COMMON OPERATIVE REGIONAL BLOCKS:

Inferior Extremity

Dr. M. M. PANDITRAO

PROFESSOR/ HEAD & I/C SICU

DEAN of Faculty of MedicineDEPT.OF ANAESTHESILOGY & CRITICAL CARE

Pad. Dr. DY PATIL MEDICAL COLLEGE,HOSITAL & RESEARCH CENTER

Dr. DY PATIL UNIVERSITYPIMPRI, PUNE 411018

INTRODUCTION DEVELOPED EARLY IN HISTORY OF ANAESTHESIA

OPIUM / ALCOHOL etc. ACT BY CENTRAL DEPRESSION

IN 1884 “NEW ERA” : COCAINE COULD NUMB A BODY PART WITHOUT NUMBING THE BRAIN

THIS “PATH-BREAKING” CONCEPT EVOLVED AS INTERVENTIONAL MANAGEMENT viz.

“BLOCKS”

GOLDEN RULES RESUSCITATION DRUGS/ EQUIPT./ O2 / I.V. ACCESS

“XYLOCAINE SENSITIVITY” TEST IS A MISNOMER

ANAESTHESIOLOGISTS DO NOT CALCULATE AS mls.

CONSIDER DOSE,CONCENTRATION & VOLUME in toto

DOSE, MIDPOINT OF RANGE TO PERMIT “TOP-UPS”

WHEN COMBINATION IS TO BE USED : LOWEST OF DOSES(mg/kg) OF EACH TO REDUCE TOXICITY

GOLDEN RULES (continued)

MIX BUPIVACANE WITH XYLOCAINE+ ADRENALINE

ADJUVANTS: NaHCO3,OPIOIDS,KETAMINE,HYLASE

“BLOCK” ALWAYS UNDER SUPERVISION

“PRACTICE MAKES MAN PERFECT”

“BACK TO BASICS” BEFORE ATTEMPTING BLOCKS

“SEDATION” SHOULD NOT EVOKE “GUILT COMPLEX”

TYPES OF BLOCKS

HEAD, NECK AND FACE BLOCKS

UPPER EXTREMITY BLOCKS

LOWER EXTREMITY BLOCKS

ABDOMINAL FIELD BLOCKS

LOWER EXTREMITY BLOCKS

PROBLEMS ENCOUNTERED:

ANATOMICALLY DIFFICULT TO BLOCK NERVES WIDE-SPREAD DISTRIBUTION OF NERVES OVERLAPPING OF DISTRIBUTION MUSCULARITY OF LOWER EXTREMITY UNRELIABILITY & “MISSED SEGMENTS” MULTIPLE PUNCTURES / INJECTIONS

SPINAL AND EPIDURAL: EASIER, VERY RELIABLE

LOWER EXTREMITY BLOCKS:

INDICATED IF NEURAXIALS NOT FEASIBLE

ALTHOUGH COMMONLY PERFORMED IN DIABETICS, EXTRA CAUTION IS NEEDED

MULTIPLE PUNCTURES = PATIENT DISCOMFIRT

“RING / ANKLET” BLOCK IS ESSENTIAL

ANATOMY

LUMBAR PLEXUS:

Investment: L1 - L3 Ventral rami

Contribution From L4

From T12 In 50% patients

Distribution:Ventral Aspect of Inf.Extremity

T12, L1 : Superior; Ilio - inguinal,

Ilio - hypogastric

Inferior; Genito - Femoral

L 2-3-4 : Femoral, Obturator, Lat.Cut. Of Thigh

ANATOMY (Contd.)

Lumbo-sacral: Dorsal aspect of Inf. Extremity Investment: L

4-5, S1-2-3 Ventral Rami

Occasionally S4

Of Interest : Sciatic; Combination of Two

Tibial & Common Peroneal

Tibial; Ventral Branches of all 5

Common Peroneal; Dorsal Branches of all 5

Distribution: Leaves Pelvis Via Gr. Sc. Foramen

Enters thigh bet. Gr.Tr. & Isch. Tub.

INGUINAL PERI-VASCULAR BLOCK(3- IN- 1 BLOCK)

First described by Winnie 1973 Principle: At the level of Inguinal Ligament Femoral Nerve

“Wrapped Around” by

Fascia Iliacus on lateral border

Psoas Fascia on Medial Border

Transversalis Fascia as Anterior Wall

Drug Injected around the nerve ascends

up to “lumbar Plexus” near Psoas, blocking

“Femoral, Lateral Cutaneous Of Thigh, & Obturator

Viz: “Three-in –One” Block

TECHNIQUE (3- IN- 1 BLOCK)

Inguinal Ligament - ASIS to Pubic Symphisis Mid Point Femoral Arterial Pulsations 1cm. Below and lateral Insert Needle and direct cephalad at 60o angle If nerve-locator needle is used, at 0.5 mA current “

Patellar Dance” will be seen Minimum of 30 ml. of LAA to be injected If only medial side of thigh stimulated: go laterally

OBTURATOR BLOCK (Individually)

Supine Position Extremity to be blocked, Slightly abducted Pubic Tubercle 1.5 cm .Caudally, 1cm. Lateral to Tubercle (also

corresponds to midpoint between Pubic Tubercle and Femoral Arterial Pulsations

Spinal Needle, 22 Gz. And about 6-8 Inches long insert Perpendicular, till hits Pubic Ramus (1.5-4 cm.) Needle re-directed more laterally, 2-3 cms. more

deeper than Ramus (depth of First needle) Aspirate & inject 15 mls. in arrow-head manner

SCIATIC NERVE BLOCK (Classic)

Labat in1930 Lateral Position (Sim’s); affected side up Thigh Flexed completely and Knee flexed over Thigh Gr. Tr. and PSIS identified and Joined Perpendicular line from Midpoint on this line drawn Sacral Hiatus marked and line joined Gr. Tr. This line intersects Perpendicular At this point; Insert, 22 Gz. 6-8 inch long needle for about 4 inches/ if electrical stimulation possible then

movement in leg and foot 20-25 ml of LAA

SCIATIC NERVE BLOCK (Raj)

Raj in 1975 Patient Supine Leg is raised till Thigh is 900 to Trunk Knee is flexed at 900 to Thigh Gr. Tr. and Isch. Tuberosity marked Line joining them along with Gluteal Crease Midpoint Needle inserted perpendicular to skin and directed

cephalad 20-25 ml of LAA

ANKLE BLOCK

5 Nerves: Superficial Peroneal, Sural, Posterior Tibial, Saphenous, and Musculocutanous

Main 3: First Three.

1. Superficial Peroneal: Dorsalis Pedis Artery Pulsations, Between Tendons

of Ext. Hallucis longus & Ext. Digitorum longus 22 Gz. needle, perpendicular to skin, 1.5- 2cm.depth Hit the bone Withdraw, above Inf. Ext. Retinaculum Inject 6-8 ml. LAA Come upto Skin; Raise weal; “Anklet Block”

ANKLE BLOCK(Contd.)

2. Sural (Lateral Calcaneal & Lateral Dorsal Cutaneous) Just Behind Lateral Malleolus Hit the bone 7-8 ml. of LAA Anklet Block

3. Posterior Tibial Behind Medial Malleolus Posterior Tibial Artery Hit the bone Inject 7-8 ml LAA Anklet Block

HERNIA BLOCK

LOWER 3 – 6 INTER-COSTALS (IF REQUIRED) SUBCOSTAL ILIO-INGUINAL & ILIO- HYPOGASTRIC GENITAL branch of GENITO-FEMORAL

BEFORE ADVENT OF SAFER INHALATIOAL AGENTS / RELIABLE NMBDs / MONITORING / POST-OPERATIVE CRITICAL CARE, POPULAR

“SKILLED” ANAESTHESIOLOGISTS = SAFE G.A.

HERNIA BLOCK(CONTINUED)

“HYPOTHETICAL” MISSING OF LAT. CUTANEOUS BRANCH HAS BEEN PROVEN WRONG

“DREADED!” COMPLICATION OF PNEUMOTHORAX, FOUND TO BE NEGLIGIBLE (0.07% - 0.4%)

SERIES SHOWED SAFE SURGICAL CONDITIONS PRODUCED WITH SEDATION AND MONITORING

HERNIA BLOCKSubcostal : Mid- clavicular line, Subcostal Margin

Laterally and Medially

Infiltrate 7-8 mi.

Ilio-Inguinal & Ilio- Hypogastric:

1 finger breadth anterior to ASIS

Hit the Bone

Fan-shaped- “Arrow-head” Block

10-15 ml. of AA

Genital Branch of Genito - Femoral

Pubic Tubercle

Perpendicular to Skin

Hit the Bone

5-7 ml. of LAA

CONCLUSION

“SKILL & THRILL” OF ANAESTHESIOLOGIST

PROPER SELECTION, SAFE PRECAUTIONS

COST-EFFECTIVE & LESSER MORBIDITY

EXCELLENT “TOOL” OF TRAINING