PERIPHERAL REGIONAL ANAESTHESIA

Tutorial COMPACT

dition nded E a p x E 2nd

Mehrkens H.-H., Geiger P., Winckelmann J. Department of Anesthesiology/Intensive Care Medicine and Pain Therapy Ulm Rehabilitation Hospital and University Clinic

Preface
After so many of our colleagues have expressed the wish for a pocket edition of our Peripheral Regional Anesthesia Tutorial published by the Ulm Rehabilitation Hospital (RKU), we have now complied by offering this compact version. The fundamentals contained in this condensed guide still grow from the now almost 20 years of clinical and practical experience gained in our hospital. This book differs from Prof. H.-H. Mehrkens, M.D. the previous, more comprehensive Director, Dept. of Anesthesiology/ Tutorial Script in that it includes many Intensive Care Medicine new developments and supplemental information. These shall be incorporated into the next edition of the tutorial script and its coming Internet version. It is here that I would like to extend my very special thanks to the managing Senior Physician of our Department, Dr. Peter Geiger. Without his tireless assistance, the production of the compact version of this pocket tutorial would not have been possible. Additional thanks go to B. Braun Melsungen, whose continuing technical and financial support have been invaluable for the completion of this work. Ulm, June 2004 Prof. H.-H. Mehrkens, M.D.

Preface to the 2nd Expanded Edition

Now, five years after the first pocket edition of the Peripheral Regional Anesthesia Tutorial appeared, the time is right to pay tribute to the rapid-paced developments taking place in this field of medicine. In doing so, we have made special efforts to include ultrasoundguided nerve block techniques whenever we felt it was sensible. Certainly, P. M. Geiger, M.D. our daily routine has become unimagiMedical Director, Department of nable without visualization of the nerves Anesthesiology/Intensive Care we want to block. At the same time, we Medicine and Pain Therapy believe that nerve stimulation and ultrasonographic visualization are not competing methods. Indeed, seeing as not every block is equally suited for one or the other of the two, a command of both is required. In many cases, combining ultrasound with nerve stimulation yields major advantages. Nerve blocks guided by ultrasound thrive on visual dynamics. For that reason, we have intentionally refrained from using static pictures of needle positions or of the local anaesthetics spread around the target structures. Instead, this booklet has placed particular emphasis on the ultrasonographic normal situs at typical puncture sites, which should assist the reader in identifying key structures. Motion images shall be made available on an updated Tutorial DVD soon.

It is here that I would like to extend my special thanks to Prof. H.-H. Mehrkens, MD, my predecessor and the initiator of the Tutorial Series, who regularly takes time off from his retirement to lend us his valuable advice. My managing senior physician, Dr. Jrg Winckelmann, also deserves great recognition for his untiring commitment to the production of this new edition. Not least, I would like to thank B. Braun Melsungen AG: without the companys support, this project would not have been possible. We authors hope that this current pocket-sized version will be used effectively and we are equally looking forward, as in the past, to its readers critiques and constructive suggestions on the Internet Forum www.nerveblocks.net.

Ulm, August 2009

P. M. Geiger, MD

Contents
General
Nerve stimulation ..................................................... 4 Transcutane nerve stimulation ................................ 8 Sonography ............................................................ 10 Drugs ....................................................................... 13 Anatomy: Diagram of the brachial plexus ............ 14 Anatomy: Diagram of the lumbosacral plexus ..... 15 Continuing education materials ............................. 94

Upper extremity
Anterior interscalene nerve block ......................... 18 Posterior interscalene nerve block ........................ 24 Supraclavicular brachial block ............................... 28 Infraclavicular block ............................................... 30 Axillary nerve block ............................................... 36 Suprascapular nerve block .................................... 42

Lower extremity
Psoas compartment block .................................... 46 Femoral nerve block ............................................. 50 Saphenous nerve block ........................................ 56 Obturator nerve block ........................................... 62 Parasacral sciatic nerve block .............................. 68 Transgluteal sciatic nerve block ........................... 72 Anterior sciatic nerve block .................................. 76 Subtrochanteric sciatic nerve block ..................... 80 Lateral distal sciatic nerve block ........................... 84 Popliteal sciatic nerve block .................................. 90

Nerve stimulation

Nerve stimulator
Current range from 1.0 0.1 mA Pulse duration 0.1 ms (mixed nerve) 1.0 ms (sensory nerve) Constant square wave pulse over a wide impedance range e.g. Stimuplex HNS 11 and Stimuplex HNS 12 (B. Braun Melsungen AG)

Single shot technique

Unipolar needles of varying length e.g., Stimuplex D or Stimuplex D Plus for ultrasoundguided nerve blocks (B. Braun Melsungen AG)

Catheter technique
Unipolar needles in a plastic introducer of varying lengths e.g.: Contiplex D Sets with a flexible and non-wired catheter or Contiplex S (B. Braun Melsungen AG)

Equipment Stimuplex HNS 12

(B. Braun Melsungen AG)

Stimuplex D / Stimuplex D Plus (B. Braun Melsungen AG)

Contiplex D (B. Braun Melsungen AG)

Contiplex Tuohy, Contiplex S (B. Braun Melsungen AG)

Transdermal nerve stimulation

Stimulation and injection technique

1. Initial current 2. Pulse duration 1.0 mA 0.1 ms (mixed nerve) or use the SENS mode setting on the stimulator

3. Threshold current 0.3 0.2 mA 4. Aspiration test 5 10 ml LA injected slowly 5. Increase to 1.0 mA initial current No stimulatory response Recurring stimulatory response: may indicate (partial) intravascular needle position. Attempt careful aspiration, perform reinjection slowly with constant verbal monitoring. 6. Administration of remaining LA 1.0 mA 7. Catheter placement after primary LA administration Upper extremity: Lower extremity: 8. Catheter aspiration test Approx. 3 cm beyond the end of the introducer sheath Approx. 4 cm beyond the end of the introducer sheath

Technique

Stimuplex Pen / Stimuplex Guide

The Stimuplex Pen can be used together with the nerve stimulator to locate nerves transdermally and to trigger the corresponding motor response. PEG (Percutaneous Electrode Guidance) The Stimuplex Guide first induces percutaneous stimulation with the sterile needle and then the actual nerve block.

Areas of application
For primary orientation before blocking a nerve To demonstrate specific stimulatory responses (for training purposes)

Block technique
Prerequisite: superficial location of the nerves Change the settings on the nerve stimulator to: Pulse duration 1.0 ms, baseline amplitude 2.5 3.0 mA, Good conductivity of the pen tip (electrode gel, water) Continuous impedance display (HNS 12) can be helpful as an indirect measure of unimpeded current flow

Sonography

General prerequisites
Knowledge of (incisional) anatomy Proper material (ultrasound imager, needles, local anaesthetics) Routine application (to train hand-eye coordination)

Insertion techniques
Insertion Advantages Disadvantages

Transverse to ultrasound Usually short distance Difficult to visualise plane (so called short axis) to target (nerve/plexus) needle tip In-plane with ultrasound beam (so called log axis)

Needle and target area fully visualised

Distance to the target is often long

Practical procedural tips

Create ergonomic circumstances (patient, puncturing physician, ultrasound imager) Perform a trial sonography for orientation Sterile prep insertion site and transducer Advance the insertion needle into target area and deliver local anaesthetic Correct needle position and inject more local anaesthetic as needed

10

Technique

Short axis (out-of-plane technique)

Long axis (in-plane technique)

11

Equipment

Stimuplex D Plus

(B. Braun Melsungen AG)

conventional needle shaft

Stimuplex D Plus (new echogenic needle shaft)

Ultrasound imager requirements

Compact and robust Easy to operate Quickly ready and mobile (boot time etc.) Suitable high-frequency transducer (7 12 MHz)

(e.g. GE Venue 40)

Stimuplex Needle Guide (B. Braun Melsungen AG)

12

Drugs

Drugs
Conventional, medium-acting local anesthetics (LA) like prilocaine mepivacaine and long-acting ones like ropivacaine bupivacaine. For anesthesia, we prefer a combination of prilocaine 1 % (20 40 ml) and ropivacaine 0.5 0.75 % (10 20 ml). This combination has the advantage that a LA with comparably low toxicity is given primarily and inadvertent intravascular injections mostly occur during the prodromal stage. Subsequently, a long-acting LA is administered to achieve a blockade of sufficient duration. For analgesia, 0.2% ropivacaine is generally administered. The preferred mode of delivery is through a PCA pump equipped with basal rate and bolus settings or by continuous infusion through the nerve catheter. Intermittant bolus injections are rarely used.

13

Intoxication

Local anesthetic-induced systemic intoxication CARDIOCIRCULATORY CEREBRAL

Asystolia

Degree of intoxication

Seizure

Bradycardia Extrasystoles Hypotension

Confusion Dizziness Tinnitus Metallic taste

Hypertension Tachycardia

Mentally abnormal

14

Drugs

15

Brachial plexus

Anatomy

1 5 6 3 2

A B C D

F
12

7 8 9 10 11 15

14

A B C D E F 1 2 3 4

Upper trunk Middle trunk Lower trunk Lateral cord Posterior cord Medial cord Dorsal scapular nerve. Suprascapular nerve Subclavian nerve Pectoral nerves

5 6 7 8 9 10 11 12 13 14 15

Musculocutaneus nerve Axillary nerve Radial nerve Median nerve Ulnar nerve Medial brachial cutaneous nerve Medial antebrachial cutaneous nerve Long thoracic nerve Subscapular nerve Axillary artery Thoracodorsal nerve

16

Lumbosacral plexus

Anatomy

2 3 4
1 2 3 4 5 6

Lateral femoral cutaneous nerve Femoral nerve Genitofemoral nerve Sciatic nerve Obturator nerve Pudendal nerve

17

Nerve stimulation

Approach according to Meier

Indications
Operative procedures on the shoulder, proximal upper arm and lateral clavicle Analgesia

Contraindications
Contralateral phrenic and recurrent paresis

Side effects / complications

Horners syndrome Phrenic paresis Recurrent paresis Vessel puncture (external jugular vein)

Anatomical landmarks
Sternocleidomastoid muscle Superior thyroid notch Scalenus gap VIB (vertical infraclavicular blockade) point

1 Sternocleidomastoid muscle, 2 Thyroid notch, 3 Puncture site

18

Anterior interscalene nerve block

Anatomical landmarks

1 3 2

19

Nerve stimulation

Blockade technique The patient lies supine, head turned slightly to contralateral side, shoulder and arm positioned comfortably. Puncture site: Posterior edge of the sternocleidomastoid muscle at the level of the thyroid notch (1.5 2 cm above the cricoid). Insertion direction tangential to the course of the plexus in the direction of the VIB point or anterior axillary line. Puncture depth: 2 4 cm. Positive stimulatory response from the upper trunk (lateral cord): biceps and/or brachial muscle.

Dosage
20 40 ml LA

Single shot technique

e.g. Stimuplex D, 50 mm

Catheter technique
e.g. Contiplex D-Set, 55 mm Advance the soft plastic catheter max. 3 cm beyond the end of the introducer sheath.

20

Anterior interscalene nerve block

What to do when ...?

Stimulation of the axillary nerve (deltoid muscle) or radial nerve (triceps muscle) occurs: Leave the needle in place u Administer LA. Stimulation of the suprascapular nerve (levator scapulae muscle) occurs: The insertion direction is too lateral and dorsal u Retract the needle, advance it markedly more to the ventral and somewhat more medial. Stimulation of the phrenic nerve (unilateral singultus) occurs: The insertion direction is too ventral and medial u Retract the needle, advance it slightly more to the lateral and dorsal. Blood is aspirated: Retract the needle, check direction of puncture u Readvance needle.

Potential errors and hazards

Always avoid a medial direction of puncture: Risk of puncturing large vessels (carotid and vertebral arteries, internal jugular vein). Risk of intrathecal injection = high spinal! (Most suitable and reliable stimulatory response: biceps and/or brachial muscle = most lateral part of plexus [C5])

21

Sonography

Nerve block technique Short axis is preferable (catheter placement), long axis possible for Single shot Sonoanatomic landmarks: - Sternocleidomastoid muscle - Scalenus anterior and scalenus medius muscles - Nerve roots of the brachial plexus Blockade objective: Infiltrate at least the superior roots (C 5 C 7) with local anaesthetic. As a general rule, 15 - 20 ml will suffice. Practical tip: The ideal insertion site is most successfully located by tilting the transducer from the supraclavicular to the interscalene position, following the plexus fibres.

22

Anterior interscalene nerve block

Sonoanatomic landmarks

medial

23

lateral

Nerve stimulation

Approach according to Pippa

Indications
Operative procedures on the shoulder, proximal upper arm and lateral clavicle Analgesia

Contraindications
Contralateral phrenic and recurrent paresis

Side effects / complications

Horners syndrome Phrenic paresis Recurrent paresis Vessel puncture

Anatomical landmarks
Spinous process C7 (vertebra prominens) Spinous process C6 Cricoid Sternocleidomastoid muscle

1 C6, 2 C7, 3 Puncture site

24

Posterior interscalene nerve block

Anatomical landmarks

3 2

25

Nerve stimulation

Blockade technique Patient is in axially aligned recumbent position (or seated); the cervical spine is flexed backwards; shoulder and arm are relaxed. Puncture site: 3 cm midline between the two spinous processes C6 and C7, Insertion direction 5 10 to the lateral, aimed at the height of the cricoid. Puncture depth: 6 8 cm, depending on the distance between puncture site and posterior edge of the sternocleidomastoid muscle. A promising stimulatory response elicited from the upper trunk (lateral sheath): biceps muscle and/or brachial muscle and/or deltoid muscle.

Dosage
30 50 ml LA

Single shot technique

e.g. Stimuplex D, 80 100 mm

Catheter technique
e.g. Contiplex D-Set, 80 110 mm Advance the soft plastic catheter max. 3 cm beyond the end of the introducer sheath.

26

Posterior interscalene nerve block

What to do when ...?

Stimulation of the axillary nerve (deltoid muscle) or radial nerve (triceps muscle) occurs: Leave needle in situ u Inject a slow, fractionated dose of local anaesthetic. Stimulation of the suprascapular nerve (levator scapulae muscle) occurs: Insertion direction too lateral u Retract the needle, advance it slightly to the medial and slightly deeper. Stimulation of the phrenic nerve (unilateral singultus) occurs: Insertion direction too deep and too medial uRetract the needle, advance it more to the lateral and less deep. Blood is aspirated: retract the needle, check puncture direction uReadvance the needle.

Potential errors and hazards

Always avoid a medial insertion direction: Risk of puncturing the vertebral artery. Risk of intrathecal injection = high spinal! (Most suitable and reliable stimulatory response: biceps and/or brachial muscle = most lateral part of plexus [C5])

27

Sonography

Preliminary note: The supraclavicular plexus block is a classic indication for the use of ultrasound guidance since it can reliably depict delicate structures like the subclavian artery and the pleura, in particular. Or, stated the other way around: Do not perform supraclavicular blocks without ultrasound. Nerve block technique: Long (single-shot technique) and short axis (catheter technique) possible Sonoanatomic landmarks: - Anterior scalene and middle scalene muscles - Subclavian artery - First rib - Pleura Blockade objective: To infiltrate all parts of the plexus (here: trunks) with local anaesthetic.

28

Supraclavicular brachial block

Sonoanatomic landmarks

medial

29

lateral

Nerve stimulation

Approach according to Kilka, Geiger, Mehrkens

Indications
Operative procedures on the distal upper arm, forearm and hand Analgesia

Contraindications
Chest deformities Healed, but dislocated (shortened) fracture of the clavicle

Side effects / complications

Horners syndrome Phrenic paresis Vessel puncture (cephalic vein, subclavian artery and vein) Pneumothorax

Anatomical landmarks
Suprasternal notch Lateral edge of the acromion Infraclavicular fossa

1 Lateral edge of acromion, 2 Suprasternal notch, 3 Infraclavicular fossa, 4 Puncture site

30

Infraclavicular block

Anatomical landmarks

3 1 4 2

31

Nerve stimulation

Blockade technique The patient is supine, with his hand relaxed on abdomen. Puncture site: Half the distance between the jugular fossa and the ventral end of the acromion directly underneath the clavicle. (The medial edge of Mohrenheims fossa is used to confirm the insertion site). Insertion direction must be absolutely perpendicular to the supporting surface (operating table). Puncture depth: 2 4 cm. Positive stimulatory response from the posterior cord: Extensor or flexor muscle D 1 3 (= radial or median nerve).

Dosage
30 50 ml LA

Single shot technique

e.g. Stimuplex D, 50 mm

Catheter technique
e.g. Contiplex D-Set, 55 mm Advance the soft plastic catheter max. 3 cm beyond the end of the introducer sheath.

32

Infraclavicular block

What to do when ...?

Lateral landmarks (ventral apophysis of acromion) cannot be found: Palpation of the clavicle from medial to lateral leads to the acromioclavicular joint u The lateral edge of the acromion is located ventral and lateral. Palpation of the crest of the scapula from dorsal to lateroventral leads to the acromion and stops at the correct site. Stimulation of the musculocutaneous nerve (biceps muscle = lateral cord) occurs: Puncture is too medial and superficial u Retract the needle, shift it subcutaneously to the lateral (0.3 0.5 cm) and then advance it perpendicularly (!) approx. 0.5 1 cm deeper than before. Blood is aspirated: Puncture site is too medial or too far away from the lower clavicular edge u Retract the needle, check lateral landmarks (ventral apophysis of the acromion) and readvance the needle.

Potential errors and hazards

Puncture too medial (establish a lateral landmark as described above). Puncture is not performed in a perpendicular direction. Puncture depth orientation: estimated distance between surface and palpable lower clavicular margin + 1 cm (Beware > 4 cm in persons with asthenic physiques).

33

Sonography

Preliminary note: As a general rule, ultrasound visualization of the infraclavicular cords is less pronounced than of the supraclavicular. It may sometimes be helpful to extend the arm. Nerve block technique: Short and long axis possible Sonoanatomic landmarks: - Subclavian artery and vein - Pectoralis major and minor muscles - Pleura Blockade objective: To infiltrate all cords with local anaesthetic

34

Infraclavicular block

Sonoanatomic landmarks

cranial

35

caudal

Nerve stimulation

Approach according to de Jong

Indications
Operative procedures on the elbow, forearm and hand Analgesia

Contraindications
No particular

Side effects / complications

Haematoma if the radial artery is injured

Anatomical landmarks
Axillary artery Coracobrachialis muscle Medial bicipital groove Pectoralis major and minor muscles

= Puncture site

36

Axillary blockade

Anatomical landmarks

37

Nerve stimulation

Blockade technique With the patient supine, the shoulder joint is abducted 90, elbow joint extended 90. Puncture site: Slightly above the axillary artery in the gap between artery and coracobrachialis muscle, at the highest point in the axilla and slightly beneath the pectoralis major muscle. Insert the needle approx. 30 parallel to the axillary artery, taking a very superficial course. Puncture depth: 1 3 cm. A promising stimulatory response elicited from the median nerve or, rather, from the radial nerve: flexor digitorum muscles / extensor digitorum muscles.

Dosage
30 50 ml LA

Single shot technique

e.g. Stimuplex D, 50 mm

Catheter technique
e.g. Contiplex D-Set, 55 mm Advance the soft plastic catheter 5 cm beyond the end of the introducer sheath.

38

Axillary blockade

What to do when ...?

There is no stimulatory response: The puncture has probably gone too deep u Retract the needle and advance at a flatter (more tangential) angle, watching out for any fascial click. Stimulation of the musculocutaneous nerve: The needle is not positioned within the neurovascular sheathu Retract the needle, advance it less deep and more tangential to the artery.

Potential errors and hazards

Puncture too deep. Difficulties identifying the axillary artery.

39

Sonography

Nerve block technique: Short axis is preferable Sonoanatomic landmarks: - Axillary artery and vein - Triceps brachii muscle Blockade objective: To infiltrate all four main nerves of the brachial plexus with local anaesthetic

40

Axillary blockade

Sonoanatomic landmarks

cranial

41

caudal

Nerve stimulation

Approach according to Meier

Indications
Frozen shoulder (for pain management and mobilization therapy) Analgesia

Contraindications
No particular

Side effects / complications

No particular

Anatomical landmarks
Spine of scapula

1 Lateral end of the spine of scapula, 2 Medial end of the spine of scapula, 3 Puncture site

42

Suprascapular nerve block

Anatomical landmarks

3 1

43

Nerve stimulation

The patient is seated, hand on their contralateral shoulder. 1 2 cm cranial and medial to the mid-spine. Insertion direction approx . 45 caudad and lateral towards the humerus head. Puncture depth: 3 5 cm. Positive stimulatory response: supraspinatus or infraspinatus muscles.

Dosage
10 20 ml LA

Single shot technique

e.g. Stimuplex D, 50 mm

Catheter technique
e.g. Contiplex D-Set, 55 mm Advance the soft plastic catheter < 3 cm beyond the end of the introducer sheath.

44

Suprascapular nerve block

What to do when ...?

There is no stimulation response: Try to find the floor of the supraspinous fossa or retract the needle and advance it at a flatter angle towards the humerus head. Note two important aspects: 1. A muscular stimulatory response is not imperative to achieve blockade. 2. The suprascapular nerve is not involved in the (sensory ) skin supply of the shoulder!

Potential errors and hazards

Puncture is made too deep and steep.

45

Nerve stimulation

Approach according to Chayen

Indications
Operative procedures in the lumbar plexus supply area In combination with proximal sciatic nerve block for complicated operations on the whole leg distal to the hip (total knee arthroplasty, cruciate ligament replacement ...) Analgesia

Contraindications
Extreme hyperlordosis (relative) Coagulation disorders

Side effects / complications

Vessel puncture (paravertebral veins) Dissemination similar to epidural anesthesia (contralateral) High (total) spinal anesthesia

Anatomical landmarks
Posterior superior iliac spine Iliac crest Spinous process L4 Costal process L5
1 Iliac crest, 2 Posterior superior iliac spine, 3 Spinous process L 4, 4 Puncture site

46

Psoas compartment block

Anatomical landmarks

1 4

47

Nerve stimulation

Blockade technique The patient is in the lateral recumbent position (or seated), the cervical spine is flexed backwards. Puncture site: 3 cm caudad and 4 cm paramedian to the spinous process of L4. Sagittal insertion direction; upon contact with the transverse process of L5, retract needle slightly, correct downward and advance over the transverse process (2 cm). Alternatively: Divide the connecting line between the spinous process of L4 and the posterior superior iliac spine in thirds; insert the needle at the transition from the medial to lateral third. Puncture depth: 6 10 cm. Positive stimulatory response from the femoral nerve: quadriceps muscle (usually the vastus lateralis muscle). Puncture is also possible at the level of the transverse process L4; now advance the caudad aligned needle under the transverse process.

Dosage
30 50 ml LA, test dose 5 ml

Single shot technique

e.g. Stimuplex D, 80 120 mm

Catheter technique
e.g. Contiplex D-Set, 80 110 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

48

Psoas compartment block

What to do when ...?

Stimulation of the obturator nerve (contraction of the adductor group) occurs: Puncture direction is too medial uRetract the needle, then lateralize it somewhat. Stimulation of the fourth lumbar nerve (= lumbosacral trunk, contractions in the peroneal group) occurs: Puncture direction is much too medial u Retract the needle; advance it markedly in the lateral direction. No transverse process contact and no stimulatory response is achieved: Puncture site and/or direction may be too lateral u Check the distance between puncture site and midline (max. 4 cm), and, if needed, adjust the puncture direction to the patients position. Adequate stimulatory response may also be possible without prior transverse process contact!

Potential errors and hazards

Always avoid a medial puncture direction (towards the spinal column)! Risk of epidural or even intrathecal dissemination of the LA. Perform a test dose.

49

Nerve stimulation

Femoral nerve block

Indications
Operative procedures in areas supplying the femoral and lateral femoral cutaneous nerves In combination with proximal sciatic nerve block, operative procedures on the whole leg (from distal thigh to foot) Analgesia

Contraindications
No particular

Side effects / complications

Vessel puncture (of the femoral vein or artery)

Anatomical landmarks
Groin Femoral artery Anterior superior iliac spine Pubic tubercle Inguinal ligament
1 Anterior superior iliac spine, 2 Pubic tubercle, 3 Puncture site

50

Femoral nerve block

Anatomical landmarks

51

Nerve stimulation

Blockade technique The patient lies on his back, his leg loosely abducted and turned to the outside. Puncture site: 2 cm caudad to the groin, 1 2 cm lateral to the femoral artery. Puncture direction: 30 45 cranial parallel to the artery. Puncture depth: 2 4 cm. Positive stimulatory response from the femoral nerve: Rectus muscle of the thigh (dancing patella).

Dosage
20 40 ml LA

Single shot technique

e.g. Stimuplex D, 50 mm

Catheter technique
e.g. Contiplex D-Set, 55 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

52

Femoral nerve block

What to do when ...?

Stimulation of the sartorius muscle (medial contraction) occurs: Puncture direction usually too medial u Retract the needle, and shift it slightly to the lateral. Direct stimulation of the sartorius muscle (rare): Puncture direction is usually too lateral u Shift the needle slightly to the medial. Femoral artery puncture: Retract the needle u Shift puncture direction to the lateral.

Potential errors and hazards

LA injection in the case of sartorius muscle stimulation.

53

Sonography

Nerve block technique Both long and short axis insertion is possible Sonoanatomic landmarks: - Femoral artery and vein - Iliac fascia - Iliopsoas muscle Blockade objective: To infiltrate the entire femoral nerve with local anaesthetic

54

Femoral nerve block

Sonoanatomic landmarks

lateral

55

medial

Nerve stimulation

Saphenous nerve block

Indications
Operative procedures in the area supplying the saphenous nerve In combination with distal sciatic nerve block for operations on the whole lower leg and foot Analgesia

Contraindications
No particular

Side effects / complications

No particular

Anatomical landmarks
Patellar crest Sartorius muscle Vastus medialis muscle

= Puncture site

56

Saphenous nerve block

Anatomical landmarks

57

Nerve stimulation

Blockade technique The patient is supine on his back, with the extended leg in a neutral position, rotated slightly outwardly. Puncture site: Approx. 2 4 cm cranial and medial to the superior edge of the patella. Insert needle perpendicularly into the palpable space between the sartorius muscle and the vastus medialis muscle. Insert the needle perpendicular through the muscle up to the subsartorial fatty tissue. Puncture depth: 3 5 cm. Electrical paresthesias at the medial calf at a pulse duration of 1.0 ms and/or a motor response from the muscular branches of the sartorius muscle are promising responses.

Dosage
10 15 ml LA

Single shot technique

e.g. Stimuplex D, 50 80 mm

Catheter technique
e.g. Contiplex D-Set, 55 80 mm Advance the soft plastic catheter 3 cm beyond the end of the introducer sheath.

58

Saphenous nerve block

What to do when ...?

Motor stimulatory response from the sartorius muscle is a promising response: u Inject local anaesthetic Patient is uncooperative: Femoral nerve block (as described above) with reduced LA volume (20 ml). Alternative technique: Subcutaneous infiltration below the medial knee joint from the medial head of the gastrocnemius muscle to the tibial tuberosity (10 15 ml LA).

Potential errors and hazards

No particular.

59

Sonography

Nerve block technique: Long axis (single-shot) is preferable Sonoanatomic landmarks: - Sartorius muscle Blockade objective: Infiltrate the saphenous nerve with local anaesthetic

60

Saphenous nerve block

Sonoanatomic landmarks

cranial

61

caudal

Nerve stimulation

Obturator nerve block

Indications
Suppression of the adductor reflex for transurethral lateral bladder wall resection Treatment of adductor spasm Adjunct to femoral nerve blocks for postoperative medial knee joint pain Analgesia

Contraindications
No particular

Side effects / complications

Vessel puncture (obturator artery or vein)

Anatomical landmarks
Origin of the adductor longus muscle Pubic tubercle Femoral artery Anterior superior iliac spine

1 Adductor longus muscle, 2 Puncture site

62

Obturator nerve block

Anatomical landmarks

63

Nerve stimulation

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 superior iliac spine. Puncture depth: 4 6 cm. Positive stimulatory response from adductor group.

Dosage
10 15 ml LA

Single shot technique

e.g. Stimuplex D, 80 mm

Catheter technique
e.g. Contiplex D-Set, 80 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

64

Obturator nerve block

What to do when ...?

Persistent adductor spasm despite (proper) obturator nerve block occurs: Perform an additional femoral nerve block, which will block any accessory obturator nerve that runs together with femoral nerve. Note: The adductor reflex for transurethral lateral bladder wall can only be reliably suppressed by a separate obturator nerve block (not by a femoral nerve block nor spinal anesthesia!).

Potential errors and hazards

No particular.

65

Sonography

Nerve block technique: Long axis is preferable Sonoanatomic landmarks: - Femoral artery and vein - Pectineus muscle - Adductor muscles (longus and brevis) Blockade objective: Infiltrate the anterior and posterior branch of the obturator nerve

66

Obturator nerve block

Sonoanatomic landmarks

67

medial

lateral

Nerve stimulation

Approach according to Mansour

Indications
Operative procedures in areas supplying the sciatic nerve In combination with psoas compartment block/femoral nerve block for operations on the whole leg Analgesia

Contraindications
No particular

Side effects / complications

Vessel puncture (inferior gluteal artery)

Anatomical landmarks
Posterior superior iliac spine Ischial tuberosity

1 Greater trochanter, 2 Posterior superior iliac spine, 3 Ischial tuberosity, 4 Puncture site

68

Parasacral sciatic nerve block

Anatomical landmarks

2 4

69

Nerve stimulation

Blockade technique The patient is placed in the lateral recumbent position, hip flexed 45, knee flexed 70, or both knees against the abdomen (favorable when combined with a psoas compartment block). Puncture site: Approx. 5 6 cm caudad to the posterior superior iliac spine along the connecting line to the ischial tuberosity. Insertion direction 20 30 caudad to midline between ischial tuberosity and greater trochanter. Puncture depth: 6 8 cm. Promising stimulatory response from the tibial and peroneal nerves: Extensors and/or flexors of feet/toes, ischiocrural muscle group

Dosage
20 30 ml LA

Single shot technique

e.g. Stimuplex D, 80 120 mm

Catheter technique
e.g. Contiplex D-Set, 80 110 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

70

Parasacral sciatic nerve block

What to do when ...?

Bone contact occurs: Shift puncture site further caudad or puncture direction more caudad. No stimulatory response is elicited: Shift puncture direction more caudad and lateral.

Potential errors and hazards

LA injection upon stimulatory response from the gluteal muscles.

71

Nerve stimulation

Approach according to Labat

Indications
Operative procedures in areas supplying the sciatic nerve In combination with psoas compartment block/femoral nerve block for operations on the whole leg Analgesia

Contraindications
No particular

Side effects / complications

Vessel puncture (inferior gluteal artery)

Anatomical landmarks
Posterior superior iliac spine Greater trochanter Sacral hiatus

1 Greater trochanter, 2 Posterior superior iliac spine, 3 Ischial tuberosity, 4 Sacral hiatus, 5 Puncture site

72

Transgluteal sciatic nerve block

Anatomical landmarks

5 3 4

73

Nerve stimulation

Blockade technique The patient is placed in the lateral recumbent position; hip flexed 45, knee flexed 70 (stable recumbent position). Puncture site: 4 5 cm mediocaudal on the mid-perpendicular lines between greater trochanter and posterior superior iliac spine; connecting line between the greater trochanter and sacral hiatus intersects the insertion point at the mid-perpendicular line. Insertion direction perpendicular to the surface. Puncture depth: 5 8 cm. Promising stimulatory response from the tibial and peroneal nerves: Extensors and/or flexors of feet/toes, ischiocrural muscle group

Dosage
20 30 ml LA

Single shot technique

e.g. Stimuplex D, 80 100 mm

Catheter technique
e.g. Contiplex D-Set, 80 110 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

74

Transgluteal sciatic nerve block

What to do when ...?

Contractions of the gluteus maximus muscle (= direct muscular stimulation or stimulation of the muscular branches of the gluteal muscle): Continue to advance the needle until the typical response is elicited. Bone contact, no stimulatory response: Correct insertion direction to midline between greater trochanter and ischial tuberosity.

Potential errors and hazards

LA injection upon stimulatory response from the gluteal muscles.

75

Nerve stimulation

Approach according to Meier

Indications
Operative procedures in the area supplying of the sciatic nerve In combination with psoas compartment block/femoral nerve block for operations on the whole leg Analgesia

Contraindications
No particular

Side effects / complications

Vessel puncture (femoral artery and vein, inferior gluteal artery and vein) Neural injury (femoral nerve)

Anatomical landmarks
Anterior superior iliac spine Pubic symphysis Greater trochanter Compartment between sartorius and rectus femoris muscles.
1 Anterior superior iliac spine, 2 Pubic symphysis, 3 Greater trochanter, 4 Puncture site

76

Anterior sciatic nerve block

Anatomical landmarks

2 3

77

Nerve stimulation
Blockade technique The patient is supine on his back, with the leg in a neutral position. Puncture site: Divide into thirds the line connecting the anterior superior iliac spine and the middle of the pubic symphysis. A perpendicular line at the transition from the medial to the middle third intersects a parallel line to the inguinal ligament through the greater trochanter at the insertion point. Palpate the muscle compartment and, using two fingers, press against the femur, forcing the vessels to the medial. Insert the needle sagittally and 70 80 to the cranial, without touching the femur. Alternatively, target the muscle compartment about 8-10 cm caudad of the femoral nerve insertion site Puncture depth: 8 15 cm. Positive stimulatory response from the peroneal or tibial nerves: extensors or flexors of the foot/toes.

Dosage
20 30 ml LA

Single shot technique

e.g. Stimuplex D, 100 150 mm

Catheter technique
e.g. Contiplex D-Set, 110 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

78

Anterior sciatic nerve block

What to do when ...?

Primary femur contact occurs: Insertion point too far to the lateral u Retract the needle and shift insertion to the medial. Primary vessel puncture (femoral vein or artery): Insertion too far medial u Retract the needle and shift the insertion to the lateral. Deep vessel puncture (gluteal artery and vein): Correct insertion direction slightly to the lateral. Stimulation of femoral nerve branches: Retract the needle and bypass stimulation area.

Potential errors and hazards

A neutral leg position is imperative.

79

Nerve stimulation

Approach according to Guardini

Indications
Operative procedures in the area supplying of the sciatic nerve In combination with psoas compartment block/femoral nerve block for operations on the whole leg Analgesia

Contraindications
Status secondary to total ipsilateral hip replacement (relative)

Side effects / complications

No particular

Anatomical landmarks
Greater trochanter Ischial tuberosity

1 Greater trochanter, 2 Ischial tuberosity, 3 Puncture site

80

Subtrochanteric sciatic nerve block

Anatomical landmarks

3 2

81

Nerve stimulation

Blockade technique The patient is supine, with the leg in a neutral position or rotated slightly inwards. Padding under the lower leg and pelvic helps with orientation. Puncture site: Approx. 2 cm dorsal and 3 4 cm distal to the greater trochanter. Insertion direction horizontal and somewhat cranial towards the ischial tuberosity without femur contact. Puncture depth: 6 10 cm. Positive stimulatory response from the peroneal or tibial nerves: extensors and/or flexors of feet/toes, ischiocrural muscle group

Dosage
20 30 ml LA

Single shot technique

e.g. Stimuplex D, 80 100 mm

Catheter technique
e.g. Contiplex D-Set, 80 110 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

82

Subtrochanteric sciatic nerve block

What to do when ...?

Femur contact occurs: Insertion too far ventral u Move insertion more to the dorsal. No stimulatory response is elicited: u Direct insertion a little to the ventral and emphasize inward rotation in the hip joint. Alternative technique: Leg is rotated slightly inward with flexed knee joint upright on the table. Puncture site: 2 3 cm caudad from the midpoint of the line connecting greater trochanter and ischial tuberosity. Insert the needle in the cranial and slightly medial direction (modified dorsodorsal access according to Raj).

Potential errors and hazards

Make sure that the leg is in a neutral position (with a slight inward rotation).

83

Sonography

Preliminary note: It is occasionally difficult to visualise the nerves due to their deep location (with linear high-frequency transducer). Block technique: Long axis is preferable, short axis possible Sonoanatomic landmarks: Gluteal muscles Blockade objective: To infiltrate the entire nerve with local anaesthetic

84

Subtrochanteric sciatic nerve block

Sonoanatomic landmarks

medial

lateral

85

Nerve stimulation

Lateral distal sciatic nerve block

Indications
Operative procedures in the areas supplying the sciatic nerve on the whole lower leg and foot In combination with saphenous nerve block for operations of the whole lower leg Analgesia

Contraindications
Stent (relative)

Side effects / complications

Vessel puncture (popliteal artery/vein)

Anatomical landmarks
Patellar crest Vastus lateralis muscle Long head of the biceps femoris muscle

1 Patellar crest, 2 Puncture site

86

Lateral distal sciatic nerve block

Anatomical landmarks

87

Nerve stimulation

Blockade technique The patient is supine on his back, with the leg in a neutral position (rotated slightly inwards), padding under the lower leg. Puncture site: Approx. 3 8 cm above the patella in the lateral muscle compartment between lower edge of the vastus lateralis muscle and biceps femoris muscle. Insertion direction slightly dorsocranial. Puncture depth: 3 5 cm. Positive stimulatory response from the peroneal or tibial nerves: extensors or flexors of the foot/toes.

Dosage
20 40 ml LA

Single shot technique

e.g. Stimuplex D, 50 80 mm

Catheter technique
e.g. Contiplex D-Set, 55 80 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

88

Lateral distal sciatic nerve block

What to do when ...?

No stimulatory response is elicited: Insertion direction is usually too far ventral u Correct to the dorsal. Femur contact occurs: Puncture site and/or insertion direction too far to the ventral u Check puncture site, correct to dorsal if needed; shift insertion direction more to the dorsal. Vessel puncture popliteal artery/vein: Puncture too deep and too ventral u Retract the needle, correct insertion direction to the dorsal, reduce insertion depth.

Potential errors and hazards

Make sure that the leg is in a neutral position (with a slight inward rotation).

89

Sonography

Nerve block technique: Long axis is preferable Sonoanatomic landmarks: Medial edge of the long head of the biceps femoris muscle Blockade objective: To infiltrate the entire sciatic nerve or its two terminal branches with local anaesthetic Practical tip: The patients calf is placed on an elevated arm extension, for example. This allows the ultrasound beam to be directed from the dorsal onto the distal sciatic nerve cranial to the popliteal fossa.

90

Lateral distal sciatic nerve block

Sonoanatomic landmarks

lateral

91

medial

Nerve stimulation

Popliteal sciatic nerve block

Indications
Operative procedures in the area supplying the sciatic nerve of the lower leg and foot Operations on the whole lower extremity in combination with a saphenous nerve block. Analgesia

Contraindications
Stent (relative)

Side effects / complications

Vessel puncture (popliteal artery/vein)

Anatomical landmarks
Popliteal fossa Popliteal fold Long head of the biceps femoris muscle Medial and lateral epicondyle of the femur

1 Lateral epicondyle of the femur, 2 Medial epicondyle of the femur, 3 Puncture site

92

Popliteal sciatic nerve block

Anatomical landmarks

93

Nerve stimulation

Blockade technique The patient is either in the prone position or lying on his side, leg extended. Puncture site: Approx. 8 12 cm above the fold of the popliteal fossa at the medial edge of the biceps femoris muscle, laterally marking the popliteal fossa. Insertion direction approx. 30 cranial and slightly medial. Puncture depth: 2 4 cm. Positive stimulatory response from the peroneal and tibial nerves: extensors or flexors of the foot/toes.

Dosage
20 40 ml LA

Single shot technique

e.g. Stimuplex D, 50 mm

Catheter technique
e.g. Contiplex D-Set, 55 mm Advance the soft plastic catheter < 4 cm beyond the end of the introducer sheath.

94

Popliteal sciatic nerve block

What to do when ...?

Femur contact occurs: Insertion too deep and too medial Retract the needle u Correct puncture direction or insertion site to the lateral, reduce insertion depth. Vessel puncture popliteal artery/vein: Puncture too deep and too medial Retract the needle u Correct insertion direction to the lateral, reduce insertion depth.

Potential errors and hazards

Puncture site is too far caudad (popliteal fold): It may be that the tibial nerve (med.) and peroneal nerve (lat.) are separated so far apart that complete blockade cannot be achieved with a single LA injection at the two sciatic branches.

95

Other publications appearing in this series

Brochure (DIN A4) Peripheral Regional Anesthesia at the Ulm Rehabilitation Hospital Interactive DVD Tutorial Peripheral Regional Anesthesia at the Ulm Rehabilitation Hospital

These materials can be requested at your B. Braun partner in your country

B. Braun Melsungen AG Carl-Braun-Strae 1 34212 Melsungen Germany Tel. +49 5661 71 4657 Fax. +49 5661 75 4657 E-mail: wolfgang.pape@bbraun.com

Online Tutorial and Discussion Forum

www.nerveblocks.net
The state of medical knowledge is subject to constant change due to new research and clinical evidence. The authors of this book have been very careful to comply with the current state of the art. Nevertheless, users of this information carry their own responsibility and liability when establishing the diagnosis and implementing therapy.

The Tutorial was made possible by the kind support of B. Braun Melsungen AG.

Nr. 6064605B

The Tutorial was made possible by the kind support of B. Braun Melsungen AG.

B. 03. 01 . 10 /1 Nr. 6064605 B