Ilioinguinal / Iliohypogastric Block Santhanam Suresh, MD, FAAP Director of Research, Department of Pediatric Anesthesia Professor of Anesthesiology and Pediatrics Northwestern University’s Feinberg School of Medicine Children’s Memorial Hospital Chicago, Illinois

SKILL COMPONENTS Pre-operative Preparation Strategy of Procedure Ilioinguinal/Iliohypogastric Block (single injection) SKILL COMPONENTS Pre-operative Preparation Strategy of Procedure Preparation Position Procedure 1. Needle Placement 2. Injection 3. Monitoring Clean up Handling Post-op Adverse Events

Preoperative prep: CONSENT Ilioinguinal/Iliohypogastric Block (single injection) Component 1: Preoperative prep: CONSENT Steps: How to obtain consent. Insert video “Ilioconsent.mov”

Strategy of Procedure Component 2: Ilioinguinal/Iliohypogastric Block (single injection) Component 2: Strategy of Procedure Steps: Choice of equipment 2. Choice of local anesthetic Dose of local by weight 4. Confer with surgeon Ultrasound Probe: Use either high frequency linear probe or hockey stick probe. Either probe can be used, but hockey stick probe may be more effective for infants and young children since the nerves are closely situated beneath the skin.

Strategy of Procedure Anesthetic Agent: Component 2: Steps: Ilioinguinal/Iliohypogastric Block (single injection) Component 2: Strategy of Procedure Steps: Choice of equipment 2. Choice of local anesthetic Dose of local by weight 4. Confer with surgeon Anesthetic Agent: 0.25% bupivacaine with epinephrine 1:200,000 To avoid profound motor block, use 0.125%. Duration will be the same, but motor block will be less.

Strategy of Procedure Component 2: Weight (kg) Dose (mL) 10 kg 1 mL Ilioinguinal/Iliohypogastric Block (single injection) Component 2: Strategy of Procedure Steps: Choice of equipment 2. Choice of local anesthetic Dose of local by weight 4. Confer with surgeon Weight (kg) Dose (mL) 10 kg 1 mL 15 kg 1.5 mL 20 kg 2 mL 25 kg 2.5 mL 30 kg 3 mL Check with Suresh? Weight of anesthetic dose: 0.1mL/kg Calculate the proper dose by using the weight of the patient in kg.

Strategy of Procedure Component 2: Confer with surgeon: Ilioinguinal/Iliohypogastric Block (single injection) Component 2: Strategy of Procedure Steps: Choice of equipment 2. Choice of local anesthetic Dose of local by weight 4. Confer with surgeon Confer with surgeon: Identify site specificity. Discuss transient femoral nerve block. Not sure what to add here!

Prepare for block Component 3: Ilioinguinal/Iliohypogastric Block (single injection) Component 3: Prepare for block Steps: Identify surface landmarks 2. Get materials How to prep Palpate for anterior superior iliac spine. This will be your major landmark.

Prepare for block Component 3: Steps: Identify surface landmarks Ilioinguinal/Iliohypogastric Block (single injection) Component 3: Prepare for block Steps: Identify surface landmarks 2. Get materials How to prep 27 gauge needle Betadine prep Bupivacaine 0.25% w 1:200,000 epinephrine Sterile dry gauze Sterile field area Rolling cart/MAYO tray Sterile Gloves

Prepare for block Component 3: Ilioinguinal/Iliohypogastric Block (single injection) Component 3: Prepare for block Steps: Identify surface landmarks 2. Get materials 3. How to prep If you are using chlorhexadine make sure that the surface is completely dry prior to needle insertion.

Patient position for block Ilioinguinal/Iliohypogastric Block (single injection) Component 4: Patient position for block Steps: Supine position Need help here…… Patient should be supine, and under general anesthesia.

Procedure for block Component 5: Ilioinguinal/Iliohypogastric Block (single injection) Component 5: Procedure for block Steps: Placement of probe - Begin medially 2. Injection - Insertion - Aspiration - Observation Monitoring - Watch EKG Probe should be placed immediately medial to superior aspect of ASIS, overriding it.

Procedure for block Component 5: Ilioinguinal/Iliohypogastric Block (single injection) Component 5: Procedure for block Steps: Placement of probe - Begin medially 2. Injection - Insertion - Aspiration - Observation Monitoring - Watch EKG Locate nerves between internal oblique and transversus abdominis.

Procedure for block Component 5: Ilioinguinal/Iliohypogastric Block (single injection) Component 5: Procedure for block Steps: Placement of probe - Begin medially 2. Injection - Insertion - Aspiration - Observation Monitoring - Watch EKG Needle should be placed in-plane, pointing toward the umbilicus. Nerve is, on average, 8 mm deep and 7 mm medial to ASIS.

Procedure for block Component 5: Steps: Placement of probe Ilioinguinal/Iliohypogastric Block (single injection) Component 5: Procedure for block Steps: Placement of probe - Begin medially 2. Injection - Insertion - Aspiration - Observation Monitoring - Watch EKG see video – InguinalBlock.dv Video of injection.

Procedure for block Component 5: Ilioinguinal/Iliohypogastric Block (single injection) Component 5: Procedure for block Steps: Placement of probe - Begin medially 2. Injection - Insertion - Aspiration - Observation Monitoring - Watch EKG Pull back plunger to 1mL mark to check for possible intravascular injection.

Procedure for block Component 5: Ilioinguinal/Iliohypogastric Block (single injection) Component 5: Procedure for block Steps: Placement of probe - Begin medially 2. Injection - Insertion - Aspiration - Observation Monitoring - Watch EKG See video – Inguinal.mp4 Observe anesthetic spreading between muscle layers.

Procedure for block Component 5: Ilioinguinal/Iliohypogastric Block (single injection) Component 5: Procedure for block Steps: Placement of probe - Begin medially 2. Injection - Insertion - Aspiration - Observation Monitoring - Watch EKG Train yourself to look at the EKG for increasing heart rate and blood pressure.

Clean up after block Component 6: Clean area with wet gauze. Steps: Ilioinguinal/Iliohypogastric Block (single injection) Component 6: Clean up after block Steps: Clean area Place patient in planned position for surgery. Clean area with wet gauze.

Handling post-operative adverse events Ilioinguinal/Iliohypogastric Block (single injection) Component 7: Handling post-operative adverse events Lipid Rescue: Steps: Lipid Rescue Colonic Puncture Lipid Infusion Therapy is an apparently effective treatment for the most devastating complication of regional anesthesia: cardiovascular collapse from local anesthetic overdose. The Lipid Sink Theory explains the effect by postulating that the lipophilic local anesthetics are absorbed into the infused lipid, thus preventing their toxic effect on the tissue. Recent research suggests that there may be another mechanism for effect. Rx: “20% Intralipid: 1.5 mL/kg as an initial bolus, followed by 0.25 mL/kg/min for 30-60 minutes. Bolus could be repeated 1-2 times for persistent asystole. Infusion rate could be increased if the BP declines.

Handling post-operative adverse events Ilioinguinal/Iliohypogastric Block (single injection) Component 7: Handling post-operative adverse events Colonic Puncture: Steps: Lipid Rescue Colonic Puncture Due to the closely situated peritoneum in children, these blocks can lead to colonic or small bowel puncture, or pelvic hematoma. Rx: Alert surgeon of possible puncture before start of procedure so that it can be investigated.