Regional Anesthesia. Nerve Blocks & Local Anesthetics

Anticoagulation and Spinal and Epidural Nerve Blocks

Time recommendations for positioning and removal of spinal anesthesia and catheters.
NOTE. Patients with impaired drug elimination (eg renal failure) may require longer periods of time than recommended here. Combinations of anticoagulants increase the risk of bleeding
Type of anticoagulant (anticoagulant drug) intended for dose.Dose of anticoagulantRecommended time interval from administration of anticoagulants to catheter insertion or catheter manipulation or removal of catheter during epidural anesthesiaTime interval from spinal anesthesia (insertion, catheter manipulation or catheter removal) for administration of anticoagulants
Heparines/Xa inhibitors
Unfractioned heparin (UHF)
Heparines/Xa inhibitors≤ 5000 E (70E/kg)/day4 hours. Normal APTT and normal platelets1 hour
Heparines/Xa inhibitors> 5000 E (70-100E/kg)/day4 hours. Normal APTT and normal platelets6 hours recommended. Shorter time down to 1-2 hours is practice in some places.
Unfractioned heparin (UHF)> 100 E/kg/day4 hours. Normal APTT and normal platelets6 hours. Start epidural the evening of the operation.
Low molecular weight heparin (LMWH), dalteparine (Fragmin) or enoxaparin (Klexane)≤ 5000 E or ≤ 40 mg/day10 hours6 hours recommended. 2-4 hours are common practice.
Low molecular weight heparin (LMWH), dalteparine (Fragmin) or enoxaparin (Klexane)>5000 E or > 40 mg /day24 hours6 hours recommended. 2-4 hours are common practice.
Fondaparinux (Arixtra) ≤ 2,5 mg/day (Xa+at) 36 hours6 hours
Rivaroxaban (pi/oral) (Xa) (Xarelto) 18 hours6 hours
Vitamin K-antagonists
Warfarin (Waran) 1-4 days dose dependant, INR ≤1,4-2,2Resume after removal of epidural / spinal catheter
Platelet inhibiting drugs
Acetylsalicylic acid (ASA) 12 hours in patients with indication of secondary prevention.
3 days in the rest (1 week after doses> 1g/day)
Resume as soon as possible after surgery.

Resume after surgery
Dipyridamol (Persantin) No limitsNo limits
NSAID
Diklofenac 12 hours 
Ibuprofen 12 hours 
Ketoprofen (propion acid derivative) 12 hours 
Indometacin 24 hours 
Ketorolak 24 hoursNon selective NSAIDs should be avoided when planning the catheter manipulation, in patients with epidural catheter and concurrent treatment with LWMH or other anticoagulants. One should choose COX2 inhibitor.
Naproxen 48 hours 
Lornoxicam 24 hours 
Piroxicam 2 weeks 
Tenoxicam (Alganex) 2 weeks 
ADP-receptor inhibitors
Clopidrogrel (Plavix, Iscover) 5 daysAfter removal of catheter
Ticlopidin (Ticlide) 5 daysAfter removal of catheter
Pracurgrel (Efient) Probably 5 days. Secure data is missing.After removal of catheter

Adductor Canal Block/Subsartorius block

Body position: Supine position

Indication: Surgery with vena saphena stripping. Adjuvant in medial foot/ankle joint surgery in combination with sciatic nerve block and analgesia for knee surgery in combination with other pain relief.

Transducer: 10-16 MHz, linear probe (“Hammerhead Shark”)

Position of the probe: In plane technique (along the probe held transversely across the leg), lateral insertion.

Injection needle: 22G, 8 cm long, cross-sectional.

Set depth in the ultrasound image: 2.5-4 cm.

Technique: Transverse anterior medial of the thigh at the junction between the middle and the distal third of the thigh or below the knee in line with the tuberositas tibia.

Video link: Click here.

Ideal image: The local anesthetic is spread laterally in the thigh and deep against the sartorius muscle or more distally under the knee, adjacent to the vena saphena magna.

Local anesthetics: 

  • Mepivacaine 10 mg/ml (1%) 5-10 ml
  • Ropivacaine 5 mg/ml, 5-10 ml, (25-50 mg). Applying time 1-15 min, duration 2-4 hours
  • Lidocaine 10 mg/ml, 5-10 ml (50-100 mg)

Note the anatomy:

Caution: Avoid puncture of the artery. Do not inject in the nerves themselves, observe and avoid sluggish injection resistance. In case of accidental artery puncture pull out the needle and compress vigorously for 3-5 minutes. Then repeat the needle puncture during better visualization with In-plane technology.


Axillary Plexus Block

Body position

Supine position of the patient with arm bent at an angle in the elbow joint and hand raised above the head. Easily lowered head of the table, pillow under the arm. The anaesthesiologist can sit either below or above the patient’s arm. Advantageously, an assistant can perform the actual injection of LA as you basically need three hands for a blockade.

Indication

Surgery in the elbow, forearm or hand.

Video link: https://www.youtube.com/watch?v=GaH-CO6OrV0

Technique

Use In-plane technique with injection from the lateral side of the ultrasonic probe. Insert the needle under the probe parallel to the probe head. The needle tip target is inside the plexus sheat. Perform as few injections as possible, preferably 2-3, deep and laterally about the artery. Ideal spread is around the hyperechogenous nerve root structures, about 5 ml in each place. Note hydrodissection, ie. plexus nerve sheath filling with the anesthetic fluid (LA). During proper hydrodissection, a short-term compression of the artery usually occurs. The needle is easier to visualize in the image with In-plane technology than with Out-of-Plane technology.

At Out-of-Plan technique, insert the needle at the center of the probe head into the middle of the probe. The needle should come into the image vertically in the median line. The needle or needle movements can still be seen in the picture. Move the needle regularly to see it in the picture. In case of difficulty visualizing brachial vein, this often results in excessive pressure of the probe against the armpit. Lighten the pressure and the vein can usually be visualized more easily. The venous is usually immediately medial of the artery.

Transducer: 10-16 MHz, linear probe (“Hammerhead Shark”).

Probe position: Either with Out-of-plane technique (in transverse mode) or In-plane technique (in transverse or longitudinal position) with axillary artery in the armpit. Primary In-plane technique just distal about the center of the armpit.

Injection needle: 22G, 5 cm long, cross-sectional. 

Nerve stimulation response: Hand movements

Set depth in the ultrasound image: 2.5-3 cm.

Local anesthetics: 

  • Mepivacaine (Marcain®) 10 mg/ml (1%) 20-30 ml.
  • Ropivacaine (Naropin®) 5 mg/ml 50-100 mg 10-20 ml

Out of plane (across brachial artery): Provides the image of the axillary artery as a pulsating hypoechogenic globe. Insertion takes place along the needle from the lateral side cranially about the head of the probe. The eye of the needle is placed posterior (below) and laterally of the artery.

In plane (along with brachial artery): Provides a longitudinal section of the artery that allows deposition of local anesthetic agents with clear hydrodissection of the nerve sheath that lifts during the course of the injection. Clearly rejects incorrect injection.

Note the anatomy: The artery lies in the nerve and vascular sheath that can sometimes be identified by ultrasound. Three nerve structures can be identified around the artery as hyperechogenous zones, usually median nerve at. 12-13, the ulnar nerve at. 16-17 and radial nerve at. 18-19 if the artery is resembled a dial. Anatomical abnormalities may occur.

Musculocutaneus nerve (McN) is located laterally a bit out and below the axillary outside the nerve vessel. In order to reach n musculocutaneus, a longer needle, 8 cm, is usually needed. The appearance of McN is more elongated and triangular compared to other nerves in the axilla, blocked by only 3-5 ml of LA.

Caution: Avoid puncture of brachial artery or brachial vein . Do not inject in the nerves themselves, observe and avoid sluggish injection resistance. In case of accidental artery puncture pull out the needle and compress vigorously for 3-5 minutes. Then repeat the needle puncture during better visualization with In-Plane Technique.


Caudal Nerve Block

Puncture with needle alone or with a catheter with a guidewire to permit better penetration.

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Caudal Block for Surgical Anesthesia

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®)10 mg/ml20–40 ml200–400 mg
Mepivacaine (Carbocaine®10 mg/ml15–20–30 ml150–200–300 mg
Mepivacaine (Carbocaine® 20 mg/mlup to 17.5 ml350 mg
Caudal Block in Small Children
Bupivacaine (Marcaine ®) 2,5 mg/ml
with epinephrine
0,5 ml/kg
Ropivacaine (Naropin®)2 mg/ml1 ml/kg

Fascia Iliaca Compartment Block (FICB)

Fascia iliaca block is an alternative to block of femoral nerve or pl. lumborum to anesthetize the lower limb. This block is possible because the femoral and lateral femoral nerves are located below the fascia iliaca. Therefore, a sufficient amount of local anesthetic deposited under the fascia iliaca, although distant from the nerves, can spread under the fascia and block these nerves.

Indications: Anterior thigh and knee surgery, analgesia after hip and knee procedures

Transducer position: transverse, close to the thigh and laterally in the femur

Objective: Medial-lateral spread of local anesthesia during fascia iliaca

 Local anesthetics: 30-40 ml (e.g., 0.2% ropivacaine)

  • Ropivacaine (Naropine) 2 mg/ml, 30-40 ml, 60-80 mg.
  • Ropivacaine (Naropine) 5 mg/ml, 20-30 ml, 100-150 mg.

Video link: Click here.


Femoral Nerve Block

Body Position: Supine position.

Indication: Surgery or pain in femur, front of the groin, knee.

Transducer: 8-16 MHz linear probe (“Hammerhead shark”).

Position of the probe: In the groin just below the ileoinguinal ligament. Put the probe parallel to the ileoinguinal ligament. Identify first the femoral artery, then the femoral nerve. Tape up excess abdominal folds.

Injection needle: 21 G, 10 cm long, cross-sectional.

Nervous stimulation response: Quadriceps muscles contractions.

Set depth in the ultrasound image: 4 cm.

Technique

Use In-plane technology with insertion on the lateral side of the head of the ultrasound probe. Insert the needle under the probe parallel to the longitudinal direction of the probe in the medial direction above the iliac muscles. The needle tip target is lateral and below the femoral axis. Perform as few injections as possible, preferably 1-2. Ideal spread is around the hyperechogenous nerve root structure. Note hydrodissection, ie. filling around the nerve of LA.

Local anesthetic:

  • Ropivacaine (Naropine) 7,5 mg/ml (0.75%) 15-20 ml
  • Mepivacaine (Carbocaine) 10 mg/ml (1%) 15-20-30 ml

Ideal image: Visible iliac muscles, femoral artery, iliac fascia, fascia lata and femoral nerve.

Note the anatomy: Femoral nerve is located laterally of femoral artery with a hyperechogenic structure. Note the nerve is located below the iliac fascia.

Caution: Avoid puncture of femoral artery. If a patient is patient, it may be better to put a pillow under the same side’s hip to expand in the hip joint if possible.

Video link: : https://www.youtube.com/watch?v=5ht_N8j2KL8


Foot Block

Body Position of the Patient

Supine position. The leg bent in 70 degrees in the knee joint, angled or rotated as needed. The blockade can be performed using ultrasound, but usually without.

Indications

Hallux valgus, forefoot surgery. Anesthesia of posterior Tibial nerve, profound Peroneal nerve, superficial Peroneal nerve and Sural nerve.

Transducer

8-16 MHz, linear probe.

Position of the Probe

The probes are placed transversely across the ankle (a.dorsalis pedis), respectively, in the medial of the ale of tibialis posterior.

Injection Needle

20-22 G, 5 cm long, cross-sectional.

Set depth in the ultrasound image: 2-4 cm.

Technique

A footblock consist of three parts.

A). Block of the profound peroneal nerve with an injection in the middle above the ankle. Move the needle between extensor hallucis longus tendon and extensor digitorum longus tendon, inject fan shaped approximately 2 cm deep, aspirate blood and deposit about 5 ml local anesthetic deep against the extensor retinacle. This will block profund peroneal nerve. You may also stumble a little further down the back of the foot and then immediately inject medially on a. Dorsalis pedis (see image below).

Retract the needle, aim it superficially towards the lateral malleol. Deposit 3-5 ml subcutaneously to block superficial n. Peroneus profundus. Hereafter the needle is superficially directed towards the medial malleol. Deposit 3-5 ml subcutaneously to block the saphenous nerve.

B) Immediately laterally (behind) a. tibialis posterior immediately behind and below the medial malleolus to anesthetize the posterior n.tibialis. Insert the needle posteriorly behind the artery, in line with the medial malleolus. Advance the needle slowly and carefully and be observant of any paraesthesia. Here 5-8 ml of local anesthetic is injected about 1 cm deep.

C) A curtain 5-15 cm above the lateral malleol to anesthetize the n. Peroneus superficialis laterally of tibia. Here 5-10 ml of local anesthetic is injected into a curtain about 2 cm deep. N. peroneus superficialis innerves most of the dorsal side of the foot, including the big toe. Below the lateral malleolus, n. Suralis is anesthetized by the inner side of the foot.

Note the Anatomy

Use In-plane technology with 0.5 cm insertion from the medial side of the head of the ultrasound probe. Insert the needle underneath the probe medially about the target. The target for the needle tip is n.tibialis posterior, n.peroneus profundus, n. Peroneus superficialis and n. Suralis.

Warning: Check if necessary any neurological injuries, diseases or withdrawal symptoms of the patient prior to the positioning of the blockade. If Paresthesias occur withdraw the needle half a centimeter before injection.

Video link:

Local anesthetics

  • Mepivacaine (Carbocaine) 10 mg/ml (1%) 15-20 ml
  • Ropivacaine (Narop) 5 mg/ml (0.5%) 15-20 ml
  • Ropivacaine (Narop) 7.5 mg/ml (0.75%) 15-20 ml
  • Bupivacaine (Marcaine) 3.75 mg/ml (0.375%) 15 ml 

Ilioinguinal Block

Body position: Supine backrest. Arms out (abducted).

Indication: Collum fracture, inguinal hernia. Anesthesia of the ileoinguinal nerve and ileohypogastric nerve.

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Transducer: 8-16 MHz, linear probe.

Probe position: Just above the iliac crest angled towards the umbilicus. The probe is placed in transverse position parallel to the ribs.

Injection needle: 22 g, 10 cm long, cross-sectional.

Nervous stimulation response: none.

Set depth in the ultrasound image: 3.4 cm.

Local anesthetic:

  • Mepivacaine (Carbocaine) 10 mg/ml (1%) 20-40 ml (20 ml on each side)
  • Ropivacaine (Naropine) 7.5 mg/ml (0.75%) 15-20 ml
  • Bupivacaine (Marcaine) 3.75 mg/ml (0.375%) 15 ml

Ideal image: Visualize iliac crest laterally in the image (spina iliaca ant sup). N. ilioinguinal nerve lies between transverse abdominal muscle (above) and internal oblique muscle. The rectus muscle is medially positioned and passed outwards.

Note the anatomy: The transverse abdominal muscle is under the obliquus internus, which in turn is under the obliquus externus muscle. Above the obliquus externus there is abdominal fat. The nerves are located between the oblique internal muscle and the transverse abdominal muscle (between 2nd and 3rd muscular layers). M. obliquus internus is usually the thickest muscle layer.

Technology: Use in-plane technology with 0.5 cm insert from the medial side of the head of the ultrasound probe. Insert the needle underneath the probe medially about the target. The goal of the needle tip is between m. obliquus internus and m. transversus abdominis. The penetration of the rear fascia may feel like a “pop” or “loss”. Perform as few injections as possible, preferably only one. Note proper hydrodissection, ie. filling of the space between the muscular layers.

Warning: Difficult in obese patients. A pillow under the hip can facilitate by elevating the hip. Avoid injecting through the peritoneum.

Video link: https://www.youtube.com/watch?v=e1PemJ5lDrM
https://www.youtube.com/watch?v=gTJ6IrhVqwo


Infiltration Anesthesia

Infiltration Anaesthesia with Local Anaesthetic Agents

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Mepivacaine (Carbocaine®) 10 mg/ml1–20 ml 10–200 mg
Lidocaine (Xylocaine®) 10 mg/ml5-40 ml 50-400 mg
Levobupivacaine (Chirocaine®) 2,5–5 mg/ml1–20 ml 2,5–100 mg
Prilocaine (Citanest®)  5 mg/ml1-20 ml 5-100 mg

Infraclavicular Plexus Block

Body position: Supine position of patient with arm upwards. The anaesthesiologist can sit during injection either below or above the patient’s shoulder. Advantageously, an assistant can perform the actual injection of LA as you basically need three hands for a blockade. If you are sitting above the patient’s shoulder, the insertion is most suitable from above the probe (cephal).

Indications: Surgery of the upper arm, elbow, forearm or hand.

Transducer: 10-16 MHz, linear probe (“Hammershark head”).

Probe position: In-plane (in longitudinal position) just below the clavicle. The probe can be placed in the cephal-caudal direction (head of the probe in the longitudinal direction of the body). Insertion from above (cephal part).

Injection needle: 21-22 G, 8-10 cm long, cross-sectional.

Nervous stimulation response from: Hand.

Set depth in the ultrasound image: 5 cm.

Technique:

Use in-plane technology with injection from the lateral side of the ultrasonic probe. Insert the needle under the probe parallel to the longitudinal direction of the probe head. The goal of the needle tip is the nerves around the artery. Perform as few injections as possible, preferably 2-3, deep and laterally about the artery, possibly even medially. Ideal spread is around the hyperechogenous nerve root structures, about 5-10 ml in each place. Note hydrodissection, ie. completion with the local anesthetic fluid (LA). During proper hydrodissection, a short-term compression of the artery usually occurs. The injection needle is much better seen with In-plane technology than with Out-of-plane technology.

Ideal image: In-plane (above axillary artery): Provides the image of the axillary artery  as a pulsating hypoechogenic globe. Insertion occurs from the cephal side (short edge center) of the head of the probe. The needle’s eye is placed laterally, medially and below the artery.

Note the anatomy: The major pectoral muscle is positioned at the top. The artery is under the fascia of the minor pectoral muscle which can be identified by ultrasound. The axillary vein (v subclavia) lies immediately medially, caudally of the artery and is usually larger. Three nerve structures (medial, lateral and posterior branches of the axillary plexus) can be identified around the artery as hyperechogenic zones, usually the medial branch is at clock 14-15, posterior branch at 17-18 and lateral branch at 20-21 if the artery resembles a dial. Anatomical abnormalities occur.

Local anesthetic:

  • Ropivacaine (Naropine) 7.5 mg/ml (0.75%) 15-20 ml.
  • Mepivacaine (Carbocaine) 10 mg/ml (1%) 20-30 ml.

Warning: Avoid puncture of brachial artery or brachial vein. Do not inject in the nerves themselves, observe paresthesias or sluggish injection resistance. In case of accidental artery puncture pull back the needle and compress vigorously for 3-5 minutes. Then repeat the needle puncture during better visualization, with In-plane technology. Avoid entering the nerve roots, which gives a sluggish injection resistance or paresthesias.

Video link: https://www.youtube.com/watch?v=hRyDtXrfYqc


Interscalenius Block

Body position: Supine position or half-seated or half-side positioned.

Indication: Surgery on the shoulders, distal clavicle, proximal humerus.

Transducer: 10-16 MHz, linear probe (“Hammarhead shark”). 

Probe position: Over the external jugular vein, about 3 cm above the clavicle.

Injection needle: 22G, 5 cm long, cross-sectional. 

Nerve stimulation response: Skull, arm, forearm.

Set depth in the ultrasound image: 3 cm.

Technique

Use In-plane technology with insertion from the lateral side of the ultrasound probe. The probe should be easily angled against the jugulum. Insert the needle under the probe parallel to the longitudinal direction of the probe. The goal of the needle tip is the interscalenius space (pit space). Perform as few injections as possible, preferably 2-3. Ideal spread is between ASM and MSM around the hypoechogenic nerve root structures. In case of difficulty in illustrating the nerve root structures, begin scanning directly above the clavicle and go 3-5 cm upwards in the cranial direction. 

Note the anatomy: Visualize the anterior scalenius muscle (msa) and median scalenius muscle (msm). Two to three (2-3) hypoechogenic structures correspond to the interscalenius nerve branches.

Ideal picture: 2-3 branches of the nerve tree should be visible in the image.

Local anesthetic:

  • Mepivacaine (Carbocain) 10 mg/ml (1%) 10-20 ml.
  • Ropivacaine (Naropin) 7.5 mg/ml (0.75%) 15-20 ml

Warning: Avoid injections in the vertebral artery or into the nerves. Caution in patients with advanced COPD, pulmonary emphysema and or dyspnea.

Video link: https://www.youtube.com/watch?v=h_30mwMLH6M


Intrathecal Pain Management

Intrathecal pain treatment is applied by placing an epidural catheter under strict sterile conditions in the spinal space (intrathecally) via a lumbar puncture with an epidural needle. The catheter is then used for continuous spinal anesthesia via pump – e.g. Gemstar pump or CAD pump. This puncture is performed as a spinal anesthesia with an epidural needle. Through the epidural needle, the spinal space is first identified with a spinal needle, a “needle-through-needle technique”. Next, an epidural catheter is placed high up about 15 cm after insertion into L2-L3. The catheter may be advantageously tunnelled subcutaneously from the site of insertion to the side of the patient. Intrathecal drugs are 100-300 times stronger than perorally given.

Contraindications

High intracranial pressure, sepsis, severe coagulation disorder, increased bleeding risk, anticoagulation treatment (Warfarin, Plavix) and infected skin, eg in the event of pressure ulcers near the inlet area. 

Preoperative blood samples

  • PK (INR)
  • APT(T)
  • platelets
  • CRP

Anticoagulation-treated patients

Waran treatment is discontinued. Operating doctors report acceptable INR in each case. Patients treated with low molecular weight heparin, eg dalteparin (Fragmin), should be treated as follows: At dalteparin 5000 Units s c, 10 hours should pass before insertion, position adjustment or removal. Subsequent dalteparin dose is given 2 hours after insertion or removal of the intrathecal catheter. At enoxaparin (Klexane) 40 mg s.c. 10 hours should pass before insertion, positioning or deletion. Following enoxaparin dose is given 2 hours after insertion, position adjustment or removal of the intrathecal catheter. Clopidogrel (Plavix) is ​​discontinued 10 days before surgery. 

Medicines for intrathecal administration

95 ml of bupivacaine (Marcain) 5 mg/ml are mixed with 5 ml of Morphine 10 mg/ml to a volume of 100 ml. The concentration of Marcain (bupivacaine) is 4.75 mg/ml and the concentration of morphine becomes 0.5 mg/ml. A recommended starting dose is 0.3 ml/h with the ability to provide a bolus dose of 0.2 ml if necessary. Peroperative pain relief usually occurs by the administration of local anesthetic agents with the addition of opiates, usually morphine 0.1 mg, 100 μg. There is a possibility of adding a mixture of opiates and clonidine (Catapresan). Such a mixture is, for example:

  • Morphine Special 0.1-0.3 mg, 0.4 mg/ml, 0.25-0.75 ml
  • Sufentanil (Sufenta) 10 μg, 5 μg/ml, 2 ml
  • Clonidine (Catapres) 75 μg, 150 μg/ml, 0.5 ml

Check for intrathecal (subarachnoidal) administration of opioids

After the morphine has been given intrathecally, the following controls are performed for 12 hours and after intrathecal fentanyl or sufentanil have been given for 6 hours. 1 time/hour after spinal anesthetic has been given control:

  • Visual Analogue Scale (VAS)
  • Sedation Degree (RASS)
  • Respiratory rate (if the degree of sedation> 1)
  • Nausea
  • Itching

Hereafter, controls are performed every 4 hours for another 12 hours. Extra control 2 times/hour for 2 hours when adding sedative or respiratory depression medication.

Urinary catheter for at least 12 hours. Check bladder function after urinary catheter has been removed.


Intravenous Regional Anesthesia (IVRA)

Dose Mepivacaine (0.5%): 3 mg/kg = 0.6 ml/kg body weight intravenously, in venous cannula on dorsal side of hand. Minimum dose: 35 ml. Maximum dose: 65 ml.

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  • Bildresultat för Intravenous Regional Anesthesia (IVRA)

Intravenous Regional Anaesthesia IVRA Biers' Block

Target OrganLocal Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Mepivacaine (Carbocaine®) 0,5%5 mg/ml0,6 ml/kg3 mg/kg
Arm (Hand)Mepivacaine (Carbocaine®) 0,5%5 mg/ml20-60 ml100-300 mg
Arm (Hand)Lidocaine (Xylocaine®) 0,5%5 mg/ml20–40 ml100–200 mg
Leg (Foot)Lidocaine (Xylocaine®) 0,5%5 mg/ml40 ml200 mg
Arm (Hand)Prilocaine (Citanest®) 0,5%5 mg/ml 20-40 ml100-200 mg
Leg (Foot)Prilocaine (Citanest®) 0,5%5 mg/ml60-80 ml300-400 mg
Remark: intravenously, in a venous cannula on the dorsal side of the hand. Minimum dose: 35 ml. Maximum dose: 65 ml.

Nerve Block of Fingers and Toes

Nerve Block of Fingers and Toes

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml 2–4 ml 20–40 mg
Mepivacaine (Carbocaine®) 10 mg/ml2–5 ml 20–50 mg
Mepivacaine (Carbocaine®) 20 mg/ml1-5 ml 20-100 mg
Prilocaine (Citanest®) 5 mg/ml1-5 ml 5-25 mg

Patient Controlled Epidural Anesthesia (PCEA)

Contains continuous infusion plus patient-controlled bolus doses or intermittent infusion with bolus doses only epidurally, with the ability for the patient to self-control the treatment at his or her own request in the form of small bolus doses. PCEA is given epidurally and the aim is to provide better pain relief with smaller doses in total compared with continuous infusion. The method allows the patient to control the treatment for own activities with mobilization and the need for pain relief. The method smooths out the large inter-individual differences between patients in the need for postoperative pain relief. Typically, PCEA is used for 2-4 days after medium and large surgical procedures and in obstetric analgesia. PCEA is well suited for obstetric analgesia and has been shown to provide better pain relief compared with conventional epidural. In childbirth analgesia, PCEA can be given either as self-administered bolus doses or as continuous infusion plus PCEA. When setting bolus doses only, these are given in larger doses than in combination with continuous infusion with PCEA, for example 8 ml instead of 5 ml per dose.

Risk groups in general are elderly patients, heavily overweight, patients with respiratory insufficiency, severely injured, sedated, drowsy, disoriented, confused or unhealthy patients. In obstetric analgesia, risk groups are predominantly overweight and patients with preeclampsia.

Common pumps used are GEM star, CAD or Deltec.

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Standard infusion PCEA

Continuous infusion of 4-10 ml/h. Bolus dose 2 ml, shutter time 10 minutes and maximum dose of bolus doses per hour set to 4. At 10 ml/h infusion rate with maximum number of injections set at 4, a total dose of 18 ml/h is recommended, which is recommended as the maximum dose.

Some suggestions for combination therapy at PCEA

  • Bupivacaine (Marcaine) 1.0 mg/ml + Fentanyl 2 μg/ml + Adrenaline 2 μg/ml. Dosage: 4-10 ml/h, bolus dose 2 ml.
  • Ropivacaine (Naropine) 2 mg/ml, + Sufentanil 1 μg/ml, 3-10 ml/h, bolus 2 ml during surgery. The next morning one can switch to ropivacaine (Naropine) 1 mg/ml + Sufentanil 0.5 μg/ml to allow patient patient mobilization according to the surgeons instructions. This infusion may continue for a further few days.
  • Ropivacaine (Naropine) 2 mg/ml + Sufentanil 1 μg/ml + Clonidine (Catapres) 3 μg/ml. 3-10 ml/h, bolus 2 ml.

Suggested obstetric epidural with PCEA

Bupivacaine (Marcain) 0.6 mg/ml + Sufentanil 0.5 μg/ml, continuous 5 ml/h infusion, bolus 5 ml. Barring time 30 minutes.

In postoperative/ICU/obstetric treatment, the number of doses requested, the number of doses delivered and the total dose given are recorded and documented. The goal of PCEA is VAS <4 and 1-2 bolus doses per hour. In the obstetric department, it is important to monitor and check every four hours of VAS, respiratory rate, sedation rate, nausea, itching, bladder function. Additional controls must be made if the doses are increased with controls every 30 minutes for two hours. In case of insufficient pain relief, LA doses can be given every 10 minutes until good pain relief is achieved. If the number of PCEA doses exceeds 3 per hour, the continuous infusion is increased. In case of insufficient pain relief at the maximum dose, consider adjuvant pain treatment or to exchange the epidural catheter.

In the treatment of patients with mild preeclampsia, coagulation tests should be checked no later than 6 hours prior to the establishment of an EDA. In case of severe eclampsia, these samples (INR/APT(T)/TPC) should not be older than 2 hours.


Paravertebral Block

Body position: Seated or lying on the side.

Indication: Thoracic surgery (chest surgery), breast surgery. Th2 – Th6.

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  • Bild 3 Paravertebralblockad
  • Bild 4 Paravertebralblockad
  • Bild 5 Paravertebralblockad
  • Bild 6 Paravertebralblockad
  • Bild 7 Paravertebralblockad
  • Bild 8 Paravertebralblockad

Transducer: 8-16 MHz, linear probe.

Position of the probe: Place the probe in the vertical direction (paramedian mode) about 5 cm at the side of the spine against the upper part of the back. 

Injection needle: 20 g, 10 cm long, cross-sectional.

Nerve stimulation response from: None.

Set depth in the ultrasound image: 3-5 cm.

Technique: Angle the bottom of the probe parallel to the scapula’s medial edge. Use In-plane technology with 0.5 cm insertion from the lateral side (caudal end) of the head of the ultrasound probe. Insert the needle under the head of the probe laterally about the target. Identify the space between the fourth and fifth ribs. The ribs appear as rounded large densities. Between and below these are internal intercostal muscle and below the pleura. Ideal spread of local anesthetic imaging is between internal intercostal muscles and pleura. One should penetrate the upper costotransversal membrane (superior costotransversal ligament) under internal intercostal muscles. Perform as few injections as possible, preferably only one. Note proper hydrodissection, i.e. filling of the space between internal intercostal muscles and pleura. Pleura should preferably bend down with hydrodissection during the injection.

Ideal picture: Th 4-Th 5. Visualize first rib, then second, third and fourth ribs. Visualize two transverse transverse processes, then interstitial intercostalis and pleura below.

Note the anatomy: M. trapezius, m. romboideus minor, m. romboideus major. Processus transversus, fourth and fifth ribs. M. intercostalis intern. Pleura. Paravertebral space to be reached lies just above the pleura at the level of the foot (lower part) of adjacent transverse processus (as a plane at the foot of two mountain coats). 

Local anesthetic:

  • Mepivacaine (Carbocain) 10 mg/ml (1%) 20 ml (20 ml on each side).
  • Ropivacaine (Naropin) 5 mg/ml (0.5%) 15-20 ml unilaterally or 30-40 ml to 2 sides.
  • Bupivacaine (Marcain) 5 mg/ml (0.5%) 15-20 ml unilaterally (not bilaterally).

Caution: Difficult in obese patients. Seated position is preferable, but included patients or strongly sedated patients should be in side position. Of course, avoid injection through the pleura. Avoid bilateral blockade due to the risk of bilateral pneumothorax. An assistant should monitor the patient from the front. Aspirate before any injection. Use small repeated doses of LA during blockade.

Video link: https://www.youtube.com/watch?v=tFfetJitDrk

https://www.youtube.com/watch?v=vSbhqR5oIAs


PECS 2 Block

Body Position: Supine Position.

Indications: Breast surgery. Surgery of the thorax wall. Anesthesia of n. pectoralis medianus, n pectoralis lateralis and intercostal superficial nerve branches.

Transducer: 10-16 MHz, linear probe (“Hammer head shark”)

Probe position: In plane technology (with transverse or longitudinal probe)

Injection needle: 22 G, 8 cm long, cross-sectional.

Set depth in the ultrasound image: 3-5 cm.

Technique

At pectoral muscle level, muscle vasculatures create four potential compartments for injection of local anesthesia:

  1. Between the superficial and deep pectoral muscle fascia
  2. Between pectoral fascia and clavipectoral fascia
  3. Between the clavipectoral fascia and the shallow edge of the m. Serratus anterior
  4. Between m. serratus anterior and the extrathoracic fascia

PECS II ultrasound image as below: Step two to locate the injection points. A: Left picture: Begin from the clavicle; right picture: count the ribs down to the shoulder. B: Left Image: The first injection takes place between M. pectoralis major and M. pectoralis minor; Right Image: Angle the probe to find Gilbert’s ligament. C: Left: Over the serratus muscle; right: under the serratus muscle;

Cl; clavicel, SCM; subclavius ​​muscle; PM; pectoralis major; PM; pectoralis minor; VA; axillary vein, AA; axillary artery, PL; pleura; SM, musculus serratus.

Ideal image: The local anesthetic is injected into two points: A first injection of approximately 0.2 ml/kg of long-acting local anesthetic is done between M. pectoralis major and M. pectoralis and a second injection of 0.2 ml/kg is made between pectoralis and m serratus anterior. The figure below illustrates the sonographic anatomy, needle lane and desired injection spread.

Caution: Avoid puncture of the artery. Do not inject into the nerves themselves, observe and avoid sluggish injection resistance. In case of accidental artery puncture withdraw the needle and compress vigorously for 3-5 minutes. Then repeat the needle puncture during better visualization with In-plane technology.

Video link: Click here!

Local anesthetic:

  • Mepivacaine (Carbocaine) 10 mg/ml (1%) 20-40 ml
  • Ropivacaine (Naropine) 5 mg/ml, 10-30 ml, (25-150 mg). Applying time 1-15 min, duration 2-4 hours
  • Lidocaine (Xylocain) 10 mg/ml, 20-40 ml (200-400 mg)

Popliteal Nerve Block

Body position: Side position, supine or extended side position.

Indication: Surgery or pain in ankle or foot.

Transducer: 8-16 MHz, linear probe.

Position of the probe: Approximately 4-5 cm above the knee joint, in the base of popliteal fossa.

Injection needle: 22G, 5-8 cm long, cross-sectional.

Nerve stimulation response from (if used): Foot or toe.

Set depth in the ultrasound image: 4 cm.

Ideal picture: Visible sciatic nerve division in peroneus communis nerve and tibial nerve about 5 cm above the knee joint.

Note the anatomy: Popliteal artery. Femur. The sciatic nerve is above and laterally about the vein and artery, note the tendon as the sciatic nerve is located in the M semitendinosus.

Technique: Use In-plane technology with insertion on the lateral side of the head of the ultrasound probe. Insert the needle under the probe laterally on the target. The needle tip needle is N sciatic us, the needle must come inside the latex. Perform as few injections as possible, preferably 2, one stick on each side of the nerve, approximately 2 cm deep. Ideal spread is around the hyperecogenous nerve root structure of the sciatic us nerve or between n peroneus communis and n tibialis. Note hydrodissection, ie. filling around the nerve of LA.

At Out-of-plane technique, the needle drops into the image vertically in the middle line.

Local anesthetic:

  • Mepivacaine (Carbocaine) 10 mg/ml (1%) 15-30 ml.
  • Ropivacaine (Naropine) 7.5 mg/ml (0.75%) 15-25 ml.

Caution: Follow the propagation and division of the nerve. The blockade can also be added slightly higher up. If laying catheters are laid, this must be placed inside the lower edge. Will take about 30 minutes for full blockade.

Video link: https://www.youtube.com/watch?v=kzhSiQBPE7s


Regional Nerve Blocks

Here are some recommended dosages of local anaesthetics in regional nerve blocks

Major Nerve Block

Axillary Plexus Block, TAP-block, Fascia Iliaca Compartment Block (FICB)
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml10-40 ml100-400 mg
Mepivacaine (Carbocaine®) 10 mg/ml20–40 ml200–400 mg
Mepivacaine (Carbocaine®) 20 mg/ml10–17,5 ml200–350 mg
Ropivacaine (Naropin®) *5 mg/ml10-40 ml75-300 mg
* Onset time 10-25 min, duration 6-10 h.

Medium Size Block

Supraclavicular Plexus Block, Infraclavicular Plexus Block, Interscalenius Block, Femoral Block, Sciatic Nerve Block, N. Saphenus Block, Ileoinguinal Nerve Block, Popliteal Block, PECS 2, M. Serratus Anterior Plane Block, Foot Block, Quadratus Lumborum Block
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml10-20 ml100-200 mg
Ropivacaine (Naropin®) *5 mg/ml1-30 ml5-150 mg
Ropivacaine (Naropin®) *7,5 mg/ml1-30 ml7,5-225 mg
Mepivacaine (Carbocaine®) 10 mg/ml10–20 ml100–200 mg
* Onset Time 1-15 min, duration 2-6 h.

Small Nerve Blocks

Block of Nervus medianus, n. ulnaris, n. radialis, n. cutaneus antebrachi lateralis, n. suprascapularis, n. lateralis cutaneus femoris, n. tibialis posterior, n. peroneus profundus and n. peroneus superficialis.
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml2-5 ml20-50 mg
Ropivacaine (Naropin®) *5 mg/ml2-5 ml10-25 mg
Mepivacaine (Carbocaine®) 10 mg/ml2–5 ml20–50 mg
* Onset Time 1-15 min, duration 2-6 h.

Saphenus Nerve Block

Body position on the patient: Supine position, with abduced out-rotation of legs and easy bend in the knee joint.

Indication: Addition to popliteal blockade or sciatic block in surgery below knee joint.

Transducer: 8-16 MHz, linear probe.

Probe position: At the top of the knee joint on the thigh side (front), approx. 10 cm above the knee joint.

Injection needle: 22G, 8-10 cm long, cross-sectional.

Nerve stimulation response from: medial part of the lower leg and the calf.

Set depth in the ultrasound image: 4-6 cm.

Technique: Use In-plane technology with insertion from the lateral side of the head of the ultrasound probe. Insert the needle under the probe laterally on the target. The goal of the needle tip is saphenus nerve laterally of femoral artery below the sartorius muscle. Perform as few injections as possible, preferably only one. Ideal spread is around the hyperechogenous nerve root structure of the saphenus nerve or around and below the femoral axis. Note hydrodissection, i.e. filling around the nerve of LA. The saphenus blockade can also be placed down the knee joint on the lateral side.

At Out-of-plane technique, the needle should get into the image vertically in the median line.

Ideal image: Visualize femoral artery. Saphenus nerve lies in front of (laterally) a femoralis below the sartorius muscle.

Video link: https://www.youtube.com/watch?v=rn1pI48D3Ik

Note the anatomy: Femur, femoral artery. Saphenus nerve can be difficult to visualize. Vastus medialis muscle. Sartorius muscle.

Caution: Follow the propagation and division of the nerve. N saphenus can be difficult to visualize.

Local anesthetic:

  • Mepivacaine (Carbocaine) 10 mg/ml, 20-40 ml (200-400 mg)
  • Mepivacaine (Carbocaine) 20 mg/ml, 10-17.5 ml (200-350 mg)
  • Lidocaine (Xylocaine) 10 mg/ml, 10-40 ml (100-400 mg)
  • Ropivacaine (Narop) 5 mg/ml, 10-40 ml (75-300 mg). Onset time 10-25 min, duration 6-10 h.
  • Ropivacaine (Narop) 7.5 mg/ml, 10-30 ml (75-225 mg). Onset time 10-25 min, duration 6-10 h

Serratus Muscle Plane Block

Body position: Side position with one arm forward is preferred.

Indication: Surgery in the chest wall.

Transducer: 10-16 MHz, linear probe (“Hammarhead shark”)

Position of the probe: In plane technology (in transverse or longitudinal mode) or Out-of-plane.

Injection needle: 22G, 8 cm long, cross-sectional.

Nerve stimulation response: Set depth in the ultrasound image: 2.5-3 cm.

Technique: There are two main methods to identify the location of the serratus block. The first method requires counting the ribs from the clavicle while moving the probe laterally and distally until the fourth and fifth ribs can be identified (see figure). The probe should be oriented in the horizontal plane and then tilted backwards until m. latissimus dorsi (a superficial thick muscle) can be identified. M. Serratus Anterior, a thick, hypoechoic structure, lies deeply against m. latissimus dorsi, which is depicted over the ribs. If the probe is directed backwards, identification of the plane between m. serratus anterior and m. latissimus dorsi is possible. An alternative method is to place the probe over the axillary, where m. latissimus dorsi will appear more clearly (see Figure). The location of the thoracodorsal artery is easier to identify in this way. Both In-plane and Out-of-plane methods are suitable for puncture.

Caution: Avoid puncture of the artery. Do not inject into the nerves themselves, observe and avoid sluggish injection resistance or paresthesias. In case of accidental artery puncture pull out the needle and compress vigorously for 3-5 minutes. Then repeat the needle puncture during better visualization with In-plane technology.

Video link: Click here for link

Local anesthetics:

  • Carbocain 10 mg/ml (1%) 20-40 ml
  • Narop 5 mg/ml, 10-30 ml, (25-150 mg). Applying time 1-15 min, duration 2-4 hours
  • Xylocain 10 mg/ml, 20-40 ml (200-400 mg)

Ideal image: Blocked by Serratus plane is performed in the axillary region, but lateral and dorsal compared to PECS I and II blocks. At the axillariosis lies the intercostobrachial nerve, and lateral cutaneous branches of the intercostal nerves (T3-T9), the long thoracic nerve and thoracodorsal nerve located in a compartment between m. serratus anterior and m. latissimus dorsi, between the rear and midaxillary lines.

Note the anatomy: The two main anatomical landmarks are m. latissimus dorsi and m. serratus anterior. The thoracodorsal artery runs in the fascia plane between the two muscles. Ribs, pleura and intercostal muscles can also be seen during the procedure.


Sciatic Nerve Block

Body position

Prone position, side position, or extended side position.

Indication

Surgery or pain in the knee or knee region. Anesthesia of Sciatic nerve.

Transducer

6-16 MHz, linear array probe or curved array probe on larger patients.

Probe position

Subgluteal.

Injection needle

21G, 10 cm long, cross-sectional.

Nerve stimulation response from

Foot or calf.

Set depth in the ultrasound image

5 cm or more, varies with patient size.

Ideal image

Make the sciatic nerve visible as well as the epineural sheet.

Note the anatomy

The sciatic nerve lies directly below the m gluteus maximus and above the m cuadratus femoralis. Trochanter Major. Tuber ischiadicus. Triangular nerve structure.

Technique

Use In-plane technology with insertion 3-4 cm from the lateral side of the head of the ultrasound probe. Insert the needle under the probe laterally on the target. The goal of the needle tip is sciatic nerve, the needle must come inside the nerve sheet. Perform as few injections as possible, preferably only 2, one injection on each side of the nerve. Ideal spread is around the hyperecogenous nerve root structure. Note hydrodissection, ie. fluid filling around the nerve of LA. You may need to press the probe relatively strongly against the patient’s thighs.

Caution: The puncture may become relatively deep with difficulty visualizing the sciatic nerve in obese patients.

Video link: https://www.youtube.com/watch?v=rl8rZOEMveE

Local anesthetics

  • Ropivacaine (Narop) 5 mg/ml, 20-30 ml, (100-150 mg). Onset time 10-15 min, duration 2-4 hours
  • Ropivacaine (Narop) 7.5 mg/ml, 10-20 ml, (75-150 mg)
  • Mepivacaine (Carbocaine) 10 mg/ml, 20-30 ml (200-300 mg)
  • Lidocaine (Xylocaine) 10 mg/ml, 20-30 ml (200-300 mg)

Supra Clavicular Plexus Block

Body Position: Supine position or half-side position. Slight rotation of face in the opposite direction. Light head-up.

Indication: Surgery on humerus, elbow, or hand.

Transducer: 10-16 MHz, linear probe (“Hammarhead shark”).

Position of the probe: In the supraclavicular pit (fossa). Laterally on the head of the clavicle, in the cephal-caudal direction.

Injection needle: 22 G, 5 cm long, cross-sectional.

Nerve stimulation response: Arm, forearm.

Set depth in the ultrasound image: 3 cm.

Technique: Use In-plane technology with insertion on the lateral side of the ultrasonic probe. Insert the needle under the probe parallel to the longitudinal direction of the probe as shown in the pictures. The goal of the needle tip is inside the plexus nerve fascia laterally of subclavian artery and above the first rib. Perform as few injections as possible, preferably 2-3. Ideal spread is around the hyperecogenous nerve root structures. In case of difficulty in illustrating nerve root structures, scanning begins immediately above the clavicle. Note hydrodissection, ie. plexus sheat dilatation with the injection of LA.

Video link: https://www.youtube.com/watch?v=ztOIvfjsB-U

Local anesthetics:

  • Mepivacaine (Carbocaine) 10 mg/ml (1%) 20-30 ml.
  • Ropivacaine (Naropin) 7.5 mg/ml (0.75%) 15-25 ml

Ideal picture: Brachial plexus and subclavian artery above the first rib and pleura.

Note the anatomy: Subclavian artery. First rib. Pleura. Nerve plexa has a honeycomb pattern that is both hypoechogenic and hyperechogenic, which lies immediately laterally of a subclavia and medially about m skalenius medius (msm). The nerve roots are usually hypoechogenic.

Caution: Avoid injection through pleura and puncture of subclavian artery. Caution in patients with advanced COPD, pulmonary emphysema or dyspnoea.


Suprazygomatic Maxillary Nerve Block

Body position: Supine

Indication: Palate surgery, teeth extraction, craniofacial surgery in the maxillary area.

Transducer: Hockey club probe in children, linear assay probe in adult.

Probe position: Below the Zygomatic arch.

Injection needle: 25-27 G, 40-50 mm (preferably longer in adults)

Nerve stimulation response: Response in the masseter muscles, which ceases when the needle tip passes out of the muscle in the pterygopalatineal fossa.

Ideal picture: The nerve and the needle are difficult to visualize in the picture, but the maxillary artery can often be seen, and the spread of local anesthetics in the area around the artery.

Technique: The needle is inserted perpendicular to the skin about 1 cm laterally to the lateral orbit edge, above the zygomatic arch, to the bone contact at 1-2 cm depth (sphenoid wing). The needle is then withdrawned slightly, and is directed towards the filtrum (the furrow between the upper lip and the nose), and is inserted 35-45 mm (in adults sometimes more). A “pop” or release may be felt when the needle penetrates through the masseter muscle into the pterygopalatineal fossa, but is not always present.

Caution: Careful aspiration, the maxillary artery runs caudally around the nerve. The injection should go easily, if it is sluggish to inject there is a risk that the needle is in the nerve.

Local anesthetic:

  • Ropivacaine (Naropine) 2 mg/ml, 0.15 ml/kg
  • Levobupivacaine (Chirocaine) 2.5 mg/ml, 0.15 ml/kg
  • Lignocaine (Xylocaine) 20 mg/ml, 3 ml for adults

 

References:

  1. Chiono, J., O. Raux, S. Bringuier, C. Sola, M. Bigorre, X. Capdevila, and C. Dadure. “Bilateral Suprazygomatic Maxillary Nerve Block for Cleft Palate Repair in Children: A Prospective, Randomized, Double-Blind Study Versus Placebo.” Anesthesiology 120, no. 6 (Jun 2014): 1362-9.
  2. Mesnil, M., C. Dadure, G. Captier, O. Raux, A. Rochette, N. Canaud, M. Sauter, and X. Capdevila. “A New Approach for Peri-Operative Analgesia of Cleft Palate Repair in Infants: The Bilateral Suprazygomatic Maxillary Nerve Block.” Paediatr Anaesth 20, no. 4 (Apr 2010): 343-9.
  3. Radder, K., A. Shah, S. Fatima, C. Kothari, S. Zakaullah, and A. Siddiqua. “Efficacy and Feasibility of Frontozygomatic Angle Approach for Extra Oral Maxillary Nerve Block in Oral Surgery: A Descriptive Clinical Trial.” J Maxillofac Oral Surg 13, no. 3 (Sep 2014): 231-7.

By Ellinor Wisén

Dep of Anaesthesia and Intensive care

Sahlgrenska University Hospital


TAP-block (Transversus Abdominis Plane)

Body position of the patient: Supine position. Arms out (abducted).

Indication: Postoperative analgesia after lower abdominal surgery, gynecological or urological surgery. Hysterectomy, lung fracture.

  • Bild 1 TAP-blockad
  • Bild 2 TAP-blockad
  • Bild 3 TAP-blockad
  • Bild 4 TAP-blockad
  • Bild 5 TAP-blockad

Transducer: 8-16 MHz, linear probe.

Position of the probe: Between iliac crest and the lower rib of the ribs just above the navel height. The probes are placed in transverse position parallel to the ribs of the ribs.

Injection needle: 20-22 G, 10 cm long, cross-sectional.

Set depth in the ultrasound image: 4 cm.

Technique: Use In-plane technology with 0.5 cm insert from the media side of the head of the ultrasound probe. Insert the needle underneath the probe medially about the target. The goal of the needle tip is the TAP space between m. obliquus internus and m. transversus abdominis. The penetration of the rear fascian may feel like a “pop” or “loss”. Perform as few injections as possible, preferably only one. Ideal spread is below the rear rectus fascian. Note proper hydrodisection, ie. filling of TAP. The TAP blockade is advantageously added on both sides.

Ideal image: Visibility of the rectus muscle medially. M. transversus abdominis is located below the rectus muscle and below m. obliquus internus, which in turn is below m. obliquus externus. The rectus muscle is medially followed and outwards during scanning.

Note the anatomy: M. transversus abdominis is under the obliquus internus, which in turn is under the obliquus externus. Above the obliquus externus there is abdominal fat. Transversus abdominal plane (TAP) is located below the rear rectus fascian. The nerves are located between transversus abdominis and m. obliquus internus (between the 2nd and 3rd muscular layers).

Local anesthetics:

  • Mepivacaine (Carbocaine) 10 mg/ml (1%) 20-40 ml (20 ml on each side)
  • Ropivacaine (Naropin) 5 mg/ml (0.5%) 15-20 ml unilaterally or 30-40 ml to 2 sides
  • Bupivacaine (Marcain) 3.75 mg/ml (0.375%) 15 ml unilaterally or 30 ml to 2 sides

Caution: Difficult in obese patients. A pillow under the hip can facilitate. Avoid stabbing through the peritoneum.

Video link: https://www.youtube.com/watch?v=9TIHDn7uBZI


Local Anesthetics in Regional Blocks

Infiltration Anaesthesia with Local Anaesthetic Agents

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Mepivacaine (Carbocaine®) 10 mg/ml1–20 ml 10–200 mg
Lidocaine (Xylocaine®) 10 mg/ml5-40 ml 50-400 mg
Levobupivacaine (Chirocaine®) 2,5–5 mg/ml1–20 ml 2,5–100 mg
Prilocaine (Citanest®)  5 mg/ml1-20 ml 5-100 mg

Nerve Block of Fingers and Toes

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml 2–4 ml 20–40 mg
Mepivacaine (Carbocaine®) 10 mg/ml2–5 ml 20–50 mg
Mepivacaine (Carbocaine®) 20 mg/ml1-5 ml 20-100 mg
Prilocaine (Citanest®) 5 mg/ml1-5 ml 5-25 mg

Major Nerve Block

Axillary Plexus Block, TAP-block, Fascia Iliaca Compartment Block (FICB)
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml10-40 ml100-400 mg
Mepivacaine (Carbocaine®) 10 mg/ml20–40 ml200–400 mg
Mepivacaine (Carbocaine®) 20 mg/ml10–17,5 ml200–350 mg
Ropivacaine (Naropin®) *5 mg/ml10-40 ml75-300 mg
* Onset time 10-25 min, duration 6-10 h.

Medium Size Block

Supraclavicular Plexus Block, Infraclavicular Plexus Block, Interscalenius Block, Femoral Block, Sciatic Nerve Block, N. Saphenus Block, Ileoinguinal Nerve Block, Popliteal Block, PECS 2, M. Serratus Anterior Plane Block, Foot Block, Quadratus Lumborum Block
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml10-20 ml100-200 mg
Ropivacaine (Naropin®) *5 mg/ml1-30 ml5-150 mg
Ropivacaine (Naropin®) *7,5 mg/ml1-30 ml7,5-225 mg
Mepivacaine (Carbocaine®) 10 mg/ml10–20 ml100–200 mg
* Onset Time 1-15 min, duration 2-6 h.

Small Nerve Blocks

Block of Nervus medianus, n. ulnaris, n. radialis, n. cutaneus antebrachi lateralis, n. suprascapularis, n. lateralis cutaneus femoris, n. tibialis posterior, n. peroneus profundus and n. peroneus superficialis.
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml2-5 ml20-50 mg
Ropivacaine (Naropin®) *5 mg/ml2-5 ml10-25 mg
Mepivacaine (Carbocaine®) 10 mg/ml2–5 ml20–50 mg
* Onset Time 1-15 min, duration 2-6 h.

Epidural Anesthesia for Surgical Procedures

Local Anaesthetic AgentConcentrationBolus dose (ml)Bolus dose (mg)LA for continuous infusionBolus dose (mg)
Mepivacaine (Carbocaine®) 10 mg/ml10-20 ml100-200 mg
Mepivacaine (Carbocaine®) 20 mg/ml10-17.5 ml 200-350 mg
Bupivacaine (Marcaine®) 2.5 mg/ml 20 ml 50 mg followed by 6-16 ml/h15-40 mg *
Bupivacaine (Marcaine®) 5 mg/ml 15-30 ml75-150 mg
Bupivacaine (Marcaine®) 5 mg/ml20 ml followed by 50 mg followed by 2.5 mg/ml, 6-16 ml/h15-40 mg *
Levobupivacaine (Chirocaine®) 5.0-7.5 mg/ml10-20 ml 50-150 mg
Ropivacaine (Naropin®) 5-7.5 mg/ml 15-20 ml100-200 mg
Ropivacaine (Naropin®) 5 mg/ml 6-10 ml 6-10 ml/h30-50 mg *
* Every 4-6 hours alternatively in continuous infusion depending on the desired number of anethetized segments and the age of the patient

Epidural Block in Caesarian Sectio

Local Anaesthesia AgentConcentrationLoading VolumeLoading Dose
Levobupivacaine (Chirocaine®) 5 mg/ml*15–30 ml 75–150 mg
Mepivacaine (Carbocaine®)20 mg/ml 10–17,5 ml 200–350 mg
Bupivacaine (Marcaine®)5 mg/ml15–30 ml 75–150 mg
Chloroprocaine (Nesacaine®)30 mg/ml (3% )15–20 ml in bolus
Ropivacaine (Naropin®)5 mg/ml15-20 ml 113-150 mg
* By slow injection

Epidural for Obstetric Analgesia

Local Anaesthetic AgentConcentrationOpioidBolus doseContinuous infusion
Bupivacaine (Marcaine®) 2,5 mg/ml6-10 ml (15-25 mg)2-5 ml/h (5-12,5 mg/h)
Bupivacaine (Marcaine®)1 mg/ml plusSufentanil 1 microg/ml8-12 ml6-9 ml/h
Levobupivacaine (Chirocaine®) 2,5 mg/ml6-10 ml (15-25 mg)4-10 ml/h (5-12,5 mg/h) (1,25 mg/ml)
Ropivacaine (Naropin®) 2 mg/ml10-15 ml (20-30 mg),2-5 ml/hr (4-10 mg/hr)(2 mg/ml )
Ropivacaine (Naropin®) 1 mg/ml plusSufentanil 1 microg/ml12 ml6-9 ml/h
Standard mixture of local anesthetics plus opioid is usually given at a dose of 4-16 ml/h

Conversion of Epidural from Obstetric Analgesia into Caesarian Sectio ("Top-Up for C-Sec")

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)Opioid
Ropivacaine (Naropin®)5 mg/ml15-20 ml 113-150 mg+ Sufentanil 25 μg
Levobupivacaine (Chirocaine®) *5 mg/ml15–20 ml 75–100 mg
Bupivacaine (Marcaine®)5 mg/ml15–20 ml75–100 mg
Chloroprocaine (Nesacaine®)30 mg/ml (3% )15–20 ml
* Slow injection

Continous Epidural Anesthesia for Postoperative Analgesia

Local anestheticConcentrationOpioidAdditiveDosage
Bupivacaine (Marcaine®)1,0 mg/ml
(Breivik's blend, BFA)
Fentanyl 2 μg/mlAdrenaline 2 μg/ml8-14 ml/hour
Bupivacaine (Marcaine®)2,5 mg/mlSufentanil 0,5 μg/ml8-12 ml/hour
Bupivacaine (Marcaine®) 2,5 mg/mlMorphine Special 0,03 mg/ml5-10 ml/hour
Bupivacaine (Marcaine®)1,0 mg/mlSufentanil 1 μg/ml8-16 ml/hour
Ropivacaine (Naropin®)2 mg/mlSufentanil 1 μg/ml8-16 ml/hour
Ropivacaine (Naropin®)1 mg/mlSufentanil 0,5 μg/ml8-16 ml/hour
Ropivacaine (Naropin®)2 mg/mlSufentanil 1 ug/mlClonidine 3 ug/ml6-14 ml/hour
Ropivacaine (Naropin®)2 mg/mlMorphine Special 0,03 mg/ml5-10 ml/hour
Levobupivacaine (Chirocaine®)1,25 mg/mlSufentanil 1 μg/ml8-16 ml/hour
Levobupivacaine (Chirocaine®)1,25 mg/mlMorphine Special 0,03 mg/ml5-10 ml/hour
Continous epidural anesthesia without opioids
Bupivacaine (Marcaine®)2,5 mg/ml5-7,5 ml/hour
Ropivacaine (Naropin®)2 mg/ml6-14 ml/hour
Levobupivacaine (Chirocaine®)1,25 mg/ml10-15 ml/hour
Levobupivacaine (Chirocaine®)2.5 mg/ml5-7,5 ml/hour
Standard blend of local anesthetics plus opioid is usually given at a dose of 4-16 ml/h

Spinal Anesthesia for General Surgery

Lower limb surgery including hip surgery

Local Anaesthetic AgentConcentrationDose (ml)Dose (mg)Onset TimeDuration
Bupivacaine (Marcaine Spinal®) 5 mg/ml2–4 ml 10–20 mg5–15 min2–4 hours
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml2–4 ml10–20 mg3–15 min1,5–3 hours
Ropivacaine (Naropin®)5 mg/ml3–4 ml15–20 mg1–5 min 2–6 hours
Levobupivacaine (Chirocaine®)5 mg/ml 3 ml15 mg
Urology surgery
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml 1,5–3 ml7,5–15 mg5–8 min1,5–3 hours
Abdominal Surgery
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml2–4 ml10–20 mg5–8 min45–60 min

Spinal Anaesthesia for Caesarian Sectio (C-Sec)

Local Anaesthetic AgentConcentrationDose (ml)Opioid
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml1,8–2,4 ml (7,5–12,5 mg)
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml1,8-2,4 ml + Fentanyl 15-25 μg
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml1,8-2,4 ml + Morphine 0,1 mg (0.4 mg/ml 0.25 ml)
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml1,8-2,4 ml + Fentanyl 15-25 μgram + Morphine 0,1 mg (0,4 mg/ml 0,25 ml)
Ropivacaine (Naropin®)5 mg/ml1,5-3 ml (7,5-15 mg)
Spinal Anesthesia for pain during delivery final
Ropivacaine (Naropin®)5 mg/ml0,2-0,3 ml (1-1,25 mg)Sufentanil 5 μg/ml 1-1,5 ml (7,5 mikrog)
Bupivacaine (Marcaine Spinal®) 5 mg/ml0,2-0,4 ml (1-2 mg)Sufentanil 5 μg/ml 1-1,5 ml (7,5 mikrog)

Opiates as Adjuncts in Spinal Anesthesia

Local Anaesthetic AgentConcentrationDose in mgDose in ml
Morphine0.4 mg/ml0,1–0,2 mg0,25-0,5 ml
Fentanyl50 mikorg/ml20–40 μg0,4-0,8 ml
Sufentanil5 μg/ml5–10–(15) μg1-1,5 ml

Caudal Block for Surgical Anesthesia

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®)10 mg/ml20–40 ml200–400 mg
Mepivacaine (Carbocaine®10 mg/ml15–20–30 ml150–200–300 mg
Mepivacaine (Carbocaine® 20 mg/mlup to 17.5 ml350 mg
Caudal Block in Small Children
Bupivacaine (Marcaine ®) 2,5 mg/ml
with epinephrine
0,5 ml/kg
Ropivacaine (Naropin®)2 mg/ml1 ml/kg

Intravenous Regional Anaesthesia IVRA Biers' Block

Target OrganLocal Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Mepivacaine (Carbocaine®) 0,5%5 mg/ml0,6 ml/kg3 mg/kg
Arm (Hand)Mepivacaine (Carbocaine®) 0,5%5 mg/ml20-60 ml100-300 mg
Arm (Hand)Lidocaine (Xylocaine®) 0,5%5 mg/ml20–40 ml100–200 mg
Leg (Foot)Lidocaine (Xylocaine®) 0,5%5 mg/ml40 ml200 mg
Arm (Hand)Prilocaine (Citanest®) 0,5%5 mg/ml 20-40 ml100-200 mg
Leg (Foot)Prilocaine (Citanest®) 0,5%5 mg/ml60-80 ml300-400 mg
Remark: intravenously, in a venous cannula on the dorsal side of the hand. Minimum dose: 35 ml. Maximum dose: 65 ml.


Post Dural Puncture Headache (PDPH)

Definition

PDPH is defined according to international classification as postoperative headache which occurs within 5 days after a dura punction, and spontaneously passes within one week or within 48 hours after an epidural blood patch. It is also associated with neck stiffness, tinnitus, hearing loss, sensitivity to light and nausea (1).

Background

After puncture of the dura mater, liquor leakage to the epidural space may occur. This can give rise to intracranial hypovolemia, with traction of intracranial structures. Headache may occur, but you do not know the exact mechanism of the cause. The intracranial hypovolemia can lead to cranial nerve affection and venodilatation and thus a risk of development of a subdural hemorhage.

The severity of the headache is affected by the needle’s thickness and shape, the age and sex of the patient, with the greatest risk of young women after a large needle puncture. Obstetric patients thus represent a risk group in terms of age, gender and frequency of epidural anesthesia in childbirth. Risk of PDPH after puncture with a 27 G Pencil Point spinal needle is estimated to be between 0-2%, while the risk of PDPH after accidental puncture with a 16-18 G epidural needle is 45-80% (2, 3). Incidence of accidental dural puncture in obstetric epidural anesthesia is approximately 1% (4).

Symptomatology

The typical inconvenience is severe posture dependant headache. It appears in 90% of cases within 3 days after the puncture (2, 5). The headache usually occurs frontally, but can also sit in the neck with radiance to the shoulders. The headache is exacerbated in upright posture and is easily relieved in lying. Nausea, dizziness, ears, hearing impairment and sensitivity to light are relatively common symptoms (2, 4).

Differential Diagnosis

Intracranial mass effect (eg bleeding, tumor), cerebral vein thrombosis, migraine, infectious meningitis, tension headache, preeclampsia, anemia, Sheehans syndrome, posterior reversible encephalopathy syndrome (PRES) (2, 3, 6). Forecast in most cases the inconvenience goes spontaneously within one week (2). However, chronic disorders also occur. Complications in the form of cranial nervous system and subdural hematoma can occur (6, 7). In a case series, the incidence of subdural hematoma was 0.026% in unsorted obstetric epidural depleted population and 1.1% (1 in 87) in the group where dura puncture was observed in conjunction with the establishment of epidural anesthesia (8).

Treatment

Many different treatments have been tried to relieve this intense headache. Professional support, accurate explanation of the inconvenience and follow-up are important. Although the inconvenience is relieved during bed rest, it has not been seen that bedtime can affect the duration (2). To avoid dehydration, giving analgesics, triptans, antiemetics and acupuncture can relieve the symptoms, but rarely give full relief of symptoms. These methods can be tried in mild complaints and/or in contraindications for treatment with blood patch. However, some effect has been demonstrated by prophylactically given cosyntropin IV and epidurally given morphine (9, 10). The most effective treatment so far is epidural blood patch.


Post Dural Puncture Headache – Treatment

Treatment of PDPH with epidural blood-patch

The method means that anesthetist injects 20 ml of autologous blood into the epidural space, at the same level as the dura puncture, or one interstitium below. Theoretically, a momentarily volume and pressure increase in the spinal canal with subsequent decreasing traits in intracranial structures is then achieved. This leads to a rapid decrease of the headache. The blood is then spread relatively quickly in the epidural space, especially in the cranial direction. The blood forms a “clot” at the tissue damage in the dura and seals the hole (2, 3, 11). Epidural blood patches were first described in the 60’s and a lot of knowledge about the treatment is based on case descriptions and retrospective studies. Divergent recommendations are given regarding volume of injected blood, timing of treatment and whether prophylactic/therapeutic treatment should be applied (2, 3, 12, 13). There is some support for this treatment should be given at the earliest 24 hours after the puncture, to reduce the need for repeated treatment (3, 14).

Indication

Invalidating, classical, position-related headache after reviewing epidural anesthesia, where other differential diagnoses are considered but excluded. Investigation: BP, temperature, Hgb, white blood count and CRP.

Contraindications

Common for spinal/epidural anesthesia: coagulation disorders, anticoagulant therapy, sepsis, injection site infection, patient refusal. In patients with blood contamination, individual assessment may be made.

Method

Under sterile conditions, the epidural space is located with the usual epidural needle and technique, preferably an interstitial caudal of previous puncture. Assistant (usually nurse) then performs sterile venipuncture and aspirates at least 20 ml of autologous blood from the patient. The blood syringe is immediately transferred to the anestesiologist for immediate slow injection of blood (up to 20 ml) into the epidural space. The injection should be discontinued if the patient indicates any back pain. Fit dressing over the insertion point. Bedding is recommended for 1-2 hours and then careful mobilization.

Response from headache is achieved in > 70% of PDPH patients treated with blood patch (2, 3). If headache recur with typical symptoms, blood-patch treatment may need to be repeated (4, 5).

Since the diagnosis of PDPH is primarily clinical, differential diagnoses must be taken into account on broad indications. In the event of atypical, recurrent or recurring discomfort, altered type of headache and/or the occurrence of other neurological disorders, extensive investigation must be carried out with e.g. CT/MR (2, 6, 8).

Risks/Complications

There is a risk of an additional dura puncture in connection with the location of the epidural space. Light backache up to 5 days occurs after blood-patch (3) as well as spinal canal infection. If the blood is accidentally injected subdurally/intradurally, it can cause serious complications in the form of arachnoiditis, cauda equina syndrome and permanent nerve damage (3, 15, 16).

After PDPH and/or blood patch, the patient must be followed closely and must not leave hospital if severe headache persists. Detailed information, oral and written, regarding the complication and its risks must be given. Clear instructions on where the patient should turn in case of recurrent symptoms. Complication must be recorded.

By 2016, a European observation study has begun, EPiMAP. Hopefully, this will give us more knowledge of blood patches as treatment of PDPH.

References:

  1. International classification of headache disorders 2nd edition. Cephalgia: 2004, 24: 79.
  2. Post-dural puncture headache: pathogenesis, prevention and treatment. BJA (2003) 91 (5):718-729.
  3. Post-dural puncture headache: The worst common complication in obstetric anesthesia. Seminars in perinatology: vol 38 Issue 6 (2014) 386-394.
  4. Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey. Acta Anaesth Scand 2011; 55: 46–53.
  5. Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. IJOA: (2009) 17; 329-335.
  6. Intracranial subdural haematoma following neuraxial anaesthesia in the obstetric population: a literature review with analysis of 56 reported cases. IJOA vol 25 febr 2016, 58-65.
  7. MBRRACE-rapporten 2009-2011 (2012).
  8. Subdural Hematoma Associated With Labour Epidural Analgesia: A case Series. Reg Anesth and Pain medicine: 2016: vol 41(5) 628-631.
  9. Prevention of post-dural puncture headache in parturients: a systematic review and meta-analysis. Acta anaesth Scand 2013:57:417-430.
  10. Cosyntropin for profylaxis against Post Dural Puncture Headache after Accidental Dural Puncture. Anesthesiology: 2010, vol 113(2)413-420.
  11. Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18h. BJA: 1993:71(2) 182-188.
  12. Prophylactic vs therapeutic blood patch for obstetric patients with accidental dural puncture-a randomized controlled trial. Anaethesia 2014, 69, 320-326.
  13. Accidental dural puncture, postdural puncture headache, intrathecal catheters and epidural blood-patch: revisiting the old nemesis. J Anesth (2014) 28:628-630.
  14. The influence of timing on the effectiveness of epidural blood patches in parturients. IJOA (2013) 22, 303-309.
  15. Spinal subdural haematoma after an epidural blood patch. IJOA: vol 24 Issue 3 Aug 2015, 288-289.
  16. Chronic adhesive arachnoiditis after repeat epidural blood patch. IJOA: vol 24 Issue 3 Aug 2015, 280-283.