PERIPHERAL REGIONAL BLOCKS by Mike DeBroeck, DNP, CRNA
Why am I bothering with this topic at all?
Do CRNAs REALLY even do peripheral regional anesthetics?
YES!!!!!!!
TOPICS GENERAL INFO SUCCESS RATES COMPLICATIONS LA CHOICE SPECIFIC BLOCKS
General Information
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.
KEYS TO SUCCESS
KNOW THE PHYSICAL ANATOMY!!!!
KNOW THE SENSORY/MOTOR INNERVATIONS!!!
GET COMFORTABLE WITH ULTRASOUND
LEARN HOW TO USE A NERVE STIMULATING NEEDLE PROPERLY
MANAGE TIME
EDUCATE SURGEONS
EDUCATE THE STAFF
EDUCATE PATIENTS
SUCCESS RATES
SO, HOW GOOD ARE THEY, REALLY?
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.
INDIVIDUAL SUCCESS RATES TEND TO PARALLEL PROPER USE OF EQUIPMENT, PROPER TECHNIQUE, AND ADEQUACY OF TRAINING
COMPLICATIONS Local anesthetic systemic toxicity Intravascular injection Choice of LA Neurotoxicity/Nerve injury Intraneuronal injection Patchy block Block failure
SO WHY DON T WE USE THEM MORE?
WE RE TOO LATE PUTTING THEM IN. THIS IS A FUNCTION OF SCHEDULING
WE DON T WAIT LONG ENOUGH FOR THEM TO SET UP THIS, TOO, IS MOSTLY A FUNCTION OF SCHEDULING
WE RE TOO SLOW PERFORMING THE PROCEDURES This is a function of training and experience THE WAY YOU PRACTICE IS THE WAY YOU PLAY
LOCAL ANESTHETIC CHOICE
PICK THE RIGHT DRUG FOR THE RIGHT OUTCOME.
What are you trying to accomplish? Quick onset? Long duration? Differential blockade? Adjunct to general or neuraxial anesthesia? Post-op pain control? Sole anesthetic?
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
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,
Amide LA Max Dosage/Concentration/Procedure Recommendations Without epi with epi
ADJUNCTS Epinephrine 5 mcg/ml Clonidine - 2 -adrenoceptor agonist*** 100 mcg = 100 extra minutes More just gets more side effect Dexmedetomidine -- 0.75mcg 1mcg/kg Faster onset, longer duration Dexamethasone 1-2 mg vs 8-10 mg? Longer duration but neural toxicity?
BLOCKS
BRACHIAL PLEXUS FEMORAL NERVE SCIATIC NERVE
BRACHIAL PLEXUS BLOCKS
Brachial Plexus Anatomy
Innervations
Block Choices Interscalene High Low Supraclavicular Infraclavicular Axillary Mid-humeral/rescue blocks Wrist
Interscalene
Surgical Coverage
C6 SCM EJV CLAVIC LE Landmarks: Cricoid cartilage, posterior border of sternocleidomastiond muscle, and external
Note neddle insertion perpendicular to neck with slight caudad angulation never cephalad
Ultrasound Positioning
Supraclavicular
Surgical Coverage
Surgical Coverage
Ultrasound Positioning
Infraclavicular
Surgical Coverage
Ultrasound Placement
Axillary
Surgical Coverage
Ultrasound Positioning
Midhumeral/Rescue Blocks
Midhumeral (Upper 3 rd ) View
3 Often Needed Supplementals All blocked at axilla with single generous SC injection.
Intercostobrachial Nerve Block
Lower Extremity Blocks
Lumbar Plexus Block Femoral/3 in 1 Block Adductor Canal Block Saphenous Nerve Block Sciatic Nerve Block Popliteal Block Ankle Block Mayo Block
Femoral Nerve Block
2 cm below & 1 cm medial to ASIS 1 cm lateral to artery
Surgical Coverage
Patella elevates with Stimulation
Ultrasound Positioning
Adductor Canal Block
Ultrasound Positioning
Sciatic Nerve Block
Classic Position and Landmarks
3cm
Ultrasound Positoning for Subgluteal Approach
2 cm 4 cm LLE Lateral View
Popliteal Nerve Block
Landmarks
Ultrasound Positioning
Alternate Positioning
So what s the take away?
OUR PRACTICE WORLD IS CHANGING!
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 2017. 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
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.
So how does that translate for me as a provider right now?
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
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
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
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
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.
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.
QUESTIONS?