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FEMORAL NERVE BLOCKS
AND3-IN-1 NERVE BLOCKS
Soli Deo Gloria
Developing Countries Regional Anesthesia Lecture Series
Daniel D. Moos CRNA, Ed.D. U.S.A. moosd@charter.net Lecture 17
Disclaimer
Every effort was made to ensure that material and information contained in this presentation are correct and up-to-date. The author can not accept liability/responsibility from errors that may occur from the use of this information. It is up to each clinician to ensure that they provide safe anesthetic care to their patients.
Introduction
Currently underutilized for clinical anesthesia and postoperative pain management.
Lower extremity peripheral nerve blocks have historically been performed less frequently than peripheral nerve blocks of the upper extremities.
3-in-1 Block
Suppose to block the femoral nerve, lateral femoral cutaneous nerve, and obturator.
Indications for FNB/3-in-1 Block Operations of anterior thigh (lacerations,
skin grafts, muscle biopsy) Pin or plate insertion at the upper femur Femur fractures Analgesia of hip (dislocations, femoral
nerve fractures) Analgesia of the knee
Limitations- Knee
Not complete analgesia of the knee. The knee is innervated by the femoral, obturator, and sciatic nerve.
These blocks will create a motor block of the quadriceps.
Limitations- Hip
Hip is innervated by the femoral, obturator, and lateral femoral cutaneous nerve.
A small contribution comes from the sciatic but should not be significant.
Anatomy
The femoral nerve is the largest branch of the lumbar plexus.
Femoral nerve is created from contributions from L2, L3, and L4.
The femoral nerve enters into the thigh under the inguinal ligament, between the psoas and iliacus mucle.
Femoral Triangle
Anatomy
Pectineous muscle
Iliopsoas muscle
Fascia iliaca
Fascia lata
Skin
Femoral Vein
Femoral Artery
Femoral Nerve
Anatomy
Femoral Nerve “sheath”
Contains the femoral nerve and artery It is located between the psoas and
iliacus muscle. It is located below the fascia iliaca.
Lateral Femoral Cutaneous Nerve and Obturator Nerves
Lateral femoral cutaneous nerve is formed by contributions from L2 and L3
Obturator nerve is formed by contributions from L2, L3, and L4
Innervations
Femoral Nerve: anterior and medial portion of the thigh (sartorious, pectineus, quadriceps); cutaneous portion of medial and lateral thigh; periosteum of the femur. The posterior division of the femoral nerve will become the saphenous nerve.
LFCN: purely sensory to lateral buttock, thigh, and knee joint.
Obturator Nerve: sensory to medial thigh, hip joint, and adductor muscles.
Anatomy
Contraindications
Burn or infection at the injection site Coagulopathy Vascular graft Neurological disease (relative) Patient refusal Local anesthetic allergy
Technique
Same for either block Locate the anterior superior iliac spine
and the pubic tubercle. A line between these two structures is where the inguinal ligament is located.
Just below this line is the femoral nerve.
Technique
Palpate the femoral artery The femoral nerve should be located 1
cm lateral to the palpation. Medial to lateral the structures are
femoral vein, artery, and nerve.
Technique
For paresthesia technique a blunted needle should be used.
Insert perpendicular while aspirating for blood
Once paresthesia is elicited pull back slightly and inject. There should be no pain.
If you are at a depth of 4-5 cm pull back and start over.
As with any peripheral nerve block frequent aspiration is mandatory.
Technique 2 pop technique
Blunted needle A slight increase in resistance followed
by a loss of resistance indicates that you have transversed the fascia lata.
A second increase in resistance followed by a loss of resistance indicates that you have transversed fascia iliaca.
Deposit local anesthetic. (aspirate, make sure no pain, etc.)
Technique Nerve Stimulator
2 inch, 22 gauge needle (insulated) 2 cm lateral to femoral pulse, 2 cm down
from inguinal ligament. Identify quadriceps contraction Reduce stimulation to 0.5 mA and adjust
needle for continued quad contraction. Injection of 1 ml of local anesthetic
should see the contractions start to fade.
Local Anesthetics
FNB = 15-20 ml of local 3-in-1 NB = 25-30 ml of local Use 1:200,000 epi containing solutions or
add yourself. 1-2% lidocaine will have an onset of 10-20
minutes and last 2-5 hours for anesthesia; up to 8 hours for analgesia.
Bupivacaine will have an onset of 15-30 minutes and last up to 5-15 hours for anesthesia and up to 30 hours for analgesia
Complications
Intravascular injection Local anesthetic toxicity Nerve trauma Prolonged motor blockade of the
muscles of the thigh Hematoma formation Block failure
Differences between FNB and 3-in-1 Nerve Block
Volume: 20 ml or less for FNB; 25-30 ml of 3-in-1 Nerve Block
More volume = more spread Pressure applied distally to the injection
site will help the spread of local anesthetic further up to the lateral femoral cutaneous nerve and LFCN.
Controversy
Studies have found that the 3-in-1 nerve block inconsistently blocks the obturator nerve (4%-78%) depending on volume (up to 40 ml).
Most likely the 3-in-1 nerve block will consistently block the FN and LFCN
Controversy “Is there really a sheath”
Cadaver studies have found no conclusive evidence that there is a femoral sheath.
References Burkard J, Lee Olson R., Vacchiano CA. Regional Anesthesia. In Nurse
Anesthesia 3rd edition. Nagelhout, JJ & Zaglaniczny KL ed. Pages 977-1030.
Morgan, G.E. & Mikhail, M. (2006). Peripheral nerve blocks. In G.E. Morgan et al Clinical Anesthesiology, 4th edition. New York: Lange Medical Books.
Moos, D.D. & Cuddeford, J.D. (1998). AANA Journal Course for nurse anesthetists- Femoral nerve block and 3-in-1 nerve block in anesthesia. AANA Journal volume 66; issue 4.
Wedel, D.J. & Horlocker, T.T. Nerve blocks. In Miller’s Anesthesia 6th edtion. Miller, RD ed. Pages 1685-1715. Elsevier, Philadelphia, Penn. 2005.
Wedel, D.J. & Horlocker, T.T. (2008). Peripheral nerve blocks. In D.E. Longnecker et al (eds) Anesthesiology. New York: McGraw-Hill Medical.
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