Anna Welbourn

Regional Anaesthesia
Introduction

 General consideration
 Upper Limb blocks
 Lower Limb blocks
 Neuroaxial blocks (Spinal/Epidural/Caudal)
 Ganglion Stellatae block
 IVRA
Regional anaesthesia
Why?
Advantages Disadvantages
 Avoidance of general anaesthesia in high-risk patients
 Stable
Time consuming – most sciatic and
intraoperative conditions (i.e. cardiovascular)
 Effective perioperative pain control, extending into postoperative
femoral blocks take 15–30 min to be
period with catheter techniques
 Reduced nausea and vomiting effective
 Antithrombolytic, therefore reduced risk of deep vein thrombosis
 Avoidance
Failure rate about 5% even in the best
of opioids in elderly patients, confused or opioid-

sensitive patients
hands
 Preoperative pain control (e.g. pre-amputation ischaemic pain)
 No effect on bowel motility or urinary function (opioids increase Inadequate training of consultants and
constipation, urinary retention)?
 Improved early mobilization of major joints?
trainees
General consideration
Essential steps

Room
• Anaesthetic Site
machine • Correct
• Post-procedure
Resuscitation position
drugs • • Monitoring
Full asepsis
• Resus equipment (G,G,C,M) • Verbal contact
Patient
• Trained assistant • Performing • Check
• Explain
• Right LA block motor/sensory
procedure level
• Complications • Iv access
• Positioning
• Consent • Monitoring
(NIBP,ECG,SpO2)
General consideration
Nerve stimulator vs. Ultrasound
Nerve stimulator

 Grounding electrode –anode

 insulated needle - cathode (Tuohy,
Sprotte)
 Insulated needle prevents dispersion
of current
 Constant controlled current 0.06 – 6
mA
 Pulse 1-2 Hz, 0.1 ms square wave (only
stimulate motor fibres, avoids C fibres)
 If end-point achieved with < 0.2 mA =
risk of nerve penetration
General consideration
Anticoagulation (European and North American
Consensus Guidelines)
Drug Guidelines

Aspirin and NSAIDs No CI

Clopidogrel Stop 7 days prior to surgery
Subcutaneous unfractionated heparin Give 4h before or >1h after block

Intravenous unfractionated heparin Stop 2-4h before block

give > 1h after
Remove catheter 2-4h after dose
LMWH Block 12 h after prophylactic dose
24h after therapeutic dose

Warfarin INR </= 1.5

Rivaroxaban (direct thrombin blocker Give 6-10 post op.
Remove cath. 12-18 h after dose
Wait 6h for the next dose
General consideration

 Contraindication
 Patient’s refusal

 Uncooperative patient

 Anticoagulation/coagulopathy (Plt < 70ml x10^9)

 Major and local infection

 Trauma/burns over the injection site

▪ for CNB + untreated hypovolaemia, fixed CO?, raised ICP

 Risk of compartment syn. (trauma)

 Lack of appropriately trained staff and equipment (incl. resus equipment, iv

access)
Structured approach when learning
about regional anaesthesia

 Name

 Indication/Contraindication

 Complications/SE

 Anatomy, Nerves/Dermatomes

affected

 Landmarks/Approach

 End-point

 LA/needle/patient position
Brachial plexus blocks
Elbow/Antecubital fossa

Upper limb blocks

Brachial Plexus Blocks
Indication
 Interscaleni (shoulder, humerus, elbow)

 Supraclavicular ( whole limb except

shoulder)

 Infraclavicular (elbow, forearm, hand)

 Axillary (elbow, forearm, hand)

Brachial Plexus Block
Anatomy
 Roots C5 – Th1 – ant. Primary rami
 Ant. and med. scaleni muscles -
roots
 Posterior triangle –
upper/middle/lower trunk
 Behind clavicle – anterior and
posterior division
 Axilla – medial/lateral and
posterior cords
 Individual nerves
Brachial plexus vs. major structures
Upper limb innervation
Brachial plexus innervation

ANTERIOR POSTERIOR
 BPB – interscalene & supraclavicular
approach
Block Interscalene
Indication Proximal surgery incl. shoulder
Complications Failure on ulnar side, Horner’s
syn., phrenic nerve block,
vertebral aa. Injection, epidural
injection
Anatomy Roots
Landmarks Interscalene groove btw ant.
and mid. scalenus at the level of
the cricoid cartilage (C6),
lateral border of the
sternomastoid muscle.
End-point Deltoid muscle motor response
(Phrenic nerve – too anterior
Dorsal scapular n.- shoulder
elevation – too posterior)
LA/Needle/Patient position Max 50 mm/Supine, head to
contra lateral side
Supraclavicular
Upper arm, elbow, radial aspect
mid forearm
Pneumothorax, phrenic n. palsy
(specific CI: recurrent laryngeal n.
palsy, pneumothorax on the
opposite side, neck abnormality)
Sheath, Trunks/proximal division
Lat. To clavicular head of SMC,
interscaleni groove, mid-point at
clavicle, 1 cm post., above /lat.,
pulsation of subclavian artery
(anterior & inferior to BP)
Triceps (radial n.-post. cord, elbow
ext.) & biceps (musculocutaneous-
lateral cord, elbow flex.) motor
response
Hand if distal surgery
30-40ml/as IS block/Subclavian
perivascular approach (Winnie)
BPB – axillary approach
Block Axillar

Indication Hand, wrist, lower forearm

Complications Arterial puncture, Nerve damage

Anatomy Terminal branches

Triple injection technique
(musculocutaneous, median,
radial)
Landmarks Axillar artery pulsation
(2 fingers on, aim sup. and inf.)

End-point Median = flexion wrist, fingers

Ulnar/Radial = ext. elbow – wrist
- fingers

LA/needle/patient position 40 ml LA, shoulder and the elbow

should be in 90° abduction
and flexion
Axillary block
BPB – common approaches
Anatomy - Antecubital fossa
 Blocks at the elbow
Block Medial n. Ulnar n. Radial n.

Indication Surgery of a wrist, hand, forearm/supplement to PBB

Complications Iv/ia injection, haematoma, intraneural injection

Anatomy medial to the brachial See below See below

artery, deep
to the tough bicipital
aponeurosis

Landmarks Flexor crease of ACF Sulcus behind medial Groove btw the
(1-2 cm above), med. to epicondyle (humerus), 2 brachioradialis muscle
brachial artery cm prox. and the biceps
Tendon (2 cm proximal
to the flexor crease),
aim for lat. epicondyle

End-point Flexion of wrist and Extension wrist and

fingers fingers

LA/Needle/Patient External rotation of arm,

position flexion at elbow
Blocks at the elbow
Lumbar plexus
Femoral block
Sciatic block 1/2/3
Ankle block

Lower limb block

Lower limb innervation
 Anterior  Posterior
Lumbar plexus

Lumbar plexus

Lateral
Femoral Obturator Genitofemoral
femoral cut.

Ant. Cut. Fem. Femoral

Cut. branch
branch branch

Saphenous
Lower limb block

 Indication
 Hip and knee surgery
▪ Anaesthesia, post-op analgesia
 Vascular procedures
 Amputation
Lumbar plexus block
Block

Indication Analgesia, hip or femoral

operations including knee
Complications Psoas haematoma,
epidural injection
Anatomy femoral, obturator and
lateral cutaneous nerve of
thigh
Landmarks Tuffier’s line (a), PSIS
(b),4-5 cm from midline

End-point Quadriceps contraction at

0.3 mA
( hip flex = too deep,
adduction =too med.,
hamstring contraction =
too caudal)
LA/Needle/Patient Lateral, 100 mm
position
Femoral block
Block
Indication Adj.knee surgery
Complications
Anatomy See pic.
Landmarks Inquinal ligament (1
cm below), pulsation of
femoral artery (1 cm
lat., aim cephalad, 2
clicks = the fascia lata
and the ilio-pectineal
fascia)
End-point Patellar twitch
LA/Needle/Patient 20-30 ml, 50 mm,
position supine
Sacral plexus
Sacral plexus

Superior/Inferior Nerves to Post. Femoral

Sciatic Pudendal
gluteal piriformis, cut.
quadratus fem.,
int. obturator

Tibial Common
fibular
Sural

Medial Deep fibular

plantar

Superficial
Lateral
fibular
plantar
 Sciatic block – parasacral (Mansour)
Block
Indication Hip/knee surgery,
amputation
Complications Blocked pelvic
splanchnic nerves
(occasional urinary
retention).
Anatomy Sacral plexus blocked
Landmarks Line connecting PSIS
and ischial tuberositas,
6 cm down, needle
slightly cephalad 5-7
cm, redirect slightly
caudal when bony
resistance
End-point Plantar flexion (tibial)
LA/Needle/Patient 10 – 25ml/100
position mm/lateral
Sciatic block – Inferior (Raj)
Block
Indication Knee and lower leg
Complications general
Anatomy
Landmarks Ischial tuberositas,
greater trochanter,
midpoint btw.
End-point dorsiflexion
LA/Needle/Patient 15-20 ml/50-100
position mm/supine –knee
and hip flexed to 90
 Sciatic block – posterior (Labat)
Block
Indication Knee and lower leg
surgery
Ankle and foot surgery
(+ if tourniquet used)
Complications General
Anatomy See pic.
Landmarks PSIS, greater
trochanter, sacral hiatus
End-point Gluteal contraction
(advance1-2 cm)
Plantar flexion (tibial)
Dorsiflexion (peroneal)
LA/Needle/Patient 15-20
position ml/100mm/Simm’s
position, operated limb
up
Ankle blocks
Block Superficial peroneal nerve Deep peroneal nerve
Indication Foot surgery
Complications
Anatomy
Landmarks After deep p.n. block Intermalleolar line, 3 cm
Laterally and medially to distal, lat. to ext. hallucis
the plantar junction longus is art. dorsalis
pedis, injection med./lat.
to pulsation
End-point
LA/Needle/Patient position 10ml 2+2ml/23-25G
Ankle blocks
Block Saphenous Sural Tibial
Indication
Complications
Anatomy See below See below See below
Landmarks Medial malleolus, Lateral malleolus, Line btw. med.
saphenous vein Achilles tendon Malleolus and
(infiltration on calcaneus, insertion
either side) behind artery
End-point Loss of sensation Loss of sensation Parasthesia/plantar
flexion
LA/Needle/Patient Supine, leg 5 ml/23-25G 6-10 ml/22G 50 mm
position externally rotated
Ankle blocks- foot innervation
Spinal
Epidural
Caudal

Central Neuroaxial Blocks

Spinal
Onset 2-5 min Op site Block LA
level volume
Duration 2 – 3 hours (hyperbaric
bupivacaine
Drug volume 2.5 – 4 ml 0.5%)
(0.2 ml/segment
to be blocked)
Quality of block Rapid surgical
anaesthesia
Perianal L4/5 2.5 ml
Major factors affecting intrathecal
spread of LA
Urogenital T10 2.75 – 3.0
Baricity of LA ml
Posture Lower T6/7 3.0 – 3.25
abdo ml
Volume of LA
Volume of CSF
(Height, weight, age)
Spinal – Complications/SE
Very common – common (1:10 – 1:100) Rare (1:10 000)
Hypontension Nerve damage
Itching (permanent nerve damage is very rare)
Urinary retention - Bleeding, Infection, Direct Injury
Pain during an injection
Headache
Failure of procedure
Spinal
Indication Emergency/electiv
e surgery below
umbilicus
Complications see complication
slide
Anatomy See pic.
Landmarks Iliac crests-Tuffier’s
line (L4), not above
End-point Sensory/motor
block
LA Hyperbaric
bupivacaine 0.5%
Needle Quinke x Whitacre,
Sprotte
Patient position Lateral/sitting
Spinal - equipment
Epidural
Onset 20 – 30 min Major factors influencing epidural
spread of LA
Duration 3–5h
Drug volume 20 – 30 ml Drug mass
Quality of block May be inadequate
in some Site of injection (Epidural space volume
dermatomes sacral>lumbar>thoracic>cervical)

Age (> 40y gives further block)

Raised abdo pressure (pregnancy,

obesity)

Patient position

Injection technique (smooth,

unfractionated gives better block)
Epidural – complications/SE
Very common – common (1:10 – 1:100) Rare (1:10 000)
Hypontension (dizziness, nausea) Nerve damage
Itching (added opioids) (permanent nerve damage is very rare)
Urinary retention - Bleeding, Infection, Direct Injury
Pain during an injection
Headache (Post-dural puncture
headache)
Failure of procedure

Other: Backache (diff. dg: injection canal pain, epidural abscess/haematoma,

extreme position during procedure, chronic back pain)
Epidural
Indication Surgery/acute pain
relief/chronic pain
Complications See complications
Anatomy See pic.
Landmarks Lumbar/Thoracic
Midline/Lateral
approach
End-point Sensory block
LA Lidocaine 2%,
Bupivacaine 0.5-
0.75%, Ropivacaine
7.5 mg/ml
Needle Tuohy needle
LOR syringe
Catheter/filter
Patient position Sitting/lateral
Epidural equipment
 Intercostal block
Block
Indication Rib #, insertion of
chest drain, post
herpetic neuralgia
Complications Pneumothorax, high
local absorption of LA,
accidental i.a or i.v
injection
Anatomy Neurovascular bundle
VAN
Landmarks Costal angle (7 cm
from midline), needle
cephalad to hit the rib,
redirect caudally till
“pop”
End-point
LA/Needle/Patient 2-3 ml, Max 20 ml
position 0.5% bupivacaine in
70kg patient
Reference

 http://www.usra.ca
 www.nysora.com
 2 x OSCE books
 Oxford specialist handbooks (Obstetric
anaesthesia)
Caudal block
IVRA
Block
Indication
Complications
Anatomy
Landmarks
End-point
LA/Needle/Patient
position
Ganglion stellatae block
Block
Indication
Complications
Anatomy
Landmarks
End-point
LA/Needle/Patient
position