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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Peripheral nerve blocks.

Andrew Chang ; Anterpreet Dua ; Karampal Singh ; Brad A. White .

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Last Update: July 6, 2023 .

• Continuing Education Activity

Recent advances in surgical techniques and the development of a greater number of minimally invasive procedures have led to an increase in outpatient procedures. Analgesic techniques must keep pace with these surgical advancements. Studies have shown that peripheral nerve blocks are usually well-tolerated and provide regional analgesia that is superior to other modalities, such as oral pain medications or general anesthesia. This activity reviews the indications, contraindications, and mechanisms of action of medications used in nerve blocks. Additionally, this activity highlights the critical role of the interprofessional team members in monitoring patients to minimize complications and improve outcomes.

• Identify the indications for peripheral nerve blocks.
• Describe the preparation needed before performing a peripheral nerve block.
• Describe the potential complications of medications used for peripheral nerve blocks.
• Describe interprofessional team strategies for optimizing care coordination and communication to ensure patient safety during peripheral nerve blocks.
• Introduction

Recent advances in various surgical techniques and the development of more minimally invasive procedures have spurred an increase in outpatient procedures. With these developments, it requires that analgesic techniques keep pace with these surgical advancements. Studies have shown that peripheral nerve blocks are usually well-tolerated and provide regional analgesia superior to other modalities such as oral pain medications or general anesthesia. [1] [2] [3]

• Anatomy and Physiology

Anatomy and landmarks depend on the type of block being performed. Please refer below to techniques for specifics to the more common peripheral nerve blocks performed.

• Indications

There is no strict set of guidelines for the use of peripheral nerve blocks. However, the general rationale is to implement regional blocks in cases where conservative measures have failed or to avoid the side effects and complications of general anesthesia and oral medications. The following include examples of where peripheral nerve blocks may be preferable:

• Patients who are at high risk of respiratory depression related to general anesthesia
• Patients who want to avoid systematic medications
• Patients intolerant or not responsive to oral medications
• Contraindications

Absolute contraindications to the use of peripheral nerve blocks include allergy to local anesthetics, inability to cooperate, or patient refusal. It is advised to postpone or reconsider a nerve injection when there is an active infection at the injection site, pre-existing neural deficits along with the distribution of the block, and in patients with coagulopathies or on antithrombotic drugs.

Equipment that is used is dependent upon the type of technique utilized. The following is a list of equipment used based on technique.

• Nerve stimulator guidance: peripheral nerve stimulator that delivers an adjustable electrical current to the tip of a hollow insulated disposable needle. The needle has specific tubing attached to a syringe that allows for aspiration and injection of a local anesthetic. A wire runs between the needle and an electrode and allows the electrical pulse to be transmitted to stimulate the nerve.
• Ultrasound guidance: portable ultrasound machines with both high and low-frequency probes that can identify superficial and deeper nerves
• Continuous catheter: numerous kits available, which usually contain a needle and catheter. A standard epidural kit can often be utilized.

A well-versed medical professional that is highly familiar and experienced with the type of block being performed should be performing the specific injection.

• Preparation

Taking a detailed medical history is necessary to determine conditions like coagulopathy or respiratory compromise that may impact the decision to perform a block. A thorough physical exam is prudent as well to determine preexisting sensory or motor deficits in the distribution of the block. Studies show that patients with preexisting sensory or motor deficits may be more likely to develop new deficits following a block than patients without preexisting deficits. Following the history and physical, the patient should be made familiar with the risks, benefits, and care needed during the recovery phase of the block.

For patients that are receiving a nerve block for a surgical procedure, they should follow the same fasting guidelines for the surgery as it may be necessary for deep sedation to be used in cases of an inadequate block. Also, intravenous access should be obtained due to the risk of potential complications like vasovagal events, local anesthetic toxicity, and the possible use of general anesthetics.

• Technique or Treatment

The technique for peripheral nerve blocks is based on the type of block. A quick summary of some of the more common blocks is listed below.

• Interscalene block: anesthetizes nerve roots from the cervical plexus (C3, C4, supraclavicular nerve) and upper and middle trunks of the brachial plexus (C5-C7). For positioning, the patient is placed in a supine position with the head turned away from the side of the block. Sternal notch, the sternal and clavicular heads of the sternocleidomastoid muscle, and clavicle are identified and marked. A probe is placed in a transverse position with its long axis across the neck just above the clavicle if using ultrasound. The carotid artery and internal jugular vein are visualized. The subclavian artery is identified by directing the beam towards the first rib. Nerves are then traced to cephalad. At the C6 nerves of the brachial plexus are visualized in a vertical orientation within the interscalene groove. A needle is then placed in-plane or out-of-plane and directed toward the nerves. A needle tip is placed next to the nerve roots. A total of 12 cc to 30 cc of local anesthetic is injected.
• Supraclavicular block: the patient is placed in the supine position with arms by the sides and the head turned away from the side of the block. The probe is placed in a transverse position just above the clavicle using ultrasound. The carotid artery and internal jugular vein are visualized. The needle is inserted in-plane (parallel to the probe), and a local anesthetic is injected to hydro dissect between the nerves until the tip reaches an area bordered by the first rib, subclavian artery, and brachial plexus. 20 cc to 30 cc of local anesthetic is injected. Before injection, however, aspiration should be performed to ensure there is no blood.
• Infraclavicular block: the patient is placed in the supine position with the head turned away from the side of the block. The arm is abducted with the elbow flexed to identify the coracoid process. The axillary artery is identified, and the cords of the brachial plexus are visualized adjacent to the artery using ultrasound. The needle is placed adjacent to the axillary artery in the cranio-posterior quadrant, and 30 to 40 cc of local anesthetic is administered. Before injection, however, aspiration should be performed to ensure there is no blood
• Axillary block: block anesthetizes nerves of the brachial plexus at the level of the individual nerves and often requires multiple injections. The patient is positioned supine with the arm abducted 90 degrees, and the elbow is flexed. The transducer is placed transversely in the axilla using ultrasound. The needle is introduced perpendicular to the skin and advanced until the tip is next to each nerve.
• Intercostobrachial block: the patient is positioned supine with the arm abducted to expose the axillary fossa. The intercostobrachial nerve runs in the subcutaneous tissue of the medial upper arm. The needle is advanced subcutaneously across the medial aspect of the arm while injecting 5 cc to 10 cc of local anesthetic.
• Radial nerve block: radial nerve emerges between the brachioradialis tendon and the radius, just proximal to the styloid process. The needle is inserted subcutaneously, just proximal to the styloid process of the radius, aiming medially, and 3 cc to 5cc of local anesthetic is injected.
• The median nerve block is located between the tendons of the flexor palmaris longus and the flexor carpi radialis. The need is inserted between the two tendons until it penetrates the fascia and advanced until contact is made with bone. The needle should be redirected and local anesthetic injected in lateral and medial directions.
• Ulnar nerve block: ulnar nerve runs between the ulnar artery and flexor carpi ulnaris tendon. The tendon is just superficial to the ulnar nerve. A needle is placed under the tendon close to its attachment just above the styloid process of the ulna and advanced 5 mm to 10 mm, and 3 cc to 5 cc of local anesthetic is injected at this location.
• Lumbar plexus block: The patient is placed in the lateral decubitus position operative side up with the leg flexed at the hip and knee. It is placed longitudinally adjacent to the spine at the second to third lumbar level using the ultrasound probe. The needle is inserted at the cephalad edge using the in-plane technique. The length of the needle should be seen as it approaches the target structure, which is the posterior third of the psoas major muscle.
• Femoral nerve block: The patient is placed in a supine position. Using ultrasound, the nerve is visualized, which is lateral to the artery. An in-plane or out-of-plane approach can be used where the needle is inserted, and the tip is placed adjacent to the nerve, and 20 cc to 50 cc of local anesthetic is injected in 5 cc increments. Before injection, however, aspiration should be performed to ensure there is no blood.
• Fascia iliaca block: the patient is placed in a supine position where using ultrasound, the probe is placed transversely to the leg at the junction of the middle and lateral thirds (between the ASIS and pubic tubercle) to identify the fascia lata, iliacus muscle, and fascia iliaca. The needle is introduced in-plane inferior to the inguinal ligament and guided beneath the fascia iliaca, and 30 cc of local anesthetic is injected in 5 cc increments. Before injection, however, aspiration should be performed to ensure there is no blood.
• Obturator nerve block: the patient is placed in the supine position with the leg externally rotated. Using an ultrasound probe, it is placed in the inguinal crease, and the femoral vein is identified. The probe is then moved medially to visualize the pectineus and adductor longus muscles. The needle is inserted in-plane or out of plane and is directed to the fascial plane between the adductor brevis and magnus, and 5 cc to 10 cc of local anesthetic is injected. Before injection, however, aspiration should be performed to ensure there is no blood.
• Sciatic nerve block: can be approached anteriorly or posteriorly. The patient is placed in the lateral decubitus position with the hip flexed at 45 degrees and the knee at 90 degrees for the posterior approach. In the anterior approach, the patient is positioned in the same manner. Using an ultrasound probe, it is held transverse to the course of the nerve. The nerve is found lateral to the ischial tuberosity and deep to the gluteus maximus muscle. The needle is inserted in-plane from the lateral aspect of the transducer and positioned with the tip of the needle adjacent to the nerve. Approximately 20 cc of local anesthetic is injected in 5 cc increments with gentle aspirations between injections. Before injection, however, aspiration should be performed to ensure there is no blood.
• Popliteal nerve block: the patient can be placed in either prone, lateral decubitus or supine. There are two approaches. For the posterior approach, the biceps femoris and semitendinosus/semimembranosus tendons are palpated. The ultrasound probe is placed transverse to the thigh and in the popliteal crease. The popliteal artery is used as the landmark, and the tibial nerve is found superficial and lateral to the popliteal artery. The nerve is then followed cephalad to the point where the common fibular nerve joins the tibial nerve from the lateral side to form the sciatic nerve. The sciatic nerve is blocked proximal to this to ensure that both the common fibular and tibial nerves are anesthetized.
• Saphenous nerve block: the patient is positioned supine with the leg straight. Using the ultrasound probe, it is placed perpendicularly to the thigh at the midpoint between the anterior superior iliac spine and the distal end of the femur. The nerve is identified as it exits from the adductor canal adjacent to the femoral artery. As it is followed distally, it becomes more superficial, traveling with an arterial branch just deep to the sartorius muscle. Using an in-plane approach 10 cc of local anesthetic is injected deep into the sartorius muscle at the lateral border of the artery. 
• PENG block: The pericapsular nerve group (PENG) block is an interfascial plane block aiming to block articular branches supplied by femoral, obturator, and accessory obturator nerves. PENG block is indicated for anterior hip arthroplasties, lateral hip arthroplasties, and for hip fractures. It is performed in supine position by depositing 15-20 ml of local anesthetic in the plane between the psoas tendon and the pubic ramus under direct ultrasound visualization. Femoral nerve block, fascia iliaca compartment block, or lumbar plexus block have been used to manage post-operative analgesia in hip surgeries. These blocks result in weakness of quadriceps muscles and thus predispose to fall. These blocks also result in incomplete analgesia to the hip as here is sparing of few articular branches to the hip. The main advantage of PENG block is that it provides better analgesia of the hip without causing any muscle weakness. As there is no muscle weakness so the patient can participate in physical therapy early.
• iPACK block: IPACK block is an acronym for infiltration of local anesthetic into the interspace between the popliteal artery and the posterior capsule of the knee. This technique was first introduced by Dr. Sanjay K Sinha at the American Society of Regional Anesthesia (ASRA) meeting in 2012. iPACK block is used for postoperative analgesia for total knee arthroplasty and cruciate ligament repair. Posterior knee pain is mediated by articular branches arising mainly from the tibial nerve with contributions from the obturator nerve. In iPACK block, 15-20 ml of local anesthetic is deposited under ultrasound guidance in tissue plane femoral artery and posterior aspect of the capsule of the knee joint. The main advantage of iPACK block is that it is a muscle strength sparing block and doesn't result in foot drop or loss of sensorimotor function of leg and foot.
• Complications

Potential complications and side effects are dependent upon the type of block performed. However, complications include peripheral nerve injury (although not common, the rate may be as high as 8% to 10%), hematoma, local anesthetic systemic toxicity, allergic reaction, infection, and a secondary injury, which includes reduced sensation after nerve block. [4] [5] [6]

• Enhancing Healthcare Team Outcomes

Peripheral nerve blocks are often performed by anesthesiologists, surgeons, and emergency department physicians. However, a dedicated nurse must monitor the patient's vital signs during the procedure. More important, resuscitation equipment must be in the room before starting the procedure. A protocol should be established to conduct a peripheral nerve block to ensure patient safety and improve patient outcomes.

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Supraclavicular Ultrasound-guided, Brachial Plexus Nerve Block Contributed by StatPearls

Live ultrasound guided in plane median nerve block, flexor digitorum superficialis, flexor digitorum profundus Contributed by John Pester, DO

Sural Nerve Block Figures Contributed by Ryan D'Souza, MD

Saphenous Nerve Block Image Contributed by Mark Brady, MD

 Suprascapular Nerve Block, Video. Ultrasound-guided suprascapular nerve block at the level of the suprascapular notch. Contributed by Eric Helm, MD

Disclosure: Andrew Chang declares no relevant financial relationships with ineligible companies.

Disclosure: Anterpreet Dua declares no relevant financial relationships with ineligible companies.

Disclosure: Karampal Singh declares no relevant financial relationships with ineligible companies.

Disclosure: Brad White declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Chang A, Dua A, Singh K, et al. Peripheral Nerve Blocks. [Updated 2023 Jul 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Peripheral nerve blocks for anaesthesia and postoperative analgesia. [Curr Opin Anaesthesiol. 2003] Peripheral nerve blocks for anaesthesia and postoperative analgesia. Grossi P, Urmey WF. Curr Opin Anaesthesiol. 2003 Oct; 16(5):493-501.
• Effectiveness of ondansetron as an adjunct to lidocaine intravenous regional anesthesia on tourniquet pain and postoperative pain in patients undergoing elective hand surgery: a systematic review protocol. [JBI Database System Rev Implem...] Effectiveness of ondansetron as an adjunct to lidocaine intravenous regional anesthesia on tourniquet pain and postoperative pain in patients undergoing elective hand surgery: a systematic review protocol. Badeaux J, Bonanno L, Au H. JBI Database System Rev Implement Rep. 2015 Jan; 13(1):27-38.
• Review Regional analgesia for minimally invasive cardiac surgery. [J Card Surg. 2019] Review Regional analgesia for minimally invasive cardiac surgery. Yu S, Valencia MB, Roques V, Aljure OD. J Card Surg. 2019 Nov; 34(11):1289-1296. Epub 2019 Aug 23.
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INTRODUCTION

This topic will discuss aspects of PNBs that are common to multiple blocks. Issues and techniques specific to particular blocks are discussed separately. (See 'Techniques for specific nerve blocks' below.)

USE OF NERVE BLOCKS

Indications  —  Indications for peripheral nerve blocks (PNBs) are diverse and vary widely. Blocks are often used to avoid the effects of alternative anesthetics or analgesics. The most common rationale for their use is to avoid side effects and complications of general anesthesia (GA), particularly respiratory-related effects, and to provide analgesia while minimizing opioid use.

Examples of circumstances in which PNBs might be preferable to GA as a sole anesthetic include:

● Patients at risk of respiratory depression related to GA (eg, obstructive sleep apnea, severe obesity, underlying pulmonary disease, advanced age)

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Continuous Peripheral Nerve Blocks

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Chapter 68. Peripheral Nerve Blocks

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• Peripheral Nerve Blocks: Introduction
• Indications for the Use of Nerve Blocks
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• Performance and Assessmentof Nerve Blocks
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The interruption, interference, or blockade of painful stimuli has been used in the management of pain for several decades. Acute, chronic, and postoperative pain can be diminished with various types of regional anesthesia or specific nerve blocks. In the setting of chronic pain management, various peripheral nerve blocks can be diagnostic, prognostic, or therapeutic in nature. A nerve block involves the injection or infusion of a short- or long-acting local anesthetic around a peripheral sensory nerve, motor nerve, or sympathetic nerve plexus. In addition to local anesthetic, a steroid preparation may be added to decrease any suspected inflammatory process. Neurolytic nerve blocks can be performed utilizing various techniques including chemical, heat, or cold. Chemical agents such as alcohol or phenol are used for the selective destruction of nerves. Pulsed radiofrequency and cryoanalgesia cause neurolysis via heat or cold lesioning. Advances in fluoroscopic imaging and computed tomography (CT) scanning allow direct visualization and targeting of specific nerves and nerve plexuses. Other improvements include the use of nerve stimulators during interscalene and axillary blocks or sensory and motor nerve stimulation performed during radiofrequency procedures to assist in accurate needle placement.

Nerve blocks are generally most useful when a specific nerve or limb is affected. Neuropathies with bilateral or multiple areas of involvement may benefit from other forms of neuromodulation including pharmacologic management, transcutaneous electrical stimulation (TENS), or spinal cord stimulation. 1 , 2

Successful treatment outcomes involve numerous factors including proper patient selection, understanding the anatomy, side effects, and potential complications of each specific nerve block. A comprehensive approach to chronic pain management has been shown to produce superior outcomes. 3 Nerve blocks, when appropriate, should be considered part of the overall multidisciplinary treatment plan.

Patients selected for nerve block therapy or regional anesthesia should have an accurate diagnosis for the origin of their pain. In some instances nerve blocks may aid in the diagnosis of certain acute and chronic conditions. The relief of pain comes from the interruption of nociceptive or pain sensory pathways, sympathetic blockade, or somatosensory blockade. Regional anesthesia may be used to interrupt the afferent limb of abnormal reflexes that contribute to the pathogenesis of some pain syndromes. Regional anesthesia may block efferent sympathetic outflow, which contributes to postoperative, post-traumatic, and chronic pain syndromes with sympathetic involvement such as complex regional pain syndrome (CRPS) or postherpetic neuralgia. 4

A complete history and physical evaluation of the patient should be performed including review of laboratory studies, imaging studies, medications, and allergies. Psychiatric and psychosomatic assessment should be carried out when appropriate. Special attention should be paid to anticoagulant medications, sensory loss or motor weakness on physical examination. Complaints of sexual dysfunction, and bowel or bladder problems should also be noted. Any abnormal findings should be documented and may require further evaluation prior to any interventional nerve blocks.

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PERIPHERAL NERVE BLOCKS - PowerPoint PPT Presentation

PERIPHERAL NERVE BLOCKS

Peripheral nerve blocks r1 regional anesthesia needle delivery technique perineural sheath * nerve ... – powerpoint ppt presentation.

• Regional anesthesia? ???? ??
• needle delivery technique
• perineural sheath? ???? ??
• nerve stimulatior
• elicitation of paresthesia
• ? ? ultra sound, doppler,
• sensory nerve stimulationetc.?? ?? ?
• Choice of anesthesia
• - risk? benefit? ??
• type of surgery
• surgeons preference
• experience of anesthesiologist
• physiological and mental state of the patient
• Less immunosuppressive than GA
• Less postop. nausea vomiting, aspiration,
• malignant hyperthermia
• Hemodynamically compromised pt.
• or too ill to tolerate GA? ??
• Systemic toxicity of local anesthetics
• Chronic paresthesia nerve damage
• Respiratory failure( phrenic n.blockade)
• Seizure ( intraarterial inj.)
• Uncooperative patient
• Bleeding diathesis
• Local anesthetic toxicity
• - anesthetic? ?? ?? ?? ???? ??
• (eg, bilateral axillary nerve blocks)
• Peripheral neuropathy
• - contralateral phrenic n.palsy? ?? ??
• ipsilateral interscalene n. block? ??
• Time to onset
• Duration of action
• Degree of sensory vs motor block
• Cardiac toxicity
• ??? holding area? procedure room? ??
• - ??? monitoring system? resuscitation ?? ??
• ???? ?? intravascular inj.?? ??
• systemic toxicity??
• - peak blood level? ???? ?????
• delayed toxicity? ??
• - aspiration of the syringe
• - 3mL test dose of anesthetic with 1200,000
• or 1400,000 epinephrine
• - heart rate? baseline?? 20?? ??? ???
• intravascular inj.??
• Common local anesthetic solution
• - lidocaine 1.52
• - mepivacaine 2
• - bupivacaine 0.5
• - levobupivacaine0.5
• - ropivacaine0.5
• Post op. analgesia more dilute solution
• Benzodiazepine, opioid
• - anxiety ??, pain threshold??
• Sedation? ??? practioner? ?? ??
• - nerve stimulator??? deep sedation??
• Supplemental oxygen??? ??
• ????? ?? ?? local anesthetic?
• single or mult. Inj.
• - Supf.cervical block
• - to supplement axillary braqchial plexus
• ankle blokcs
• - Minor,supf. surgery
• Brachial plexus axillary artery ? ??
• Mucocutaneous n.
• coracobrachialis m.? body ??
• Intercostal n.
• rib? inf.border? ??
• (????? vein,artery,nerveVAN)
• neurovascular bundle?? ??
• (lateral???? nerve,artery, vein,
• empty space, lymphatics NAVEL)
• Needle? sensory n.? ?? ?? ? paresthesia
• - perineural ?? intraneural ?? ??? ??
• perineural inj.
• -brief accentuation of the paresthesia
• intraneural inj.
• hydrostatic injury-gtintense,searing pain
• Blunt bevel needle? ??
• - blunt tip, smaller cutting edge
• - nerve? ???? piercing? ????
• Needle tip? low level eletrical current
• (0.16.0mA)? ??
• - motor n.? ??? specific m.??
• -needle? ????? ???? ??? ??
• Optimal positioning? 0.5mA???
• evoked contration???
• 1-2mL? local anesthetic? ???
• evoked reponse ???
• C5T1? ant.primary
• 3trunk? ant.middle
• scalene m.??? ??
• - sup.trunk? C5C6
• - mid.trunk?C7
• - inf.trunk? C8T1
• trunk? 1st rib? lateral
• border?, clavicle ???
• - ant. post. division
• - clavicle??? ??? ?
• ?? 3?? cord?
• - sup. mid. trunk?ant.
• -median n.?lat.branch
• musculocutaneous n.
• - inf.trunk? ant. division
• - median n.? medial br.
• - ?? cord? post.division
• - axillary n. radial n. cord?
• pectoralis m.? lat.border??
• ???? terminal n.??
• Brachial plexus? ??? ?? fascial sheath?
• intervertebral foramen?? upper arm??
• ???? ? sheath??? injection? ??
• Interscalene approach
• - shoulder, arm, forearm? optimal
• - C57dermatome? ??, but C8T1?? ???
• -gt ulnar n.distribution? ?? procedure? ???
• Axillary approach- elbow hand ? procedure
• - C7T1dermatome? ??
• -gt shoulder, upper arm C56 procedure? ???
• Supraclavicular,infraclavicular approach
• - even distribution
• - arm,forearm and hand procedure? ??
• ant. mid. scalene m. ??,
• cricoid cartilage level
• - ??? supine, contralateral? 30? head rotation ??
• ? ? interscalene groove?
• ??,?? SCM. ant. scalene m. ?? groove?
• ???? ??? ??
• 22-gauge,1.5in B bevel needle??
• - skin? ????, ?? medial, caudal direction
• ?? paresthesia or evoked muscle contraction
• - nerve stimulator???
• phrenic n. activity -gt too anterior
• trapezius m.activity -gt too posterior
• COMPLICATION
• - incidental block
• - stellate ganglion -gt Horner's syndrome
• (myosis, ptosis, anhidrosis)
• - phrenic n. -gt dyspnea
• - recurrent laryngeal n -gt hoarseness
• - intra-arterial inj. into vertebral a.
• -gtseizure?? (??? brain??? ??)
• - venous inj.
• - slower onset of CNS toxicity
• - epidural, subarachnoid, subdural
• - close proximity of cervical intervertebral foramen
• - pneumothorax
• - ant.scalene m.?
• lat.border??
• brachial plexus?
• first rib? clavicle???
• ?? axilla? ??
• - ??? supine, contralateral?
• 30? head rotation
• - interscalene groove? ??
• ?? ?? ?? (subclavian a.
• pulse???? ????) ? ?
• - 1.5in B bevel needle????
• subclavian a. ?????
• caudal direction inj.
• (skin? flat? ???)
• - relatively high incidence (1-6) ?
• pneumothorax ??
• - Hemothroax
• - Horners syndrome
• - Phrenic n. block
• - arm? ??? ????
• - coracoid process
• 2cm medial,
• 2cm caudal??
• floor? ???? insert
• CLASSIC APPROACH
• - supine,procedure side?? ??? ?? ??? operative
• limb? abduction to 90
• clavicle? midpoint?? 2cm
• caudal direction?? 45?
• angle? axillary a. pulsation?
• - 4 inch 21gauge (nerve stimulator needle? insulated)
• ? ??, hand? motor activity
• - hemothorax
• - chylothorax (left sided block)
• - supraclavicular approach?? ?? ????
• - subclavian a.? clavicle?
• -gt axillary a.
•     -gt ? ???? trunk?
• ant. post. division??
• pectoralis minor m.?
• lateral border?? cord?
• large terminal branch??
• - musculocutaneous n.?
• axilla?? ?? brachial
• plexus? sheath? ?? 
• costobrachialis m.?? ??
• - plexus? sheath? fascial
• septum? ??? ?? ??
• ???? ?????? ??
• ? ??  patchy" anesthesia
• ? ??-gtincomplete spread
• of local anesthetic within the
• plexus sheath
• - supine position with the arm abducted,
• the elbow flexed at 90
• Transarterial technique
• - axilla? high(proximal) area?? axillary a.?
• pulse? palpation
• -gt immobile technique"?? 22gauge, 1.5inch B-bevel
• needle inj. aspiration -gt blood? ???? blood
• aspiration? ?? ??? needle? ????? ??,
• ????? 40ml? ?? (sheath?? septa ?? ?
• ???? ??? needle? artery? ?? anterior 20ml,
• posterior 20ml? ??? ???? clinician? ??)
• ELICITATION OF PARESTHESIA TECHNIQUE
• - single, specific or multiple paresthesia? ??? ?
• ?? needle? axillary a.???? ?? 
• -gt plexus sheath?? septation? ?? ??? ???
• ulnar, median, radial n. distribution ??? ?? ???
• ? ??? ?? -gt total 40ml? local anesthetic??
• NERVE STIMULATOR TECHNIQUE
• - 2inch 22gauge insulated stimulating needle? ????
• ?? identified?? 0.5mA??? stimulation? ???
• ?? ???? 1mL? local anesthetic? ????
• motoractivity? ???? ?? ???? negative
• aspiration??
• - very low complication rate
• -gtproviding intravascular injection is avoided
• but, multiple sites ? ?? repeated elicitation of
• paresthesia? postoperative neuropathy? incidence? ?????? ??.
• hematoma, infection? rare
• All four major nerves of the arm can be blocked separately at the level of the midhumerus.
• - nerve stimulator? ??
• - similar success rate to classic axillary block
• but, the onset of the blockade is slower
• Block proximal to the axilla for shoulder surgery or for any upper extremity procedure that involves use of a pneumatic tourniquet(medial brachial cutaneous nerve often leaves the sheath just below the clavicle)
• -gt may be missed with the axillary block
• -gt prevent pain from an arm tourniquet
• Intercostobrachial nerve
• medial brachial cutaneous nerve
• gtfield block -gt 5mL local anesthetic
• - used to supplement an incomplete brachial plexus blocks
• - brachial plexus? post.cord br.? humerus? ?? ???? triceps m.? innervation
• -. Humerus? musculospiral groove? ?? elbow
• ? lateral? ?? -gt terminal sensory br arm?
• lateral cutaneous n., forearm? post. Cutaneous n.
• elbow? lat.epicondyle?? supf. deep br.? ??
• Deep br. -gt forearm? extensor group? innervation
• Supf. Br-gt radial a.? ?? ?? dorsal wrist? radial aspect, lateral 3 2/1? dorsal aspect? innervation
• At the upper arm
• - radial n.? musculospiral groove?? triceps two head??? ??-gt??? lat. Epicondyle??? line?? radial n.??-gtepicondyle?? proximal 24cm?? needle inj.-gtbone? contack?? 0.5cm???? 5ml inj.
• At the elbow
• - antecubital space?? biceps tendon? ??? flexion crease? needle inj.-gt direction supf.to radial head toward the lat. epicondyle
• At the distal forearm
• - ulnar styloid level?? thumb? lat.side??? sensory br.? radial a.? flexor carpi radialis tendon??? ?? -gt? ??? inj.
• - Radial a. inj. intraneural inj.
• brachial plexus? lat. med. cords?? ??
• - brachial a.? medial ???? ??-gt antecubital space?? biceps tendon insertion site? ?? wrist finger flexor m.?? motor br.??-gt prox.wrist flexion crease?? palmaris longus tendon? ?? ???? carpal tunnel? ??
• at the elbow
• - biceps tendon insertion??? medial ??? brachial a.? ???? medial?? inj.-gt med. Epicondyle? ??-gt paresthesia or wrist flexion or periosteum contact??(??? ?? ??)
• At the wrist
• - ???? wrist flexion? ?? palmaris longus tendon? ??? medial?? inj.
• - brachial plexus? medial cord? ??
• - axillary brachial a.? medial side? ??
• -gt med. Condyle? arcuate lig.??? ??
• -gt mid forearm?? flexor digitorum profundus flexor carpi ulnaris??? ??
• -gt wrist ? flexor carpi ulnaris tendon? lateral, ulnar a.? medial ?? ??
• - arcuate lig.? proximal ?? one finger??? needle inj.
• - ulnar a.? ?? medial side or flexor carpi ulnaris ? lat. Side? inj.
• Insert at the medial and lateral aspects of the base of the selected digit
• - periosteum? ?????.
• ??? vasoconstrictor(epinephrine)? ?? ????? ???
• 4560? ??? ??? ??( eg, carpal tunnel release)
• - ??? intravenous catheter? ???? arm? double pneumatic tourniquet? ???.
• -gt catheter? 0.5lidocaine (25ml for forearm, 50ml for arm, 100ml for thigh)? 23?? ??? ??
• -gt ?? 510?? ?? ??
• Femoral n L2L4
• Obturator n.- L2L4
• Lateral femoral n.- L1L3
• Sciatic n. L4S3
• - Lumbar plexus? the fascis of the psoas muscle(ant.to the plexus)? the fascia of the quadratus laborum(post. to the plexus)? ?? ?????? psoas compartment? ????
• - insert to the psoas compartment(7090mm)
• -gt quadriceps motor response??
• -gt epidural space? ???? loss of resistance? ????
• -gt ant. Thigh, knee, medial foot? ??
• - psoas m.? ?? thigh?? femoral a.? lat.inguinal lig.? ????? ??-gt quadriceps, sartorius, pectineus m.? motor br.? ??
• -gt medial ant.thigh? sensory br. ??(psoas m.?? inguinal lig.????? sheath? encased)
• - inguinal lig.? ???? midpoint?? femoral a.? ????, femoral a.? 2cm lateral ? inj.
• Femoral n. obturator n., lat. Femoral cutaneous n.? ??? block??? ????, ?? ??? ??
• Fascia iliaca compartment
• - space bordered by the fascia iliaca(ant.) and iliopsoas muscle(post)
• -gt femoral nerve,lat.femoral cutaneous, obturator n. genitofemoral n.? fascia????? ????????? ??? compartment block
• -gt two pops fascia lata, fascia iliaca
• -gt nerve stimulator ??? ????
• -gt hip, thigh, knee surgery? ??
• - L23 lumbar plexus?? ?? psoas m.? ?? iliacus m.? ?? anterolaterally?? ??
• - ant.sup. Iliac spine?? 2cm meddistal site? inj.
• -gt needle? sheath? ????(pop)? ???? ?? fascia lata
• lat. Thigh? skin, m.biopsy, skin graftetc.
• - obturator foramen? ?? ??
• sensory innervation to the medial thigh and hip
• motor innervation to adductor m. of thigh
• - pubic tubercle?? 1.5cm lat. 1.5cm inf.??-gtsup.pubic ramus? ?? ???? ??, bone contact? lat.caudal direction?? 24cm ? ??(to enter the obturator foramen)-gt adductor motor response??
• Sciatic nerve
• - originate from the lumbosacral plexus(L4-5 S1-3) -gt sensory innervation to the post.hip capsule and knee
• -gt motor to the hamstring, all the lower extremity m. distal to the knee
• POSTERIOR APPORACH
• - lat. decubitus ?? ??? hip? knee? flexion
• -gt great trochanter? prominence?? post.sup.iliac spine?? line? ?? midpoint?? ???? caudal??? 46cm??? ???? inj.
• Lithotomy approach
• - supine position?? knee? 90?flexion, hip? 90120? flexion? great trochanter? ischial tuberosity?? midpoint?? skin? ???? inj.
• Anterior apporach
• - hip? flexion?? ????
• - supine position?? ??? ?? ext.rotation? femoral a.? 2cm medial ???? needle? lesser trochanter? ?? ??
• - sciatic n.? popliteal fossa(lat.??? biceps femoris tendon, medial ??? semitendinosus semimembranosus tendon? ??) ?? tibial n.? common peroneal n.? ??
• Posterior approach
• prone position
• - popliteal fossa is identified as a triangle
• -gt ?? biceps femoris
• -gt ?? semitendinosus semi membranosus
• -gt ?? popliteal crease
• - apex?? 1cm??,1cm lat?? inj.
• Lateral approach
• - patella ? sup.notch?? proximal 1012cm?? vastus lateralis? biceps femoris m.??? intertendinous groove? ?? -gt 30? ???? ?? -gt distal ankle, foot, toes? motor response??
• - femoral n.? terminal extension, medial aspect of the lower leg( knee? medial malleolus??)? sensory innervation
• -gt tibial tuberosity? ???? subcutaneously infiltrate
• Popliteal block ? ???? ??
• saphenous n. (femoral n.? terminal br.)
• anteromedial foot? supf.sensory innervation        
•  medial malleolus ?? ??? ??
• deep peroneal n. ( common peroneal n.? br.)
• toe extensor m.? innervation , dorsal foot? medial? sensory
• medial malleolus?? flexor hallucis longus? lateral? ??
• supf. peroneal n. (common peroneal n.? br) dorsal foot? sensory innervation
•          lateral malleolus?? extensor digitorum longus? lateral? ??
• posterior tibial n. (tibial n.? br.) medial malleolus? ??? post. tibial a. ?? ??
•          ???? ???(lateral ?? ??)? sensory innervation
• sural n. (tibial n.? br.) Achilles tendon? lateral malleolus??? ??
•          lateral foot? sensory innervation
• - deep peroneal n. block
• -gt intermalleolar line?? extensor digitorum longus ?  extensor hallucis longus tendon??? ??
• - supf. peroneal n. saphenous n. block -gt deep peroneal n. inj. Site?? lat. malleolar ? ?? subcutaneous infiltration
• - saphenous n. block
• -gt deep peroneal n. inj. site?? med. malleolar? ?? subcutaneous infiltration
• - post. tibial n. block
• -gt medial malleolus ???? post. tibial a. pulse? ???? needle? inj.
• - sural n. block
• -gt lateral malleolus? Achilles tendon ??? subcutaneous infiltration
• - cervical plexus(C1-C4)? SCM m. ?? platysma m.?? ??
• - jaw, neck, occiput and chest, shoulder close to clavicle? sensory innervation
• supine position, SCM? post. border? ?? 1/3??? needle? inj.-gt SCM? post. border? ?? cephalic ???? ??? ? needle? ?????? subcutaneous infiltration
• -gt needle? 180? ??? SCM? post. border? ?? caudal ???? inj.? ? ?? needle? ?????? subcutaneous infiltration
• ??????? ? ??? ??
• To supplement general anesthesia
• For postoperative analgesia following thorasic and upper abdominal surgery
• For relief of pain associated with rib fx., herpes zoster, and cancer
• - thorasic spinal n.?? ???? ? rib? ???? artery, vein? ?? ??(nerve? ?? ?? ??)
• - lateral decubitus or supine?? ?? mid or post. axillary line?? rib? ??? inj. -gtaspiration?? ? 3-5ml? ????? ??
• - intravascular inj.
• pneumothorax
• Spinal nerve? intervertebral foramina?? ???? two rami? ??, ?? smaller posterior ramus? back and neck? skin? muscle? innervation
• - thorasic paravertebral space?
• post.- sup.costotransverse lig.
• anterolaterally- parietal pleura
• medially vertebra and intervertebral foramen
• sup. inf. heads of the ribs
• - sitting position? C7 ? prominence??
• ? spinous proc.?? lat.2.5cm ??(inj. Point)
• - needle insertion? transverse proc.? contact?? ???? ?? ???? ??-gt? ???? ? 1cm ? ???? (costovertebral lig.??? pop? ????? ??.
• - ilioinguinal n., iliohypogastric n. - L1 or T12?? ??
• iliohypogastric n.
• - lateral br. - hip buttock? lateral sensory innervation
• - ant. br. - lower abdomen? innervation
• ilioinguinal n. -gt inguinal canal? ??
•         male scrotum, penis, medial thigh? sensory innervation
•          female labia, mons pubis? innervation
• ?? ant. sup. iliac spine? 2cm medial?? transversalis abdominis m. internal oblique m.? ??
• - genitofemoral n. - L1 and L2?? ??
• - femoral br femoral a.? ?? ??
• inguinal lig.??? cutaneous sensation
•             - genital br. inguinal canal? ??
• male scrotum
• female labium major? innervation
• - ant. sup. iliac spine? medial 2cm???? needle? skin? ???? inj.
• -gt fascia ?? ??? ????? ??
• genitofemoral n.? genital br.? pubic tubercle? lateral? 2-3ml? local anesthetic ??
• femoral br.? inguinal lig.?? ??? subcutaneous inj.
• - pudendal n. -gt dorsal n. of penis bilaterally -gt Bucks fascia? ??? dorsal ventral br.??
• Fan-shaped field block
• - penis? base? 24cm lat.?? inj.
• - more extensive surgery? ??, Bucks fascia? 1030 130 ???? ???? inj.(epinephrine ??)

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JACQUELINE L. YURGIL, DO, CHAD D. HULSOPPLE, DO, AND JEFFREY C. LEGGIT, MD

Am Fam Physician. 2020;101(11):654-664

This is part I of a two-part article on nerve blocks. “ Part II, Lower Extremity ,” appears in this issue of AFP .

Author disclosure: No relevant financial affiliations.

Procedural anesthesia is administered by family physicians for a variety of conditions, including neuropathies, fracture reduction, foreign body removals, and complex wound management. A nerve block may be preferred because it provides effective regional anesthesia with less anesthetic. Nerve blocks require a thorough understanding of relevant anatomy, aiding the physician in optimizing the anesthesia effect while minimizing complications. Nerve blocks can be guided by bony landmarks, peripheral nerve stimulation, or ultrasonography. Ultrasound-guided nerve blocks are superior in decreasing procedural complications and procedure time. Physicians should be aware of these techniques to appropriately counsel their patients on procedural options. Nerve blocks of the ulnar, median, and radial nerves at the wrist and elbow provide effective anesthesia for a wide range of medical procedures in the upper extremity.

Family physicians use anesthesia via local, field, and nerve blocks to perform outpatient procedures. Local anesthesia is provided by infiltrating the anesthetic into the procedural field, whereas field blocks are performed by infiltrating the anesthetic around the procedural area leaving the procedural field undisturbed. A nerve block provides anesthesia to specific, innervated regions distal to the block. A nerve block may be preferred because it provides effective regional anesthesia with less anesthetic. Figure 1 illustrates cutaneous innervation of the upper extremity. 1 This article, part I of a two-part series, discusses landmark and ultrasound-guided nerve blocks of the elbow and wrist. Part II, in this issue of American Family Physician , focuses on landmark and ultrasound-guided nerve blocks of the lower extremity. 2

Nerve blocks are used when managing neuropathies, fracture reduction, foreign body removals, and complex wounds. Table 1 lists conditions that warrant consideration for upper extremity nerve blocks. Additionally, a nerve block can be a diagnostic aid by helping to determine the source of a patient's pain. For instance, pain relief after an ulnar nerve block at the elbow confirms that the pain originates from the structures innervated by the ulnar nerve at or distal to the site of the nerve block, thus narrowing the differential diagnosis. Nerve blocks provide analgesia by blocking or inhibiting pain sensation via the perineural injection of anesthetics, allowing the patient to remain awake during invasive procedures that might otherwise necessitate centrally acting medications.

Nerve blocks require a thorough understanding of anatomy and the requisite training in the preferred technique to avoid complications, such as local anesthetic system toxicity. Nerve blocks can be guided by bony landmarks, peripheral nerve stimulation, or ultrasonography.

Peripheral nerve stimulation–guided blocks are anatomically based, with further localization using a specialized needle placed near the intended nerve. An electric stimulator sends a current from the needle to the desired distribution of the nerve, eliciting a muscle twitch to confirm correct localization. The same needle is then used to inject the anesthetic solution. A Cochrane review found moderate-quality evidence that ultrasound-guided blocks are superior to other techniques by providing sufficient and adequate anesthesia with a reduction in complications and procedure time. 3 A systematic review and meta-analysis of randomized controlled trials demonstrated that compared with peripheral nerve stimulation guidance, ultrasound guidance reduces nerve block failures, neurovascular trauma, the time required for the procedure, and the time to onset of anesthesia while increasing the duration of adequate anesthesia. 4 One study showed that ultrasound guidance reduces the local anesthetic dose by 30% compared with peripheral nerve stimulation guidance. 5 Anatomic variation must always be considered, and the use of ultrasound guidance allows direct visualization not possible with landmark-based injections.

See a  video summarizing the basics of ultrasound-guided nerve blocks .

Ultrasound-Guided Technique

Procedure setup.

A standardized office protocol must be established for procedure setup, infection control, safety measures, and informed consent documentation. 6 Patients should be counseled on the expected motor and sensory effects based on the known innervation of a target nerve and the expected duration of the recommended nerve block. Patients should be monitored for symptoms of toxicity, which include lightheadedness, tinnitus, metallic taste, visual disturbance, oral numbness, agitation, blood pressure and pulse changes, arrhythmias, and cardiac arrest. 7 , 8

Equipment setup and patient positioning depend on the anatomic area involved and procedure choice. Ultrasound-guided procedures are best performed with patient positioning that allows for direct alignment of the injection site with the physician's line of sight to the ultrasound screen ( Figure 2 ) . A high-frequency linear array ultrasound transducer (i.e., a probe that has a frequency range of 5 to 12 MHz) is well suited for the superficial nerve blocks discussed in this article.

The use of sterile gloves is not superior to the use of nonsterile gloves when establishing a clean procedural area. 9 A 2015 Cochrane review demonstrated lower rates of surgical site infections from intact skin procedures with a 0.5% chlorhexidine skin preparation compared with povidone-iodine paint. 10 The American Institute of Ultrasound in Medicine provides guidelines for establishing office protocols for cleaning of ultrasound probes and the use of sterile vs. nonsterile ultrasound gel, as well as training resources. 11

A 25- to 27-gauge, 1.5-inch needle is recommended, although some patients may require longer needles because of a larger body habitus, which will be readily apparent on ultrasonography. Ultrasound-guided nerve blocks can be administered using an in-plane or an out-of-plane injection method. With the in-plane (parallel) method, the transducer and needle are in the same plane, and the length of the needle is advanced in a visible field of view toward the target ( Figure 3 ) . With the out-of-plane (perpendicular) method, the needle passes through the visible plane of the transducer 12 ( Figure 4 ) . The choice of method depends on physician preference and the anatomic area.

The anesthetic is chosen based on the expected duration of the procedure, distribution, and location of the intended effect. 13 – 20 For example, a shorter-lasting anesthetic such as lidocaine may be selected because of its faster onset of action and a shorter procedure time, whereas the longer-lasting ropivacaine (Naropin) may be chosen for a longer procedure, bearing in mind that its onset of action will be slower. Local anesthetics can also be combined to take advantage of their different properties. Table 2 lists the characteristics of common anesthetics. 8 , 13 – 21

Beyond the anesthetic agents used in nerve blocks, various adjuvant therapies are available. Adjuvants may be beneficial in lengthening the duration of anesthesia, decreasing procedural bleeding, and reducing postoperative pain. A 2015 Cochrane review demonstrated that lidocaine augmented with epinephrine may prolong the duration of anesthesia and reduce bleeding during the procedure. 21 A 2017 Cochrane review concluded that dexamethasone may prolong the duration of sensory blocks and is effective in reducing postoperative pain intensity and opioid consumption in upper extremity procedures. There was not enough evidence to determine the benefits of dexamethasone in lower extremity procedures. 22

The volume of the injected agent varies by location and approach. Landmark-based injections commonly require 5 to 10 mL to bathe and anesthetize the nerve, whereas an ultrasound-guided injection usually requires only 2 to 5 mL.

Potential risks of a nerve block include soft tissue and neurovascular injury and vascular injection of the agent. A common practice to avoid inadvertent vascular injection is to aspirate before injection and reorient the needle out of the blood vessel if any blood is aspirated. Ultrasound guidance greatly reduces inadvertent vascular injection.

Median Nerve Block

The median nerve enters the cubital fossa just medial to the brachial artery between the two heads of the pronator teres and traverses distally between the flexor digitorum superficialis and flexor digitorum profundus muscles. 23 At the wrist, the median nerve is between the flexor carpi radialis and palmaris longus tendons.

The median nerve is a mixed sensory and motor nerve formed from the fibers of C5-T1 nerve roots. Its sensory distribution is depicted in Figure 1 1 and is generally from the palmar, or volar, aspect of the thumb to the radial aspect of the ring finger, and on the dorsal side includes the tip of the index finger, middle finger, and radial aspect of the ring finger. The anatomy of the median nerve is illustrated in Figure 5 and Figure 6 . 24

LANDMARK-GUIDED INJECTION

The patient's forearm is placed in a supinated position, and the needle is advanced at a 30-degree angle ( Figure 5 ) . The agent is injected approximately 1 cm medial to the palpable brachial artery within the antecubital crease. At the wrist, the patient's forearm is placed in a supinated position, and the needle is advanced at the wrist crease between the palmaris longus and the flexor carpi radialis tendons, aimed distally at a 45-degree angle ( Figure 6 24 ) . If the palmaris longus tendon is absent, which is the case in 15% of the population, the needle is inserted at the palmar crease 1 cm medial to the flexor carpi radialis tendon. 25 As the needle is advanced through the flexor retinaculum, there will be a decrease in resistance where the agent is injected.

ULTRASOUND-GUIDED INJECTION

The patient is seated, and the forearm is placed in a supinated position with the elbow extended. The transducer is placed transversely to the length of the forearm in the cubital fossa to visualize the median nerve next to the vascular structures ( Figure 3 ) . Real-time visualization of pulsating arteries and compressible veins allows for distinction under ultrasound guidance. When the nerve is visualized on ultrasonography in short axis, the nerve has a characteristic honeycomb pattern, which is a result of hypoechoic nerve fibers embedded in a hyperechoic background of connective tissue. 12 , 26 Advancing the needle medial to lateral, in plane with the transducer, the agent is injected in the perineural space of the median nerve.

An ultrasound-guided median nerve block at the wrist begins with the patient seated and the forearm in a supinated position. The transducer is placed transversely to the length of the forearm at the wrist crease ( Figure 4 ) , which is at the level of the proximal carpal bones in the carpal tunnel. The median nerve can be differentiated from the flexor tendons by its relative honeycomb appearance and minimally affected by loss of echogenicity (anisotropy) compared with nearby tendons. Additionally, if the patient actively moves the fingers while the transducer is across the wrist crease, the flexor tendons in the carpal tunnel will glide in the longitudinal plane while the median nerve slides in the carpal tunnel between the tendons. One way to perform this injection is using an out-of-plane technique, advancing the needle distal to proximal at the level of the wrist crease and injecting the agent in the perineural space of the median nerve.

See a video demonstrating two approaches to an ultrasound-guided median nerve block at the wrist .

Ultrasound-Guided Median Nerve Block

Radial nerve block.

The radial nerve enters the forearm just volar to the lateral epicondyle and quickly divides into deep and superficial branches. The deep branch traverses through the two heads of the supinator muscle where it emerges as the posterior interosseous nerve. The superficial branch stays just below the brachioradialis muscle as it courses distally toward the wrist, dividing proximal to the radial styloid process into the dorsal and palmar branches. The anatomy of the radial nerve is illustrated in Figure 7 and Figure 8 .

The radial nerve is a mixed motor and sensory nerve formed from the fibers of the C5-T1 nerve roots and provides sensation to the central portion of the dorsal aspect of the forearm; the dorsal aspect of the thumb, index, and middle fingers; and the radial half of the ring finger. It spares the distal dorsal surface of the index, middle, and ring fingers' nail beds, which are innervated by sensory branches of the median nerve 27 ( Figure 1 1 ) .

The patient's forearm is placed in a supinated position, and the needle is inserted 1 to 2 cm proximal to the antecubital crease. It is advanced at a 45-degree angle toward the humerus between the lateral border of the biceps tendon and the brachioradialis muscle, where the agent is injected ( Figure 7 ) . At the wrist, the patient is positioned with the radial (thumb) side up and the ulnar side resting on the table. The needle is advanced into the subcutaneous tissue at a 10- to 20-degree angle, approximately 1 to 2 cm proximal and lateral to the radial styloid process ( Figure 8 ) . The agent is injected into the subcutaneous tissue.

The patient is seated with the forearm pronated and elbow flexed at 90 degrees. The transducer is placed transversely to the length of the forearm over the extensor muscle mass ( Figure 9 ) . The radial nerve is visualized in the short axis 3 to 4 cm distal to the lateral epicondyle. It should be noted that there is great variability in the location of the radial nerve branching deep and superficially. The transducer may need to be moved proximally or distally to optimize visualization of the radial nerve. The agent is injected in the perineural space of the radial nerve by advancing the needle lateral to medial in plane with the transducer.

An ultrasound-guided radial nerve block at the wrist begins with the patient seated and the radial side of the wrist facing up. The transducer is placed transversely over the radius about 2 cm proximal to the radial styloid process ( Figure 10 ) . The radial nerve is visualized in the short axis proximal to the radial styloid process before the bifurcation. The radial nerve is identified, and the needle is advanced out of plane with the transducer. The agent is injected in the perineural space.

Ulnar Nerve Block

The ulnar nerve enters the forearm posteriorly as it courses through the cubital tunnel. It exits the cubital tunnel and traverses distally between the flexor carpi ulnaris and flexor digitorum profundus muscles. At the wrist, the ulnar nerve enters the hand through the Guyon canal. The ulnar nerve is a mixed motor and sensory nerve formed from the fibers of the C8-T1 nerve roots and occasionally C7 nerve roots. It provides palmar and dorsal sensation to the little finger and the ulnar aspect of the ring finger 28 ( Figure 1 1 ) . The anatomy of the ulnar nerve is illustrated in Figure 11 29 and Figure 12 . 30

The patient is in a supine position with the arm resting overhead. The elbow is flexed to 90 degrees, and the forearm is supinated. The needle is advanced at a 30-degree angle approximately 0.5 cm deep, midway between the olecranon and medial epicondyle, where the agent is injected ( Figure 11 29 ) . At the wrist, the forearm rests on the table with the palm up. The needle is inserted at a 45-degree angle 2 cm proximal to the medial wrist crease and radial to the flexor carpi ulnaris tendon ( Figure 12 30 ) . The agent is injected in this area just proximal to the ulnar styloid process.

The patient is in a supine position with the arm abducted to 90 degrees, the elbow flexed to 90 degrees, and the forearm supinated. The transducer is placed transversely to the length of the forearm over the flexor mass ( Figure 13 ) . The ulnar nerve is visualized in the short axis approximately 3 to 4 cm distal to the medial epicondyle. The ulnar nerve is identified, and the needle is advanced via an in-plane approach with the transducer. The agent is injected into the perineural space.

An ultrasound-guided ulnar nerve block at the wrist begins with the patient in a seated position, with the palm up and forearm resting on the table. The transducer is placed transversely to the length of the forearm over the wrist crease ( Figure 14 ) . The ulnar artery and nerve are visualized in the short axis at the level of the pisiform bone. The ulnar nerve is identified, and the needle is advanced out of plane with the transducer. The agent is injected into the perineural space.

See a video demonstrating two approaches to an ultrasound-guided ulnar nerve block at the wrist .

Ultrasound-Guided Ulnar Nerve Block

This article updates some aspects of a previous article on this topic by Salam . 13

Data Sources: A PubMed search was completed in Clinical Queries using the key terms peripheral, nerve, and block. The search included meta-analyses, randomized controlled trials, systematic reviews, and evidence-based guidelines. Also searched were the Agency for Healthcare Research and Quality Effective Healthcare reports, U.S. Preventive Services Task Force guidelines, the Cochrane database, and Essential Evidence Plus. Search dates: November 26, 2018; March 13, 2019; and February 19, 2020.

The views expressed are those of the authors and do not reflect the official policy or position of the Departments of the Army or Air Force, the Department of Defense, or the U.S. government.

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Peripheral Nerve Blocks using Nerve Stimulator

Dec 20, 2019

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Peripheral Nerve Blocks using Nerve Stimulator. Dr.D.KANNAN. D.A., D.N.B., Consultant Anaesthesiologist, Meenakshi Mission Hospital And Research Centre, Madurai. Peripheral Nerve Blocks using Nerve Stimulator. Introduction Nerve stimulator Drugs and toxicity Advantages of block Anatomy

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Peripheral Nerve Blocks using Nerve Stimulator Dr.D.KANNAN. D.A., D.N.B., Consultant Anaesthesiologist, Meenakshi Mission Hospital And Research Centre, Madurai.

Peripheral Nerve Blocks using Nerve Stimulator Introduction Nerve stimulator Drugs and toxicity Advantages of block Anatomy Nerve blocks Femoral N Obturator N Sciatic N Saphenous N Ankle block

EQUIPMENTS Nerve Stimulator Unipolar needles of varying length Flexible catheter Electrode

Nerve Stimulator Current range from 0.1-5.0 mA Pulse Frequency 1 Hz -Mixed nerve 2 Hz - Sensory nerve

Nerve Stimulator The electrical current required to trigger muscle contractions correlates with the distance of the tip of the needle to the nerve. That means that the closer the needle is to the nerve, the lower the electrical current that is required to induce contractions or sensory responses

Unipolar needle

Unipolar needles

Stimulation and Injection tecnique Initial current 2-3 mA Frequency 1-2 Hz Threshold current 0.3- 0.5 mA Aspiration test 5- 10 ml LA injected slowly Increase the current to initial level No stimulatory response - inject the remaining drug Recurring response - May indicate intra vascular needle position

Drugs 2% Plain Lignocaine 3 mg / kg 2% Lignocaine with adrenaline 7 mg / kg of 0.5% Bupivacaine 2 mg / kg o.75 % Ropivacaine 2-3 mg / kg Analgesic: 0.125% Bupivacaine, 0.2% Ropivacaine, Opiods, Clonidine.

Local Anaesthetic Toxicity

Advantages of Block On Arrival block Preemptive analgesia Post operative pain relief Rescuing a risky patients Less complications Cost factor

Lower Limb innervations The innervations of the leg is derived from the lumbar and sacral plexuses Lumbar plexus formed by T12–L4 The main branches are Lateral cutaneous N of thigh Femoral N Genitofemoral N Obturator N

Lower Limb innervations Lumbo sacral plexus formed by L4 –S5 Main branches are Sciatic nerve Posterior cutaneous nerve of thigh Pudental nerve

Lumbosacral Plexus Lateral cutaneous N of thigh Femoral N Genitofemoral N Sciatic N Obturator N Pudental N

Distribution of Lumbo sacral plexus Lateral cutaneous nerve of thigh Femoral nerve Sciatic nerve Obturator nerve

Lower Limb Blocks Femoral Nerve Block Obturator Nerve Block Lateral cutaneous Nerve Block Trans gluteal Sciatic Nerve Block Popliteal Saphenous Nerve Block Ankle Block

Femoral Nerve Block Indications Operative procedures in areas supplying the femoral and lateral femoral cutaneous nerves In combination with proximal sciatic nerve block, operative procedure on the whole leg. Analgesia

Femoral Nerve Block Contraindications No particular Side effects / complications Vessel puncture (of the femoral vein or artery)

Femoral Nerve Block Anatomical landmarks Groin Femoral artery Anterior superior iliac spine Pubic tubercle Inguinal ligament

Femoral Nerve Block Blockade technique The patient lies on his back, his leg loosely abducted and turned to the outside. Puncture site: 2cm caudad to the groin, 1 – 2 cm lateral to the femoral artery.

Femoral Nerve Block Puncture direction: 30 ̊ – 40̊ cranial parallel to the artery. Puncture depth: 2 – 4 cm. Positive stimulatory response from the femoral nerve: Rectus muscle of the thigh (“dancing patella”).

What to do when? Stimulation of the Sartorius muscle (medial contraction) occurs Puncture direction usually too medial. Retract the needle, and shift it slightly to the lateral. Direct stimulation of the Sartorius muscle (rare): Puncture direction is usually too lateral Shift the needle slightly to the medial. Femoral artery puncture: Retract the needle Shift puncture direction to the lateral.

Potential errors and hazards LA injection in the case of Sartorius muscle stimulation. Intravascular injection

Obturator nerve block Indications Suppression of the adductor reflex for the transurethral lateral bladder wall resection. Treatment of adductor spasm. Adjunct to the femoral nerve blocks for postoperative medial knee joint pain. Analgesia.

Obturator nerve block Contraindications No particular Side effect / complications Vessel puncture (obturator artery or vein)

Anatomical landmarks Origin of adductor longus muscle Pubic tubercle Femoral artery Anterior superior iliac spine

Obturator nerve block Blockade technique The patient is supine on his back, his leg is rotated outwardly and abducted. Puncture site: 5 – 10 cm beneath the pubic tubercle directly lateral to the tendon origin of the adductor longus muscle.

Obturator nerve block Puncture direction approx. 45 ̊ craniolateral pointing towards the anterior iliac spine. Puncture depth: 4 – 6 cm. Positive stimulatory response from adductor group.

What to do when? Persistent adductor spasm despite proper ONB Perform additional femoral block Note The adductor reflux for TURP can reliably suppressed by separate Obturator Nerve block Not by Femoral N block nor Spinal anaesthesia

Transgluteal sciatic nerve block Indications Operative procedure in areas supplying the sciatic nerve In combination with psoas compartment block / femoral nerve block for operations on the whole leg Analgesia

sciatic nerve block Contraindications No particular Side effects / complications Vessel puncture (inferior gluteal artery)

Transgluteal sciatic nerve block Anatomical landmarks Greater trochanter Posterior superior iliac spine Ischial tuberosity Sacral hiatus Puncture site

Transgluteal sciatic nerve block Blockade technique The patient is placed in the lateral recumbent position; hip flexed 45 ̊, knee flexed 70 ̊(“Stable recumbent position”)

Puncture site 4 – 5 cm mediocaudal on the mid-perpendicular lines between greater trochanter and posterior superior iliac spine; connecting line between the greater trochanter and sacral hiatus intersects the insertion point at the mid-perpendicular line.

Puncture depth 5 – 8 cm Positive stimulatory response From the peroneal or tibial nerves: Extensors or flexors of the foot or toes Dosage 20-40 ml

What to do when? Contraction of the Gluteus maximus muscle (= direct stimulation) occurs: Continue to advance the needle until the typical response is elicited. Stimulatory response from the ischiocrural muscle group: LA injection possible Delayed onset of action

What to do when? Bone contact, No Stimulatory response: Correct insertion direction to midline between greater trochanter and ischial tuberosity Potential errors and hazards LA injection upon stimulatory response from the gluteal muscles.

Popliteal sciatic nerve block Indications Operation procedure in the area supplying the sciatic nerve of the lower leg and foot In combination with saphenous nerve block, operations on the whole lower extremity. Analgesia.

Popliteal sciatic nerve block Contraindications Stent (relative) Side effects / complications Vessel puncture (popliteal artery/vein)

Popliteal sciatic nerve block Anatomical landmarks Popliteal fossa Popliteal fold Long head of the biceps femoris muscle Medial and lateral epicondyle of the femur

Popliteal sciatic nerve block Blockade technique Patient is either in prone position or lying on his side, leg extended Puncture site 8-12 cm above the fold of popliteal fossa at the medial edge of biceps femoris muscle.

Popliteal sciatic nerve block Puncture depth 2-4 cm Positive stimulatory response From the Peroneal and Tibial nerve (extensors or flexors of the foot or toes) Dosage: 30 – 40 ml

What to do when…? Femur contact occur: Insertion too deep and too medial Retract the needle Correct direction or insertion site to the lateral, reduce insertion depth. Vessel puncture popliteal artery/vein: Puncture too depth and too medial Retract the needle Correct insertion direction to the lateral, reduce insertion depth.

Potential errors and hazards Puncture site is too for caudad (popliteal fold): It may be that the tibial (med.) and perpneal nerve (lat.) are separated so far apart that complete blocked cannot be achieved with a single LA injection at the two sciatic branches.

Saphenous nerve block Indications Operative procedures in the area supplying the saphenous nerve. In combination with distal sciatic nerve block for operations on the whole lower leg and foot. Analgesia.

Saphenous nerve block No contraindications /side effects Anatomical Landmarks Petellar crest Sartorius muscle Vastus medialis muscle

Saphenous nerve block Blockade technique Patient lies on his supine back with extended leg in neutral position, rotated slightly outwards. Puncture site: Approx. 2 – 4 cm cranial and medial of the upper patellar crest over the sartorius muscle. Puncture direction perpendicular through the muscle up to the subsartorial fatty tissue.

Saphenous nerve block Puncture depth: 3 – 5 cm. Positive response include paresthesias on the medial lower leg at a pulse duration of 1.0 ms. Dosage 10 – 15 ml LA

What to do When…? Motor stimulatory response comes from the Vastus medialis muscle Consider as positive Inject the drug Alternative technique Subcutaneous infiltration below the medial knee joint from the medial head of gastronemius muscle to the tibial tuberosity

Ankle Block An ankle block is essentially a block of four branches of the sciatic nerve Deep Peroneal N Superficial Peroneal N Tibial N Sural N one cutaneous branch of the femoral nerve Saphenous N

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