial,fibular- lateral. Probably best to obtain plantar flexion (tibial twitch) for best effectBlockade of the sciatic nerve at mid thigh level will not block the posteriorcutaneous nerve of thigh - tourniquet discomfort.

Caution Avoid adrenaline containing solutions near the sciatic nerve. Bloodsupply may be damaged. When combining sciatic nerve blocks with lumbarplexus or femoral nerve blocks - a large combined volume of LA is used,care that the max recommended dose is not exceeded

FIGURE 69: Lateral approach

Sciatic nerve block

FIGURE 70: Anterior and lateral approach

3

Medial

1

(1) Femoral vessels(2) Femur(3) Sciatic nerve

2


FIGURE 71: Sciatic nerve block - inferior approach

Inferior approach (Raj)Indications: As with other approachesLandmarks:Greater trochanter (GT), ischial tuberosity (IT)Technique: (See Figures 71 & 72)

• With the patient supine, flex the knee to 90 degrees

• Draw a line connecting the GT to the IT

• Mark a point half way in the groove between the hamstring and adductor muscles

Needle: 50-100mm insulatedDirection: Perpendicular to skin, slight medial intentDepth: 40-80 mmVolume: 10-20 mlsLA: 1% Lidocaine, 1% Prilocaine

0.25% - 0.5% LevobupivacaineStimulation: As for posterior approachSide effects and Complications:As for other approaches

FIGURE 72: Sciatic nerve anatomy

(1) Ischial tuberosity(2) Greater trochanter

2

1

1

2

Sciatic nerve block


Indications:Solely - analgesia for fractured femoral shaft, post-op analgesia after knee surgeryCombination with sciatic- for knee and lower leg surgery with or without GALandmarks: Inguinal ligament, femoral artery (See Figures 73, 74 & 75)

Technique:• At a point 1cm below the inguinal ligament and 1cm lateral to the femoral arteryNeedle: 50mm insulated/uninsulatedDirection: 45º proximalDepth: 30-50mm

Two distinct “pops” may be felt (fascia lata, fascia iliacus/pectineus)

Stimulation: Patellar twitchVolume: 10-15mls (isolated femoral nerve) 20-30mls

(femoral and lateral cutaneous nerve of thigh) “2 in 1 block”. Note that the obturator nerve can not be reliably blocked by this route

LA: 1% Prilocaine, 1% Lidocaine 0.25% -0.5% Levobupivacaine

Complications:Vascular punctureInadvertent intravascular injectionClinical tips:Sartorius twitch - too superficialKeep close to the inguinal ligament as the femoral nerve divides soon after this.

Femoral nerve block

FIGURE 73: Cross section of femoral triangle

FIGURE 75: Femoral triangle anatomy

FIGURE 74: Femoral nerve block

743

(1) Sartorius muscle(2) Iliopsoas(3) Fascia lata(4) Fascia iliacus/pectineus

(5) Femoral nerve(6) Femoral artery(7) Femoral vein(8) Pectineus

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6

5

4

3

2

5

(1) Anterior Superior Iliac Spine(2) Lateral cutaneous nerve of thigh(3) Femoral nerve(4) Femoral artery

(5) Femoral vein(6) Inguinal ligament(7) Pubic tubercle

1

2

1

8

7


Indications:Anaesthesia lateral thigh (hip/femoral operations)

Landmarks:ASIS, inguinal ligament.

Technique:

• At a point 2cms medial / 2cms inferior to the ASIS (below the inguinal ligament)

Needle: 21- 23G 50mm uninsulated Direction: Perpendicular to skinDepth: 1-3cmEndpoint: Click as the fascia lata is pierced (infiltrate above and below the

fascia lata)

Volume: 10mls in total

LA: 1% Lidocaine, 1% Prilocaine

0.25% Levobupivacaine

Complications:Accidental femoral nerve block

Lateral cutaneous nerve of thigh block

FIGURE 77: Lateral cutaneous nerve of thigh anatomy

FIGURE 76: Lateral femoral cutaneous nerve block

1

(1) Anterior superior iliac spine(2) Lateral cutaneous nerve of thigh(3) Femoral nerve

2 cm

2 cm3

1

2

2cm

2cm


Knee/popliteal blocks


FIGURE 78: Popliteal fossa

FIGURE 80: Cross section at level of patella

FIGURE 79: Popliteal block - lateral approach

(1) Semimembranosus(2) Semitendinosus(3) Biceps femoris

(4) Popliteal artery(5) Tibial nerve(6) Common fibular nerve

c/s

Medial Lateral

4

6

5

6

7

(1) Patella(2) Vastus lateralis(3) Femur(4) Biceps femoris(5) Lateral head of gastrocnemius

(6) Common fibular nerve(7) Tibial nerve(8) Semimembranosus(9) Semitendinosus

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1

2

45

8

9

31

2

Indications:Ankle and foot surgeryLateral popliteal approachLandmarks:Patella, biceps femoris, vastus lateralisTechnique:• Flex the knee • Identify vastus lateralis above and the tendon of biceps femoris below• Mark the groove between, drop a line from the superior border of the patella • Mark the point of intersection (See Figure 78, 79 & 80)

Needle: 50mm insulated Direction: 15º caudad, 30º posteriorDepth: Common peroneal (fibular) 10-20mm, tibial 30-50mmStimulation: Tibial - plantar flexion of foot

Common peroneal (fibular) - dorsiflexion/eversion of footVolume: 10-15 mls at each nerveLA: 1% Lidocaine, 1% Prilocaine


1

Prone posterior approachLandmarks:Semimembranosus, biceps femoris and the popliteal crease.Technique:• With the patient prone and the leg resting on a pillow, flex the knee, mark the

popliteal crease• Palpate the apex of the fossa, marking the boundaries (lateral - biceps femoris,

medial - semimembranosus)• Draw a line from the apex to the middle of the popliteal crease• Mark a point 6cm - 8cm proximal to the crease and 1cm lateral

(See Figure 78 & 81)

Needle: 50-80mm insulated Direction: 45º proximal, moving laterally to identify tibial then common

fibular (peroneal)Depth: 30-80mmStimulation: Tibial - plantar flexion of foot

Common fibular (peroneal) - dorsiflexion/eversion of footVolume: 10-15 mls at each locationLA: 1% Lidocaine, 1% Prilocaine

0.25%-0.5% Levobupivacaine Side effects: Nil of noteComplications: Vascular punctureClinical tip: 75% of sciatic nerves divide within 10cm of the popliteal crease. If fine movementsof the needle cause both fibular and tibial nerves to be stimulated assume nervesare close enough together to use a single 20 - 30 ml injection of LA


Knee/popliteal blocks

FIGURE 82: Popliteal block - Supine posterior approach

Supine posterior approachTechnique:

• With the patient supine, flex the knee and hip to 90º, asking an assistant tosupport the leg

• Identify the borders & apex of the popliteal fossa

• Mark a point, 1cm lateral to the midline and 6-8cm proximal to the poplitealcrease(See Figures 78 & 82)

Needle: 50-80mm insulated Direction: Perpendicular to skin, moving laterally to identify tibial then

common fibular (peroneal).Depth: 40-80mmStimulation: Tibial - plantar flexion of foot

Common fibular (peroneal) - dorsiflexion/eversion of footVolume: 10-15 mls at each locationLA: 1% Lidocaine, 1% Prilocaine



Complications:Vascular puncture

FIGURE 81: Popliteal block - Prone posterior approach


Intra-articular knee block

Indications:Arthroscopy/postoperative analgesiaLandmarks:Lateral border of patellaTechnique:• With the knee extended, palpate the lateral border of the patella, inserting a needle

just beneath the patella into the jointNeedle: 19-21G 35mm Endpoint: Withdraw synovial fluid, easy injection Volume: 20-30mlsLA: 1% Lidocaine, 0.25%-0.5% Levobupivacaine

with/without 1:200,000 AdrenalineClinical tips:Always perform intra-articular injections under strict asepsisInfiltrate arthroscope portals with Lidocaine + AdrenalineThis technique can only be use without a tourniquetFollowing arthroscopy, injection may be repeated (as original LA is washed out), opiate may be added ie: morphine / diamorphine

FIGURE 83: Intra-articular knee block

Indications:Ankle and foot surgery (in addition to popliteal block - tibial + fibular nerves)Incisions over the antero-medial aspect of the lower legLandmarks:Tibial tubercle, medial condyle of the tibialTechnique: (See Figures 84 & 85)• Draw a line joining the tibial tubercle to medial condyle of the tibia, infiltrated

subcutaneously along this lineVolume: 10-20 mlsLA: 1% Prilocaine, 1% Lidocaine

0.25% Levobupivacaine Side effects:NilComplications:Bleeding (long saphenous vein)

Saphenous nerve block


FIGURE 84: Saphenous nerve block

FIGURE 85: Saphenous nerve anatomy

(1) Saphenous nerve(2) Saphenous vein

2 1


Indications:Forefoot and toe surgery

Landmarks:Dorsalis pedis (DP), posterior tibial artery, medial malleolus and sustentaculum tali

Technique:

Deep fibular (peroneal) nerve: (See Figure 92)

• 2-3 cm distal to the inter-malleolar line palpate the Dorsalis Pedis artery. Insert a 23-25G needle - medial & lateral to DP to bone, inject 2mls on each side

Superficial fibular (peroneal) nerve:• From the above point, infiltrate subcutaneously laterally and medially across the

dorsum of the foot to dorsum/plantar junction

Volume: 6-10mls

Tibial nerve:• Draw a line joining the medial malleolus to the posterior inferior border of the

calcaneum

• Mark a point just posterior to the posterior tibial pulse (half way)

Needle: 25-50 mmStimulation: Plantar-flexion toes, paraesthesia to the sole of foot/toesVolume: 5-8mls

Sural nerve:• Infiltrate subcutaneously from lateral malleolus to lateral border of Achilles tendon

Volume: 5mls

Clinical Tips:Use in conjunction with an ankle tourniquet for all minor foot surgeryPainful block in non-anaesthetised patient - sedation advised.

Sustentaculum Tali (ST) injection (Alternativeapproach to Tibial Nerve):• Palpate ST, prominence directly inferior to medial malleolus

• Insert 25G needle to pass beneath ST - depth 25mm - inject 5mls LA

Ankle and foot

FIGURE 86: Cutaneous innervation of foot and ankle

(1) Medial and lateral plantar (tibial) - sole of foot(2) Tibial nerve (calcaneal) - heel(3) Saphenous nerve (femoral) - medial side of foot variable innervation

to head of 1st metatarsal(4) Sural (fibular) - lateral margin of foot and fifth digit(5) Superficial fibular (peroneal) nerve - dorsum of foot(6) Deep fibular nerve - web between 1st and 2nd toe

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62 4

3

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1

2


FIGURE 87: Cross section ankle

FIGURE 89: Medial ankle

2

(1) Deep fibular (peroneal) nerve(2) Talus(3) Fibula

(4) Tibia(5) Medial & lateral plantar nerves (6) Sural nerve

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2

3

4

(1) Posterior tibial artery(2) Tibial nerve

(3) Medial malleolus(4) Calcaneal branch of tibial nerve

4

3

FIGURE 88: Tibial block

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Lateral

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5

1


FIGURE 90: Sural nerve FIGURE 92: Deep fibular nerve block

FIGURE 91: Lateral ankle

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1

(1) Small saphenous vein(2) Sural nerve(3) Lateral malleolus(4) Achilles tendon

FIGURE 93: Dorsal foot

(1) Superficial fibular nerve(2) Saphenous nerve(3) Extensor hallucis longus(4) Deep fibular nerve(5) Dorsalis pedis artery

1

3

4

5

2


Mid Tarsal Indication:Post-op pain control. Minor surgery of the forefoot or toes.Use in conjunction with an ankle tourniquet


• Palpate the metatarsophalangeal joint (MTPJ). Mark a point 2cm proximal to theMTPJ

Needle: Insert a 21-23G needle either side of the metatarsal to plantar aspect offoot. Inject 6-8mls while withdrawing needle

LA: 1% Prilocaine, 1% Lignocaine0.5% Levobupivacaine

Side effects: Pain with injection

Complications: Haematoma

Clinical tips: There will be no appreciable motor block

Digital nerve block and webspace blockSee pages 50-53 for similar blocks for the fingers

FIGURE 94: Mid tarsal injection

FIGURE 95: Mid tarsal anatomy

2

(1) Metatarsals (2) Digital nerves

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1

11

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SECTION SIX / PRACTICAL APPLICATION / 99

ShoulderCutaneous innervation Anterior/Posterior-supraclavicular nerves (superficial cervical plexus - C3-4),Intercostobrachial nerve T2Laterally over deltoid insertion - axillary nerve C5-6JointSuprascapular nerve (superior trunk C5-6)Axillary nerve (posterior cord C5-6)Lateral pectoral nerve (lateral cord C5-7)Analgesia - Suprascapular nerve block +/-superficial cervical plexus blockAnaesthesia / analgesia - Interscalene brachial plexus block Catheter techniques for extended analgesia / physiotherapyClinical tipsSupraclavicular/infraclavicular brachial blocks seldom block suprascapular nerve.

ElbowCutaneous innervationMedial cutaneous nerve of arm /forearm (medial cord C8-T1)Posterior cutaneous nerves of arm / forearm (radial nerve -posterior cord C5-8 +T1)Lateral cutaneous nerve of forearm (lateral cord C5-7)JointPrimarily by the musculocutaneous (C5-7), radial (C5-8, T1) and ulnar nerve (C7,8,T1)Anaesthesia / analgesia - brachial plexus block (supra / infraclavicular, axillary andmidhumeral)Catheter techniques for extended analgesia (supra / infraclavicular & axillaryClinical tipsTo ensure adequate cutaneous anaesthesia (axillary & midhumeral approaches) cutaneousinfiltration of medial cutaneous nerve of arm needs to be added (nerve lies outside of sheath).

Wrist Cutaneous innervationMedial cutaneous nerve of forearmPosterior cutaneous nerve of forearmLateral cutaneous nerve of forearmCutaneous branches of the median, ulnar and radialJointAnterior interosseous nerve (median)Posterior interosseous nerve (radial)Dorsal and deep branches of the ulnar nerve Anaesthesia / analgesiaSupraclavicular, Infraclavicular, axillary or midhumeral (interscalene - often misses lowerroots, ulnar border wrist and hand)Clinical tipsBier’s block (IVRA) suitable for minor superficial operations or ‘K’ wires.

Anaesthesia / analgesia for major jointsurgery / replacement

SECTION SIX

Practical application of peripheral nerveblocks

SECTION SIX / PRACTICAL APPLICATION / 101100 / SECTION SIX / PRACTICAL APPLICATION

Cutaneous innervation1. Palmar cutaneous branch of the median nerve - skin lateral palm/thenar eminence2. Medial/lateral branches of the median nerve - skin palmar surface, dorsum of

terminal digits & nail beds of radial 31/2 digits.3. Superficial branch ulnar nerve - skin of ulnar 11/2 digits.4. Palmar cutaneous nerve of ulnar - skin over medial palm and hypothenar eminence5. Superficial branch radial nerve - skin over dorsum of hand thumb and lateral

aspect.

Analgesia and analgesiaWrist blocks are sufficient with a wrist tourniquet for most minor surgery.Complete anaesthesia and immobility - midhumeral, axillary and infraclavicularapproaches to the brachial plexus.Surgery isolated to digits - web space or digital nerve blockBier’s block sufficient for all minor hand surgery + minor bone work MUA + K wires.

Clinical tipsPalmar cutaneous branches of both ulnar and median leave their respective nerveproximal to the wrist - ulnar mid forearm, median proximal to flexor retinaculum -passing superficial to it.

Cutaneous innervation in the hand is very variable

Hip Cutaneous innervationLower intercostal nerves- subcostal (T12) ilio-hypogastric (L1)Lateral cutaneous nerve of thigh (lumbar plexus L2-3)Superior cluneal nerve (dorsal rami L1-3)Joint innervationFemoral nerve (L2-4 - branch to rectus femoris)Obturator nerve (L3-4 - anterior divisions)Sciatic nerve (L4-S3 - nerve to quadratus femoris) Superior gluteal nerve (L4-S1)Analgesia - Lumbar plexus block - posterior or anterior +/- parasacral blockAnaesthesia - difficult to obtain complete surgical anaesthesia due to multiple innervationsand varied surgical approachesCatheter techniques can be used for extended analgesia i.e lumbar plexus block for femoralshaft fracturesClinical tips Complete anaesthesia / analgesia is best obtained with either spinal or epidural techniques

Knee Cutaneous innervationFemoral and saphenous nerve (L2-4)Posterior femoral cutaneous nerve (S2-3 - sacral plexus)Common fibular nerve (sural cutaneous nerve)Joint innervation Branches from femoral, obturator, tibial and common fibular nervesAnalgesia - lumbar plexus block - posterior/anteriorAnaesthesia - lumbar plexus + sciatic nerve +/- obturatorCatheter techniques for extended analgesia Clinical tipsAnaesthesia for arthroscopy can be achieved with intra-articular LA + infiltration of portals.For tourniquet add femoral nerve block.Sciatic and femoral blocks provide good analgesia but are not suitable as sole technique forknee replacement unless combined with light GA

AnkleCutaneous innervationSaphenous nerveSuperficial fibular (peroneal) nerveSural nerve (arises from both tibial and common fibular nerve)Tibial nerveJoint innervationTibial nerve and deep fibular nerveAnalgesia/anaesthesia - sciatic nerve block (above the knee) or tibial + common fibularnerve (popliteal approach).Clinical tipsSaphenous nerve should be included for all medial ankle operations Thigh tourniquet required - proximal sciatic nerve and femoral nerve block

FIGURE 96: Cutaneous innervation of hands

Hand

53

2

3

4

2

1

102 / SECTION SIX / PRACTICAL APPLICATION

Cutaneous innervation1) Medial and lateral plantar (tibial) - sole of foot2) Tibial nerve (calcaneal) - heel3) Saphenous nerve (femoral) - medial side of foot, variable innervation to head of the

first metatarsal4) Sural (fibular) - lateral margin of foot and fifth digit5) Superficial & deep fibular nerves - dorsum of foot6) Deep fibular nerve - web between 1st and 2nd toe

Analgesia and analgesiaDeep and superficial peroneal / fibular nerves + tibial nerve (behind medial malleoli) -sufficient for most toe surgery/ except little toe (sural nerve)- use in conjunction withANKLE tourniquet,Complete anaesthesia / immobile foot - tibial + common fibular (popliteal block) +saphenous nerve blockIf high tourniquet required - proximal sciatic nerve + femoral nerve block.

Clinical tipsThe foot is not immobile following an ankle blockAnkle blocks are uncomfortable to perform on awake patients - use sedation.

FIGURE 97: Cutaneous innervation of foot

Foot

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5

4

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4

3

1

1

SECTION SIX / PRACTICAL APPLICATION / 105104 / SECTION SIX / PRACTICAL APPLICATION

Catheter techniques

AdvantagesExtension of anaesthesia and analgesia into the post operative period - 24-72hrsExtended physiotherapy - frozen shoulder, complex regional pain syndromes (CRPS)72hrs - 7days

DisadvantagesTechnically more difficult to perform, larger needles, non standardisation of kitHigh failure rate - greater then 25%Labour intensive ie. Top ups, infusion pumps and nurse monitoring

General principles

• Catheter needs to ideally lie parallel/alongside the nerve or plexus being blocked• Therefore needle should be inserted as near to parallel to the nerve / plexus as

possible to facilitate this• Not so important when using Tuohy needle as catheter comes out at right angles to

the needle direction- in theory (in practice 45º)• Prior to passing catheter, distend the space with 10-20mls of saline or local anaesthetic• Only thread 3-5cms of catheter into space (unless using stimulating catheter – then

thread to target)• Always flush the catheter after insertion - avoids blockage with blood• Securely fix catheter (falling out! commonest cause of failure)

Commercially available kits

Cannula over needle - Catheter through cannulaAdvantagesCheap, smaller needle

DisadvantagesHigh failure rate • Needle is the only reliable indicator of position - stimulating nerve• When cannula is advanced off needle NO guarantee it will lie next to nerve (cannula

needs to be advanced millimetres not centimetres otherwise it will kink)• Cannula is often damaged by needle making it impossible to thread catheter• Catheter often difficult to thread, lack of rigidity - use 18G

epidural catheter- this is stronger, less floppy

Catheter through needle - Tuohy / Sprotte /Faceted tipAdvantagesCatheter placed at site of stimulation, more reliable placement

DisadvantagesNeedle size (18G)

Stimulating catheter AdvantagesReliable placement of catheter stimulating chosen nerve or plexus. Confirm position of catheter prior to bolus of local anaesthetic i.e. stimulating C5/6 for shoulderreplacementCheck catheter position during post-operative period and reposition as necessary(withdraw slightly)

DisadvantageCan be uncomfortable to place in awake patients, as saline must be used to distendspace rather than LAStimulating catheter is fairly stiff, can cause pain/paraesthesia on insertionCost

106 / SECTION SIX / PRACTICAL APPLICATION

Suggested regimes / postoperative care

All catheters need their position (non vascular/perineurally) and effect (anaesthesia/analgesia of the target plexus / nerve) confirmed prior to commencing infusion orbolus dosing

Therefore• If performing regional block before threading catheter - use short acting LA

(Lidocaine /Prilocaine) for block & long acting LA (Levobupivacaine) throughcatheter - if anaesthesia lasts longer than 4hrs - greater likelihood catheter is in thecorrect place.

• Always bolus catheter with a volume large enough to exclude intravascular placement (+/-adrenaline) prior to commencing continuous infusion,

• Allow block to wear off prior to bolusing &/or commencing infusion - guarantees position and effect

Bolus top-ups Brachial plexus / Lumbar plexus catheters Levobupivacaine 0.25% 20-30mls - 6-12hrsBolus injections should always be carried out in a controlled environment withresuscitation equipment available

Continuous infusionsBrachial plexus / Lumbar plexus cathetersLevobupivacaine 0.25% Levobupivacaine 0.1% +/- Fentanyl 2mcg/ml

levobupivacaine HCI

Equal efficacy and lower toxicity than bupivacaine1

Prescribing information can be found on reverse

Why take the risk?

Licensed indications and dosage guidelines 2

Adults Epidural – post-operative 150 mg 18.75 mg/hrpain

Epidural – obstetrics 150 mg 12.5 mg/hr

Intrathecal 15 mg N/A

Peripheral nerve block 150 mg 400 mg/24hrs

Ophthalmic blocks 112.5 mg N/A

Local infiltration 150 mg 400 mg/24hrs

Children Ilioinguinal/2.5 mg/kg N/AIliohypogastric blocks

Recommended max multiple dose or infusion

Licensed indications Recommended max single dose

Preparationsavailable:

2.5 mg/ml

5.0 mg/ml

7.5 mg/ml

NOTES

108 / NOTES

Chirocaine (Levobupivacaine Hydrochloride) Prescribing Information. Presentation: Threestrengths are available, 2.5 mg/ml, 5.0 mg/ml and 7.5 mg/ml of levobupivacaine as levobupivacainehydrochloride. Each strength is available in 10ml polypropylene ampoules in packs of 10. Indications: Adults:Surgical anaesthesia - Major, e.g. epidural (including for Caesarean section), intrathecal, peripheral nerve block- Minor, e.g. local infiltration, peribulbar block in ophthalmic surgery. Pain management - Continuous epiduralinfusion, single or multiple bolus epidural administration for the management of pain especially post-operativepain or labour analgesia. Children: analgesia (ilioinguinal/iliohypogastric blocks). Dose andAdministration: The precise posology will depend upon the procedure and individual patient concerned.Careful aspiration before and during injection is recommended to prevent intravascular injection. When a largedose is to be injected, e.g. in epidural block, a test dose of 3-5 ml lidocaine (lignocaine) with adrenaline isrecommended. An inadvertent intravascular injection may then be recognised by a temporary increase in heartrate and accidental intrathecal injection by signs of a spinal block. Aspiration should be repeated before and duringadministration of a bolus dose, which should be injected slowly and in incremental doses, at a rate of 7.5 -30 mg/min, while closely observing the patient’s vital functions and maintaining verbal contact. Therecommended maximum single dose is 150 mg. The maximum recommended dose during a 24 hour period is400 mg. For Post-operative pain management, the dose should not exceed 18.75 mg/hour. For Caesareansection, higher concentrations than the 5.0 mg/ml solution should not be used. For labour analgesia by epiduralinfusion, the dose should not exceed 12.5 mg/hour. In children, the maximum recommended dose for analgesia(ilioinguinal/iliohypogastric blocks) is 1.25 mg/kg/side. Contra-indications: Patients with a knownhypersensitivity to local anaesthetic agents of the amide type; intravenous regional anaesthesia (Bier’s block);patients with severe hypotension such as cardiogenic or hypovolaemic shock; and use in paracervical block inobstetrics. The 7.5 mg/ml solution is contra-indicated for obstetric use due to an enhanced risk for cardiotoxicevents based on experience with bupivacaine. There is no experience of levobupivacaine 7.5 mg/ml in obstetricsurgery. Precautions: Epidural anaesthesia with any local anaesthetic may cause hypotension and bradycardia.All patients must have intravenous access established. The availability of appropriate fluids, vasopressors,anaesthetics with anticonvulsant properties, myorelaxants, atropine, resuscitation equipment and expertise mustbe ensured. Levobupivacaine should be used with caution for regional anaesthesia in patients with impairedcardiovascular function e.g. serious cardiac arrhythmias and in patients with liver disease or with reduced liverblood flow e.g. alcoholics or cirrhotics. Interactions: Metabolism of levobupivacaine may be affected byCYP3A4 inhibitors eg: ketoconazole and CYP1A2 inhibitors eg: methylxanthines. Levobupivacaine should be usedwith caution in patients receiving anti-arrhythmic agents with local anaesthetic activity, e.g., mexiletine, or classIII anti-arrhythmic agents since their toxic effects may be additive. No clinical studies have been completed toassess levobupivacaine in combination with adrenaline. Side-Effects: Adverse reactions with local anaestheticsof the amide type are rare, but they may occur as a result of overdosage or unintentional intravascular injectionand may be serious. Accidental intrathecal injection of local anaesthetics can lead to very high spinal anaesthesiapossibly with apnoea, severe hypotension and loss of consciousness. The most frequent adverse events reportedin clinical trials irrespective of causality include hypotension (22%), nausea (13%), anaemia (11%), post-operative pain (8%), vomiting (8%), back pain (7%), fever (6%), dizziness (6%), foetal distress (6%) andheadache (5%). Other side effects include: CNS effects: numbness of the tongue, light-headedness, dizziness,blurred vision and muscle twitch followed by drowsiness, convulsions, unconsciousness and possible respiratoryarrest. CVS effects: decreased cardiac output, hypotension and ECG changes indicative of either heart block,bradycardia or ventricular tachyarrhythmias that may lead to cardiac arrest. Neurological damage is a rare butwell recognised consequence of regional and particularly epidural and spinal anaesthesia. This may result inlocalised areas of paraesthesia or anaesthesia, motor weakness, loss of sphincter control and paraplegia. Rarely,these may be permanent. Use in Pregnancy and Lactation: Levobupivacaine should not be used duringearly pregnancy unless clearly necessary. The clinical experience of local anaesthetics of the amide type includingbupivacaine for obstetrical surgery is extensive. The safety profile of such use is considered adequately known.There are no data available on excretion of levobupivacaine into human breast milk. However, levobupivacaineis likely to be transmitted in the mother’s milk, but the risk of affecting the child at therapeutic doses is minimal.Overdose: Accidental intravascular injection of local anaesthetics may cause immediate toxic reactions. In theevent of overdose, peak plasma concentrations may not be reached until 2 hours after administration dependingupon the injection site and, therefore, signs of toxicity may be delayed. Systemic adverse reactions followingoverdose or accidental intravascular injection reported with long acting local anaesthetic agents involve bothserious CNS and CVS effects. Special Storage Conditions: No special storage precautions for the closedampoule. Once opened, use immediately. Legal Category: POM. Marketing Authorisation Number:PL 0037/0300-0302. Basic NHS Price: 2.5 mg/ml pack: £16.60, 5.0 mg/ml pack: £19.00, 7.5mg/mlpack: £28.50. Further information is available on request from Abbott Laboratories Ltd, Abbott House, NordenRoad, Maidenhead, Berkshire SL6 4XE. PI/93/1/001. References: 1. Burke D, Bannister J. CurrentAnaesthesia and Critical Care 1999; 10:262-269. 2.Chirocaine Summary of Product Characteristics.

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