1. 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

2. 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

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

4. 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.

5. 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.

6. 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.

7. 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!

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

9. Prepare for block Component 3: Steps: Identify surface landmarks
Ilioinguinal/Iliohypogastric Block
(single injection)
Component 3:
Prepare for block
Steps:
Identify surface landmarks
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

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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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 minutes. Bolus could be repeated 1-2 times for persistent asystole. Infusion rate could be increased if the BP declines.

21. 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.