mackenzie kuhl, do marquette general hospital august 2013 regional techniques
TRANSCRIPT
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MACKENZIE KUHL, DOMARQUETTE GENERAL HOSPITAL
AUGUST 2013
Regional Techniques
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Regional Techniques
Neuraxial nerve blocks Spinal anesthesia Epidural anesthesia
Peripheral nerve blocks Upper extremity (Brachial plexus blocks)
Axillary nerve block Supraclavicular nerve block Interscalene nerve block
Lower extremity Femoral nerve block Sciatic nerve block Popliteal nerve block
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Neuraxial techniques
Neuraxial techniques are used for pain control for operative anesthesia, obstetric anesthesia, and chronic pain management
Spinal Single shot technique in which local anesthesia +/-
narcotic is placed into the subarachnoid space, used for surgical anesthesia
Epidural Catheter based technique in which local anesthesia
+/- narcotic is placed into the epidural space, mainly used for postoperative pain control
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Spinal Anesthetic
Local anesthetic +/- narcotic placed in subarachnoid space
Usually done at lumbar vertebrae (L3-L4, iliac crests)
Dermatomal level T4 level for C-section T10 level for hip and knee procedures
Lidocaine 1 hour duration
Bupivacaine 2-3 hours duration
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Dermatomal patterns
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Neuraxial techniques
Catheter placed in the epidural space under aseptic conditions
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Epidural Anesthetic
Catheter based technique in which local anesthetic +/- narcotic is placed in epidural space
Usually done at lumbar and thoracic vertebrae for postoperative pain control (cervical nerve roots for chronic pain management)
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Catheter being placed
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Indications for neuraxial techniques
Orthopedic Total knee and hip arthroplasties, ankle surgeries
General Exploratory laparotomies, breast cancer surgeries
Vascular AAA repair
Genitourinary TURP’s, nephrectomies, open prostatectomies
Obstetric Cesarean section
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Absolute contraindications to neuraxial anesthesia
Infection at the site of injectionPatient refusal or inability to cooperateCoagulopathy or other bleeding diathesis
Platelets>100,000 and INR <1.4Severe hypovolemiaIncreased intracranial pressureSevere mitral/aortic stenosisAllergy to local anesthetics
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Complications of neuraxial techniques
Physiologic responses Urinary retention Hypotension High block Nausea Pruritus
Related to needle/catheter placement Backache Postdural puncture headaches Neural injury Catheter shearing or tearing Inflammation Infection Bleeding
Drug toxicity TNS Cauda equina syndrome Systemic local anesthetic toxicity Respiratory depresssion
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ASRA guidelines
Subcutaneous UFH (5000U BID) Twice daily dosing (5000U)
No contraindication to neuraxial technique Because HIT may occur, ASRA recommends that patients receiving
heparin for more than 4 days receive a platelet count prior to epidural placement or removal
Thrice daily dosing Must weigh risks vs benefits on individual basis
LMWH Once daily dosing (40mg SQ)
Must wait 12 hours from last dose for neuraxial technique Twice daily dosing
Must wait 12 hours from last dose for neuraxial technique, must remove epidural catheter postoperatively before instituting
Dabigatran Must wait 72 hours prior to neuraxial procedure
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Benefits
• 528, 495 patients undergoing primary knee or hip arthroplasty Memtsoudis, et al. Anesthesiology May 2013; 118: 1046-1058
Decreased 30 day mortality Decreased prolonged length of stay Decreased transfusion requirements Decreased in-hospital complications
Pulmonary embolism Pulmonary compromise CVA Acute renal failure
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Benefits
Reduction of postoperative mortality and morbidity with epidural or spinal anesthesia: results from overview of randomized trials (9559 patients) Rodgers, et al. BMJ December 2000; 321(7275): 1493
Decreased DVT by 44% Decreased PE by 55% Decreased transfusion requirements by 50% Decreased pneumonia by 39% Decreased respiratory depresion by 59% Decreased myocardial infarctions
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Benefits
Anesthetic Technique for Radical Prostatectomy Surgery Affects Cancer Recurrence, Biki, et al. Anesthesiology Aug 2008; 109: 180-187
Open prostatectomy with GA plus epidural postoperative analgesia was associated with less risk of biochemical cancer recurrence
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Why?
Altered coagulationIncreased blood flowImproved pulmonary mechanicsReduction in surgical stress responses
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Peripheral nerve blocks
Peripheral nerve blocks Upper extremity (Brachial plexus blocks)
Axillary nerve block Supraclavicular nerve block Interscalene nerve block
Lower extremity Femoral nerve block Popliteal nerve block Sciatic nerve block
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Peripheral nerve blockade
Primary anesthetic for peripheral limb surgery Mainly done with direct visual ultrasound and nerve
stimulation Inject local anesthesia around nerves to obtain surgical
anesthesia or postoperative pain control Benefits
Excellent pain control Decreased narcotic use
Risks Bleeding Infection Nerve damage Systemic local anesthetic toxicity
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Brachial plexus
The brachial plexus is responsible for cutaneous and muscular innervation to upper arm except with two exceptions:
The trapezius muscle innervated by the spinal accessory nerve and an area of skin located in the axilla which is
innervated by the intercostobrachial nerve
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Brachial plexus blockade
Axillary nerve blockSupraclavicular nerve blockInterscalene nerve block
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Axillary nerve block
Anesthesia to arm, elbow, FOREARM and HANDBlocks median, ulnar and radial nervesUsually misses musculocutaneous
nerve, must block separately
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Axillary nerve block
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Supraclavicular nerve block
Anesthesia to ARM, ELBOW and hand (“spinal of upper extremity”) Blocks median, ulnar and radial nerves Risk is pneumothorax
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Supraclavicular nerve block
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Interscalene nerve block
Anesthesia to SHOULDER, upper arm and elbow Blocks median, ulnar and radial nerves Patients may develop ipsilateral Horner’s syndrome
and diaphragmatic paralysis (due to phrenic nerve block)
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Interscalene nerve block
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Lower extremity nerve blocks
Femoral nerve blockSciatic nerve blockPopliteal nerve block
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Femoral nerve block
Anesthesia to anterior thigh and anterior knee
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Femoral nerve block
Anesthesia to anterior thigh and anterior knee
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Sciatic nerve block
Anesthesia to posterior aspect of the thigh, hamstring, part of hip and knee joint, and the entire leg below the knee except for medial aspect of lower leg (innervated from saphenous nerve)
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Popliteal nerve block
Anesthesia for ankle and foot surgery