PERIPHERAL REGIONAL BLOCKS. by Mike DeBroeck, DNP, CRNA

Transcription

1 PERIPHERAL REGIONAL BLOCKS by Mike DeBroeck, DNP, CRNA

2 Why am I bothering with this topic at all?

3

4 Do CRNAs REALLY even do peripheral regional anesthetics?

5 YES!!!!!!!

6 TOPICS GENERAL INFO SUCCESS RATES COMPLICATIONS LA CHOICE SPECIFIC BLOCKS

7 General Information

8 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.

9 KEYS TO SUCCESS

10 KNOW THE PHYSICAL ANATOMY!!!!

11 KNOW THE SENSORY/MOTOR INNERVATIONS!!!

12 GET COMFORTABLE WITH ULTRASOUND

13 LEARN HOW TO USE A NERVE STIMULATING NEEDLE PROPERLY

14 MANAGE TIME

15 EDUCATE SURGEONS

16 EDUCATE THE STAFF

17 EDUCATE PATIENTS

18 SUCCESS RATES

19 SO, HOW GOOD ARE THEY, REALLY?

20 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.

21 INDIVIDUAL SUCCESS RATES TEND TO PARALLEL PROPER USE OF EQUIPMENT, PROPER TECHNIQUE, AND ADEQUACY OF TRAINING

22 COMPLICATIONS Local anesthetic systemic toxicity Intravascular injection Choice of LA Neurotoxicity/Nerve injury Intraneuronal injection Patchy block Block failure

23 SO WHY DON T WE USE THEM MORE?

24 WE RE TOO LATE PUTTING THEM IN. THIS IS A FUNCTION OF SCHEDULING

25 WE DON T WAIT LONG ENOUGH FOR THEM TO SET UP THIS, TOO, IS MOSTLY A FUNCTION OF SCHEDULING

26 WE RE TOO SLOW PERFORMING THE PROCEDURES This is a function of training and experience THE WAY YOU PRACTICE IS THE WAY YOU PLAY

27 LOCAL ANESTHETIC CHOICE

28 PICK THE RIGHT DRUG FOR THE RIGHT OUTCOME.

29 What are you trying to accomplish? Quick onset? Long duration? Differential blockade? Adjunct to general or neuraxial anesthesia? Post-op pain control? Sole anesthetic?

30 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

31 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,

32 Amide LA Max Dosage/Concentration/Procedure Recommendations Without epi with epi

33 ADJUNCTS Epinephrine 5 mcg/ml Clonidine - 2 -adrenoceptor agonist*** 100 mcg = 100 extra minutes More just gets more side effect Dexmedetomidine mcg 1mcg/kg Faster onset, longer duration Dexamethasone 1-2 mg vs 8-10 mg? Longer duration but neural toxicity?

34 BLOCKS

35 BRACHIAL PLEXUS FEMORAL NERVE SCIATIC NERVE

36 BRACHIAL PLEXUS BLOCKS

37 Brachial Plexus Anatomy

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42 Innervations

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44 Block Choices Interscalene High Low Supraclavicular Infraclavicular Axillary Mid-humeral/rescue blocks Wrist

45 Interscalene

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47 Surgical Coverage

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49 C6 SCM EJV CLAVIC LE Landmarks: Cricoid cartilage, posterior border of sternocleidomastiond muscle, and external

50 Note neddle insertion perpendicular to neck with slight caudad angulation never cephalad

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52 Ultrasound Positioning

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54 Supraclavicular

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56 Surgical Coverage

57 Surgical Coverage

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59 Ultrasound Positioning

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61 Infraclavicular

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63 Surgical Coverage

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65 Ultrasound Placement

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67 Axillary

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70 Surgical Coverage

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72 Ultrasound Positioning

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74 Midhumeral/Rescue Blocks

75 Midhumeral (Upper 3 rd ) View

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77 3 Often Needed Supplementals All blocked at axilla with single generous SC injection.

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79 Intercostobrachial Nerve Block

80 Lower Extremity Blocks

81 Lumbar Plexus Block Femoral/3 in 1 Block Adductor Canal Block Saphenous Nerve Block Sciatic Nerve Block Popliteal Block Ankle Block Mayo Block

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85 Femoral Nerve Block

86 2 cm below & 1 cm medial to ASIS 1 cm lateral to artery

87 Surgical Coverage

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89 Patella elevates with Stimulation

90 Ultrasound Positioning

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92 Adductor Canal Block

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95 Ultrasound Positioning

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97 Sciatic Nerve Block

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102 Classic Position and Landmarks

103 3cm

104 Ultrasound Positoning for Subgluteal Approach

105 2 cm 4 cm LLE Lateral View

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107 Popliteal Nerve Block

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109 Landmarks

110 Ultrasound Positioning

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112 Alternate Positioning

113 So what s the take away?

114 OUR PRACTICE WORLD IS CHANGING!

115 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 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

116 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.

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

118 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

119 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

120 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 Things we re going to need to master

121 New Trends and yes, they all use 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

122 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.

123 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.

124 QUESTIONS?