Master lower extremity blocks
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1 Master lower extremity blocks Anasuya Vasudevan MD FRCA Director- Regional anesthesia and Acute pain service Director- Anesthesia Quality Improvement Clinical Associate Professor Geisinger Commonwealth School of Medicine Danville PA
2 Disclosures None
3 Goals and ObjecHves Innate challenges with Lower extremity blocks Nuts and Bolts of Lower extremity blocks Tailoring experhse to evidence base and current accountable care expectahons
4 Challenges with lower extremity innervahon Nerves arise from lumbar and sacral plexi Only centralneuraxial block renders complete anesthesia Single plexus blocks inadequate to provide total coverage Eg. Knee joint- sciahc, femoral and obturator branches
5 Changes in Healthcare Increasing no. of outpahent procedures Increasing need to! start PT day 0! ambulate on day 0 Reduce hospital and rehabilitahon stay AnHcoagulaHon Challenges with lower extremity blocks
6 Ideal Lower extremity anesthesia/ analgesia Good and prolonged pain relief Minimal motor block Minimal risks /systemic toxicity Reasonable cost Easy and painless to perform and learn Challenges with lower extremity blocks
7 Common Lower extremity Surgical procedures Arthroplasty Sports medicine/arthroscopic procedures Trauma AmputaHons Vascular procedures/free flaps
8 Branches of Lumbar plexus- Proximal to distal
9 Focus on ArthroplasHes Hip Knee Ankle
10 InnervaHon of Hip Obturator nerve Femoral nerve superior gluteal nerve ArHcular branches of sciahc nerve NYSORA
11 What is feasible? Lumbar plexus FIB Femoral N block especially for fracture femur Peri arhcular infiltrahon
12 Lumbar plexus L3- L5 level US guidance Combine with Nerve shm- elicit femoral response SciaHc nerve is spared Complex deep block Many side effects if not done well
13 Lumbar Plexus Block: Nerve SHmulaHon Technique Equipment Marker and ruler Needle: mm 21 G insulated Nerve shmulator PosiHoning Lateral decubitus Local AnesthesHc cc 0.25% bupivacaine Or 0.2% ropivacaine Nerve SHmulaHon ma L.Kunze
14 Lumbar Plexus Block: Nerve S6mula6on Approach Technique Mark lumbar spine, PSIS, iliac crest Measure and mark a line 3-4 cm parallel to spine (should align cephalad from PSIS) Insert needle at level of iliac crest or 1 cm cephalad. Advance needle in sagittal direction with nerve stimulator set ma When quadriceps stimulation observed between ma inject local anesthetic. Inject 1 cc slowly, then inject cc over 3 minutes.
15 Pearls & pifalls Pearls If transverse process contacted withdraw needle and advance above or below. If hip flexion observed (psoas stimulation), withdraw needle slightly. If no stimulation within reasonable distance adjust slightly medially (5-10 degrees), and advance needle Pitfalls Epidural spread common (highly assymetrical) Intrathecal injection likely if nerve stimulation < 0.5mA Treat block like neuraxial for anticoagulation purposes
16 Ultrasound image
17 OpHmizaHon Psoas compartment block - depths greater than 6 cm. Medium to low frequency probe(4-8 MHZ). Use of a curvilinear probe expands the visual field and needle visualizahon easier. Steep angle of approach, needle visualizahon may shll prove challenging. ReflecHve ultrasound block needle or hydro dissechon technique, or both. Adjustment of gain and focus point.
18 ComplicaHons Epidural spread, high neuraxial block Hypotension second common complicahon Unilateral sympathectomy, but with epidural spread can be bilateral Systemic toxicity is higher Injectate is in vessel rich muscle rather than epi- neural fascia Direct vascular injechon is low. PotenHal for Renal injury and llio- psoas hematoma with nerve compression.
19 Fascia iliaca Anatomy
20 Fascia Iliaca scanning High frequency probe MHZ usually adequate Locate femoral artery- Probe parallel to inguinal ligament Scan laterally Sartorius will begin to appear lateral to the femoral nerve IdenHfy the medial border of the sartorius as it rests on the iliopsoas muscle
21 Fascia iliaca Block Advance block needle inplane Advance through the sartorius and place needle Hp deep to the medial border of sartorius Probe parallel/horizontal to inguinal ligament Inject ccs of your choice of local anesthehc LA will expand the plane and spread along the iliopsoas muscle- where the lumbar plexus traverses
22 OpHmizaHon Morbidly obese- Pannus- tape to clear your field IF performing for a fracture, Hssue edema may confound planes Ensure LA injechon is in the plane of femoral nerve
23 Surgery on knee Femoral Nerve bock/3 in 1 Block Adductor canal block Subsartorial block Saphenous nerve block SciaHc/Popliteal block SelecHve Hbial Nerve block
24 Femoral nerve - OPTIMIZING SCANNING TECHNIQUE! The nerve is relahvely superficial at this level! Use an ultrasound probe with high frequency (10-12 MHz) LATERAL MEDIAL! Adjust the depth to 1-3 cm! OpHmize gain! The femoral nerve is olen found within a triangular hyperechoic region, lateral to the femoral a. and superficial to the iliopsoas muscle Iliopsoas muscle FN F A FV
25 In which direc6on do you move the probe to improve visualiza6on?
26 Nerve supply knee joint Femoral nerve- branches to the vash Tibial Nerve- Superior medial, inferior medial and middle genicular branches Common peroneal- Superior lateral, inferior lateral, recurrent genicular branches Obturator nerve- Genicular branch from posterior division
27 Nerves targeted in adductor canal block
28 Sub sartorial- saphenous nerve block lower third Supine AbducHon at hip joint, Knee slightly bent High frequency probe Track lateral to medial aspect- middle third of thigh IdenHfy femur- Vastus medialis- Sartorius Femoral artery pulsahon can be idenhfied Saphenous nerve may be hard to visualize Inverse horseshoe appearance of injectate
29 Sub- sartorial Saphenous Nerve block- transverse sechon- middle of right thigh Saphenous nerve is a branch of the posterior division of the femoral nerve Adductor canal/sub- sartorial canal/ Hunter s canal: Floor/posterior wall: adductor longus and adductor magnus Anterior wall: Vastus medialis Roof: Fibrous membrane and sartorius 29 Contents: Femoral artery, Femoral vein, Saphenous nerve, Nerve to vastus medialis, and subsartorial plexus ( anterior division of obturator nerve, branches from saphenous nerve and medial cutaneous nerve of thigh
30 Sacral Plexus
31 SciaHc Nerve Anatomy Originates from L4-5, S1,2,3 nerve roots Composed of 2 nerves that become: Tibial Nerve Common Peroneal Nerve (separated by Compton- Cruveilhier septum) Clear division of nerves in 12% people Exits pelvis via greater sciahc foramen below piriformis
32 SciaHc Nerve Anatomy Appears flaoened in gluteal area, more rounded distally Cutaneous innervahon of posterior thigh is from: Posterior Femoral Cutaneous Nerve branches off in pelvis and runs superficially on biceps femoris
33 Dermotomes, Myotomes, Osteotomes Osteotomes: Foot Ankle Knee (parhal) Tibia (some contribuhons from femoral nerve in proximal medial aspect) Posterior hip capsule
34 Ultrasound Techniques: Posterior Gluteal Approaches
35 Ultrasound Techniques: Posterior Approaches Place probe along line between greater trochanter and ischial tuberosity. The nerve should be viewed in axial dimension. Tilt to obtain best image. May move proximally or distally if necessary.
36 Gluteal (Raj) Ultrasound Images Subgluteal Karmakar, M.K. et.al. Br J Anesth 2007; 98: Kunze, 2013
37 Pearls TilHng of probe improves image PosHon pahent to relax the gluteal muscles Don t be fooled by the ligament near the greater trochanter. It appears bright like a nerve. The nerve is closer to the ischial tuberosity! Use Nerve SHmulaHon to confirm structure May use in- plane or out- of- plane approach The nerve is never deeper than the distance between the skin and femur with the subgluteal approach.
38 Pifalls Obesity Nerve is more superficial with the Subgluteal approach Fall Risk Loss of dorsiflexion and knee flexion may put pahents at higher risk of fall Anisoechoic Nerve Tilt probe Use Nerve shmulahon ( ma) More connechve Hssue in nerve with aging which can worsen this problem
39 Pifalls (conhnued) Failure to block Posterior Cutaneous Nerve Block nerve proximal to ischial tuberosity Not needed for leg and foot procedures AnHcoagulaHon This is a deep block follow ASRA guidelines Blood vessels Medial circumflex artery Inferior gluteal artery
40 Anterior sciahc block Can be challenging Supine posihon 100 mm + needle
41 Method 1- CurviLinear probe + Nerve shm Approximately mid thigh Use the liner high frequency probe Advance needle between femur and femoral artery under US guidance SciaHc nerve visualised close to the femur Nerve shm- Dorsiflexion of foot
42 Method 2- Low frequency probe + nerve shm Approximately mid thigh Use the linear high frequency probe Advance needle between femur and femoral artery under US guidance Walk off femur gradually at 6-8 cms ( without US) Nerve shm- Dorsiflexion of foot
43 Ankle innervahon Posterior Hbial nerve Superficial peroneal nerve Deep peronel nerve Saphenous Sural nerve
44 Ankle Popliteal block Saphenous nerve block Ankle block
45 Popliteal Fossa Anatomy The Sciatic Nerve (SN) passes into the thigh anterior to the hamstrings and posterior-lateral to the popliteal artery & vein. The SN divides into the medial Tibial Nerve (TN) and lateral Common Peroneal Nerve (CP) components in the popliteal fossa. This division commonly occurs 5-10cm SUPERIOR to the popliteal crease. At this point, the nerve(s) lies 2-4 cm below the skin surface. The SN can be blocked anywhere along its course through the proximal thigh to the popliteal fossa. Blocking the nerve before it divides into the TN and CP components simplifies the technique. Popliteal crease Popliteal fossa is most widely chosen site to block the sciatic nerve. Av_2013
46 Popliteal Fossa Anatomy II L a t e r a l Popliteal Artery Popliteal vein Tibial Nerve Common Peroneal Nerve Av_2013 Base: Popliteal crease Medial Border: Tendons of semimembranosus and semitendinosus Lateral Border: Biceps femoris 46 With the long axis of the linear probe parallel to the popliteal crease, trace tibial component of the sciatic nerve cranially and identify the point of divison of the sciatic into the common peroneal and tibial nerves.
47 Technique: Popliteal fossa Lateral approach Supine- with feet elevated- useful in pa6ents with painful fractures/ external- fixators Position and prep Prone, lateral decubitus, supine with leg elevated on support Foot should be hanging off support to ensure free ROM Prep area above and below popliteal crease with iodine or chlorhexidine solutions A 22g block needle or 18 g ( for catheters) 50mm or 80mm needles( based on the depth of structures) 47
48 Popliteal fossa block- prone posihon - contd. M ed Trace the bright structure cephalad Common Peroneal Nerve Biceps femoris Popliteal Artery Tibial Nerve Semi tendinosus & Semi membranosus i a l Tilt/angle probe slightly towards feet for better visualization of the nerve Common peroneal nerve will appear lateral to the tibial nerve,along the medial border of biceps femoris The tibial nerve and common peroneal nerve appear to fuse i.e., the point where sciatic nerve divides into tibial and common peroneal nerves 48
49 Sciatic nerve at popliteal fossa surrounded by local anesthetic solution needle Sciatic Nerve Local anesthetic Local anesthetic choice: Bupivacaine or ropivacaine Volume: mls depending on the spread and accuracy of needle placement 49
50 Special situahons AmputaHon Free flaps Femoral/sciaHc catheters AnH coagulahon Indwelling Vascular stents
51 Back to basics Difficult posihoning BMI Supervising Trainees ProducHon pressure Develop a method Scan back to original posihon Workshops Adequate Hme Skilled assistance
52 THANK YOU
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