Peripheral Nerve Blocks

Nerve blocks may be classified as:

1. central neuraxial blocks {spinal and epidural).
2. peripheral nerve block​.

What are the indications of nerve block?

1. for regional anesthesia.
2. for acute and chronic pain relief.

😉TECHNIQUE​:
-The method of giving a nerve block is by eliciting paresthesia and/or using the nerve stimulator.
- Also can be use ultrasound to do the procedure.

BLOCKS OF UPPER LIMB

▶ Brachial Plexus Block:

💪
-second most commonly performed block (after central neuraxial block).
- it is used for surgery of the upper limb and shoulder.
- can be blocked by 4 approaches➡ interscalene​, ​supraclavicular, infraclavicular and axillary
approach.

1.lnterscalene Approach:​ 🧡
-indication for interscalene block is surgery on the shoulder or upper arm.
- in this technique brachial plexus is blocked between anterior and middle scalene at the level of
the cricoid.
- ​Blockade​ occurs at the level of the superior and middle trunks.

😨
- ​Ulnar nerve is usually not involved with this approach​ ​making it unsuitable for hand surgeries.
- ​Complications ​: 1.pherenic nerve block
2.horner syndrome
3.Epidural and intrathecal injection.
4.pnemothorax
Also ​General complications​ like nerve injury,neuritis, intravascular injection, bleeding and
hematoma formation, infection or injury to a nearby structure and systemic toxicity of local
anesthetic.

🙁
✋
2.Supraclavicular Approach:
-usually employed for surgeries on lower arm, elbow, forearm and hand.

😨
-​Blockade​ occurs at the level of distal trunk and proximal division of brachial plexus.
- ​Complications ​: 1.pnemothorax
2.phrenic nerve block
3.horner syndrome
4.general complications

3.Axillary Approach: 😷
-The drug is injected around the axillary artery in the axilla. - - ​Blockade​ occurs at the level of
the terminal nerves.
- ​The advantage over supraclavicular approach is the complication of it can be avoided.
-Disadvantage: Musculocutaneous and intercostobrachial nerves are not involved in the axillary
block, ​so not suitable for arm surgery.
-The chances of intravascular injection and hematoma formation are also high with axillary
approach.

4.lnfraclavicular Approach: 😵
-In this approach brachial plexus is blocked either just below the midpoint of clavicle (classical
approach) or just medial to coracoid process
(coracoid approach).
- ​The advantage is that musculocutaneous and axillary nerves can be blocked.
- Infraclavicular route for blocking brachial plexus is not utilized routinely due to➡high failure
rate & increased incidence of pneumothorax and hemothorax.

▶Individual Nerve Block:

* Radial, ulnar and median nerves can be blocked
separately at elbow and wrist.

😉
▶Intravenous Regional Block (Bier Block)​:
​Technique..
- After applying tourniquet (which prevents systemic absorption of drug) 30-40 mL of 0.5%
lignocaine (xylocard) or prilocaine is injected into a peripheral vein.
- Deflation or leak can cause drug toxicity and death.
- bupivacaine is absolutely contraindicated for Bier block.
- lignocaine with adrenaline should not be used.

😍 ​Advantages:
1.Easy procedure.
2.Almost no chances of failure.
3.Rapid onset (within 5 minutes).
4.Good muscle relaxation.

☹ Disadvantages:​
1.Tourniquet discomfort or compartment syndrome.
2.Venous engorgement caused by vasodilation.
3.utilized only for short duration procedures.
4.Accidental deflation or leak of tourniquet can cause severe drug toxicity and even death.
5.Tourniquet cannot be released before 30 minute (even if the surgery finishes before it).

😥 ​Contraindications​:
❌sickle cell patients.
❌Raynaud's disease and scleroderma
BLOCKS OF LOWER LIMB
rarely used for providing anesthesia.

🍄
The nerve blocks which are sometimes utilized are:

🍄
Psoas compartment block➡To block lumbar plexus.

🍄
Perivascular block (3 in 1 block)➡blocking femoral sciatic and obturator nerves.
Fascia iliaca nerve (modified femoral) block➡ A large volume of drug is injected just below

🍄
the fascia iliaca to block femoral nerve as it traverses the fascia iliaca.
Ankle block: Performed for foot surgeries.

🍉
BLOCKS OF THE HEAD AND NECK, THORACIC AND ABDOMINAL AREA
Cervical Plexus Block➡ best utilized for carotid endarterectomy and to do tracheostomy and

🍉
thyroidectomy with bilateral cervical plexus block.

🍉
Airway Block➡ popular in the past for awake intubation.
Phrenic Nerve Block

🍊 ilioinguinal and iliohypogastric Nerve Block:

-Performed for hernia repair, these are blocked at a point 3cm medial to anterior superior iliac

🥕
spine.
Penile Block:
-Pudenda! nerve is blocked by injection of 10-15 mL of local anesthetic at the base of penis.
-Xylocaine with adrenaline is contraindicated for penile block.

🍍Paravertebral Block:
-In the paravertebral block, each spinal nerve is blocked just after it exits from intervertebral
foramen.
-Can be utilized for breast, thoracic or abdominal surgeries in patients where general anesthesia
is contraindicated.

🍋intercostal Nerve Block:

-Most often performed for pain relief for rib fractures and post-herpetic neuropathies.
-Also can be used for chest tube insertion or doing thoracostomies.

😨
-Block is given at the lower border of rib, usually at the posterior angle of rib.
- complications :
1⃣ pneumothorax
2⃣ risk of systemic local anesthetic toxicity (maximum systemic absorption occurs after
intercostal nerve block).

❌
CONTRAINDICATIONS FOR PERIPHERAL NERVE BLOCKS:

❌
Patient suffering from coagulopathy or on anticoagulants (except aspirin)

❌
Infection at the site of needle placement

❌
Known Case of drug allergy to local anesthetics
Pre-existing neuropathy-Avoid regional
anesthesia to avoid medicolegal issues.