NB by Dr Rafia Komal.pptx
- 1. Peripheral Nerve block I. Wrist Dr Rafia Komal PGR Anesthesia CPEIC
- 2. Wristblock Dr Rafia Komal PGR Anesthesia CPEIC
- 3. Essentials Indications: surgery on the hand and fingers Nerves: 1. Radial, 2. Ulnar, 3. Median Dr Rafia Komal PGR Anesthesia CPEIC
- 4. Functional Anatomy-ulnar nerve The ulnar nerve provides sensory innervation to the skin of the little finger and the (ulnar aspect) half of the ring finger, and to the corresponding area of the palm. The same area is covered on the corresponding dorsal side of the hand. Dr Rafia Komal PGR Anesthesia CPEIC
- 5. Functional Anatomy-median nerve Sensory supply: -palmar aspect of thumb, index, middle and radial border of the ring finger, -dorsal surface of the distal phalanges of index and middle, radial border of the ring finger. Dr Rafia Komal PGR Anesthesia CPEIC
- 6. Functional Anatomy- Radial nerve The radial nerve lies on the anterior aspect of the radial side of the forearm. supply sensation to the dorsum of the thumb and the dorsum of the hand (the thumb, index, middle and one-half ring finger as far as the distal interphalangeal joint). Dr Rafia Komal PGR Anesthesia CPEIC
- 7. Epinephrine Is Safe in the Finger It was once widely believed that injected epinephrine frequently caused finger ischemia and necrosis. That belief was widespread before 1948 when procaine was the only injectable local anesthetic. Before expiration dates were mandated by the FDA in 1972, procaine (pH 3.6) that had become increasingly acidic during storage was used in surgical procedures 2 Batches of procaine with a pH of 1 were used for injections as late as 1948 More finger necrosis occurred with procaine without epinephrine than occurred with procaine combined with epinephrine, but epinephrine was blamed because of its vasoconstrictive effect. Wide-awake Hand and Wrist Surgery: A New Horizon in Outpatient Surgery 息 2015 AAOS Instructional Course Lectures, Volume 64 http://handsurgery.org/multimedia/files/preCourse/AAOS%20paperchapter%20with%20Jupiter%20and%20Amadio.pdf Dr Rafia Komal PGR Anesthesia CPEIC
- 8. Epinephrine Is Safe in the Finger Level I evidence has shown that phentolamine, an alpha blocker that became available in 1957, reliably reverses epinephrine vasoconstriction in the human finger. However, its use is seldom required in clinical practice. The literature has reports from large studies that clinical epinephrine has been used without inducing infarction. In addition, no cases of digital infarction have been reported with high-dose (1:1000) accidental epinephrine finger injections, so it is unlikely that epinephrine would infarct fingers at a concentration of 1:100,000. More cases of digital infarction have been reported with improperly used digital tourniquets than with lidocaine and epinephrine use, although both are rare Dr Rafia Komal PGR Anesthesia CPEIC
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- 11. Maneuvers to Facilitate Landmark Identification-radial block Palpation of the radial styloid. The superficial radial nerve is blocked by an injection just proximal to the styloid. Dr Rafia Komal PGR Anesthesia CPEIC
- 12. Maneuvers to Facilitate Landmark Identification- median nerve Outlining palmaris longus tendon. A maneuver to accentuate the tendons of the flexors of the wrist. (A) Shown are palmaris longus (white arrow) and flexor carpi radialis (red arrow) tendons. Dr Rafia Komal PGR Anesthesia CPEIC
- 13. Maneuvers to Facilitate Landmark Identification- median nerve The palmaris longus tendon can be accentuated by asking the patient to oppose the thumb and fifth finger while flexing the wrist. Dr Rafia Komal PGR Anesthesia CPEIC
- 14. Maneuvers to Facilitate Landmark Identification- ulnar nerve Outlining flexor carpi ulnaris tendon. Dr Rafia Komal PGR Anesthesia CPEIC
- 15. Block of the Ulnar Nerve The needle is inserted just medial to and underneath the flexor carpi ulnaris tendon to inject local anesthetic in the immediate proximity of the ulnar artery. The needle is advanced 5 to 10 mm to just past the tendon of the flexor carpi ulnaris . After negative aspiration, 3 to 5 mL of local anesthetic solution is injected. A subcutaneous injection of 2 to 3 mL of local anesthesia just above the tendon of the flexor carpi ulnaris is advisable for blocking the cutaneous branches of the ulnar nerve, which often extend to the hypothenar area. Dr Rafia Komal PGR Anesthesia CPEIC
- 16. Block of the Median Nerve The median nerve is blocked by inserting the needle between the tendons of the palmaris longus and flexor carpi radialis . The needle is inserted until it pierces the deep fascia, and 3 to 5 mL of local anesthetic is injected. Although piercing of the deep fascia has been described to result in a fascial click, it is more reliable to simply insert the needle until it contacts the bone. The needle is withdrawn 2 to 3 mm, and the local anesthetic is injected. Dr Rafia Komal PGR Anesthesia CPEIC
- 17. Block of the Median Nerve A fan technique is recommended to increase the success rate of the median nerve block. After the initial injection, the needle is withdrawn back to skin level, redirected 30属 laterally, and advanced again to contact the bone. After pulling back the needle 1 to 2 mm from the bone, an additional 2 mL of local anesthetic is injected. A similar procedure is repeated with medial redirection of the needle. Paresthesia in the median nerve distribution warrants a 1- to 2- mm withdrawal of the needle, followed by a slow measured injection of the local anesthetic. If paresthesia worsens or persists, the needle should be removed and reinserted. Dr Rafia Komal PGR Anesthesia CPEIC
- 18. Block of the Radial Nerve The superficial branches of the radial nerve are blocked by a subcutaneous injection of local anesthetic in a circular fashion. The injection is made proximal to the radial styloid head (circle) The radial nerve block is essentially a field block and requires more extensive infiltration because of its less predictable anatomic location and division into multiple smaller cutaneous branches. 5ml of local anesthetic should be injected subcutaneously just proximal to the radial styloid, aiming medially. Then the infiltration is extended laterally, using an additional 5 mL of local anesthetic Dr Rafia Komal PGR Anesthesia CPEIC
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- 21. Complications and How to Avoid Them Infection This should be very rare with use of an aseptic technique. Hematoma Avoid multiple needle insertions. Use 25-gauge needle (or smaller) and avoid puncturing superficial veins. Vascular Puncture Avoid puncturing the greater saphenous vein at the medial malleolus Intermittent aspiration should be performed to avoid intravascular injection Gangrene of the digit(s) The mechanical pressure effects of injecting solution into a potentially confined space should always be borne in mind, particularly in blocks at the base of the digit Limit the injection volume to 2mL on each side In patients with small vessel disease, perhaps an alternative method should be sought in addition to avoidance of digital tourniquet Nerve Injury Residual paresthesias are likely due to an inadvertent intraneuronal injection Systemic toxicity is rare because of the distal location of the blockade Do not inject when the patient complains of pain or when high pressures on injection are met Other Instruct the patient to the care of the insensate finger Dr Rafia Komal PGR Anesthesia CPEIC
- 22. Local Anaesthetic Systemic Toxicity (LAST) Recognition Immediate Management Treatment Follow-up Dr Rafia Komal PGR Anesthesia CPEIC
- 23. Major Signs/Symptoms Tonic-clonic seizures Global CNS depression Decreased level of consciousness Apnea Neurologic symptoms typically precede cardiovascular symptoms in lidocaine toxicity LAST -CNS Signs + Symptoms Minor sign and symptoms: Tongue and perioral numbness Paresthesias Restlessness Tinnitus Muscle fasciculations + tremors Dr Rafia Komal PGR Anesthesia CPEIC
- 24. LAST-Cardiovascular Symptoms Early Signs: Hypertension and tachycardia Late Signs Peripheral vasodilation + profound hypotension Sinus bradycardia, AV blocs Conduction defects (Prolonged PR, Prolonged QRS) Ventricular dysrhythmias Cardiac arrest Cardiovascular symptoms typically present first in bupivacaine toxicity Dr Rafia Komal PGR Anesthesia CPEIC
- 25. AAGBI: Association of anesthethics of great Britain and Ireland Dr Rafia Komal PGR Anesthesia CPEIC
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- 29. Intralipid 20% Dr Rafia Komal PGR Anesthesia CPEIC
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- 32. Reference https://www.nysora.com/digital-nerve-block http://handsurgery.org/multimedia/files/preCourse/AAOS%20paperchapte r%20with%20Jupiter%20and%20Amadio.pdf https://www.aagbi.org/sites/default/files/275%20Wrist%20Block%20- %20Landmark%20Technique.pdf https://www.nysora.com/ankle-block http://www.luigivicari.it/med/wp-content/uploads/2012/11/w-urmey- ankle-block.pdf https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf http://rebelem.com/local-anesthetic-systemic-toxicity-last/ https://emedicine.medscape.com/article/80887-technique#showall Dr Rafia Komal PGR Anesthesia CPEIC