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Anestesia Regional Barys Ihnasenka , and Kiki Nin 4/27/2013

Anestesia Regional Barys Ihnasenka , and Kiki Nin 4/27/2013. Bloqueos. Extremidades superiores Supraclavicular Infraclavicular Extremidades inferiores Femoral Popliteal. Plexo Braquial C5-T1. Supraclavicular. Indications: surgery below shoulder (elbow, wrist and hand)

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Anestesia Regional Barys Ihnasenka , and Kiki Nin 4/27/2013

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  1. AnestesiaRegional BarysIhnasenka, and Kiki Nin 4/27/2013

  2. Bloqueos • Extremidadessuperiores • Supraclavicular • Infraclavicular • Extremidadesinferiores • Femoral • Popliteal

  3. Plexo Braquial C5-T1

  4. Supraclavicular • Indications: surgery below shoulder (elbow, wrist and hand) • Anesthesia: Ropivicaine 0.5% 20-30 ml • Onset: 15-20 minutes • Duration: 8-12 hours • Risks: dano vascular, pneumothorax 0.5-6% , infecion, less risk of phrenic nerve paralysis

  5. Posicion y colocacion del probe para US bad better

  6. Supraclavicular US guiado rib Pleura

  7. “Corner pocket” Technique • Lower trunk of the brachial plexus could be positioned in the corner between the first rib or lung and subclavian artery “corner pocket” • Lower trunk is the most illusive part of brachial plexus that is frequently spared during other blocks • Needle tip should first be placed in this area to reliably block the lower trunk

  8. Tips to avoid lung injury Obtain the view when brachial plexus is sitting on the first rib (image A)instead of sitting on the cupola of the lung (image B) Lowering patient shoulder down and tilting the transducer as if you are looking under the clavicle usually helps to accomplish this This view is especially important when one targets lower trunk

  9. US probe manipulation that helps to “put the plexus and SA” on the rib (in addition to pulling shoulder down)

  10. Brachial plexus as a cluster of grapes SA rib lung

  11. Dorsal scapular artery or other vessels frequently transverse the plexus Upper and middle trunk DS artery SA rib lung Lower trunk

  12. One can use color doppler to better visualize vascular structures

  13. Plexo Braquial C5-T1

  14. Infraclavicular • Indications: surgery below shoulder (elbow, wrist and hand) • Anesthesia: Ropivicaine 0.5% 20-30 ml • Onset: 15-20 minutes • Duration: 8-12 hours • Risks: dano vascular, minimal pneumothorax, infeccion, no risk of phrenic nerve paralysis

  15. Twitches Lateral Cord twitch Medial cord twitch

  16. Posterior Cord

  17. Femoral Nerve Anatomy • Origin L2-4 • Lateral to femoral vessels • Distal to inguinal ligament • Below fascia lata and fascia iliaca L M

  18. Femoral Nerve Block • Indicaciones: lower extremity leg • Anestesia: Ropivicaine 0.5% 20ml • Onset: 15-20 minutes • Duration: 8-12hours • Riesgos: dano vascular, infecion,

  19. Sartorius Nerve/Sartorius Twitch • The nerve to the sartorius is a branch of the femoral nerve • The sartorius nerve is generally more superficial and medial to the femoral nerve (so go deeper and more lateral for “patella snap”) • Stimulation of the sartorius nerve may not be an acceptable endpoint for perfect continuous femoral nerve block even when needle is below fascia iliaca (probably OK for single shot if volume of anesthetic is about 20cc)

  20. Anatomy 1 inch N Inguinal crease FN FA FV Sartorius m

  21. Sonoanatomy of Femoral Nerve

  22. Popliteal Nerve Block • Indicaciones: surgery below knee • Anestesia: Ropivicaine 0.5% 20ml • Onset: 15-20 minutes • Duration: 8-12 hours • Riesgos: dano vascular, infecion

  23. Popliteal Sciatic Block vs. Proximal Sciatic Blocks • For inpatients subglutealcatheter is preferred by us (secondary to catheter fixation and tourniquet issues) • We prefer popliteal for outpatient setting when hamstring strength is important to keep the foot off the ground when patient uses crutches • Ultrasound-guided popliteal may be easier than US-guided subgluteal in obese patients

  24. Single Shot Popliteal Block Lateral Position (my favorite approach for ss) Peroneal nerve Tibial nerve Lateral • Find popliteal vessels at crease. Tibial nerve is usually superficial and lateral. Probe pressure and slight tilt may help to outline tibial nerve • Slide probe several cm proximal while watching for tibial nerve going deeper and for peroneal nerve that should come from lateral and join tibial in common sheath • Try to get between both nerves

  25. PoplitealFossa Anatomy

  26. Branches of Sciatic Nerve in PoplitealFossa Sciatic Nerve Dissected

  27. Landmark Based Popliteal Sciatic Nerve Block • 7-9 cm above popliteal crease (tibial and common peroneal nerves may branch higher) • Middle or 1 cm lateral • If using stimulation prefer tibial twitch (inversion) • Use high volume of LA • Block versions in supine and lateral position exist

  28. Sonoanatomy Fat SM Biceps Laterall Lateral • SN • Fat • Muscles and fat • 4. Popliteal vein • Popliteal artery • Femur

  29. Popliteal Block Tilt probe tale towards patient’s head Prone Position (best for continuous block 4 cm above the crease 7 cm above the crease Peroneal nerve Tibial nerve Peroneal nerve Tibial nerve Lateral Lateral

  30. BloqueoAxillar Guido por la technica de Ultrasonido

  31. Neurotomes

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