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Pocket compendium of peripheral nerve blocks Gisela Meier MD Johannes Bittner MD The English version t was revise / y Dag Selander MD, PhD | We mn 4 Arcis Publishing Company Cate 1h \n wow i wh 7 fe Ti oso ond hg iting congo hove win he nrmotan themed.egions ond he dongs th uo cre ‘umes ofthe oho ei oe ‘tos commandos i oder 1S denage acormerdsons ond Enmore oe 180 dupe which he ose nn a a own denon joer vodemaks ct, ode names, ot arent wal knw o ‘fttncom nbc rh apc todenok or adeno Al hts served, pac, he igh of erection ond ‘ho romain Ne po of is wok moy be proceed Sed ny oe here Pty, min Oy Pubes wine cote Poge Contents 2 Prolce 3 Rove ofthe mow! inperton local aneshetes 3 Soneral chica ond aay onpacte Cores perpharal nerve cots for po, anogesio Upper extremitos 8 Aebomy ow bret plows 10 Sernry spy of the oper enemies 11 Upper abumty moor espa to nerve simuloon 12 Inrscalne ples back ace Moe] 14 Iirccvir pon lok lox Kiko, Giga, Mere 16 Siprosopuar nee Hock ace Mot) 18 Rloy pone block 20° Blacks inthe wpper arm raion alate acne mbumera, oc, Dupré 22 “Rodel rane i i i i i i i i 1% Sayan be |. ae yee i i i i i i i i 28. Block in the wri rogion [writ block") Medion 90 “Rodd nave Lower extremities 32 Anatomy fhe mboscral plows 35, Sconry spp of he lower esromibes {37 Serory supply fhe bony srucre 38 Paaos compormon block fee. Chaye) {80 Femorl rare block the nual agen (oe. Win, Rosenblt 92 Sihwctr rare Bock ‘34 ronglma coe nave Beck oc. Lobo 4S URofadighicd cite vere boc ace fo) ‘33 Arora sion neve block foc. Ma 30 Oud ste nerve block ce. Moser 52. Sophencus nerve bask ‘54 Common prone! nore Block 136. Sods ler‘ononseria nthe fot onl locks) Sipafiil peroneal ere 58 “Deap perone! nerve 60 “Posenor ia nave | iil [SaeeceEE SES The development of anaeshesia is curently affected by the growing in ean aja noni ond onli paedar Noe wa increasing iret in peripheral nerve blocks, end in many cles th use sins method is prafred fo he cntl blocks whenever Ponte Becoming ictcsingly mare common. Whol she eason a he gio inerest ond what mekes te greater educational and proctcalefbar involved in he use of regional Blocks wore Fil fs te ingen fo papi cee Fospertve tats ocap A be ood pana Sind frcapciny coined tsa colar pas cea gal cpr engl angers winglets prance saly mobleaten and uct chblions ions. This com The effects of regional anaesthesia [most in the form of cen nevraxial block) on various outcome porometes were demonsiated in he CORTRA meloancy Rodgers tl, M2000; 3211479) ated onthe wv gston Ta incl ies inching opposing 10,008 poe Poti! groups who underwent sugery under general ancesheta were compared fo hose who eiherreceved regional onceshesia or combined generale ares Accordng oh eh, raponelenoae ‘sia reduced postoperative complications ond the overal potoperave mmrtly rote by Z0%, The auhors concluded tho! the most Fly Fecton forthe reduction of postoperative complications was the deceased ar ‘operative sess response de to regional oncesthesio block. Furhermore, ware well owar ofthe potential isk of sever pois devel ‘ping into. « chronic pein condition, a situation that can and should be toidad The mol efale way to prevent pain om becoming chon comprises regional anaesthesi techniques that block the pain stimulus ‘ear is origin, both per ond postoperatively thereby eliminating acule pain os special postoperative risk focter. The continuing development of regional onaeshesia ond analgesia i important when considering the cspects desibed above bul here are til ond econ psn viw ich cal owe ‘egional anaesthesia, Wi hi compendium of peripheral neve blocks tre proven bre evew ofthe mos commonly oed echniques. Thereby. we hope to simulate the intrest ond understanding among ou colleagues {orth use of regional anaesthesia Yachniques Action time of Fegional enaesthetics: Intraoperative and postoperative anal- ‘es + Sion infson before ont of pos operative thon il al Review of the 2 468 Scene 075% 0.75% ine 0.2% (-.0.375%) Yo 12 14 hours _Qverview ofthe most important local anesthetics for peripheral nerve Subsonce | Concantaion | Dosage’ | Tine unit | Analgesic ‘Arcesherio | Aroesbero | aiecie | acon tine ‘Anclgeia | Analgesia Ropivacaine | 05%.075% | vp 300mg | 10-20 mn Tah (Nain) _['07%.0375% | vp 28 mg/h Licoine Tet7% | wpe 500mg | 10-20nm] 2-ah Mopivocsine | 1507 wp 300mg | 10-20min| 3-ah “noose Prats] Danitwion | Elimination potency aio | binding ts) | volume | hale rworecane= 1 in plasma Ropinoco 6 % » 1 ioc ‘ o 1 le Mepiccine “ 75 au 1 Apaid een 7 ancora” rcarandaford] Repnocoie Foroucble acive dots roto * Good diferent! Bee onsen >> motor bloc) ot lower concentrations ‘ed br onlgeso Lidocoine Local aroeahehc wih medium acion tne and ow oily Neprocane * fecwens conor scam etfs ox on ih ng OEE General technical aspects on peripheral nerve blocks 1 Use septic tchnique. + Resuscitation equipment and drugs should always be availabe ‘when regional anesthesia fs wed i © Local cutaneous infitration anaesthesia, * Skin incision wih lnc before isan of shortbeveled noodle (eg. 45" bevel) ng * Nerv stimulation: Ascending om 0.1 - 1.0 mA, vl vibe muscle contactions inthe corresponding Innervation grea; then redstog te between 0.30.5 mA/O ms bear inecon of he Ioel ones + fepecied aspiration atemptsbeore and during injection of the local sxceshat A negotve auction does nl compo td an inrvasclor needle positon '* With larger doses of «local anaesthetic, use fractional injection and verbal patent menting for eoryrecogniton of cecil novos Car injection * In poorly cooperaive potent, poten under sedation or when porloring a block dso ocn'eablahed conta ok e herve block nthe presence of spinel ances] serve and unipolar needle should be used (no neuromuscular r¢ Exception: Inlration anaesthesia of purely sensory nerves ‘© Catheter technique: Placement ofthe cathelr tip 3-5 em tip ofthe introducing needle, Yo be inserted normally after it the looding dose of he local anaesthetic, '* Monitoring: When performing blocks inthe head ond neck when larger doses of local anaesthetic are used the patient tae on conul, ECG and pulse oxime applied block. Standard monitoring inelvdes ECG, pulee oximelry, sure and the degree of consciousness, ‘© Catheter: Doily control of the catheter insertion site, writen tation (see p. 7). ‘Side effects, complications /contraindications (general) Side effects and complications ‘Systemic toxicity of he local anaesthetic ‘Mest common reason’ Unintended intravascular injaction Minimize risk by Adhering he recommended dosages Repeated aspiration and lracional injection Slow injection, observe ond maintain verbal contact with the patent (NB: ngatie aspiration does ot ently exclude Intravasculor injection! Nerve damage (extremely rare) Minimize risk by Trying o avoid porestesias when inserting the needle Correct use ofa suitable nerve stimulator [2 0.3 0.5 mA/ Onl ms) + The use of atraumatic needles Hematoma Minimize rik by = No blocks in the presence of o clinically monifest coagulation disorder or anicoogulation treatment Infection (specially when ving continuous lechnique Minimize vk by Ba = Aseptic needle insertion Regia lned checks of he cee inarion site ost cones a day) ost sense indicator: Tenderness tthe pint of cathotr ery (equies mmedioe removal of theca General contraindication to regional anaesthesi Rejection ofthe echigu by he pain Cincoly menos cosulanon serdar Inecion or honors oth econ ste Eeloive conindicaton: Newey deci previous doen fofon cso ee Sa Sn Visits 1 Atlecs once @ doy ="Check catheter insertion site fies afecvanee ‘nelyse indication cra Cereltdocimenation (0p. 7) «Incase ofnsficoneectvaness Catheter postioned corey? Dislocated? In cose of patil eflectvenes: Injection of « bolus (2.9, 20 mi ropivacaine 075%) Suppiementalanolgesic [NSAID, opiods orally os needed Akdtonal pain mecication when ‘omevng eater ‘© Duration of treatment Up to 4-5 days - depending on the indication. (For chronic pain therapy a duration of more thon 100 days hos been Sescribed } «Analgesic catheter can be used in outpatients, but the corre jing prerequisites must be considored Requirements for @ nerve stimulator (cc. to Kaiser) Blciicl yout ‘dtiobe constont current inthe presence of lod of 03-10 kohm i = Monophosc squore ouput impulse SSIS toe walk (017 18 ms) Impulse amplitude (0 - 5.0 mA] with precision adjustment ond diol caplay ofthe ec! eure = Inpule Frequency 1-2 He Safety device ~ Alorm upon interruption of circuit ‘Alarm when the mox. impedance is exceeded ‘Alarm when an error occurs inside the device Unmistokoble assignment of ~ Adele operon instructions fr we, indeting he devaons toler Seo The brachiol plexus is formed by the ventral rami ofthe C5 to Thi Iworiably C4 Gnd Th2) spinel nerves © pero nk medal onabrochio tones Irom verti C5 and C5) 8 mada bach coronao n 1 mid rn ' Intrcanobrocl From ventls C7) 10 inercoal 1 inl an 1 irc m8 {fom yeorales C8 ond Tht) 12 long horace m 4 Lora cord '§ pot card 1 Noche cod 1 sprcopuar 2 maclocsonovs 3 aaiery a fatal, Hee Q f A. Bs Secinal plone nh inhaclovclr and allay region. Pee not the pasion ole corde, Anaesthesia techniques for blockade of the upper extremities, + lterscalene brachial plexus block (interscalene block, ISB) ace to Meier + Vertical infaclaviclar plexus block (vertical infraclavcular block, VIB) * Suproscapulor nerve block © Axillary plexus block * Blocks inthe upper arm region (midhumercl approach, radial n Blocks inthe region ofthe elbow (radial, musculecutaneous, median, ulnar nerves) «Blocks inthe wrist region (radial, median, vlnor nerves) ay a supply of the 2 oxillary cone a = brochal. rorlocwanecs ee 5 omebrochiah 10 medion ‘Samana dora iredain Cee eee Motor functions hie perghert Upper extremities «@ rodiln 5 tredion «ln AG precsictoncun 0 (oes: to Mai Patient position ond method: Patient spine Guiding structures: Lateral border of the sernoclidemasted m, interscalenus groove The insertion si io th evel othe thyroid nth fapros’ 2 cm cbove ther fh zd cio the poner ee esos masiid mule. The direction of inserion i clong he inlreslna prose {in caudal ond loool direction) ot on angle of operon, 30° to he sin Stimulus response: Deloid m. biceps m. Injection of he ical cnaethetc wien on adequate simul response of 0? mA/O.1 msi reached ‘Comments on the technique: {© The ciming point i in the middle third of he clavcula ‘© The subclovian 0. morks the caudal end of the inlarscolene groove. Icon be identified by polpation or with the oid ofa vascular doppler. ic the diferonce tothe clonsica imrscalee opproach aco Win etanciry eve 1 ew cere rete te peer tbr cl Wecte beacon beck the dieckn al he neal oer i conas fo Wins neg med dor ee see coe i lt nly gn ei on ‘ngle: Maiosopproch I subi for commus cohen cing, nn Indications: Special controindications: eAngestia and analgesia ofthe shoulder $ Contlaore proc pens SSnd/or of he poninal upper arm region + Cantal caret pares + Mabon fg ozo our + CORD fein hyiherpy inthe shale epn (e's, ponopeoive along mabe) ‘Therapy for pin syndromes + Srmpohialis Side effects, complications: Hira», ipiatolpvonc block, cre bck Local anaesthetics: Initial: 30 40 mi lidocaine 1% or mepivaceine 1% or 30 ml ropive- caine 0.75% Continuous: Ropivacaine 0.2 -0.375% 6 ml/h (5-15 ml, max. 37.5 mg/h bolus (clernatvely): 10 - 20 ml ropivacaine 0.2 - 0.375% [approx very 6 hours) Needle: Single shot: Shoe isle 22 G x46 em node Commas: 19 5G 6 cn flrclang 8 Ser, Fat coc Coven, 8, Sou) wit 20 6 cata odvone coher 4 on beycnd th ipo he anna, 2 ccc co aes econ Hee lee lta, Seger on cho Patient position: Patient supine Jugular notch, ventral acromial process ofthe scopula Guiding structures: ‘The distance between the jugular notch and the vental acromil process is bisected. The insertion sie must be directly under the clavieula ond toe loc in sc vertical drecion, The plows ocho or ‘approx. 3 cm (max. 5 em. Flexion ofthe fingers ot 0.3 mA/O. 1 ms form the desired stimulus response, Comments on the technique: Risk of pneumothorax Therelore, make absolutely sure to avoid: insertions too for medially Deviation from the sagitl (plumb bob} direction of insertion '* Advancing the needle > 6 cm Atvoys perform his Block using o neve sinus. A stimulus response ‘only in the biceps m. yields poor results. Pull back the needle toa sc. $flon shi igh awl ond edvonce it ogoin in hy ogi Indcoons oe contrsindistions: SFaeemer em, nk orm on Red + alee beled vr focae Trecment of pow syndromes 1 Foreign bodies te eo con Eralgesi for physetnropme neat (e'e pacamater ports) met + Sufpaien srg) fk of poem: + Simpoticohi ‘oan vloe «Unrated cooguation daorder Side effects, complications: Honor syndrom, pneursorx,novoeuar non Local anaesthetics: ia 3040 ml idocrne 1% or mpivocine 1% o 30 ml opocane 075 Continous Repacine 0:2 0.375% 6 mlfa(S- 15 ml, max. 275 mg/h Bolus (alternatively): 20 ml ropivacaine 0.2 -0.375% (approx. every 6 hours) Need ti Oot S47 £ os ol enn ten tS xSlonwih c Po col. he catisieshond 9 em ayn poten “ rere cane oe (eee to Maier Patient position: The patent i siting Guiding structures: Scop sep pert le acemin, madi nd lhe co iar sine The midpoint of the lina between thelr posterior potion like acromion ond the medil end of he scopular spine is morked, The {nseton ste is? em cronial (above) nd 2 em medial ofthis pon. The “polar needle advonced 3-8 em llerocavdaly and ony sigh ‘ertrally cf on ongle of approx. 30” inthe direction ofthe head of the ‘mere onto cect neal postion is indicated by a simols re Spore inthe ina or tho suproepinovs muscles, or unl the needle sows 2 pointes *knocking® seraaion inthe shoulder after 3 = 5 cm Comments on the technique: There is no risk of pnevmathorax if these guidelines are followed. Aspiration is necessary in oder to avoid intravascular injection |aupro- {copular artery, extremely rare). The method can also be performed with- ‘cut nerve stimulation (bone contac!) ond be used with « continuous techs nique nein srt inns toate sets rs ke Local anaesthetics: Initial: 10-15 ml lidocaine 1% or mepivacaine Continuous: Ropivacaine 0.2 - 0.375% 6 mi/h (5-15 mil, max. 37.5 ma/h bolus falernatively|: 10 mi ropivacaine 0.2 - 0.375% (approx. every 6 hours) 1% or ropivacaine 0.75% Needles: Single shot Uiplo neal 22 G x6 max. 8 cm ong, Eitincns. Eg, Pnclong 8° 19°56 om Pojsnk co or Cate B. Broun). The ‘Sets advanced oppoximotly 3m beyond the ipo he comme 16 1 mie poi the bb noel irri se: 3m medil 2m cro o the ne point 3 prospinans m. 2 nkospinohs 3 sovetn, 5 ener spel Fgomen prarcpalr» $F Siar brenchas of Ie soproscpelr 8 abode Axillary plexus block Patient position: Patent supine, rm abducted 90", externally rotted, elbow Nexed ‘opprox Guiding structures: Astley artery, coracabcochiol muscle Palpate the gap between the exilory o. ond the coracobrachia Following prepunctre ofthe skin, advance the needle poral o ond bore the atery in proximal direction ot an angio vo Skin [click phenomenon® entering neytovasculor sheath. Lower the dtl tnd ofthe edie and advance i furherCheck postion with a nerve st imuator (not compulsory wih this fechnigue, but recommended) Comments on the techni Alowsisk echnque that can be performed wihou!@ nerve stimulator: A “click” as the neurovascular sheath is penetrated end easy advancement lhe shor bevel needle with cannula indicaleso corte! needle poston Not infrequently, anaesthesia inthe radial nerves rea of cistibston le insufficient. Supplememary selective block moy be needed fe below) Indication: ol contradictions: o Sperone tm fit per Soe sth we mfr + Connon ooo a sea ebm 2 Simatic Side ofect: No special ones Local anaesthetics: Initial 30-50 ml lidocaine 1% oF mepivacaine 1% or 40 ml ropivacaine 0.75% Continuous: Ropivacaine 0.2 0.975% 6 ml/h (5-15 mil, max. 37.5 mg/h pale chro: 20 ml ropeccine 0.2 0:375% (apr. every Newdlas Sg hl on cots, Shrtmad ae rough oli como (erg 186, 48" Lovel, Pj coor 8. Sur. Afonble ctw con wal be need Wright 18 G canal The caer ixadranced 9 em beyond the ipa ho ned ‘Ahern Single tat nile needle 22 G 4 em 18 19 coracabrachil m, B sions 1 corseabeacia m 2 rodaln 3 medial onsbrochil 4 Ghar 5 brachial o & radon F mosclocontous 1 oor pecorl m co ‘Multi-stimulat Cor ors Irihomerolechnigue ce. Dip) Patient position: Fate! spine, rm cbducted approx. 80", steched ou, evenly oa Guiding structures: Junction of the proximol ond middle thirds of he upper orm, brachial = Sade) c sea oe fe leedineid ic te Opperornl bee eroese etre fe Slinna frsau ier coe ta Ges end See ee seer eee eee Faliowing jetot of he cal once, he ene price Tay oo ey epee eeteats Fe beter erie brsraea aoe (eee ery ni ms espns oh Ur sre ound Non leck he adil ere ee ‘adrecing the needle toward he lower {posterior} underlying humerus. The musculocutaneous n. is [reife Eola etal fererefions (= onl eee eae ee ar Nt peor eee othe biceps muscle dighly dering the block ofthe muscilocuamecus Comments on the Not suited for continuous blocks, imeconsuming, generally needs a ‘nerve stimulator. Short onset, bu relatively frequent problems with the ‘ourniquel, Well sited for selective supplementary block of individual nerves wth an incomplete brachial plexus block. Indications: Special controindicotions: ‘Ancaster ofthe diva om, albow ond None tend Side ofectes No specil ones Local anaesthetics: E.g. 10 mi lidocaine 1% or mepivacaine 1% ot ropivacaine 0.75% for each individal nerve block [Nocile: violr, shobevl 2G x 4-6 em Coeee Cr Patient position: Patient supine Guiding structures: ‘Middle upper orm The orm ising abducted ond extercllyrotsed (arm suppor). Insert the needle in he space between the flexor muscles and the iieeps muscles {nthe mediol side ofthe upper arm and direc it toward the lower [posterior] edge ofthe underiving humerus. Following adequate nerve simulation response, the local ancesthatic is injected. Indiotion: Ipeomplos acho pln block ‘Seguane blk, pain beropy Local anaesthetics: Initial: TO ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% Need Unipolar 22.6 x 4-6 em Cee ar ond Creo Patient position and method: fm sed ou ea xl eed ith hard pind inser the needle opprox. 1-2 cn larly odo fo he biceps or dion ond advance # toward llr picondyl nt contoct he bone ij he a nce when os pono her eve inSfcined ot 03 mA/0.1 ms ox nite the eal enoestonc ino for ‘hoped pattern whe slowly wihdrowing the needle Comments on the technique: ‘on ppemnting comp pls Hkh black mt be gem tigi sultan hs Hacks eel canbe who °C tneocuoneous block nhs ome oreo Cee Cece ISeneory supply ofthe xl side ofthe ower orm Patient position and method: ‘Arm stretched out, externally rotated withthe hand supinoted, Sabevonaous eco eral focal 1 the bieep ron ford the [oteral epicondyie ofthe humerus Comments on the technique: ‘Combination with a radial block ofthe level of the elbow is possible (one insertion, one needle). Injections that go too deep ore the mos frequent couse of file! The following applies both for blocks of the radial and the musculocutaneous nerves in the region of the elbow: Indications: Incomplete brochal plows block 3 Gino sho Local anaesthetics: 375 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% per injection Needle: 24.6 short bee, sipoler Cee ee od Median nerve Patient position and method: ‘Arm shetehed out loleally, externally rotated wih the hand supinate. The site of insertion is approx. 1 em medial (lnar) ofthe brachial ertery tangential to the nerve using @ unipolar 22 G needle of 4 em length. A Siimulus response of the medion nerve expected at a depth of 12 cm Please note: Mm = Median nerve medial tothe artery Blocks in the elbow region Crna Patient position and method: ‘The erm fcbduced, with elbow flexed 30°. The site of insertion is ‘oppor 1m proximal fo the sls ofthe unar nerve (between the fell epicondye of the humors end the olecranon). The needle is rected ongentally along the uinar nerve, ond 33 ml local anceshet. ‘Cieimecied lose fot no nel he neve. Comments on the technique: Tho inground inthe seu of he var nerve when the elbow is owed” Avoid pressure and poreshetis, the nerve is vry senavel is fecommended fo vse 0 unipolar needle {22 G, 5 em) ond neve siula- ton ‘The following applies for blocks in the region of the elbow and for both the median and the ulnar nerves: Indications Kreme nw Bock, grote bck Local anaesthetics: 375 milidocaine 1% ot mepivacaine 1% or ropivaccine 0.75% per injection Noodle: 226 4 Sem Ulnar 4 adi condyle of Rehr 23 Slcrnon proces bor nate Block: open Ten Fecal Cee Cer it ble Guiding structures and method: Timi ma nh fx ie btweun he rds he ro car muscle of the wes andthe long palmar musclo (acosionl missing). Afr eliciing presthesis, withdrow the 25 G need sighty” nd opply 5mi ofthe local onaesthet Local anaesthetic: 3-5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% cr Ca Patient position and method: ‘The erm fs stetched ou loteraly and externally otted with the hand supinated. Insert the needle approx. 34cm proximal othe hond be- rage of er fe cp malo he er oer ‘erecting @ ight poreshesio, withdraw the needle sigh ond infect 3-5 ml ofthe local cnaesheic. % Local anaesthetics: 3-5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% Needle: 22 0 246 8 Terr rr ee Se - eamaeaaeane ee ew eee ee Medion nerve block ote wt 1 pisorm bone 2 Linorm 3 dor 0 3 fete copi lors tendon 5 palmar longus Seda 6 fone capi ods ry 7 mio 8 roar ar nerve block ott wat 3 fal po ok tched out laterally with the hand supinated. Subcutaneous ewan performed on th foal side ofthe wis! 3~ 5 cm procinl ‘iain tothe oi Local enaesthetics: TO ml lidocaine 1% or mepivaccine 1% or ropivacoine 0.75% News 22 oF 246 1 spac onhas Fania 2 fedaie FFF PPR Bee Lumbar plexus The lumbar plexus is formed by the lower extremities 1 Femoral nerve with terminal soph nerve, obturator nerve pecionanas neces Lumbosacral plexus 1 poster loner Socral plexus The socto plexus is formed by nerves [lumbosacral turk) and Nerves ofthe lower extremities Sciatic n. (common peroneal ne Anaesthesia techniques: roximal sciatic nerve block | © Ankle block ee 1 eter mora 6 poner fomorl oop geroneal n fdoneou Stores snob pons 2 Fomor!» 7 sbrsorn teal loner 8 penmer til 9 Soper peronea vse 3 peroneal bibl 8 Soph 3 ote / \ u wo 13 10 os of sesary dmibtn favol neve ord ie Th irl omar u aches Yellow: Scien. ad branches nerve. Gren Ober nate, 2 urs 3 sia 3 femora $3 common peroneal ves af daibuton: A: Ferns nerve ands tranches. Green Geer nerve aril ane Srnec {oe 19 Chye) Patient position and method Cerca noes Patient in a lateral position with legs Rexed, the back kyphotic and the aa lag to be blocked uppermos, Guiding structures: LA vertebral spinous process ‘A mark is mode 3 em caudal fom the Ld veriebral spinous process in ‘he interspina line. From this point ot a right angle 16 the intrspinal line 12 cm ‘© Complete block of the socrol plexus (sciatic nis not possibl with higher volumes of locol anaesthetic 2 prooe major 3 ficelosce 8 awe Iconal p sector spinon m Indications Speciolcontraindications: ecembleton wih proximal cic rere Anicoaglaton hropy, some ac al pes ofp surgery (ncoding” —tecommendanons ax poten rose nk rawoawal ck + Wognd raotmnt inthe venta and al ‘igh vegion in grt inthe upper igh * Poin theropy fe. 9. poop. ober hip ore anger Side ofects/complicatios pura space, hemtome Local anaesthetics: inal anaesthesia, epidural block dv spread the Needles: B28, 12 cm none Initials 40 = 50 ml lidocaine 1% or mepivacsine 1% oF ES 2G Poneell wo 5a, 30 mi ropivacaine 0.75% [B bra cd} Continuous: 6 mi [5-15 ml ropivacaine 0.2 - 0.375%, max. 37.5 ma/h or Comins The ahaa i vanced S ) ‘ouda drecon bolus (ateratively|: 20 ml ropivacaine 0.2 - 0.375% (approx. every 6 h 38 See {Sint cig ce. 10 Win, contin chique oo Rosnbl Patient position and method: Pater supine wil the log buted ond externally rotted Guiding structures: The inguinal fd, fsmerlortery wth ven medial, ere lateral The insertion is? em bow th inguinal fol, 13m ler ofthe ater The simoon canis eared of 0 9° onle ma coral recton intl occurence of doublecic,indicoing perso through the fascia lata femora and the foci aco.'A moh Sol egponc in the quadceps muscle with o *dancing" kneecap af 0.3 mA/0 I re nd Cota ha he new ip sn the mma vicinity of ha femoral neve. Comments on the technique: Direct stimulus response in the sorloriue muscle may mimic a quodriceps response but leads to "anaesthesia failore" s0 make sure thatthe potell dances! Avoid intraneural needle insertion (nerve stimulation) Indicotions: Special contraindications: Viton seed in combination wih 9 Nine prota sete Bock, mew per of og + Wed rates skin groin Relative contraindicatios onal Wgh mobisics physoheopy Alte fom, popibeal bypass eh «+ Fanitechy feces of be shot evens bopper ono, hmphomas in he femeposto. ae nes it tegen {uta igamartrconanton; po llevan in hchwes of he nck ofthe to Local anaesthetics Initial: 30-40 ml lidocaine 1% or mepivacaine 1% oF ropivacaine 0.75% Continuous: 6 ml (5-15 mill ropivacaine 0.2 - 0.375%, max. 37.5 mg/ml or bolus alternatively}: 20 ml ropivacoine 0.2 - 0.375% (approx. every 6 hours Comps D° [8 Bron 2) {Comms Tho et advanced Sem beyond the end fhe conrla 0 «9 femora ney B cdi mare 1 eter femora 2 prow maim 3 Reveals 8 cburatrn 3 forte Decton of needle: Seve ithe! Bond feral wah Ramana Soe ee (31 chigu oc. 0 Win, continous echrique oc, to Rosenblo) Patient position and method: mets Pate! spine wih he lg abiciedcnd exemally rotted. Bes Guiding structures: The inguinal fold, femoral artery with vein media, nerve lateral The insertion ste is 2 em below the inguinal fold, 1'5 cm lateral ofthe crtery. The stimulation cannula is advanced ot 2 30° angle in o cranial direction uni occurence of a doubleclick, indicating passage through the fascia lata femoris and the fascia iiaca. A motor simolus response in the quadriceps muscle with 0 "dancing" kneecap at 0.3 mA/O.1 ms indi — spine) and in sighly dorsal drecfon. Afr opprox. 4B em of 03 Store 1A/0.1 ms, contractions of he adductors indicate the proximity o he 2 proonoio ‘blirolor neve. aioe ‘catheter lechrique can be sed for continuous block. The ctheer is 3 focte ‘advanced approx. 3- 4'cm beyond the fp of the needle in a cranial direction sof he isoera yolgiietiogser ibrar ak *onnegele Local anaesthetics: New insrion ‘enrol of Snow tener 10-15 mi idocoine 1% or mepivacaine 1% or ropivacoine 0.75% ireconsdocl Seno ‘Newdle: 206,10 cm hor bevel need vigor nee ro rae ST ne ee a2 (oc Labat | Patient position and method: Patient in‘ lateral postion withthe side to be blocked uppermost. The lowe legis seched, hele thot so be backed is flexed in ip and ineeoin. Guiding structures: Grealer tochantr superior posterior iliac spine Draw eine between he support io spire ad the grecter trochanter, from its midpoint perpendiclr line is drawn coudontcily. The soe dle inserion point it 45 em from the fis! ine. A confming ine con bo drown fom the rochoier fo he stl Ha, ihe rion Sle oe the lst we lines cross each other, The stmultion needle is edvanced pendiculrly to he skin. Aer 8-0 cm, contractions ofthe Sora; Fore of he fo commen pernedl neve] crf he ener he of theft bil nore] o!0:3'mA/O.1 me indicts the Cnrec! ptton of loin he imma vcny of he scot neve. Comments on the technique: # Occasional vscilar puncae [nfarior geal erry) * iret simulation of be mojo ive muscle mut Ro be mistoken fr the sciote nerve simvlton responce mec local enaeshoe oy ate simul respons nthe lower leg/Foo «Local tA fiat recommended Indications Speco contraindication: Sales gery whan conned wih Fa fob So + Ran ins on ee ee sed ‘Coagulation dierde [kof puncturing se alone) Local anaesthetics: 30-40 mi idocaine 1% or mepvaccine 1% or 530 ml ropivaccine 0.75% Need © 9. 206 1015 em long, nnlatd nipolr nese wih 30° or 15° bevel mommonmonmonm om oe eT eee eee eee eee ee ee | E LE lei ec 5 ere power tte of vaion: ‘rocton of readle persendia Beilin S-10em Soop 1 piers m 2 one Patient position and method: Fie patents supine wih te eg fo be locked flxed ot hip ond knee Gpprox. 90° and held by on oss Guiding structures: Greater Yochanter chil tuberosity Brow line between he grecer chant and the ischial berosy and ma ts midpsin This pont mark hese for need insertion. The si malin needles advanced perpendior to he skin surface ino cro fal Sinn A [Oe gooets of he oe {peroneal 9] oro the pln Bers bial no 0.3 mA/0.1 ms ind Eiri corte! poston of he nedla Comments on the technique: ‘drome: The poten on remoin spine. The echique is 0sy fo fom sa cheb pace nag nepO.Aconn ch miu con be se tions: 1 controndie types of sugary onthe leg when fre ted Mcombinaton th 9 mbar flows bloc Fon there Symoohieshsis I anaesthetics: I: 30 ml lidocaine 1% or mepivacaine 1% or 2030 mi ropivacaine 0.75% Continuous: 6 iml (5-15 ml] ropivacaine 0.2 - 0.975%, mox. 37.5 mg/h or tcl ont 20m rpirocie 0:2 0.375% (ppox. evry 6 rs) Needles: 19