1. Mackenzie Kuhl, DO Marquette General Hospital August 2013
Regional Techniques
Mackenzie Kuhl, DO
Marquette General Hospital
August 2013

2. Regional Techniques Neuraxial nerve blocks Peripheral nerve blocks
Spinal anesthesia
Epidural anesthesia
Peripheral nerve blocks
Upper extremity (Brachial plexus blocks)
Axillary nerve block
Supraclavicular nerve block
Interscalene nerve block
Lower extremity
Femoral nerve block
Sciatic nerve block
Popliteal nerve block

3. Neuraxial techniques
Neuraxial techniques are used for pain control for operative anesthesia, obstetric anesthesia, and chronic pain management
Spinal
Single shot technique in which local anesthesia +/- narcotic is placed into the subarachnoid space, used for surgical anesthesia
Epidural
Catheter based technique in which local anesthesia +/- narcotic is placed into the epidural space, mainly used for postoperative pain control

4. Spinal Anesthetic
Local anesthetic +/- narcotic placed in subarachnoid space
Usually done at lumbar vertebrae (L3-L4, iliac crests)
Dermatomal level
T4 level for C-section
T10 level for hip and knee procedures
Lidocaine
1 hour duration
Bupivacaine
2-3 hours duration

5. Dermatomal patterns

6. Neuraxial techniques
Catheter placed in the epidural space under aseptic conditions

7. Epidural Anesthetic
Catheter based technique in which local anesthetic +/- narcotic is placed in epidural space
Usually done at lumbar and thoracic vertebrae for postoperative pain control (cervical nerve roots for chronic pain management)

8. Catheter being placed

9. Indications for neuraxial techniques
Orthopedic
Total knee and hip arthroplasties, ankle surgeries
General
Exploratory laparotomies, breast cancer surgeries
Vascular
AAA repair
Genitourinary
TURP’s, nephrectomies, open prostatectomies
Obstetric
Cesarean section

10. Absolute contraindications to neuraxial anesthesia
Infection at the site of injection
Patient refusal or inability to cooperate
Coagulopathy or other bleeding diathesis
Platelets>100,000 and INR <1.4
Severe hypovolemia
Increased intracranial pressure
Severe mitral/aortic stenosis
Allergy to local anesthetics

11. Complications of neuraxial techniques
Physiologic responses
Urinary retention
Hypotension
High block
Nausea
Pruritus
Related to needle/catheter placement
Backache
Postdural puncture headaches
Neural injury
Catheter shearing or tearing
Inflammation
Infection
Bleeding
Drug toxicity
TNS
Cauda equina syndrome
Systemic local anesthetic toxicity
Respiratory depresssion

12. ASRA guidelines Subcutaneous UFH (5000U BID) LMWH Dabigatran
Twice daily dosing (5000U)
No contraindication to neuraxial technique
Because HIT may occur, ASRA recommends that patients receiving heparin for more than 4 days receive a platelet count prior to epidural placement or removal
Thrice daily dosing
Must weigh risks vs benefits on individual basis
LMWH
Once daily dosing (40mg SQ)
Must wait 12 hours from last dose for neuraxial technique
Twice daily dosing
Must wait 12 hours from last dose for neuraxial technique, must remove epidural catheter postoperatively before instituting
Dabigatran
Must wait 72 hours prior to neuraxial procedure

13. Benefits
528, 495 patients undergoing primary knee or hip arthroplasty Memtsoudis, et al. Anesthesiology May 2013; 118:
Decreased 30 day mortality
Decreased prolonged length of stay
Decreased transfusion requirements
Decreased in-hospital complications
Pulmonary embolism
Pulmonary compromise
CVA
Acute renal failure

14. Benefits
Reduction of postoperative mortality and morbidity with epidural or spinal anesthesia: results from overview of randomized trials (9559 patients) Rodgers, et al. BMJ December 2000; 321(7275): 1493
Decreased DVT by 44%
Decreased PE by 55%
Decreased transfusion requirements by 50%
Decreased pneumonia by 39%
Decreased respiratory depresion by 59%
Decreased myocardial infarctions

15. Benefits
Anesthetic Technique for Radical Prostatectomy Surgery Affects Cancer Recurrence, Biki, et al. Anesthesiology Aug 2008; 109:
Open prostatectomy with GA plus epidural postoperative analgesia was associated with less risk of biochemical cancer recurrence

16. Why? Altered coagulation Increased blood flow
Improved pulmonary mechanics
Reduction in surgical stress responses

17. Peripheral nerve blocks
Upper extremity (Brachial plexus blocks)
Axillary nerve block
Supraclavicular nerve block
Interscalene nerve block
Lower extremity
Femoral nerve block
Popliteal nerve block
Sciatic nerve block

18. Peripheral nerve blockade
Primary anesthetic for peripheral limb surgery
Mainly done with direct visual ultrasound and nerve stimulation
Inject local anesthesia around nerves to obtain surgical anesthesia or postoperative pain control
Benefits
Excellent pain control
Decreased narcotic use
Risks
Bleeding
Infection
Nerve damage
Systemic local anesthetic toxicity

19. Brachial plexus
The brachial plexus is responsible for cutaneous and muscular innervation to upper arm except with two exceptions:
The trapezius muscle innervated by the spinal accessory nerve and an area of skin located in the axilla which is
innervated by the intercostobrachial nerve

20. Brachial plexus blockade
Axillary nerve block
Supraclavicular nerve block
Interscalene nerve block

21. Axillary nerve block Anesthesia to arm, elbow, FOREARM and HAND
Blocks median, ulnar and radial nerves
Usually misses musculocutaneous nerve, must block separately

22. Axillary nerve block

23. Supraclavicular nerve block
Anesthesia to ARM, ELBOW and hand (“spinal of upper extremity”)
Blocks median, ulnar and radial nerves
Risk is pneumothorax

24. Supraclavicular nerve block

25. Interscalene nerve block
Anesthesia to SHOULDER, upper arm and elbow
Blocks median, ulnar and radial nerves
Patients may develop ipsilateral Horner’s syndrome and diaphragmatic paralysis (due to phrenic nerve block)

26. Interscalene nerve block

27. Lower extremity nerve blocks
Femoral nerve block
Sciatic nerve block
Popliteal nerve block

28. Femoral nerve block
Anesthesia to anterior thigh and anterior knee

29. Femoral nerve block
Anesthesia to anterior thigh and anterior knee

30. Sciatic nerve block
Anesthesia to posterior aspect of the thigh, hamstring, part of hip and knee joint, and the entire leg below the knee except for medial aspect of lower leg (innervated from saphenous nerve)

31. Popliteal nerve block
Anesthesia for ankle and foot surgery