Regional Anesthesia in the Outpatient Setting - PowerPoint PPT Presentation

Loading...

PPT – Regional Anesthesia in the Outpatient Setting PowerPoint presentation | free to download - id: 430155-MWU4Y



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Regional Anesthesia in the Outpatient Setting

Description:

Regional Anesthesia in the Outpatient Setting Ravindra V. Prasad, MD Department of Anesthesiology UNC School of Medicine Review 3/30 Ghia, Axillary Block 4/1 ... – PowerPoint PPT presentation

Number of Views:835
Avg rating:3.0/5.0
Slides: 34
Provided by: Ravindr6
Learn more at: http://www.unc.edu
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Regional Anesthesia in the Outpatient Setting


1
Regional Anesthesia in the Outpatient Setting
  • Ravindra V. Prasad, MD
  • Department of Anesthesiology
  • UNC School of Medicine

2
Review
  • 3/30 Ghia, Axillary Block
  • 4/1 Wilkes, Axillary Block
  • 4/8 Levin, SAB
  • 4/14 Klein, Lower Extremity Blocks
  • 4/15 Prasad, ???

3
Overview
  • Regional Anesthesia general comments
  • Upper Extremity Blocks
  • Paravertebral Blocks
  • Neuraxial Blocks
  • Lower Extremity Blocks

4
Regional advantages
  • Avoid GA complications
  • Less anesthetic required
  • faster wake-up?
  • quicker recovery?
  • Faster ambulation, faster discharge
  • N/V less common
  • post-op pain minimized

5
Regional problems
  • Time
  • Equipment
  • Personnel
  • GA still backup plan
  • Skill
  • regional techniques
  • management of awake or LIGHTLY sedated patients

6
Block Placement
  • Monitoring
  • Emergency equipment and drugs should be readily
    available
  • Block equipment readied before starting
  • POSITIONING
  • SEDATION (preoperative, intraoperative)
  • Patient selection

7
Upper Extremity Blocks
  • Brachial Plexus Blocks
  • Peripheral Nerve Blocks
  • elbow
  • wrist
  • Bier Blocks

8
Brachial Plexus
9
Dermatome Distribution
10
Brachial Plexus Blocks
  • Indications surgery of upper extremity
  • Approaches
  • Axillary
  • Infraclavicular
  • Supraclavicular
  • Interscalene (ISB)

11
ISB technique
  • Equipment
  • Drugs
  • Technique

12
ISB complications
  • Pneumothorax
  • Phrenic nerve paralysis
  • Horners syndrome
  • C6 root neuropathy (intraneural injection root
    pinned against C6 tubercle)

13
Bier Block
  • Intravenous Regional Anesthesia (IVRA)
  • Described by Bier in 1908
  • Intravenous injection of local anesthetics in an
    extremity isolated from the systemic circulation
  • A simple technique which is easy to perform
  • Widespread use in surgical cases of short duration

14
Bier Block indications
  • Surgery of the extremities, especially hand and
    forearm
  • Surgery of short duration (less than 1 hour)
  • Soft tissue procedures (block is less dense than
    nerve blocks may have pain if bony involvement)

15
Bier Block contraindications
  • Disease processes or states
  • prolonged tourniquet times contraindicated
    (Sickle Cell Disease or Trait)
  • more susceptible to toxic effects of agents used
    (Heart Block)
  • Hypersensitivity/allergy to agents used
  • Patients with a painful extremity
  • Certain patient body habitus

16
Bier Block technique
  • Equipment
  • tourniquet(s) with pressure gauge
  • rubber bandage (Martin, Esmarch)
  • Drugs
  • Local Anesthetics Lidocaine 0.5 or Prilocaine
    0.5
  • Opioids
  • Ketorolac

17
Bier Block mechanisms of action
  • Direct action at nerve endings
  • Diffusion into nerve trunks
  • Nerve trunks consist of fascicles covered with
    epineurium
  • Blood vessels contained within the epineurium
  • Capillaries within endoneurium extend
    intraneurally as vasa nervorum
  • Local anesthetic diffusion occurs from nerve core
    to the periphery

18
Bier Block complications
  • Local anesthetic systemic toxicity
  • Premature tourniquet release, malfunctioning
    tourniquet
  • Leakage through intraosseous veins or ordinary
    veins
  • Direct tissue local anesthetic toxicity
    (neuronal, muscular, vascular injury )
  • Ischemic injury (prolonged tourniquet time,
    excessive tourniquet pressure)

19
Bier Block pearls
  • Tourniquet pain
  • Tourniquet deflation
  • Prolonged surgery
  • Lower extremity surgery

20
Paravertebral Blocks (PVB)
  • Paravertebral space
  • Spinal root emerges from intervertebral foramen,
    divides into dorsal and ventral rami and
    sympathetics
  • Unilateral motor, sensory, and sympathetic block

21
PVB Indications
  • Thoracic
  • thoracotomy
  • mastectomy
  • nephrectomy
  • cholecystectomy
  • rib fractures
  • post-thoracotomy pain
  • post-mastectomy pain
  • Lumbar inguinal hernia

22
PVB technique
  • Equipment
  • Drugs
  • Technique
  • 2.5-3 cm lateral to spinous process, caudal and
    1-2 cm deep to transverse process
  • 4-5 ml local anesthetic
  • Variations

23
PVB risks
  • Reported failure rate 10-15

24
PVB breast surgery
  • Block T1-T6 go lateral to C7-T5.
  • Greengrass
  • Retrospective review, 156 blocks in 145 patients
    vs. 100 GA over 2-year period
  • 85 block alone
  • 91 block local
  • 2.6 complication (4/156)

25
PVB vs. GA breast surgery
26
PVB inguinal hernia repair
  • Block T10-L2 go lateral to T10-L2
  • Onset of surgical anesthesia 15-30 min

27
PVB IH Repair, outcome
  • 22 patients. 3 converted to GA
  • 1/3 had good block at emergence
  • failure rate 2-3/22 9-14
  • Of 20 successful blocks
  • Onset of discomfort 14 ? 11 hrs, first narcotic
    22 ? 18 hrs
  • 13 (65) no incisional discomfort for at least 10
    hrs after block
  • 3 (15) epidural spread
  • Klein, SM Greengrass RA Weltz C Warner DS, 1998

28
PVB inguinal hernia, satisfaction
29
SAB
  • Duration
  • Disadvantages
  • Advantages vs. epidural

30
Duration, SAB
31
Epidural
  • Duration
  • Disadvantages
  • Advantages vs. SAB

32
Duration, Epidural
33
Summary
  • Regional anesthesia is good
  • Use it!
About PowerShow.com