Peripheral Nerve Blocks

Dr. Weiwei Liu

Department of Anesthesiology
The First People's Hospital of Jingzhou
The First Affiliated Hospital of Yangtze University
 BLOCK TECHNIQUES

Section Ⅰ

Fundamentals
What is the Peripheral Nerve Blocks ?

Peripheral nerve blocks rely

on local anesthetics injected
around specific to prevent
sensory transmission back to
spinal cord/CNS
what is required of the well-rounded anesthesiologist?

An understanding of regional anesthesia

anatomy and techniques
The field of regional anesthesia has accordingly
expanded to one that addresses not only the
intraoperative concerns of the anesthesiologist, but
also longer term perioperative pain management.
In addition to potent analgesia, regional anesthesia may lead to
reductions in the stress response, analgesic requirements ,
opioid-related side effects, general anesthesia requirements, and
possibly the development of chronic pain.
 PATIENT SELECTION

The selection of a regional anesthetic technique is a

process that begins with a thorough history and physical
examination.

Although many patients are candidates for regional

anesthesia/analgesia, as with any medical procedure a
risk–benefit analysis must be performed.
 PATIENT SELECTION
The risk–benefit ratio often favors regional anesthesia in

• patients with multiple comorbidities for whom a GA carries a

greater risk.

• patients intolerant to systemic analgesics (eg, those with

obstructive sleep apnea or at high risk for nausea) may benefit
from the opioid-sparing effects of a regional analgesic.

• Patients with chronic pain and opioid tolerance may receive

optimal analgesia with a continuous peripheral nerve block (so-
called perineural local anesthetic infusion)
 PATIENT SELECTION

A comprehensive knowledge of anatomy and an understanding of

the planned surgical procedure are important for selection of the
appropriate regional anesthetic technique.
 RISKS & CONTRAINDICATIONS

Patient cooperation and participation are key to the success and safety
of every regional anesthetic procedure;
patients who are unable to remain still for a procedure may be exposed
to increased risk.

Examples include younger pediatric patients and some developmentally

delayed individuals, as well as patients with dementia or movement
disorders.
 RISKS & CONTRAINDICATIONS

Bleeding disorders and pharmacological anticoagulation heighten the

risk of local hematoma or hemorrhage, and this risk must be balanced
against the possible benefits of regional block.

Specific peripheral nerve block locations warranting the most concern

are posterior lumbar plexus and paravertebral blocks owing to their
relative proximity to the retroperitoneal space and neuraxis,
respectively.
 RISKS & CONTRAINDICATIONS
Placement of a block needle through a site of infection can theoretically
track infectious material into the body, where it poses a risk to the
target nerve tissue and surrounding structures.

the presence of a local infection is a relative contraindication to

performing a peripheral nerve block.

Indwelling perineural catheters can serve as a nidus of infection;

the risk in patients with systemic infection remains unknown.

 RISKS & CONTRAINDICATIONS
Although nerve injury is always a possibility with a regional anesthetic,
some patients are at increased risk.

Individuals with a preexisting condition (eg, peripheral neuropathy or

previous nerve injury) may have a higher incidence of complications,
including prolonged or permanent sensorimotor block.

The precise mechanisms have yet to be clearly defined but may

involve local ischemia from high injection pressure or vasoconstrictors,
a neurotoxic effect of local anesthetics, or direct trauma to nerve tissue.
 RISKS & CONTRAINDICATIONS
Other risks associated with regional anesthesia include local anesthetic
toxicity from intravascular injection or perivascular absorption.

In the event of a local anesthetic toxic reaction, seizure activity and

cardiovascular collapse may occur.

Supportive measures should begin immediately, including the initiation

of cardiopulmonary resuscitation, lipid emulsion administration to
sequester local anesthetic, and preparation for cardiopulmonary bypass.
 RISKS & CONTRAINDICATIONS
Systemic Toxicity(1)
Systemic toxicity results from excessive plasma concentrations
Factors:
Overdose of local anesthetics
Accidental intravascular injection
 Rapid absorption of local anesthetics from tissue injection sites
• intravascular﹥intercostal﹥ caudal﹥epidural ﹥brachial
plexus ﹥subcutaneous
Degree of vasodilation, lipid solubility of LA, presence of
renal/liver disease
 RISKS & CONTRAINDICATIONS
Systemic Toxicity(2)
Toxicity mainly affects CVS and CNS
CNS is more sensitive and usually affected first
Signs of local anesthetic toxicity with increasing plasma
concentrations include:
Light-headedness→ circumoral numbness→facial tingling
→tinnitus→Slurred speech →Seizures→Unconsciousness
→Respiratory arrest→Cardiovascular depression →Circulatory arrest
 RISKS & CONTRAINDICATIONS
Clinical features: CNS toxicity
Metallic taste
Light-headedness, talkativeness
Tinnitus
Visual disturbances
Numbness of the tongue and lips
Muscle twitching
Loss of consciousness
Tonic-clonic seizures, convulsion
Coma
CNS toxicity is exacerbated by hypercarbia, hypoxia, and acidosis
RISKS & CONTRAINDICATIONS
 RISKS & CONTRAINDICATIONS
Precautions of toxicity

Use of non-overdose
Aspiration before injection
Use of epinephrine(肾上腺素)-containing solutions for test doses
Use of small incremental volumes in establishing the block
Premedication: depressant or
Use of less dosage in elderly, poorly endurance of patients,in highly vascular
areas
Active correction of pathologic conditions such as sepsis, hypovolemia,
anemia, heart failure, hypercarbia, hypoxia, and acidosis
 RISKS & CONTRAINDICATIONS
Treatment of toxicity
Stop injecting, at the first sign of toxicity
Get help
Give 100%oxygen and artificial ventilation, and consider hyperventilation in
presence of metabolic acidosis
Maintain airway (intubate if necessary)
Treat seizures (benzodiazepines, propofol, thiopental in small
doses),succinylcholine can be given to facilitate intubation
Support circulatory stability with volume replacement and vasopressors
If cardiac arrest with LA toxicity: prolonged CPR and treatment of arrhythmias
with standard protocols
Lipid emulsion: intralipid 20%, 1.5ml/kg
 CHOICE OF LOCAL ANESTHETIC

The decision about which local anesthetic to employ for a

particular nerve block depends on the desired onset, duration, and
relative blockade of sensory and motor fibers.
CHOICE OF LOCAL ANESTHETIC
 PREPARATION

Regional anesthetics should be administered in an area where

standard hemodynamic monitors, supplemental oxygen, and
resuscitative medications and equipment are readily available.
 PREPARATION

• Patients should be monitored with pulse oximetry, noninvasive

blood pressure, and electrocardiography .

• Positioning should be ergonomically favorable for the practitioner

and comfortable for the patient.

• Intravenous premedication should be employed to allay anxiety

and minimize discomfort.

• Sterile technique should be strictly observed.

 BLOCK TECHNIQUES

Paresthesia Technique

Formerly the mainstay of regional anesthesia, this technique is now

rarely used for nerve localization. Using known anatomic
relationships and surface landmarks as a guide, a block needle is
placed in proximity to the target nerve or plexus. When a needle
makes direct contact with a sensory nerve, a paresthesia (abnormal
sensation) is elicited in its area of sensory distribution.
 BLOCK TECHNIQUES

For this technique, an insulated needle

Nerve Stimulation Technique
concentrates electrical current at the needle
tip, while a wire attached to the needle hub
connects to a nerve stimulator—a battery-
powered machine that emits a small amount
(0–5 mA) of electric current at a set interval
(usually 1 or 2 Hz). A grounding electrode
is attached to the patient to complete the
circuit.When the insulated needle is placed in
proximity to a motor nerve, muscle
contractions are induced, and local anesthetic
is injected.
 BLOCK TECHNIQUES
Ultrasound Technique
Ultrasound for peripheral nerve localization is becoming increasingly popular; it
may be used alone or combined with other modalities such as nerve stimulation.
Ultrasound uses high-frequency (1–20 MHz) sound waves emitted from
piezoelectric crystals that travel at different rates through tissues of different
densities, returning a signal to the transducer. Depending on the amplitude of
signal received, the crystals deform to create an electronic voltage that is
converted into a two-dimensional grayscale image. The degree of efficiency with
which sound passes through a substance determines its echogenicity.
Structures and substances through which sound passes easily are described as
hypoechoic and appear dark or black on the ultrasound screen. In contrast,
structures reflecting more sound waves appear brighter or white on the
ultrasound screen, and are termed hyperechoic.
 BLOCK TECHNIQUES
Ultrasound Technique

The optimal transducer varies depending upon the depth of the target nerve and
approach angle of the needle relative to the transducer.

High-frequency transducers provide a high-resolution picture with a relatively

clear image but offer poor tissue penetration and are therefore used
predominantly for more superficial nerves.

Low-frequency transducers provide an image of poorer quality but have better

tissue penetration and are therefore used for deeper structures.
BLOCK TECHNIQUES
 BLOCK TECHNIQUES

Section Ⅱ

UPPER EXTREMITY
PERIPHERAL NERVE BLOCKS
 Brachial Plexus Anatomy
The brachial plexus is formed by the
union of the anterior primary divisions
of the fifth through the eighth cervical
nerves and the first thoracic nerves.
Contributions from C4 and T2 are
often minor or absent.

As the nerve roots leave the

intervertebral foramina, they converge,
forming trunks, divisions, cords,
branches, and then finally terminal
nerves.
C5-T1
Brachial Plexus Anatomy

The three distinct trunks formed

between the anterior and middle
scalene muscles are termed
superior, middle, and inferior
based on their vertical orientation.
 Brachial Plexus Anatomy

As the trunks pass over the lateral border of the first rib . and under
the clavicle, each trunk divides into anterior and posterior divisions.
Brachial Plexus Anatomy

As the brachial plexus emerges below

the clavicle, the fibers combine again
to form three cords that are named
according to their relationship to the
axillary artery: lateral, medial, and
posterior.

At the lateral border of the pectoralis

minor muscle, each cord gives off a
large branch before ending as a major
terminal nerve.
 Brachial Plexus Anatomy

The lateral cord gives off the lateral branch of the median nerve and terminates
as the musculocutaneous nerve;

the medial cord gives off the medial branch of the median nerve and terminates
as the ulnar nerve;

the posterior cord gives off the axillary nerve and terminates as the
radial nerve.

Local anesthetic may be deposited at any point along the brachial plexus,
depending on the desired block effects
 Brachial Plexus Anatomy

median nerve

ulnar nerve

radial nerve
Interscalene Block
 Interscalene Block
An interscalene brachial plexus block is
indicated for procedures involving the
shoulder and upper arm .

Roots C5–7 are most densely blocked

with this approach; and the ulnar nerve
originating from C8 and T1 may be
spared. Therefore, interscalene blocks are
not appropriate for surgery at or distal to
the elbow.
 Interscalene Block

Contraindications to an interscalene block include local

infection, severe coagulopathy, local anesthetic allergy,
and patient refusal.
 Interscalene Block

A properly performed interscalene block invariably blocks the

ipsilateral phrenic nerve(膈神经);

so careful consideration should be given to patients with

severe pulmonary disease or preexisting contralateral phrenic
nerve palsy.

The hemidiaphragmatic paresis may result in dyspnea,

hypercapnia, and hypoxemia.
 Interscalene Block

A Horner’s syndrome (myosis,

ptosis, and anhidrosis) may result
from proximal tracking of local
anesthetic and blockade of
sympathetic fibers to the
cervicothoracic ganglion.
 Interscalene Block

Recurrent laryngeal nerve involvement often induces

hoarseness. In a patient with contralateral vocal cord
paralysis, respiratory distress may ensue.
 Interscalene Block

Other site-specific risks include vertebral artery injection

(suspect if immediate seizure activity is observed), spinal or
epidural injection, and pneumothorax. Even 1 mL of local
anesthetic delivered into the vertebral artery may induce a
seizure. Similarly, intrathecal, subdural, and epidural local
anesthetic spread is possible.
 Interscalene Block

Interscalene block. Ultrasound image of the brachial plexus in the interscalene

groove. ASM, anterior scalene muscle; MSM, middle scalene muscle; SCM,
sternocleidomastoid; N, brachial plexus nerve roots in cross-section.
 Supraclavicular Block

Once described as the “spinal of the arm,”

a supraclavicular block offers dense
anesthesia of the brachial plexus for
surgical procedures at or distal to the
elbow .Historically, the supraclavicular
block fell out of favor due to the
high incidence of complications
(pneumothorax) that occurred with
paresthesia and nerve stimulator
techniques.
 Supraclavicular Block

It has seen a resurgence in recent years as

the use of ultrasound guidance has
theoretically improved safety. The
supraclavicular block does not reliably
anesthetize the axillary and
suprascapular nerves, and thus is not
ideal for shoulder surgery. Sparing of
distal branches, particularly the ulnar
nerve, may occur.
 Supraclavicular Block

Supraclavicular block. Ultrasound image of the brachial plexus in the

supraclavicular fossa. SA, subclavian artery; R, rib; N, brachial plexus in
cross-section
 Axillary Block

At the lateral border of the pectoralis

minor muscle, the cords of the
brachial plexus form large terminal
branches. The axillary,
musculocutaneous, and medial
brachial cutaneous nerves branch
from the brachial plexus proximal to
the location in which local anesthetic
is deposited during an axillary nerve
block, and thus are usually spared
 Axillary Block

At this level, the major terminal nerves often are separated by fascia; therefore
multiple injections (10-mL each) may be required to reliably produce anesthesia
of the entire arm distal to the elbow.
 Axillary Block

There are few contraindications to axillary brachial plexus blocks.

Local infection, neuropathy, and bleeding risk must be considered.
Because the axilla is highly vascularized, there is a risk of local
anesthetic uptake through small veins traumatized by needle
placement.
Axillary Block
 Axillary Block

Ultrasound image of axillary

brachial plexus block.
AA, Axillary artery;
AV, axillary vein;
U, ulnar nerve;
M, median nerve;
MC, musculocutaneous nerve;
R, radial nerve;
CB, coracobrachialis muscle;
TM, triceps muscle;
BM, biceps muscle.