NERVE BLOCKS

A.Anees
Fathima
11201023
Local Anaesthesia
deposited close to the
main nerve trunk
usually at a distance
from the site of
operative intervention
ROLE OF NERVE BLOCKS
Eliminate or decrease
intraoperative and
postoperative pain.
Increase patients cooperation.
To reduce intraoperative
bleeding
Improved patient satisfaction
due to decreased pain, opioid
use and side effects and
decreased incidence of sleep
disturbance.
Useful in patients in whom
general anaesthesia is
contraindicated or prevent
undesired effects.
CONTRAINDICATIONS
Absolute
Contraindications:
Infection at site of block.
Patient refusal.
Allergy to local anaesthetics.
Relative
Contraindications:
Medical anticoagulation or
coagulopathy in deeper
nerve blocks.
TYPES OF NERVE BLOCKS
Single Shot:
one time injection of local
anaesthetic to target nerve
Continuous Perineural
Blockade:percutaneous
insertion of a catheter
directly adjacent to target
nerve
BRACHIAL PLEXUS BLOCK (Winnie’s block)
UPPER EXTREMITY BLOCKS
Interscalene Block -
Indication: Surgery or
manipulation of the shoulder
Supraclavicular Block -
Indication: Elbow, forearm
and hand surgery
Infraclavicular Block -
Indication: Provide
anaesthesia to the arm and
hand
Axillary Block - Forearm
and hand surgery
INTERSCALENE BLOCK
Performed at the C6 level ( cricoid
cartilage level).
Ask patient to turn head to side.
Locate groove.
Between the anterior and middle
scalene
The anterior scalene is an
important landmark that should be
identified
Posterior to the posterior aspect of
the SCM at the level of the cricoid
Enter behind the External Jugular
at 45 degrees caudal and posterior.
SUPRACLAVICULAR BLOCK

Needle enters 1.2cm

above the middle of the
clavicle.
Administer anaesthetic
while advancing needle
towards the first rib.
Anterior-posterior
direction until
parasthesias are
elicited.
Position
• Patient supine, arm at side,
head turned away
Volume of L.A: 25-30 ml
The most feared complication
of the supraclavicular block is
pneumothorax.
Its principal cause is a
needle/syringe angle that
"aims" toward the cupola of the
lung.
Special attention should be
directed toward walking the
needle in a strictly
anteroposterior direction
INFRACLAVICULAR BLOCK
Anatomy:
In the infraclavicular area, the
trunks divide intoanterior and
posterior divisions each and
then reform into lateral, medial
and posterior cords.
The infraclavicular approach
blocks the brachial plexus at
the level of the cords.
Clinical applications:
provides homogenous
anaesthesia to the brachial
plexus and can be used for
procedures involving al, elbow.
forearm and hand
Indications- Hand, wrist,
elbow and distal arm surgery
Blockade occurs at the level
of the cords of the
musculocutaneous and axillary
nerves.
Anatomical landmarks: The
boundaries of the
infraclavicular fossa are
pectoralis minor and major
muscles anteriorly
ribs medially .
clavicle and the coracoid
process superiorly.
and humerus laterally
TECHNIQUE
Pt in supine position, head
turned to opposite side, arm
abducted to 90 deg
Line drawn along entire
length of clavicle (midpoint
of clavicle marked)
Brachial artery marked high
in axilla
A line drawn from C-6 in
neck across midpoint of
clavicle & to trace brachial
artery
AXILLARY BLOCK
Position
Supine position, arm to be
blocked placed at right angle
to the body with Elbow flexed
to 90 deg
Needle entry:
Just superior to the pulsation
of the axillary artery at the
lateral border of pectoralis
major muscle
Musculocutaneous blocked by
injecting LA in the belly of the
coracobrachialis
The axillary artery is identified
with two fingers, and the needle
is inserted superior And inferior
to it.
An effective axillary block is
achieved by utilising the axillary
artery as an anatomic landmark
and infiltrating the tissue around
it in a fan-like manner
Local Anaesthetic: Bupivacaine
0.5% with Adr.
Volume 35-40 ml
Anaesthesia duration: 5-6 hrs
Analgesia: 12-24 hrs
Problems: Neuropraxia,
Intravascular injection,Haemtoma
LOWER EXTREMITY BLOCKS
Femoral Nerve Block -
Indication: Knee arthroscopy,
femoral shaft fractures, total
knee repair and ACL
reconstruction
Obturator Nerve Block -
Indication: Knee surgery, rarely
blocked on it's own
Sciatic Nerve Block -
Indication: Can be used
together with a femoral or
saphenous block for any
procedure below the knee that
doesn't need a thigh tourniquet
FEMORAL NERVE BLOCK
The femoral nerve block is one
of the most clinically
applicable nerve block
techniques that it is relatively
simple to perform, carries a
low risk of complications, and
results in a high success rate
INDICATIONS
1. Procedures on anterior thigh
(i.e. Lacerations, skin graft,
muscle biopsy)
2. Pin or plate insertion
/removal (femur)
3. Femur fractures
4. Analgesia/Anaesthesia for
knee arthroscopy.
5. as a part of multimodal
regimen.
6. Complete lower limb
anaesthesia if combined
with sciatic nerve block
Femoral nerve block
results in anaesthesia
of the anterior and
medial thigh down to
and including the knee,
as well as a variable
strip of skin on the
medial leg and foot. It
also innervates the hip,
knee, and ankle joints.
TECHNIQUE
Femoral nerve is identified.
The needle is inserted in-plane in a
lateral to medial orientation and
advanced toward the femoral nerve
The needle pierces the fascia iliac
lateral to the femoral nerve (FN) and
the needle tip is advanced along the
deep border of the nerve.
Once the needle tip is adjacent
(either above, below, or lateral) to
the nerve and after careful
aspiration, 1-2 mL of local
anaesthetic or saline is injected to
confirm proper needle placement
Proper injection will push the femoral
nerve away from the injection.
SCIATIC NERVE BLOCK
L4-5 and S1-3Runs between the
ischial spine and greater
trochanter ofthe femur.Becomes
superficial at the base of the
gluteus maximus.
Cutaneous innervation to posterior
thigh and all of the leg below the
knee minus a small medial strip.
Two approaches: Posterior and
Anterior.
Usually block is combined with
femoral, obturator, or lateral fem
cutaneous nerve blocks.
Disadvantages: technically
difficult, painful, possible
hematoma, nerve damage, slight
drop in BP due to blood pooling.
POSTERIOR APPROACH

Lateral decubitus position with leg

to be blocked flexed at the knee
with the heel resting on the
opposite knee.
Connect the posterior superior iliac
spine with the greater trochanter
with a drawing pen. Bisect this line
perpendicularly, extending caudal.
Needle entry point: 3cm downward
from the perpendicular line.
ANTERIOR APPROACH
Supine position.
Line from ASIS to pubic
tubercle. Mark point 2/3 of
the way.
Draw parallel line from
greater trochanter.
From point of first line,
continue down to second
line. Inject at this site until
bone is hit, then direct
medially.
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.
Contraindications
No particular
Side effect / complications
Vessel puncture (obturator
artery or vein)
ANATOMICAL LANDMARKS
Anatomical landmarks
Origin of adductor longus muscle
Pubic tubercle
Femoral artery
Anterior superior iliac spine
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 iliac spine.
CHOICES OF LOCAL ANAESTHETICS

Depends primarily on
required duration of
anaesthesia
Different anaesthetic drugs
have varying durations
Blockade may last up to 24
hours
Epinephrine can be added to
improve onset of action and
prolong drug action
MAJOR NERVE BLOCK
DRUGS
ULTRASOUND GUIDANCE

Allows direct visualisation of

the nerve, needle, and
anaesthetic distribution
Commonly used as an
adjunct to regional
anaesthesia techniques
Can be useful in decreasing
complications
Facilitates placement of
blocks in patients with
challenging anatomy
COMPLICATIONS
Block Failure
Perineural Hematoma
Infection
Nerve Injury
Intravascular Injection
Intraneural Injection
Excessively Dense Block