Dr Kelly Jones Anesthesiologist at Northwest Orthopedics

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1 Dr Kelly Jones Anesthesiologist at Northwest Orthopedics

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3 Decrease narcotic use in the immediate post operative period. Better Pain Control Less side effects then General Anesthesia Sedation Post operative delirium Nausea All the bad stuff that comes with general anesthesia WHY NERVE BLOCKS?

4 Earlier discharge from hospital and surgery center Improved patient satisfaction?

5 Drug overdose deaths continue to increase in the United States. From 1999 to 2017, more than 700,000 people have died from a drug overdose. Around 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid. OPIOID CRISIS

6 On average, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in Americans die every day from an opioid overdose. 1

7 1. Understand different types of nerves block. A. Upper extremity Anatomy 2. Dermatome distribution 3. Brachial plexus anatomy 4. 4 main upper extremity block locations A. Interscalene block B. Supraclavicular Block C. Infraclavicular Block D. Axillary Block OBJECTIVES

8 B. Lower Extremity Nerve Block 1. Sensory Innervation and dermatome 2. Lumbar Plexus Anatomy 3. Different Types of Blocks A. Sciatic nerve B. Femoral nerve 1. Adductor 2. Saphenous C. Popliteal Nerve D. Ankle Block

9 Indications- Clavicle, Shoulder, Elbow and upper arm surgery, May cover hand surgery with large volume of local anesthetic. Motor weakness of most to all of upper extremity muscles. INTERSCALENE NERVE BLOCK

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11 Patient refusal Infection at planned injection site Pre-existing neurologic defect Severe coagulopathy Contralateral Phrenic nerve dysfunction Severe COPD, emphysema CONTRAINDICATIONS

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13 Brachial plexus consist of nerve roots from Cervical Spine C4-T1. BRACHIAL PLEXUS

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15 CADAVER BRACHIAL PLEXUS

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17 Interscalene Brachial Plexus Block for Arthroscopic Shoulder Surgery: A Systematic Review Hughes, Michael S., MD 1 ; Matava, Matthew J., MD 1 ; Wright, Rick W., MD 1 ; Brophy, Robert H., MD 1 ; Smith, Matthew V., MD 1

18 The objective of this study was to demonstrate that regional anesthesia has several benefits over general anesthesia for this type of surgery, particularly in the ambulatory patient. Forty patients received general anesthesia and 63 an interscalene block. The regional block was found to be safe and effective, with a high degree of patient acceptance. It provided excellent intraoperative analgesia and muscle relaxation.

19 Postoperatively, regional anesthesia resulted in fewer side effects, fewer hospital admissions, and a shorter hospital stay than did general anesthesia.

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26 Failed Block, less likely US Guided High Incidence of Phrenic Nerve Numbness causing elevated diaphragm and shortness of breath. Some studies state as high 90-99% with a true Interscalene Block. Transient or permanent neuropathy. COMPLICATIONS

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28 Facial Numbness with Bell s Palsy, numbing of facial nerve from cephaled spread of local Anesthetic Unilateral vocal cord numbness with Hoarseness COMPLICATIONS CONTINUED

29 BELL S PALSY

30 Pneumothorax on same side as block. Incidence near 0% with ultrasound guidance and experienced practioner, much lower then supraclavicular block. COMPLICATIONS CONTINUED

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32 Permanent or temporary neuropathy, this can in the form of motor weakness or numbness, burning, tingling that continues beyond the duration of local anesthetic. Likely related to mechanical or chemical damage to nerve. Most resolve spontaneously without treatment within 3-6 months. Very low incidence with ultrasound guidance COMPLICATIONS CONTINUED

33 Intravascular Injection, Local anesthetic toxicity Start with neurological symptoms, ringing ears, metallic taste, blurry vision. Progresses rapidly to Confusion, agitation and seizure. If not treated appropriately and quickly progress to cardiovascular collapse. COMPLICATIONS CONTINUED

34 Treatment is Intralipid, a 20% fat solution believed to encapsulate the local anesthetic. Lipidrescue.org Has been used in multiple non LA toxicity cases including Caffeine overdose, Beta Blocker overdose, Antidepressant overdose and many more amazing stories LOCAL TOXICITY

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37 Airway Management, ACLS protocols Treat seizure, benzodiazepines preferred Avoid large doses of Propofol if hemodynamically unstable. Avoid Vasoconstrictors, limit Epinepherine doses < 1mcg/kg Avoid Calcium Channel Blockers, Beta Blockers, other local anesthestics LOCAL TOXICITY CONTINUED

38 Indications Good for Elbow, forearm and hand surgery. Possible to use for shoulder surgery but may miss supraclavicular and suprascapular nerve which are important for distal clavicle resection. Technically easy block with good landmarks Lower incidence of Phrenic Nerve numbness, reported at < 50% but in practice we find it to be much lower. Higher risk of pneumothorax. SUPRACLAVICULAR NERVE BLOCK

39 Same as other blocks Patient refusal Infection at injection site Preexisting neurological defects Coagulopathy Acceptable in respiratory compromised patients. CONTRAINDICATIONS

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43 US IMAGE

44 Failed Block Pneumothorax, higher incidence then Interscalene blocks. Intravascular injection, Local anesthetic Toxicity Transient or permanent neuropathy COMPLICATIONS

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46 Indications- Hand, forearm and elbow surgery Good landmarks but nerve are deeper and around axillary artery. Lung tissue can be very near nerves. Higher risk of pneumothorax Very near axillary of subclavian artery INFRACLAVICULAR NERVE BLOCK

47 Same as other blocks Patient refusal Infection at injection site Preexisting neurological defects Coagulopathy Acceptable in respiratory compromised patients. CONTRAINDICATIONS

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50 US IMAGE INFRACLAVICULAR

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52 Failed Block Pneumothorax, higher incidence then Interscalene blocks. Intravascular injection, Local anesthetic Toxicity Transient or permanent neuropathy COMPLICATIONS

53 Indications- Hand, Elbow and Forearm surgery. Technically easy block with very low risk of complications, nerve is very superficial. Risk of vascular injection is slightly elevated and aspiration before injection is very important. AXILLARY NERVE BLOCK

54 Same as other blocks Patient refusal Infection at injection site Preexisting neurological defects Coagulopathy Acceptable in respiratory compromised patients. CONTRAINDICATIONS

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60 Failed Block NO risk of pneumothorax Intravascular injection, Local anesthetic Toxicity Transient or permanent neuropathy COMPLICATIONS

61 Femoral Nerve Block Sciatic Nerve Block Adductor Canal Nerve Block Popliteal Nerve Block Saphenous Nerve Block Ankle Nerve Block LOWER EXTREMITY BLOCKS

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63 The femoral nerve block is one of the most clinically applicable nerve block techniques that it is relatively simple to perform, carries a low risk of complications, and results in a high success rate. FEMORAL NERVE BLOCK

64 Anterior Upper leg Surgery Knee surgery, anterior cutaneous and knee joint. (Does not cover posterior knee) ie. ACL with hamstring graft Medial Lower leg to medial malleolus Tibial surgery Patella Tendon INDICATIONS

65 Same as other blocks Patient refusal Infection at injection site Preexisting neurological defects Coagulopathy- Femoral Nerve very superficial and usually acceptable risk with anticoagulation CONTRAINDICATIONS

66 Failed Block Temporary or permanent neuropathy Intravascular Injection Quadricep weakness, risk of fall while block is working COMPLICATIONS

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71 Also known as Saphenous Block Only sensory block-no motor weakness Indications Knee surgery where Quadricep weakness in not acceptable Medial lower leg and Tibia to medial malleolus ADDUCTOR CANAL BLOCK

72 Same as other blocks Patient refusal Infection at injection site Preexisting neurological defects Coagulopathy CONTRAINDICATIONS

73 Failed Block Permanent or temporary neuropathy but less devastating as there is no motor innervation with this block Intravascular injection COMPLICATIONS

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79 Indications Lower lateral leg and foot surgery Posterior Knee, hamstring pain Below Knee amputation but will need to also block Saphenous nerve. SCIATIC NERVE BLOCK

80 Very few Patient refusal Infection at injection site Coagulopathy CONTRAINDICATIONS

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82 MULTIPLE APPROACHES

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84 Same as other blocks Failed block Intravascular injection Permanent or temporary neuropathy COMPLICATIONS

85 Also know as distal Sciatic nerve block Indications Fibula, lateral leg or ankle surgery Achilles, posterior lower leg Foot surgery POPLITEAL NERVE BLOCK

86 Preoperative Lateral Popliteal Nerve Block for Intraoperative and Postoperative Pain Control in Elective Foot and Ankle Surgery: A Prospective Analysis Dawn M. Grosser, M.D., Mark J. Herr, M.D., Richard J. Claridge, M.D., F.R.C.S.,...

87 15 of 25 patients had a complete block (motor and sensory), five of 25 patients demonstrated motor function, but denied sensation or pain, and the remaining five of 25 had sensation to light touch but no motor function or pain. None of the patients reported pain postoperatively in the PACU within an hour after surgery. The average time the block lasted was 14 hours. Overall satisfaction with the block on postoperative day one and week one was 4.8 out of 5.

88 Same as other blocks Patient refusal Infection at injection site Preexisting neurological defects Coagulopathy CONTRAINDICATIONS

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91 LATERAL APPROACH

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93 Failed block Intravascular Injection Permanent or temporary neuropathy COMPLICATIONS

94 ANKLE BLOCK

95 Technically simple block as it is a field block, 5 nerves need to be block for entire foot numbness or can target specific nerves. Multiple injection sites. Any foot or lower ankle surgery Excellent analgesia for severely ill patients who need foot ankle surgery and cannot tolerate general anesthesia INDICATIONS

96 Very few Patient refusal Infection at injection site Acceptable risk with coagulopathy CONTRAINDICATIONS

97 Same as other blocks Nerve damage Intravascular injection Seems to me that there is a higher incidence of failed blocks as there is no direct visualization of nerves. COMPLICATIONS

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103 Upper Extremity Interscalene Block Shoulder and upper arm surgery Not as good for forearm and hand Increased risk of phrenic nerve dysfunction Should not be used in pulmonary cripple, severe COPD or contralateral phrenic nerve paralysis SUMMARY

104 Supraclavicular Nerve Block Good for entire arm, elbow and hand surgery. Not good for shoulder surgery as it can miss important shoulder innervation Increased risk of Pneumothorax Acceptable risk in pulmonary cripple, severe COPD or contralateral Phrenic nerve paralysis

105 Axillary Nerve Block Good for forearm and hand surgery Increased risk of intravascular injection as nerve surround Axillary artery. No risk of phrenic nerve numbness so very acceptable and preferred for Pulmonary cripple, Severe COPD.

106 Lower Extremity Femoral Nerve Block Good for anterior upper leg, knee and lower medial leg surgery Will cause Quadricep weakness and increased risk of fall. Technically easy block with little risk of failure.

107 Adductor Canal Block Good for knee surgery, medial lower leg. Sensory block only, NO Quadricep weakness Low risk of complications and no risk of permanent weakness

108 Sciatic Nerve Block Good for posterior upper leg, lateral lower leg or foot surgery Muscle weakness of upper leg muscles, inability to flex hamstring Deep block and technically challenging block

109 Popliteal Nerve Block Good for Achilles, Lateral lower leg and entire foot surgery. Reliable anatomy for consistent block. Deep Anatomy so not good for coagulopathic patients.

110 Ankle Block Good for foot and low ankle surgery. Excellent analgesia for critically ill patients in need of amputation who are not candidates for general anesthesia Increased failure rate as it is a field block with no direct visualization of ankle nerves

111 QUESTIONS?

112 REFERENCES