PERIPHERAL REGIONAL BLOCKS

by

Mike DeBroeck, DNP, CRNA

Why am I bothering with

this topic at all?

Do CRNAs REALLY

even do peripheral

regional anesthetics?

YES!!!!!!!

TOPICS

• GENERAL INFO

• SUCCESS RATES

• COMPLICATIONS

• LA CHOICE

• SPECIFIC BLOCKS

General Information

How do we use them?

• Peripheral regional blocks can be used as

primary or adjunct anesthesia for virtually

any surgery to the upper or lower

extremities.

• They are also useful for airway

management, abdominal surgeries,

maxilla-facial/cranial surgeries, neck

surgeries, eye surgeries, and plastics

procedures.

KEYS TO

SUCCESS…

KNOW THE

PHYSICAL

ANATOMY!!!!

KNOW THE

SENSORY/MOTOR

INNERVATIONS!!!

GET COMFORTABLE WITH

ULTRASOUND

LEARN HOW TO USE A

NERVE STIMULATING

NEEDLE PROPERLY

MANAGE TIME

EDUCATE SURGEONS

EDUCATE THE STAFF

EDUCATE PATIENTS

SUCCESS RATES

SO, HOW GOOD ARE

THEY, REALLY?

SUCCESS RATES FOR MOST

SINGLE SHOT BLOCKS, WHEN

PERFORMED WITH THE PROPER

TECHNIQUE, EQUIPMENT, AND

TRAINING WILL RUN INTO THE

90% RANGE.

INDWELLING DEVICES HAVE A

SLIGHTLY LOWER SUCCESS RATE.

INDIVIDUAL SUCCESS

RATES TEND TO PARALLEL

PROPER USE OF

EQUIPMENT, PROPER

TECHNIQUE, AND

ADEQUACY OF TRAINING

COMPLICATIONS

• Local anesthetic systemic toxicity– Intravascular injection

– Choice of LA

• Neurotoxicity/Nerve injury– Intraneuronal injection

• Patchy block

• Block failure

SO WHY DON’T WE USE

THEM MORE?

WE’RE TOO LATE

PUTTING THEM IN.

THIS IS A FUNCTION OF SCHEDULING

WE DON’T WAIT LONG

ENOUGH FOR THEM TO SET

UP

THIS, TOO, IS MOSTLY A FUNCTION OF

SCHEDULING

WE’RE TOO SLOW

PERFORMING THE

PROCEDURES

This is a function of training and experience

”THE WAY YOU PRACTICE IS THE WAY YOU

PLAY”

LOCAL ANESTHETIC

CHOICE

PICK THE RIGHT DRUG FOR

THE RIGHT OUTCOME.

What are you trying to

accomplish?

• Quick onset?

• Long duration?

• Differential blockade?

• Adjunct to general or neuraxial

anesthesia?

• Post-op pain control?

• Sole anesthetic?

Amide vs Ester

• PROPERTIES AMINOESTERS AMINOAMIDES

• Metabolism rapid by plasma cholinesterase slow, hepatic

• Systemic toxicity less likely more likely

• Allergic reaction PABA derivatives form very rare

• Stability in solution breaks down (heat,sun) very stable

chemically

• Onset of action slow as a general rule moderate to fast

There is no ‘perfect’ LA

• EITHER:– RAPID ONSET

– SHORT DURATION

– LOW POTENCY

– LOW TOXICITY

• OR: – SLOW ONSET

– LONG DURATION

– HIGHER POTENCY

– HIGHER TOXICITY

LIDOCAINE,

PRILOCAINE,

MEPIVACAINE

BUPIVACAINE,

ROPIVACAINE,

Without epi with epi

Amide LA Max

Dosage/Concentration/Procedure

Recommendations

ADJUNCTS

• Epinephrine – 5 mcg/ml

• Clonidine - ∝2-adrenoceptor agonist***

– 100 mcg = 100 extra minutes

– More just gets more side effect

• Dexmedetomidine -- 0.75mcg – 1mcg/kg

– Faster onset, longer duration

• Dexamethasone – 1-2 mg vs 8-10 mg?

– Longer duration but neural toxicity?

BLOCKS

•BRACHIAL PLEXUS

•FEMORAL NERVE

•SCIATIC NERVE

BRACHIAL PLEXUS

BLOCKS

Brachial Plexus Anatomy

Innervations

Block Choices

• Interscalene

–High

–Low

• Supraclavicular

• Infraclavicular

• Axillary

• Mid-humeral/rescue blocks

• Wrist

Interscalene

Surgical Coverage

Landmarks: Cricoid cartilage, posterior border of

sternocleidomastiond muscle, and external

jugular vein

C6

EJVSCM

CLAVIC

LE

Note neddle insertion

perpendicular to neck with

slight caudad angulation –

never cephalad

Ultrasound Positioning

Supraclavicular

Surgical Coverage

Surgical Coverage

Ultrasound Positioning

Infraclavicular

Surgical Coverage

Ultrasound Placement

Axillary

Surgical Coverage

Ultrasound Positioning

Midhumeral/Rescue

Blocks

Midhumeral (Upper 3rd) View

3 Often Needed Supplementals

All blocked at axilla with single generous SC injection.

Intercostobrachial Nerve Block

Lower Extremity Blocks

• Lumbar Plexus Block

• Femoral/3 in 1 Block

• Adductor Canal Block

• Saphenous Nerve Block

• Sciatic Nerve Block

• Popliteal Block

• Ankle Block

• Mayo Block

Femoral Nerve Block

1 cm lateral

to artery

2 cm below & 1

cm medial to

ASIS

Surgical Coverage

Patella elevates with Stimulation

Ultrasound Positioning

Adductor Canal Block

Ultrasound Positioning

Sciatic Nerve Block

Classic Position and

Landmarks

3cm

Ultrasound Positoning for

Subgluteal Approach

LLE Lateral

View

4 cm2 cm

Popliteal Nerve Block

Landmarks

Ultrasound Positioning

Alternate Positioning

So…what’s the take away?

OUR PRACTICE WORLD IS

CHANGING!

Two Huge Players in Our Future

• Hospital Value Based Payment system– HCAHPS (Hospital Consumer Assessment of Healthcare

Providers and Systems) Survey – Based in part on these scores, hospitals can either lose

or gain up to 2% of reimbursement dollars in fiscal year 2017.

– Value-Based Payment Modifier. This will adjust physician reimbursements based on quality of care as defined by the Secretary of HHS and cost compared to other physicians. Essentially this will establish an arbitrary cut-off for acceptable physician costs and those physicians above this threshold will be punished.

• Practice Model adjustment based on ACA decreased reimbursement

What does that mean for us?

• All anesthesia providers need to be efficient as well

as proficient

– Potentially less physicians and MDAs as regulatory

burden increases and salaries and job satisfaction

decrease

• CRNAs will need to step up and provide care to

their full scope of practice even in non-rural,

non-military environments

– This will mean gaining or re-acquiring skills for many

practicing CRNAs

– Schools will need to be more aggressive in training

SRNA for the future job market.

So how does that translate for me as a provider right now?

New Skill Sets….• Ultrasound proficiency is now a

must.

• Basic peripheral regional block skills are a must.

• Greater use of peripheral regional blocks for improved patient satisfaction.

• Non-traditional roles for value added services to hospitals/patients

Things we’ve kind of always done…

• Interscalene block• Femoral nerve block• Lumbar plexus block• Sciatic nerve block—Labat• Ankle block• Wrist block• Spinals• Epidurals

Things we’re going to need to master…

• All of the previous blocks using US

• Supraclavicular and Infraclavicular blocks under

US guidance

• Multiple variations of sciatic blocks—lateral,

anterior, popliteal—under US guidance

• Adductor canal block under US guidance

• Suprascapular nerve blocks under US guidance

• Better isolation of particular nerves for blockade

so as to preserve as much function as possible

for earlier/faster discharge and greater pain

control

New Trends…and yes, they alluse ultrasound

• Transversus abdominus plane (TAP) block

– Mid axillary and subcostal

• Rectus sheath block

• Paravertebral block

• Pectoral nerve (interfascial plane) block

(PECS I and II)

• Fascia iliaca block

• Ilioinguinal block

• Greater occipital nerve block

Down the road…..• Exparel to replace catheters???

• Better collaboration with surgeons on

exactly where they will be operating and

what postop expectations are

• Change the way we do blocks with an eye for

efficiency– Block room

– Block team

– Equipment/Drugs standardization

– Simple pain service interventions even at small places

• Stop the madness of ‘room air general’ on

top of blocks unless absolutely necessary.

Peripheral regional blocks

ARE our job, but to do them

you have to properly trained,

properly equipped and have

the cooperation of both the

patients and the surgeons.

QUESTIONS?