Peripherial Blocks Part 1

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Regional Anesthesia for Anesthesiology
NursingPeripheral Nerve Blocks-Part 1 Jeffrey
Groom, MS, CRNA, ARNPClinical Associate
ProfessorAnesthesiology Nursing ProgramSchool
of Nursing Florida International University
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Peripheral Nerve Blocks

• Brachial Plexus-Interscalene,Axillary
• Bier Block- Upper Extremity
• Awake Intubation-Tracheal Blocks
• Eye Block- Retrobulbar

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PERIPHERAL BLOCKS

• GENERAL CONSIDERATIONS
• PreOp Assessment
  same STANDARD of CARE
• Examine block site
• Medications ? Bleeding ? Infection ?
• Patient Ed/Info and Consent
• Back-up Plan
• Documentation

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Peripheral Nerve Block
SPINAL
Epidural/PNB

• Small volume
• Direct-Sheath
• Rapid onset
• Total neural block

• Large volume
• Outside-Sheath
• Slow onset
• Block varies with dose

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PERIPHERAL vs. CENTRAL
ADVANTAGES DISADVANTAGES

• Segmental block
• Slow onset time to Rx side effects
• Flexibility in density
• Flexibility in duration
• Less side effects

• More technical more failure
• More time consuming
• Greater LA volume- gttoxicity risk
• Faulty block

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RISKS ANATOMIC

• PRIMARY Direct Nerve Injury
• SECONDARY - Associated Injury ie. pneumothorax,
  hematoma

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Lidocaine
RISKS
PLASMA
Bupivacaine
TOXICITY
CNS
Rx
CV
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CONTRAINDICATIONS

• ABSOLUTE
• Patient Refusal
• Sepsis or Infection at injection site
• When blockade would hinder proposed surgical
  procedure

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CONTRAINDICATIONS

• RELATIVE
• Patient Appropriateness
• Local Infection near injection site
• CNS Disease
• Prior block with difficulty

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PERIPHERAL NERVES

• Nerve Fibers-A,B,C
• Large,medium,small
• Nerve Function
• Motor
• Sensory
• Sympathetic
• Unmyelinated vs. M

DIFFICULT - - - - - - - - - EASY
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TECHNIQUE

• Sterile Technique
• Needles - 22ga / B-bevel Insulated Needles
• Parasthesia
• Nerve Stimulator POS - Ground NEG -
  Needle TWITCH _at_ .5-1 mA

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Drug Dosage

• VOLUME - spread related to volume
• DENSITY - related to concentration
• ONSET - rapid onset /- NaHCO3
• DURATION - drug /- EPI

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PreOP Preparation

• SAME Routine - Standard of Care
• PreOp Sedation/Narcs ?
• Monitors (EKG, BP, Pulse Ox) ?
• Block Room or OR Room ?
• Stimulator, Needles, Drapes
• Emergency Equipment
• Personnel and Communications

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Peripheral Block Technique

• Position Patient - Locate Landmarks
• Open Tray - Needles - Drugs
• Baseline Vitals - Position Patient
• Glove - Prep Patient
• Draw up Drugs - Sterile Tray Setup
• Localize Skin
• Approach - Parasthesia vs Stimulator
• Injection

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Peripheral Nerve Blocks

• Cervical Plexus- superficial vs deep FOR
  CAE, Bx, Neck
• COMPLICATIONS Phrenic, SAB/EPI, Artery,
  Cervical sympathectomy, Recurrent Laryngeal
• 10 ml per process

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Peripheral Nerve Blocks

• Brachial Plexus- Interscalene,
  Supraclavicular Axillary
• Anatomy Function
• 20 - 40 ml Local
• Complications

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AXILLARY - TRANSARTERIAL
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Prep the site
Localize the site
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Palpate the artery
Inject on both sides of the artery
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Peripheral Nerve Blocks

• Bier Block- IVRegional Upper Extremity
• Hep-Loc, 2x TQ
• Esmarch Bandage
• TQ SBP 150 mmHg
• Inject 50 ml .5 LIDO
• TQ Pain - Deflate (25min) Sequential

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Peripheral Nerve Blocks

• Awake Fiberoptic Intubation- Tracheal Blocks
• Glossopharyngeal
• Superior Laryngeal
• Transtracheal
• Oral Topicalization Prep
• 2 - 3 ml LIDO

CAUTION Following topical block pt is without
airway reflexes!
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Laryngeal Innervation

• The larynx and trachea are innervated by branches
  of the vagus nerve. The superior laryngeal nerve
  carries sensation from the base of the tongue and
  the inferior epiglottis to the vocal cords. The
  recurrent laryngeal nerve caries sensation distal
  to the vocal cords.
• The superior laryngeal nerve travels inferior to
  the greater cornu of the hyoid bone and divides
  into internal and external branches. The internal
  branch pierces the thyrohyoid membrane with the
  laryngeal branch of the superior thyroid artery.
• The muscles of the larynx are supplied by
  branches of the vagus nerve. The cricothyroid
  muscle is supplied by the external branch of the
  superior laryngeal nerve. All of the other
  intrinsic muscles of the larynx are supplied by
  the inferior laryngeal nerve, a continuation of
  the recurrent laryngeal nerve.

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glycopyrrolate
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Peripheral Nerve Blocks

• Eye Block- Retrobulbar Peribulbar
• Anatomy
• Analgesia
• Complications - hemorrhage, OCR, CNS

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Assessing Block

• ONSET - 5 - 10 minutes
• POSITION
• DENSITY - Sympathetics
• Sensory
• Motor

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COMPLICATIONS

• HYPOTENSION - IV Fluid Pressors
• HEMATOMA direct pressure
• SYMPATHECTOMY- Treat symptoms
• PostOP Neuropathy-PNB may mask SS

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DOCUMENTATION

• Procedure
• Position and Monitors
• Skin Prep
• Landmarks Approach
• Skin Localization
• Needles - type, guage, length
• Puncture- , /- Blood, /- Paresthesia
• Nerve Stimulator
• Drug- Concentration, dose, Lot Number

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QUESTIONS ?