PERIPHERAL SYMPATHETIC BLOCKS

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PERIPHERAL SYMPATHETIC BLOCKS

• R1???

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Stellate ganglion block

• Anatomy
• Cervical sympathetic trunk? three
  interconnected ganglia? ?? sup.,mid.,inf.
  Cervical ganglia
• 80???? lowest cervical ganglion? first
  thoracic ganglion? fuse?? cervicothoracic(stellate
  )ganglion? ??
• - ?? C7 transverse process ???? T1 ??? ???? ???
  ??, ???? common carotid a.,subclavian a., thyroid
  gl., SCM, ?? prevertebral fascia? ??
• cervical ganglia? spinal cord? lat. Gray
  column???? preganglionic fiber? ???
• Preganglionic fiber for the head and neck
  emerge from the upper five thoracic spinal nerves
  ascending in the sympathetic trunk to synapse in
  the cervical ganglia
• Preganglionic fibers supplying the upper
  limb originate from the upper thoracic segment,
  T26 ascend via the sympathetic trunk to synapse
  in the cervicothoracic ganglion, where
  postganglionic fibers pass to the brachial plexus

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Effects of SGB

• Pph.vasodilatation blood flow??, brain blood
  flow??
• Lt SGB - HR??, BP??,activate sympathetic
  neural outflow to skeletal m.(no deterious effect
  on lt.ventricular function), QT interval ??
• Rt SGB sympathetic, parasympathetic
  activity??? RR interval ?? ??
• increase retinal venous blood velocity
  without changing the retinal vessel diameter
• Block side? intraocular pr. oxygen tension
  temperature ??, tympanic temp.? ???? ??? SGB 5?
  ?? ???? 30? ?? ?? ????
• ??? ??? ??? immune, endocrine systems? ?? ???
  ?? ??? ????

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Clinical indications for cervicothoracic ganglion
block

• Complex regional pain syndrome
• Acute pain of herpes zoster
• Postherpetic neuralgia
• Acute and chronic vasculaopathies of the head,
  neck and upper extremity
• etc

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technique

• Iv line resuscitative equipment
• Supine position with the head slightly lift
  forward and tilted backwards to straighten the
  esophagus and move it away from the transverse
  processes
• - mouth is slightly opened to relax the neck
  muscle
• - cricoid cartilage palpation to discern the
  level of the C6 transverse process
• - Identify Chassaignacs tubercle at C6(located
  approximately 3cm cephalad to the S-C joint at
  the
• medial border of the SCM and trachea)

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• fig80-1

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• carotid a. retraction
• 22g short beveled 4 to 5 cm needle is advanced
  downward perpendicular to the table plane, until
  it touches bone and then withdrawn approximately
  2mm to avoid inj. Into the periosteum
• Needle is contact with C6 tubercle
• C6 tubercle is covered by the prevertebral fascia
  whereas the longus colli m. is located at the
  lat. aspect of the body of the vertebra and the
  medial aspect of the transverse process
• Longus colli??? inj.?? muscle course? ?? spread ?
• Fluoroscopy? ??, 1to 2mL of contrast material?
  ???? needle placement? ????? ??
• The choic of medication and the vol. of the
  solution vary according to the preference of
  the physician

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Alternative approaches

• C7 anterior approach
• - c7? vestigial tubercle? ??? ???? c6? ?? ????
  one finger caudally?? c7 transverse process? ??
• ?? ? less volume is needed to achieve a
  sympathetic blockade vertebral a. puncture????
  pneumothorax???? ??
• Posterior thoracic approach
• Fluoroscopy ? CT guidance?? needle ? 2 4cm lat.
  to the upper thoracic spinous process ? ??,
  lamina contact? moved laterally off the lamina,
  parallel to the sagittal plane, lamina? ?? 2cm???
  costotransverse lig.?? ?? loss of resistance
  technique
• Side effects and complications
• - properly performed, SGB is safe and easy
  procedure
• complication are rare ( incidence of 0.17)

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LUMBAR PARAVERTEBRAL SYMPATHETIC BLOCK

• Anatomy
• sympathetic chain? lumbar vertebral body?
  anterolateral surface? ?? ??
• lumbar sympathetic chain ? pelvis, lower
  extremity? ?? pre, post ganglionic fiber? ???
• Lower extremity? sympathetic innervation?
  origin?? ?? 2,3 lumbar vertebral body level?
  sympathetic ganglia(lower third of the second
  lumbar vertebra, at the upper third of the third
  lumbar vertebra)
• The best site for placement of the tip of the
  needle is the anterolateral surface of the lower
  second vertebral body or at the upper third of
  the third vertebral body
• segmental a. vein? dense fascia??? tunnel?
  midportion of the lumbar verteral body? ?? ?????
  solution? ? ??? ?? epidural space? ?? ?? ??? ??

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Indication

• Sympathetic mediated pain
• Improvement of blood flow in pt. with vascular
  insufficiency of their lower extremities
• Management of neuralgic pain associated with
  pph.nerve injuries

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Technique

• Earlier technique- L2,3,4 inj.???? ?? single
  needle??
• prone position, pillow underneath the lower
  abdomen(to reduce lumbar lordosis)
• Hatangdi and Boas technique
• - 12the rib? tip? palpation(on the side to be
  injected), tip 12th rib? 23cm below and medial
  ?? needle insertion(L3)
• 57inch 22g needle ? midline?? 810cm, 3045?
  angle? lateral to the spinous process??
  anterolateral aspect of the vertebra? ?????? ??-
  contrast? ???? needle placement?? 1520ml local
  anesthetic inj.

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• fig 80-2
• fig80-3

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• neulolytic block
• Two needle technique( L2 L3)
• 24ml of 6 phenol inj. at each site
• Needle ?? ??? 1ml? air or local
  anesthetic??(neurolytic solution?
  depositioning??)
• Patient is kept on the side for 1530min. gt To
  prevent the phenol from spreading laterally
  toward the genitofemoral n. or posteriorly toward
  the somatic nerve roots, then turned supine and
  instructed not to raise head for at least 1 hours
• complication of lumbar paravertebral sympathetic
  block
• - bleeding , hematuria, infection, orthostatic
  hypotension, perforation of the abdominal
  viscera, epidural or subarachnoid blockade,
  lumbar plexus block, segmental nerve injury

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Ch.81 Complications after peripheral nerve block
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• Death, cardiac arrest, resp.arrest, permanent
  neurologic injury ? neuraxial block?? ???? ? ??
  ??? PNB?? ? ?????
• PNB? ??serious complication? intravascular inj.
  of local anesthetic ?? peripheral n. injury??. ??
  large volume of local anesthetic? ??
• Neurologic injury? subarachnoid block? ?? ??
• PNB? ??? ??????? life altering complication?
  potential? ??? ??? ??

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• Table 81-1

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Vascular complications

• Intravascular injection
• - pph.block??? vascular landmarks? ???
  unintentional intravascular inj. Of local
  anesthetic? ??????? ??? transarterial axillary
  block? careful aspiration, test dosing??? ?0.2??
  intravascular inj. ? ??
• Direct intra arterial inj. Vs intravenous inj.
• - ??? ????? ??? bupivacaine,lidocaine?? seizure?
  ???? ??? ??? lung ? whole body? ?? distribution ,
  clearing??? seizure????? ???
• Subcutaneous or interstitial tissues??
  uptake? local anesthetic ? Peak plasma level ?
  3060? ?? ???? ??? ?? total local anesthetic
  dose, vasoconstrictor, block site? ????
• - delayed toxicity? risk? intercostal n. block
  gt plexus block gt local subcutaneous infiltration?
  ??? ???
• - intravascular inj.? ?? -gt frequent
  aspiration, incremental dosing, epinephrine
  containing intravascular test dose

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• Basic local anesthetic dosing on body weight and
  body surface area? minimal value fig.81-1

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• Lower extrmity pph. Block? multiple , moderate
  volume individual n. block? ?????? ???? ??
  systemic toxicity? risk? ??
• Large volume of local anesthetic? pneumatic
  tourniquet? ???? ???,rapid, high pr. Inj.???
  systemic circulation? ??????- distal vein???
  slow(90sec)inj.? ??? complication? ??? ????
• Initial inj.? ?30??? tourniquest? deflation???
  ??????

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• Vascular injury
• - hematoma and bruising- eg. Axillary approach?
  ? 20?? bruising??
• - local anesthetic or needle induced vasospasm
  -gt transarterial axillary block? 1?? ?? but,
  1015???? resolve -gt vasospasm??? intraarterial
  lidocaint, topical warming, NTG paste?? ??
• but, prolonged vascular vasospasm? hematoma,
  arterial wall injury, dissection,
  pseudoaneurysm?? ?? ???? direct arterial
  compression? ??
• neurologic deterioration, hematoma expansion,
  unchanged neurologic exam. despite a resolving
  hematoma, documented vascular or lymphatic
  obstruction? surgical exploration??

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Neurologic complications

• 9???? ???? permanent anesthesia related nerve
  injury(ARNI)? ?? ???(lt0.02 to 0.4)
• - popliteal fossa block? ??? ??
• GA.? ?? regional A.? medicolegal claim? ???? ???
  ??
• Preexisting neuropathology ? ????? continuous
  axillary catheter techique? neurologic injury
  risk? ????? ???
• ???? perioperative peripheral n. injuries? 6????
  resolve?? ?0.4????? permanent sequelae? ???(
  peripheral n. injury? ?? ??? 4872hr??? ????,
  hematoma, postop. edema, intraoperative traction,
  trassection?? ?? 2??? injury? ?? ????? reactive
  tissue, scarring?? ?? 2??? injury? 3???????)
• - immediate consultation to help localize injury
  site, document preexisting occult or subclinical
  neurologic pathology, ensure appropriate
  rehabilitation prescription?? ??
• ???? table 81-3

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• table 81-3

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Category of the mechanism of pph. N. injury

• Mechanical injury
• - the significance of paresthesia elicitation
  is most controversial -gt some studies link injury
  to documented paresthesia within a particular
  nerves distribution, while others have been
  unable to link consistently paresthesia to
  subsequent injury
• - ?? paresthesia? definition? ???? -gt indirect
  pressure transmitted from perineural tissues,
  direct needle to nerve contat. or needle within
  the nerve
• Consensus opinion? paresthesia? n. injury???
  needle? nerve? ??? ??????? ???? endpoint or
  warning sign?? ????? ??
• Needle bevel design? role? controversial
• -gt nerve penetration? sharp needle ?? blunt
  needle? ??? ?? penetration?? damage? ??? ? ???,
  nerve fiber? parallel ?? penetration????
  transverse penetration?? ??? ? ????? ????

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• fig.81.2

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• Chemical injury
• All local anesthetics are potentially neurotoxic,
  decrease pph. Nerve blood(PNBF) -gt lidocaine2
  reduce PNBF by 40, epi.??? 20? ??(????), in
  human?? well tolerated
• Prevention
• Any specific regional anesthetic technique? ?
  ARNI? incidence? ??? ??? ??.
• pph. Nerve stimulator ??? intraneural injection
  or pph. Nerve injury? ????? ???
• Initial inj.of local anesthetic near a nerve?
  slowly, with very small volume??

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Pulmonary complications

• Pneumothorax
• Brachial plexus? lung? ?? ??(eg, Rt.side)??? ??
  ??? ??? ?? supraclavicular approach? ??
• ?? symptom? block??? 612hr?? ???? ??? pleuritic
  chest pain or dyspnea??? ?? chest radiograph??
• Phrenic nerve paresis
• Phrenic nerve(C35)? brachial plexus? ??? ????,
  above the clavicle approach? hemidiaphragmatic
  paresis? ?? ??
• Interscalene block ? 100??, ?? pulmonary
  spirometeric values ? 37?? ????
• Reduded concentration of ropivacaine, digital pr.
  applied to the interscalene groove cephalad to
  the point of injection or smaller volume of local
  anesthetic do not reduce the occurrence of
  phrenic n. blockade
• So, moderate to severe respiratory dis. ?? ?????
  above clavicle brachial plexus block? ????? ????
• Infraclavicular and axillary approach?
  resp.function? ? ??? ??

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Unintended local anesthetic destinations

• Vast network of neural structures of the neck -gt
  ease exposure to local anesthetic solution
  originally intended for the brachial plexus -gt
  subarachnoid, epidural spaces, spinal cord
• ???????? vertebral column? interscalene groove?
  ?? skin?? ? 4cm??? ??,?? anesthetized or heavily
  sedated pt. ?? subsequent intramedullary inj. and
  permanent spinal cord injury? ??
• ?? recurrent RLN(eg interscalene block?),
  cervical sympathetic nerve(-gt Horners synd.??) ?
  ??

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Hypotensive/bradycardic events

• Interscalene block?? shoulder surgery? ????
  awake, sitting pt.? ? 20?? Hypotensive/bradycardi
  c events(HBE)? ???? ??
• preop.vol. restriction, beach chair positon,
  exogenous epinephrine? empty ventricle? vigorous
  contract? ??
• Spinal anesthetic block? ? block? 3060??? ? ????
  beta blockade with metoprolol? ? ??? ?????
  ??(glycopyrrolate? ??? ??)

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• Muscle injury
• Infection
• - exogenous due to contaminated equipment or
  medication
• - endogenous secondary to a bact. Source
• - indwelling catheter? inf. complicaiton risk?
  ????? ???, ??? ??? ??? ????
• Hollow viscus penetration
• - Lower extremity pph. Nerve block? ? ??