Tutorial COMPACT

PERIPHERAL REGIONAL ANAESTHESIA
Tutorial COMPACT
dition
nded E
a
p
x
E
2nd
Mehrkens H.-H., Geiger P., Winckelmann J.
Department of Anesthesiology/Intensive Care Medicine and Pain Therapy
Ulm Rehabilitation Hospital and University Clinic
Preface
After so many of our colleagues have
expressed the wish for a pocket edition
of our Peripheral Regional Anesthesia
Tutorial published by the Ulm Rehabilitation Hospital (RKU), we have now
complied by offering this compact
version. The fundamentals contained
in this condensed guide still grow
from the now almost 20 years of clinical and practical experience gained in
our hospital. This book differs from Prof. H.-H. Mehrkens, M.D.
the previous, more comprehensive Director, Dept. of Anesthesiology/
Tutorial Script in that it includes many Intensive Care Medicine
new developments and supplemental
information. These shall be incorporated into the next edition
of the tutorial script and its coming Internet version.
It is here that I would like to extend my very special thanks to
the managing Senior Physician of our Department, Dr. Peter
Geiger. Without his tireless assistance, the production of the
compact version of this pocket tutorial would not have been
possible. Additional thanks go to B. Braun Melsungen, whose
continuing technical and financial support have been invaluable for the completion of this work.
Ulm, June 2004
Prof. H.-H. Mehrkens, M.D.
Preface to the 2nd Expanded Edition
Now, five years after the first pocket
edition of the “Peripheral Regional Anesthesia Tutorial” appeared, the time is
right to pay tribute to the rapid-paced
developments taking place in this field
of medicine. In doing so, we have made
special efforts to include ultrasoundguided nerve block techniques whenever we felt it was sensible. Certainly,
P. M. Geiger, M.D.
our daily routine has become unimagiMedical Director, Department of
nable without visualization of the nerves Anesthesiology/Intensive Care
we want to block. At the same time, we Medicine and Pain Therapy
believe that nerve stimulation and
ultrasonographic visualization are not competing methods. Indeed, seeing as not every block is equally suited for one or the
other of the two, a command of both is required. In many cases,
combining ultrasound with nerve stimulation yields major advantages.
Nerve blocks guided by ultrasound thrive on visual dynamics.
For that reason, we have intentionally refrained from using static
pictures of needle positions or of the local anaesthetic’s spread
around the target structures. Instead, this booklet has placed particular emphasis on the “ultrasonographic normal situs” at typical
puncture sites, which should assist the reader in identifying key
structures. Motion images shall be made available on an updated
Tutorial DVD soon.
2
It is here that I would like to extend my special thanks to Prof.
H.-H. Mehrkens, MD, my predecessor and the initiator of the “Tutorial Series”, who regularly takes time off from his retirement to
lend us his valuable advice. My managing senior physician, Dr.
Jörg Winckelmann, also deserves great recognition for his untiring commitment to the production of this new edition. Not least,
I would like to thank B. Braun Melsungen AG: without the company’s support, this project would not have been possible. We
authors hope that this current pocket-sized version will be used
effectively and we are equally looking forward, as in the past, to
its readers’ critiques and constructive suggestions on the Internet
Forum www.nerveblocks.net.
Ulm, August 2009
P. M. Geiger, MD
3
Contents
General
Nerve stimulation ..................................................... 4
Transcutane nerve stimulation ................................ 8
Sonography ............................................................ 10
Drugs ....................................................................... 13
Anatomy: Diagram of the brachial plexus ............ 14
Anatomy: Diagram of the lumbosacral plexus ..... 15
Continuing education materials ............................. 94
Upper extremity
Anterior interscalene nerve block ......................... 18
Posterior interscalene nerve block ........................ 24
Supraclavicular brachial block ............................... 28
Infraclavicular block ............................................... 30
Axillary nerve block ............................................... 36
Suprascapular nerve block .................................... 42
4
Lower extremity
Psoas compartment block .................................... 46
Femoral nerve block ............................................. 50
Saphenous nerve block ........................................ 56
Obturator nerve block ........................................... 62
Parasacral sciatic nerve block .............................. 68
Transgluteal sciatic nerve block ........................... 72
Anterior sciatic nerve block .................................. 76
Subtrochanteric sciatic nerve block ..................... 80
Lateral distal sciatic nerve block ........................... 84
Popliteal sciatic nerve block .................................. 90
5
Nerve stimulation
Nerve stimulator
• Currentrangefrom1.0–0.1mA
• Pulseduration0.1ms(mixednerve)
1.0 ms (sensory nerve)
• Constantsquarewavepulseoverawideimpedancerange
e.g. Stimuplex® HNS 11 and Stimuplex® HNS 12
(B. Braun Melsungen AG)
Single shot technique
• Unipolarneedlesofvaryinglength
e.g., Stimuplex® D or Stimuplex® D Plus for ultrasoundguided nerve blocks (B. Braun Melsungen AG)
Catheter technique
• Unipolarneedlesinaplasticintroducerofvaryinglengths
e.g.: Contiplex® D Sets with a flexible and non-wired
catheter or Contiplex® S (B. Braun Melsungen AG)
6
Equipment
®
Stimuplex HNS 12
®
(B. Braun Melsungen AG)
®
Stimuplex D / Stimuplex D Plus (B. Braun Melsungen AG)
®
Contiplex D (B. Braun Melsungen AG)
®
®
Contiplex Tuohy, Contiplex S (B. Braun Melsungen AG)
7
Transdermal nerve stimulation
Stimulation and injection technique
1. Initial current
1.0 mA
2. Pulse duration
0.1 ms (mixed nerve) or
use the SENS mode setting
on the stimulator
3.Thresholdcurrent0.3–0.2mA
4.Aspirationtest5–10mlLAinjectedslowly
5. Increase to 1.0 mA initial current No stimulatory response
Recurring stimulatory
response:
may indicate (partial) intravascular needle position.
Attempt careful aspiration,
perform reinjection slowly
with constant verbal monitoring.
6. Administration of remaining LA 1.0 mA
7. Catheter placement after primary LA administration
Upper extremity:
Approx. 3 cm beyond the end
of the introducer sheath
Lower extremity:
Approx. 4 cm beyond the end
of the introducer sheath
8. Catheter aspiration test
8
Technique
Stimuplex® Pen / Stimuplex® Guide
The Stimuplex Pen can be used together with the
nerve stimulator to locate nerves transdermally and to
trigger the corresponding motor response.
PEG (Percutaneous Electrode Guidance)
The Stimuplex® Guide first induces percutaneous
stimulation with the sterile needle and then the actual
nerve block.
Areas of application
•Forprimaryorientationbeforeblockinganerve
•Todemonstratespecificstimulatoryresponses(for
training purposes)
Block technique
•Prerequisite:superficiallocationofthenerves
•Changethesettingsonthenervestimulatorto:
Pulseduration1.0ms,baselineamplitude2.5–3.0mA,
•Goodconductivityofthepentip(electrodegel,water)
•Continuousimpedancedisplay(HNS12)canbehelpfulas
an indirect measure of “unimpeded” current flow
9
Sonography
General prerequisites
• Knowledgeof(incisional)anatomy
• Proper material (ultrasound imager, needles, local
anaesthetics)
• Routine application (to train hand-eye coordination)
Insertion techniques
Insertion
Advantages
Disadvantages
Transverse to ultrasound
Usually short distance Difficult to visualise
plane (so called „short axis“) to target (nerve/plexus) needle tip
In-plane with ultrasound
beam (so called „log axis“)
Needle and target
area fully visualised
Distance to the target
is often long
Practical procedural tips
• Createergonomiccircumstances(patient,puncturing
physician, ultrasound imager)
• Performa“trialsonography”fororientation
• Sterileprepinsertionsiteandtransducer
• Advancetheinsertionneedleintotargetareaanddeliver
local anaesthetic
• Correctneedlepositionandinjectmorelocalanaesthetic
as needed
10
Technique
Short axis (out-of-plane technique)
Long axis (in-plane technique)
11
Equipment
Stimuplex® D Plus
(B. Braun Melsungen AG)
conventional needle shaft
®
Stimuplex D Plus
(new echogenic needle shaft)
Ultrasound imager requirements
(e.g. GE Venue 40)
• Compactandrobust
• Easytooperate
• Quicklyreadyand
mobile (boot time etc.)
• Suitablehigh-frequency
transducer(7–12MHz)
Stimuplex® Needle Guide (B. Braun Melsungen AG)
12
Drugs
Drugs
Conventional, medium-acting local anesthetics (LA) like
• prilocaine
• mepivacaine
and long-acting ones like
• ropivacaine
• bupivacaine.
For anesthesia, we prefer a combination of
• prilocaine1%(20–40ml)andropivacaine0.5–0.75%
(10–20ml).
This combination has the advantage that a LA with comparably low toxicity is given primarily and inadvertent
intravascular injections mostly occur during the prodromal
stage. Subsequently, a long-acting LA is administered to
achieve a blockade of sufficient duration.
Foranalgesia,0.2%ropivacaineisgenerallyadministered.
The preferred mode of delivery is through a PCA pump
equipped with basal rate and bolus settings or by continuous infusion through the nerve catheter. Intermittant bolus
injections are rarely used.
13
Intoxication
Local anesthetic-induced systemic intoxication
CARDIOCIRCULATORY
Asystolia
14
Degree of
intoxication
CEREBRAL
Seizure
Bradycardia
Extrasystoles
Hypotension
Confusion
Dizziness
Tinnitus
Metallic taste
Hypertension
Tachycardia
Mentally
“abnormal”
Drugs
15
Brachial plexus
Anatomy
1
2
3
5
A
6
B
C
D
E
F
12
14
7
8
9
10 11
A
B
C
D
E
F
Upper trunk
Middle trunk
Lower trunk
Lateral cord
Posterior cord
Medial cord
1
2
3
4
Dorsal scapular nerve.
Suprascapular nerve
Subclavian nerve
Pectoral nerves
16
5
6
7
8
9
10
11
12
13
14
15
15
Musculocutaneus nerve
Axillary nerve
Radial nerve
Median nerve
Ulnar nerve
Medial brachial cutaneous nerve
Medial antebrachial cutaneous nerve
Long thoracic nerve
Subscapular nerve
Axillary artery
Thoracodorsal nerve
Lumbosacral plexus
Anatomy
1
2
3
4
5
6
1
Lateral femoral cutaneous nerve
2
Femoral nerve
3
Genitofemoral nerve
4
Sciatic nerve
5
Obturator nerve
6
Pudendal nerve
17
Nerve stimulation
Approach according to Meier
Indications
• Operativeproceduresontheshoulder,proximalupper
arm and lateral clavicle
• Analgesia
Contraindications
• Contralateralphrenicandrecurrentparesis
Side effects / complications
• Horner´ssyndrome
• Phrenicparesis
• Recurrentparesis
• Vesselpuncture(externaljugularvein)
Anatomical landmarks
• Sternocleidomastoidmuscle
• Superiorthyroidnotch
• Scalenusgap
• VIB(verticalinfraclavicularblockade)point
1 Sternocleidomastoid muscle,
2 Thyroid notch, 3 Puncture site
18
Anterior interscalene nerve block
Anatomical landmarks
1
3
2
19
Nerve stimulation
Blockade technique
The patient lies supine, head turned slightly to contralateral
side, shoulder and arm positioned comfortably.
Puncture site:
Posterior edge of the sternocleidomastoid muscle at the level
ofthethyroidnotch(1.5–2cmabovethecricoid).Insertion
direction tangential to the course of the plexus in the direction
of the VIB point or anterior axillary line.
Puncturedepth:2–4cm.
Positive stimulatory response from the upper trunk (lateral
cord): biceps and/or brachial muscle.
Dosage
20–40mlLA
Single shot technique
e.g. Stimuplex® D, 50 mm
Catheter technique
e.g. Contiplex® D-Set, 55 mm
Advance the soft plastic catheter max. 3 cm beyond the
end of the introducer sheath.
20
Anterior interscalene nerve block
?
What to do when ...?
Stimulation of the axillary nerve (deltoid muscle) or radial nerve (triceps muscle) occurs:
Leave the needle in place u Administer LA.
Stimulation of the suprascapular nerve (levator scapulae muscle) occurs: The insertion
direction is too lateral and dorsal u Retract the
needle, advance it markedly more to the ventral
and somewhat more medial.
Stimulation of the phrenic nerve (unilateral
singultus) occurs: The insertion direction is too
ventral and medial u Retract the needle, advance it slightly more to the lateral and dorsal.
Blood is aspirated: Retract the needle, check
direction of puncture u Readvance needle.
!
Potential errors and hazards
Always avoid a medial direction of puncture:
• Riskofpuncturinglargevessels(carotidand
vertebral arteries, internal jugular vein).
• Riskofintrathecalinjection=highspinal!
(Most suitable and reliable stimulatory response:
bicepsand/orbrachialmuscle=mostlateral
part of plexus [C5])
21
Sonography
Nerve block technique
Short axis is preferable (catheter placement), long axis possible
for Single shot
Sonoanatomic landmarks:
- Sternocleidomastoid muscle
- Scalenus anterior and scalenus medius muscles
- Nerve roots of the brachial plexus
Blockade objective:
Infiltrateatleastthesuperiorroots(C5–C7)withlocalanaesthetic. As a general rule, 15 - 20 ml will suffice.
Practical tip:
The ideal insertion site is most successfully located by tilting the
transducer from the supraclavicular to the interscalene position,
following the plexus fibres.
22
Anterior interscalene nerve block
lateral
medial
Sonoanatomic landmarks
23
Nerve stimulation
Approach according to Pippa
Indications
• Operativeproceduresontheshoulder,proximalupper
arm and lateral clavicle
• Analgesia
Contraindications
• Contralateralphrenicandrecurrentparesis
Side effects / complications
• Horner´ssyndrome
• Phrenicparesis
• Recurrentparesis
• Vesselpuncture
Anatomical landmarks
• SpinousprocessC7(vertebraprominens)
• SpinousprocessC6
• Cricoid
• Sternocleidomastoidmuscle
1 C6, 2 C7, 3 Puncture site
24
Posterior interscalene nerve block
Anatomical landmarks
1
3
2
25
Nerve stimulation
Blockade technique
Patient is in axially aligned recumbent position (or seated);
the cervical spine is flexed backwards; shoulder and arm are
relaxed.
Puncture site:
3 cm midline between the two spinous processes C6 and C7,
Insertiondirection5–10°tothelateral,aimedattheheightof
the cricoid.
Puncturedepth:6–8cm,dependingonthedistancebetween
puncture site and posterior edge of the sternocleidomastoid
muscle.
A promising stimulatory response elicited from the upper trunk
(lateral sheath): biceps muscle and/or brachial muscle and/or
deltoid muscle.
Dosage
30–50mlLA
Single shot technique
e.g. Stimuplex®D,80–100mm
Catheter technique
e.g. Contiplex®D-Set,80–110mm
Advance the soft plastic catheter max. 3 cm beyond the
end of the introducer sheath.
26
Posterior interscalene nerve block
?
What to do when ...?
Stimulation of the axillary nerve (deltoid muscle) or radial nerve (triceps muscle) occurs:
Leave needle in situ u Inject a slow, fractionated dose of local anaesthetic.
Stimulation of the suprascapular nerve (levator scapulae muscle) occurs: Insertion direction too lateral u Retract the needle, advance it
slightly to the medial and slightly deeper.
Stimulation of the phrenic nerve (unilateral
singultus) occurs: Insertion direction too deep
and too medial uRetract the needle, advance it
more to the lateral and less deep.
!
Blood is aspirated: retract the needle, check
puncture direction uReadvance the needle.
Potential errors and hazards
Always avoid a medial insertion direction:
• Riskofpuncturingthevertebralartery.
• Riskofintrathecalinjection=highspinal!
(Most suitable and reliable stimulatory response:
bicepsand/orbrachialmuscle=mostlateral
part of plexus [C5])
27
Sonography
Preliminary note:
The supraclavicular plexus block is a classic indication for
the use of ultrasound guidance since it can reliably depict
delicate structures like the subclavian artery and the pleura,
in particular. Or, stated the other way around: Do not perform
supraclavicular blocks without ultrasound.
Nerve block technique:
Long (single-shot technique) and short axis (catheter technique) possible
Sonoanatomic landmarks:
- Anterior scalene and middle scalene muscles
- Subclavian artery
- First rib
- Pleura
Blockade objective:
To infiltrate all parts of the plexus (here: trunks) with local
anaesthetic.
28
Supraclavicular brachial block
lateral
medial
Sonoanatomic landmarks
29
Nerve stimulation
Approach according to Kilka, Geiger, Mehrkens
Indications
• Operativeproceduresonthedistalupperarm,forearm
and hand
• Analgesia
Contraindications
• Chestdeformities
• Healed,butdislocated(shortened)fractureoftheclavicle
Side effects / complications
• Horner´ssyndrome
• Phrenicparesis
• Vesselpuncture(cephalicvein,subclavianarteryandvein)
• Pneumothorax
Anatomical landmarks
• Suprasternalnotch
• Lateraledgeoftheacromion
• Infraclavicularfossa
1 Lateral edge of acromion, 2 Suprasternal notch,
3 Infraclavicular fossa, 4 Puncture site
30
Infraclavicular block
Anatomical landmarks
3
1
4
2
31
Nerve stimulation
Blockade technique
The patient is supine, with his hand relaxed on abdomen.
Puncture site:
Half the distance between the jugular fossa and the ventral
end of the acromion – directly underneath the clavicle. (The
medial edge of Mohrenheim’s fossa is used to confirm the
insertion site). Insertion direction must be absolutely perpendicular to the supporting surface (operating table).
Puncturedepth:2–4cm.
Positive stimulatory response from the posterior cord:
ExtensororflexormuscleD1–3(=radialormediannerve).
Dosage
30–50mlLA
Single shot technique
e.g. Stimuplex® D, 50 mm
Catheter technique
e.g. Contiplex® D-Set, 55 mm
Advance the soft plastic catheter max. 3 cm beyond the
end of the introducer sheath.
32
Infraclavicular block
?
What to do when ...?
Lateral landmarks (ventral apophysis of acromion) cannot be found: Palpation of the clavicle
from medial to lateral leads to the acromioclavicular joint u The lateral edge of the acromion is
located ventral and lateral. Palpation of the crest
of the scapula from dorsal to lateroventral leads
to the acromion and stops at the correct site.
Stimulation of the musculocutaneous nerve (biceps muscle = lateral cord) occurs: Puncture is
too medial and superficial u Retract the needle,
shiftitsubcutaneouslytothelateral(0.3–0.5
cm)andthenadvanceitperpendicularly(!)approx.0.5–1cmdeeperthanbefore.
!
Blood is aspirated: Puncture site is too medial or
too far away from the lower clavicular edge u Retract the needle, check lateral landmarks (ventral
apophysis of the acromion) and readvance the
needle.
Potential errors and hazards
• Puncturetoomedial(establishalaterallandmark as described above).
• Punctureisnotperformedinaperpendicular
direction.
• Puncturedepthorientation:estimateddistance
between surface and palpable lower clavicular
margin + 1 cm (Beware > 4 cm in persons
with asthenic physiques).
33
Sonography
Preliminary note:
As a general rule, ultrasound visualization of the infraclavicular cords is less pronounced than of the supraclavicular. It
may sometimes be helpful to extend the arm.
Nerve block technique:
Short and long axis possible
Sonoanatomic landmarks:
- Subclavian artery and vein
- Pectoralis major and minor muscles
- Pleura
Blockade objective:
To infiltrate all cords with local anaesthetic
34
Infraclavicular block
caudal
cranial
Sonoanatomic landmarks
35
Nerve stimulation
Approach according to de Jong
Indications
• Operativeproceduresontheelbow,forearmandhand
• Analgesia
Contraindications
• Noparticular
Side effects / complications
• Haematomaiftheradialarteryisinjured
Anatomical landmarks
• Axillaryartery
• Coracobrachialismuscle
• Medialbicipitalgroove
• Pectoralismajorandminormuscles
= Puncture site
36
Axillary blockade
Anatomical landmarks
37
Nerve stimulation
Blockade technique
With the patient supine, the shoulder joint is abducted 90°,
elbowjointextended90°.
Puncture site:
Slightly above the axillary artery in the gap between artery
and coracobrachialis muscle, at the highest point in the axilla
and slightly beneath the pectoralis major muscle.
Inserttheneedleapprox.30°paralleltotheaxillaryartery,taking a very superficial course.
Puncturedepth:1–3cm.
A promising stimulatory response elicited from the median
nerve or, rather, from the radial nerve: flexor digitorum muscles / extensor digitorum muscles.
Dosage
30–50mlLA
Single shot technique
e.g. Stimuplex® D, 50 mm
Catheter technique
e.g. Contiplex® D-Set, 55 mm
Advance the soft plastic catheter 5 cm beyond the end
of the introducer sheath.
38
Axillary blockade
?
What to do when ...?
There is no stimulatory response:
The puncture has probably gone too deep u Retract the needle and advance at a flatter (more tangential) angle, watching out for any “fascial click“.
Stimulation of the musculocutaneous nerve:
The needle is not positioned within the neurovascular sheathu Retract the needle, advance it
less deep and more tangential to the artery.
!
Potential errors and hazards
• Puncturetoodeep.
• Difficultiesidentifyingtheaxillaryartery.
39
Sonography
Nerve block technique:
Short axis is preferable
Sonoanatomic landmarks:
- Axillary artery and vein
- Triceps brachii muscle
Blockade objective:
To infiltrate all four main nerves of the brachial plexus with
local anaesthetic
40
Axillary blockade
caudal
cranial
Sonoanatomic landmarks
41
Nerve stimulation
Approach according to Meier
Indications
• Frozenshoulder(forpainmanagementandmobilization
therapy)
• Analgesia
Contraindications
• Noparticular
Side effects / complications
• Noparticular
Anatomical landmarks
• Spineofscapula
1 Lateral end of the spine of scapula,
2 Medial end of the spine of scapula, 3 Puncture site
42
Suprascapular nerve block
Anatomical landmarks
3
1
2
43
Nerve stimulation
The patient is seated, hand on their contralateral shoulder.
1–2cmcranialandmedialtothemid-spine.Insertiondirection approx. 45° caudad and lateral towards the humerus
head.
Puncturedepth:3–5cm.
Positive stimulatory response: supraspinatus or infraspinatus
muscles.
Dosage
10–20mlLA
Single shot technique
e.g. Stimuplex® D, 50 mm
Catheter technique
e.g. Contiplex® D-Set, 55 mm
Advance the soft plastic catheter < 3 cm beyond the
end of the introducer sheath.
44
Suprascapular nerve block
?
What to do when ...?
There is no stimulation response:
Try to find the floor of the supraspinous fossa
or retract the needle and advance it at a flatter
angle towards the humerus head.
Note two important aspects:
1. A muscular stimulatory response is not imperative to achieve blockade.
2. The suprascapular nerve is not involved in
the(sensory)skinsupplyoftheshoulder!
!
Potential errors and hazards
• Punctureismadetoodeepandsteep.
45
Nerve stimulation
Approach according to Chayen
Indications
• Operativeproceduresinthelumbarplexussupplyarea
• Incombinationwithproximalsciaticnerveblockforcomplicated operations on the whole leg distal to the hip (total
knee arthroplasty, cruciate ligament replacement ...)
• Analgesia
Contraindications
• Extremehyperlordosis(relative)
• Coagulationdisorders
Side effects / complications
• Vesselpuncture(paravertebralveins)
• Disseminationsimilartoepiduralanesthesia(contralateral)
• High(total)spinalanesthesia
Anatomical landmarks
• Posteriorsuperioriliacspine
• Iliaccrest
• SpinousprocessL4
• CostalprocessL5
1 Iliac crest, 2 Posterior superior iliac spine,
3 Spinous process L 4, 4 Puncture site
46
Psoas compartment block
Anatomical landmarks
1
2
4
3
47
Nerve stimulation
Blockade technique
The patient is in the lateral recumbent position (or seated), the
cervical spine is flexed backwards.
Puncture site:
3 cm caudad and 4 cm paramedian to the spinous process of
L4. Sagittal insertion direction; upon contact with the transverse process of L5, retract needle slightly, correct downward
and advance over the transverse process (2 cm). Alternatively:
Divide the connecting line between the spinous process of L4
and the posterior superior iliac spine in thirds; insert the needle
at the transition from the medial to lateral third.
Puncturedepth:6–10cm.
Positive stimulatory response from the femoral nerve: quadriceps muscle (usually the vastus lateralis muscle). Puncture is
also possible at the level of the transverse process L4; now advance the caudad aligned needle under the transverse process.
Dosage
30–50mlLA,testdose5ml
Single shot technique
e.g. Stimuplex®D,80–120mm
Catheter technique
e.g. Contiplex®D-Set,80–110mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
48
Psoas compartment block
?
What to do when ...?
Stimulation of the obturator nerve (contraction of the adductor group) occurs: Puncture
direction is too medial uRetract the needle,
then lateralize it somewhat.
Stimulation of the fourth lumbar nerve (= lumbosacral trunk, contractions in the peroneal
group) occurs:
Puncture direction is much too medial u Retract the needle; advance it markedly in the
lateral direction.
No transverse process contact and no
stimulatory response is achieved:
Puncture site and/or direction may be too lateral u Check the distance between puncture
site and midline (max. 4 cm), and, if needed,
adjust the puncture direction to the patient‘s
position. Adequate stimulatory response may
also be possible without prior transverse processcontact!
!
Potential errors and hazards
Always avoid a medial puncture direction
(towards the spinal column)!
• Riskofepiduralorevenintrathecaldissemination of the LA. Perform a test dose.
49
Nerve stimulation
Femoral nerve block
Indications
• Operativeproceduresinareassupplyingthefemoral
and lateral femoral cutaneous nerves
• Incombinationwithproximalsciaticnerveblock,operative procedures on the whole leg (from distal thigh
to foot)
• Analgesia
Contraindications
• Noparticular
Side effects / complications
• Vesselpuncture(ofthefemoralveinorartery)
Anatomical landmarks
• Groin
• Femoralartery
• Anteriorsuperioriliacspine
• Pubictubercle
• Inguinalligament
1 Anterior superior iliac spine,
2 Pubic tubercle, 3 Puncture site
50
Femoral nerve block
Anatomical landmarks
1
2
3
51
Nerve stimulation
Blockade technique
The patient lies on his back, his leg loosely abducted and
turned to the outside.
Puncture site:
2cmcaudadtothegroin,1–2cmlateraltothefemoralartery.Puncturedirection:30–45°cranialparalleltotheartery.
Puncturedepth:2–4cm.
Positive stimulatory response from the femoral nerve: Rectus
muscle of the thigh (“dancing patella“).
Dosage
20–40mlLA
Single shot technique
e.g. Stimuplex® D, 50 mm
Catheter technique
e.g. Contiplex® D-Set, 55 mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
52
Femoral nerve block
?
What to do when ...?
Stimulation of the sartorius muscle (medial
contraction) occurs:
Puncture direction usually too medial u Retract
the needle, and shift it slightly to the lateral.
Direct stimulation of the sartorius muscle
(rare):
Puncture direction is usually too lateral u Shift
the needle slightly to the medial.
Femoral artery puncture:
Retract the needle u Shift puncture direction to
the lateral.
!
Potential errors and hazards
• LA injection in the case of sartorius muscle
stimulation.
53
Sonography
Nerve block technique
Both long and short axis insertion is possible
Sonoanatomic landmarks:
- Femoral artery and vein
- Iliac fascia
- Iliopsoas muscle
Blockade objective:
To infiltrate the entire femoral nerve with local anaesthetic
54
Femoral nerve block
medial
lateral
Sonoanatomic landmarks
55
Nerve stimulation
Saphenous nerve block
Indications
• Operativeproceduresintheareasupplyingthesaphenous nerve
• Incombinationwithdistalsciaticnerveblockforoperations on the whole lower leg and foot
• Analgesia
Contraindications
• Noparticular
Side effects / complications
• Noparticular
Anatomical landmarks
• Patellarcrest
• Sartoriusmuscle
• Vastusmedialismuscle
= Puncture site
56
Saphenous nerve block
Anatomical landmarks
57
Nerve stimulation
Blockade technique
The patient is supine on his back, with the extended leg in a
neutral position, rotated slightly outwardly.
Puncture site:
Approx.2–4cmcranialandmedialtothesuperioredgeof
the patella. Insert needle perpendicularly into the palpable
space between the sartorius muscle and the vastus medialis
muscle. Insert the needle perpendicular through the muscle
up to the subsartorial fatty tissue.
Puncturedepth:3–5cm.
Electrical paresthesias at the medial calf at a pulse duration of
1.0 ms and/or a motor response from the muscular branches
of the sartorius muscle are promising responses.
Dosage
10–15mlLA
Single shot technique
e.g. Stimuplex®D,50–80mm
Catheter technique
e.g. Contiplex®D-Set,55–80mm
Advance the soft plastic catheter 3 cm beyond the end
of the introducer sheath.
58
Saphenous nerve block
?
What to do when ...?
Motor stimulatory response from the sartorius
muscle is a promising response:
u Inject local anaesthetic
Patient is uncooperative:
Femoral nerve block (as described above) with
reduced LA volume (20 ml).
Alternative technique: Subcutaneous infiltration below the medial knee joint from the medial head of the gastrocnemius muscle to the
tibialtuberosity(10–15mlLA).
!
Potential errors and hazards
• Noparticular.
59
Sonography
Nerve block technique:
Long axis (single-shot) is preferable
Sonoanatomic landmarks:
- Sartorius muscle
Blockade objective:
Infiltrate the saphenous nerve with local anaesthetic
60
Saphenous nerve block
caudal
cranial
Sonoanatomic landmarks
61
Nerve stimulation
Obturator nerve block
Indications
• Suppressionoftheadductorreflexfortransurethral
lateral bladder wall resection
• Treatmentofadductorspasm
• Adjuncttofemoralnerveblocksforpostoperative
medial knee joint pain
• Analgesia
Contraindications
• Noparticular
Side effects / complications
• Vesselpuncture(obturatorarteryorvein)
Anatomical landmarks
• Originoftheadductorlongusmuscle
• Pubictubercle
• Femoralartery
• Anteriorsuperioriliacspine
1 Adductor longus muscle, 2 Puncture site
62
Obturator nerve block
Anatomical landmarks
2
1
63
Nerve stimulation
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. Puncture direction approx. 45° craniolateral pointing towards the anterior
superior iliac spine.
Puncturedepth:4–6cm.
Positive stimulatory response from adductor group.
Dosage
10–15mlLA
Single shot technique
e.g. Stimuplex® D, 80 mm
Catheter technique
e.g. Contiplex® D-Set, 80 mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
64
Obturator nerve block
?
What to do when ...?
Persistent adductor spasm despite (proper)
obturator nerve block occurs:
Perform an additional femoral nerve block,
which will block any accessory obturator nerve
that runs together with femoral nerve.
Note:
The adductor reflex for transurethral lateral
bladder wall can only be reliably suppressed
by a separate obturator nerve block (not by a
femoralnerveblocknorspinalanesthesia!).
!
Potential errors and hazards
• Noparticular.
65
Sonography
Nerve block technique:
Long axis is preferable
Sonoanatomic landmarks:
- Femoral artery and vein
- Pectineus muscle
- Adductor muscles (longus and brevis)
Blockade objective:
Infiltrate the anterior and posterior branch of the obturator
nerve
66
Obturator nerve block
medial
lateral
Sonoanatomic landmarks
67
Nerve stimulation
Approach according to Mansour
Indications
• Operativeproceduresinareassupplyingthesciatic
nerve
• Incombinationwithpsoascompartmentblock/femoral
nerve block for operations on the whole leg
• Analgesia
Contraindications
• Noparticular
Side effects / complications
• Vesselpuncture(inferiorglutealartery)
Anatomical landmarks
• Posteriorsuperioriliacspine
• Ischialtuberosity
1 Greater trochanter, 2 Posterior superior iliac spine,
3 Ischial tuberosity, 4 Puncture site
68
Parasacral sciatic nerve block
Anatomical landmarks
1
2
3
4
69
Nerve stimulation
Blockade technique
The patient is placed in the lateral recumbent position, hip
flexed 45°, knee flexed 70°, or both knees against the abdomen (favorable when combined with a psoas compartment
block).
Puncture site:
Approx.5–6cmcaudadtotheposteriorsuperioriliacspine
along the connecting line to the ischial tuberosity. Insertion
direction20–30°caudadtomidlinebetweenischialtuberosity and greater trochanter.
Puncturedepth:6–8cm.
Promising stimulatory response from the tibial and peroneal
nerves: Extensors and/or flexors of feet/toes, ischiocrural
muscle group
Dosage
20–30mlLA
Single shot technique
e.g. Stimuplex®D,80–120mm
Catheter technique
e.g. Contiplex®D-Set,80–110mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
70
Parasacral sciatic nerve block
?
What to do when ...?
Bone contact occurs:
Shift puncture site further caudad or puncture
direction more caudad.
No stimulatory response is elicited:
Shift puncture direction more caudad and lateral.
!
Potential errors and hazards
• LAinjectionuponstimulatoryresponsefrom
the gluteal muscles.
71
Nerve stimulation
Approach according to Labat
Indications
• Operativeproceduresinareassupplyingthesciatic
nerve
• Incombinationwithpsoascompartmentblock/femoral
nerve block for operations on the whole leg
• Analgesia
Contraindications
• Noparticular
Side effects / complications
• Vesselpuncture(inferiorglutealartery)
Anatomical landmarks
• Posteriorsuperioriliacspine
• Greatertrochanter
• Sacralhiatus
1 Greater trochanter, 2 Posterior superior iliac spine,
3 Ischial tuberosity, 4 Sacral hiatus, 5 Puncture site
72
Transgluteal sciatic nerve block
Anatomical landmarks
1
2
5
3
4
73
Nerve stimulation
Blockade technique
The patient is placed in the lateral recumbent position; hip
flexed45°,kneeflexed70°(“stablerecumbentposition“).
Puncture site:
4–5cmmediocaudalonthemid-perpendicularlinesbetween
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.
Insertion direction perpendicular to the surface.
Puncturedepth:5–8cm.
Promising stimulatory response from the tibial and peroneal
nerves: Extensors and/or flexors of feet/toes, ischiocrural
muscle group
Dosage
20–30mlLA
Single shot technique
e.g. Stimuplex®D,80–100mm
Catheter technique
e.g. Contiplex®D-Set,80–110mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
74
Transgluteal sciatic nerve block
?
What to do when ...?
Contractions of the gluteus maximus muscle
(= direct muscular stimulation or stimulation
of the muscular branches of the gluteal muscle): Continue to advance the needle until the
typical response is elicited.
Bone contact, no stimulatory response:
Correct insertion direction to midline between
greater trochanter and ischial tuberosity.
!
Potential errors and hazards
• LAinjectionuponstimulatoryresponse
from the gluteal muscles.
75
Nerve stimulation
Approach according to Meier
Indications
• Operativeproceduresintheareasupplyingofthesciatic nerve
• Incombinationwithpsoascompartmentblock/femoral
nerve block for operations on the whole leg
• Analgesia
Contraindications
• Noparticular
Side effects / complications
• Vesselpuncture(femoralarteryandvein,inferiorgluteal
artery and vein)
• Neuralinjury(femoralnerve)
Anatomical landmarks
• Anteriorsuperioriliacspine
• Pubicsymphysis
• Greatertrochanter
• Compartmentbetweensartoriusandrectusfemorismuscles.
1 Anterior superior iliac spine, 2 Pubic symphysis,
3 Greater trochanter, 4 Puncture site
76
Anterior sciatic nerve block
Anatomical landmarks
1
2
3
4
77
Nerve stimulation
Blockade technique
The patient is supine on his back, with the leg in a neutral position.
Puncture site:
Divide into thirds the line connecting the anterior superior iliac
spine and the middle of the pubic symphysis. A perpendicular
line at the transition from the medial to the middle third intersects a parallel line to the inguinal ligament through the greater
trochanter at the insertion point. Palpate the muscle compartment and, using two fingers, press against the femur, forcing
the vessels to the medial. Insert the needle sagittally and 70
–80°tothecranial,withouttouchingthefemur.
Alternatively, target the muscle compartment about 8-10 cm
caudad of the femoral nerve insertion site
Puncturedepth:8–15cm.
Positive stimulatory response from the peroneal or tibial
nerves: extensors or flexors of the foot/toes.
Dosage
20–30mlLA
Single shot technique
e.g. Stimuplex®D,100–150mm
Catheter technique
e.g. Contiplex® D-Set, 110 mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
78
Anterior sciatic nerve block
?
What to do when ...?
Primary femur contact occurs: Insertion point
too far to the lateral u Retract the needle and
shift insertion to the medial.
Primary vessel puncture (femoral vein or artery): Insertion too far medial u Retract the
needle and shift the insertion to the lateral.
Deep vessel puncture (gluteal artery and vein):
Correct insertion direction slightly to the lateral.
Stimulation of femoral nerve branches: Retract
the needle and “bypass“ stimulation area.
!
Potential errors and hazards
• Aneutrallegpositionisimperative.
79
Nerve stimulation
Approach according to Guardini
Indications
• Operativeproceduresintheareasupplyingofthesciatic nerve
• Incombinationwithpsoascompartmentblock/femoral
nerve block for operations on the whole leg
• Analgesia
Contraindications
• Status secondary to total ipsilateral hip replacement (relative)
Side effects / complications
• Noparticular
Anatomical landmarks
• Greatertrochanter
• Ischialtuberosity
1 Greater trochanter,
2 Ischial tuberosity, 3 Puncture site
80
Subtrochanteric sciatic nerve block
Anatomical landmarks
1
3
2
81
Nerve stimulation
Blockade technique
The patient is supine, with the leg in a neutral position or rotated slightly inwards. Padding under the lower leg and pelvic
helps with orientation.
Puncture site:
Approx. 2 cm dorsal and 3 – 4 cm distal to the greater trochanter. Insertion direction horizontal and somewhat cranial
towards the ischial tuberosity without femur contact.
Puncturedepth:6–10cm.
Positive stimulatory response from the peroneal or tibial
nerves: extensors and/or flexors of feet/toes, ischiocrural
muscle group
Dosage
20–30mlLA
Single shot technique
e.g. Stimuplex®D,80–100mm
Catheter technique
e.g. Contiplex®D-Set,80–110mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
82
Subtrochanteric sciatic nerve block
?
What to do when ...?
Femur contact occurs: Insertion too far ventral
u Move insertion more to the dorsal.
No stimulatory response is elicited: u Direct
insertion a little to the ventral and emphasize
inward rotation in the hip joint.
Alternative technique:
Leg is rotated slightly inward with flexed knee
joint “upright“ on the table.
Puncture site: 2–3cmcaudadfromthemidpoint of the line connecting greater trochanter
and ischial tuberosity. Insert the needle in the
cranial and slightly medial direction (modified
dorsodorsal access according to Raj).
!
Potential errors and hazards
• Makesurethatthelegisinaneutralposition
(with a slight inward rotation).
83
Sonography
Preliminary note:
It is occasionally difficult to visualise the nerves due to their deep
location (with linear high-frequency transducer).
Block technique:
Long axis is preferable, short axis possible
Sonoanatomic landmarks:
Gluteal muscles
Blockade objective:
To infiltrate the entire nerve with local anaesthetic
84
Subtrochanteric sciatic nerve block
medial
lateral
Sonoanatomic landmarks
85
Nerve stimulation
Lateral distal sciatic nerve block
Indications
• Operativeproceduresintheareassupplyingthesciatic
nerve on the whole lower leg and foot
• Incombinationwithsaphenousnerveblockforoperations of the whole lower leg
• Analgesia
Contraindications
• Stent(relative)
Side effects / complications
• Vesselpuncture(poplitealartery/vein)
Anatomical landmarks
• Patellarcrest
• Vastuslateralismuscle
• Longheadofthebicepsfemorismuscle
1 Patellar crest, 2 Puncture site
86
Lateral distal sciatic nerve block
Anatomical landmarks
1
2
87
Nerve stimulation
Blockade technique
The patient is supine on his back, with the leg in a neutral position (rotated slightly inwards), padding under the lower leg.
Puncture site:
Approx.3–8cmabovethepatellainthelateralmusclecompartment between lower edge of the vastus lateralis muscle
and biceps femoris muscle. Insertion direction slightly dorsocranial.
Puncturedepth:3–5cm.
Positive stimulatory response from the peroneal or tibial
nerves: extensors or flexors of the foot/toes.
Dosage
20–40mlLA
Single shot technique
e.g. Stimuplex®D,50–80mm
Catheter technique
e.g. Contiplex®D-Set,55–80mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
88
Lateral distal sciatic nerve block
?
What to do when ...?
No stimulatory response is elicited:
Insertion direction is usually too far ventral
u Correct to the dorsal.
Femur contact occurs:
Puncture site and/or insertion direction too far
to the ventral u Check puncture site, correct to
dorsal if needed; shift insertion direction more
to the dorsal.
Vessel puncture popliteal artery/vein:
Puncture too deep and too ventral u Retract
the needle, correct insertion direction to the
dorsal, reduce insertion depth.
!
Potential errors and hazards
• Makesurethatthelegisinaneutralposition
(with a slight inward rotation).
89
Sonography
Nerve block technique:
Long axis is preferable
Sonoanatomic landmarks:
Medial edge of the long head of the biceps femoris muscle
Blockade objective:
To infiltrate the entire sciatic nerve or its two terminal branches
with local anaesthetic
Practical tip:
The patient’s calf is placed on an elevated arm extension, for example. This allows the ultrasound beam to be directed from the
dorsal onto the distal sciatic nerve cranial to the popliteal fossa.
90
Lateral distal sciatic nerve block
medial
lateral
Sonoanatomic landmarks
91
Nerve stimulation
Popliteal sciatic nerve block
Indications
• Operativeproceduresintheareasupplyingthesciatic
nerve of the lower leg and foot
• Operationsonthewholelowerextremityincombination
with a saphenous nerve block.
• Analgesia
Contraindications
• Stent(relative)
Side effects / complications
• Vesselpuncture(poplitealartery/vein)
Anatomical landmarks
• Poplitealfossa
• Poplitealfold
• Longheadofthebicepsfemorismuscle
• Medialandlateralepicondyleofthefemur
1 Lateral epicondyle of the femur,
2 Medial epicondyle of the femur, 3 Puncture site
92
Popliteal sciatic nerve block
Anatomical landmarks
3
1
2
93
Nerve stimulation
Blockade technique
The patient is either in the prone position or lying on his side,
leg extended.
Puncture site:
Approx.8–12cmabovethefoldofthepoplitealfossaatthe
medial edge of the biceps femoris muscle, laterally marking
thepoplitealfossa.Insertiondirectionapprox.30°cranialand
slightly medial.
Puncturedepth:2–4cm.
Positive stimulatory response from the peroneal and tibial
nerves: extensors or flexors of the foot/toes.
Dosage
20–40mlLA
Single shot technique
e.g. Stimuplex® D, 50 mm
Catheter technique
e.g. Contiplex® D-Set, 55 mm
Advance the soft plastic catheter < 4 cm beyond the
end of the introducer sheath.
94
Popliteal sciatic nerve block
?
What to do when ...?
Femur contact occurs:
Insertion too deep and too medial Retract the
needle u Correct puncture direction or insertion
site to the lateral, reduce insertion depth.
Vessel puncture popliteal artery/vein:
Puncture too deep and too medial  Retract the
needle u Correct insertion direction to the lateral, reduce insertion depth.
!
Potential errors and hazards
• Puncturesiteistoofarcaudad(popliteal
fold): It may be that the tibial nerve (med.)
and peroneal nerve (lat.) are separated so
far apart that complete blockade cannot be
achieved with a single LA injection at the two
sciatic branches.
95
Other publications appearing in this series
• Brochure(DINA4)
Peripheral Regional Anesthesia
at the Ulm Rehabilitation Hospital
• InteractiveDVDTutorial
Peripheral Regional Anesthesia
at the Ulm Rehabilitation Hospital
These materials can be
requested at your B. Braun
partner in your country
B. Braun Melsungen AG
Carl-Braun-Straße 1
34212 Melsungen
Germany
Tel. +49 5661 71 4657
Fax. +49 5661 75 4657
E-mail: wolfgang.pape@bbraun.com
Online Tutorial and Discussion Forum
www.nerveblocks.net
The state of medical knowledge is subject to constant change due to new research and
clinical evidence. The authors of this book have been very careful to comply with the
current state of the art. Nevertheless, users of this information carry their own responsibility and liability when establishing the diagnosis and implementing therapy.
The Tutorial was made possible by the kind support of B. Braun Melsungen AG.
Nr. 6064605B
The Tutorial was made possible by the kind
support of B. Braun Melsungen AG.
B. 03. 01 . 10 /1 Nr. 6064605 B