Ultrasound Guided Nerve Block for Regional Anesthesia and Acute Pain

Click Here for Cervical Plexus Anatomical Review

 INDICATIONS  

CAROTID ARTERY SURGERY, NECK SURGERY

THE DEEP CERVICAL PLEXUS

FORMED BY THE EXITING C2, C3 AND C4 NERVE ROOTS AFTER THEY LEAVE THE INTER-VERTEBRAL FORAMEN.  THE PLEXUS LIES ANTERIOR TO THE 4 UPPER CERVICAL VERTEBRAE.  POSTERIOR TO THE STERNOCLEIDOMASTOID MUSCLE, THE CERVICAL PLEXUS GIVES OFF BOTH SUPERFICIAL AND DEEP BRANCHES.  THE DEEP CERVICAL PLEXUS INNERVATES THE MUSCLES AND DEEP STRUCTURES OF THE NECK.  THE DIAPHRAGM IS ALSO INNERVATED BY THE DEEP CERVICAL PLEXUS VIA THE  PHRENIC NERVE.  THE CERVICAL PLEXUS ALSO COMMUNICATES WITH TEH VAGUS HYPOGLOSSAL AND ACCESSORY CERVICAL NERVES. 

ULTRASOUND TECHNIQUE

IN THE SUPINE POSITION, SCAN THE CAROTID SHEATH, AND PLACE 10-20 ML OF LOCAL ANESTHETIC POSTERIOR TO THE CAROTID SHEATH (FOR CAROTID ARTERY SURGERY

INJECTATE

ROPIVICAINE 0.5% 30 ML (IF USED FOR POST OPERATIVE PAIN).  IF A QUICKER ONSET IS DESIRED, USE MEPIVICAINE 1.5% OR LIDOCAINE 2% WITH BICARBONATE (WITH OR WITHOUT 1:200,000 EPINEPHRINE) 20 ML, AND CONSIDER AT LEAST 10 ML OF ROPIVICAINE 0.5% OR BUPIVICIANE 0.25%-0.5% TO ENSURE THAT THE BLOCK WILL LAST UNTIL PACU DISCHARGE.

DR. ROSENBLUM'S NOTE:

 THIS BLOCK IS NOT AS DEEP, AS THE BLIND CLASSIC APPROACH.  IT IS MORE DISTAL, AND HENCE CLOSER TO THE OPERATIVE SITE.  IT IS QUITE AN EASY BLOCK TO DO, AND APPEARS TO HAVE A LOWER RISK OF VASCULAR INJECTION, AND NERVE INJURY

REFERENCES

RAJ PP, LOU L, ERDINE S, STAATS PS, WALDMAN SD.  RADIOGRAPHIC IMAGING FOR REGIONAL ANESTHESIA AND PAIN MANAGEMENT.  CHURCHILL LIVINGSTONE.  2003. p.  61-62

INDICATIONS : 

 CAROTID ARTERY SURGER, NECK SURGERY, LYMPH NODE BIOPSY, THYROID SURGERY

THE SUPERFICIAL CERVICAL PLEXUS

INNERVATES THE SKIN, AND SUPERFICIAL STRUCTURES OF THE HEAD, NECK AND SOULDER.

ULTRASOUND TECHNIQUE

DEPOSIT 5-10 ML OF LOCAL ANESTHESIA IMMEDIATELY POSTERIOR TO THE STERNOCLEIDOMASTOID, USING AN IN PLANE CROSS SECTIONAL VIEW OF THE MUSCLE.

INJECTATE

 5-10 ML OF MEPIVICAINE 1.5%, LIDOCAINE 2% FOR QUICKER ONSET BUT SHORTER DURATION.

5-10 ML  BUPIVICAINE 0.25% OR ROPIVICAINE  0.5%  FOR LONGER DURATION.

DR. ROSENBLUM'S NOTE:

 YOU MAY WANT TO SUPPLEMENT  NEAR THE ANGLE OF THE MANDIBLE FOR HIGH INCISIONS, AND LOWER DOWN NEAR THE BASE OF THE NECK TO ENSURE FULL COVERAGE (FOR LARGER INCISIONS).

ADDITIONALLY, SUCCESSFUL BLOCK OF THE SUPERFICIAL CERVICAL PLEXUS ALONE CAN BE SUFFICIENT TO PERFORM A CAROTID ENDARTERECTOMY.

INDICATIONS  

SHOULDER SURGERY, UPPER EXTREMITY  SURGERY PROXIMAL TO THE ELBOW.  THIS BLOCK DOES NOT COVER THE ULNAR NERVE DISTRIBUTION.

ULTRASOUND TECHNIQUE

SCAN MEDIAL TO LATERAL AT THE LEVEL OF THE THYROID . UPON FINDING THE BRACHIAL PLEXUS BETWEEN THE ANTERIOR AND MEDIAL SCALENE MUSCLES, LOCALIZE THE SKIN, AND USING AN IN-PLANE APPROACH INSERT THE BLUNT BLOCK NEEDLE FROM POSTERIOR (TO THE PROBE) TO ANTERIOR.  INJECT AROUND THE BRACHIAL PLEXUS. 

EXPERIENCED PHYSICIANS, CAN PLACE THE NEEDLE BETWEEN THE NERVES, AND SURROUND EACH INDIVIDUAL TRUNK OF THE BRACHIAL PLEXUS.

ALTERNATIVELY, THE BRACHIAL PLEXUS CAN BE LOCATED BY FINDING THE SUPRACLAVICULAR SUBCLAVIAN ARTERY AND BRACHIAL PLEXUS NERVES.  THE PROBE CAN THEN SCAN UP THE NECK TO LOCATE THE LOWEST LOCATION OF THE BRACHIAL PLEXUS BETWEEN THE SCALENE MUSCLES

INJECTATE

ROPIVICAINE 0.5% 30 ML (IF USED FOR POST OPERATIVE PAIN). 

IF A QUICKER ONSET IS DESIRED, USE MEPIVICAINE 1.5% OR LIDOCAINE 2% WITH BICARBONATE (WITH OR WITHOUT 1:200,000 EPINEPHRINE) 20-30ML, AND CONSIDER AT LEAST 10 ML OF ROPIVICAINE 0.5% OR BUPIVICIANE 0.25%-0.5% TO ENSURE THAT THE BLOCK WILL LAST UNTIL PACU DISCHARGE.

DR. ROSENBLUM'S NOTE:

THIS IS AN EASY NERVE BLOCK, THAT EXPERIENCED PHYSICIANS SHOULD BE ABLE TO ACCOMPLISH IN LESS THAN 5 MINUTES.  PHRENIC NERVE PARALYSIS OCCURS IN A MAJORITY OF PATIENTS.  REASSURANCE, AND ANXIOLYSIS IS USUALLY ALL THAT IS NECESSARY.  CAUTION IN PATIENTS WITH COMPROMISED RESPIRATORY STATUS.

CATHETER PLACEMENT IS POSSIBLE, BUT IT MAY BE DISLODGED EASY, AND HIGH VOLUME INFUSIONS MAY LEAD TO DEEP CERVICAL PLEXUS, STELLATE GANGLION, PHRENIC NERVE BLOCKADE.  CAUTION AS PATIENTS MAY EXPERIENCE DYSPHAGIA AND DYSARTHRIA IF VOLUME/CONCENTRATION IS TOO HIGH.

 Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine.pdf

SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK

 INDICATIONS:  

  UPPER EXTREMITY SURGERY  INCLUDING SHOULDER SURGERY (NOTE- NOT AS  RELIABLE IN ANESTHETIZING THE SHOULDER, AS IS THE INTERSCALENE BLOCK)

ULTRASOUND TECHNIQUE

INJECTATE

ROPIVICAINE 0.5% 30 ML (IF USED FOR POST OPERATIVE PAIN).  IF A QUICKER ONSET IS DESIRED, USE MEPIVICAINE 1.5% OR LIDOCAINE 2% WITH BICARBONATE (WITH OR WITHOUT 1:200,000 EPINEPHRINE) 20-30ML, AND CONSIDER AT LEAST 10 ML OF ROPIVICAINE 0.5% OR BUPIVICIANE 0.25%-0.5% TO ENSURE THAT THE BLOCK WILL LAST UNTIL PACU DISCHARGE.

DR. ROSENBLUM'S NOTE:

NEVER ADVANCE YOUR NEEDLE WITHOUT VISUALIZING THE TIP, AS THE SUPRACLAVICULAR FOSSA IS SMALL, AND THERE IS LITTLE ROOM FOR ERROR!

 INDICATIONS  

UPPER EXTREMITY SURGERY  EXCLUDING SHOULDER SURGERY (NOTE- NOT AS  RELIABLE IN ANESTHETIZING THE SHOULDER, AS IS THE INTERSCALENE BLOCK)

ULTRASOUND TECHNIQUE

WITH THE PATIENTS IPSILATERAL ARM ABDUCTED IN THE SUPINE POSITION, USE A SMALL CURVED LOW FREQUENCY ULTRASOUND PROBE TO SCAN A CROSS SECTION OF THE SUBCLAVIAN ARTERY AND VEIN. 

ENSURE THAT YOU ARE LATERAL TO THE LUNG.  IF USING A TOUHY NEEDLE, ENSURE THAT THE BEVEL IS FACING CAUDAD.

AFTER USING LIDOCAINE 2% TO CREATE A SKIN WHEAL (25g 1.5 INCH NEEDLE) BETWEEN THE ULTRASOUND PROBE AND CLAVICLE, ANESTHETIZE THE PECTORALIS MAJOR, AND MINOR MUSCLES. 

MEDIAN CORD-  STARTING AT A 90 DEGREE ANGLE TO THE FLOOR, BREAK THE SKIN USING A BLUNT (STIMIPLEX OR TOUHY) NEEDLE, ADVANCE 1 CM, AND THEN LESSEN YOUR ANGLE AND ADVANCE UNTIL THE TIP POPS INTO THE NEUROVASCULAR BUNDLE BETWEEN THE SUBCLAVIAN ARTERY AND VEIN. DEPOSIT 1/3 OF INJECTATE (ABOUT 13 ML) AROUND THE MEDIAN CORD OF THE BRACHIAL PLEXUS

LATERAL CORD-  WITHDRAW THE NEEDLE, BACK INTO THE PECTORALIS MUSCLES, AND STEEPEN YOUR ANGLE.  ADVANCE AT THIS ANGLE, AND POP INTO THE NEUROVASCULAR BUNDLE ON THE OTHER SIDE OF THE ARTERY.  YOU WILL BE AT A 3 O'CLOCK POSITION (OR 9 O'CLOCK POSITION DEPENDING ON PROBE ORIENTATION) TO THE ARTERY, WHERE YOU WILL BE NEAR THE LATERAL CORD.  DEPOSIT 1/3 OF INJECTATE.

POSTERIOR CORD- AT THE LATERAL CORD POSITION, LESSEN YOUR NEEDLE ANGLE, AND SCOOP THE ARTERY UPWARDS WITH THE NEEDLE, WHILE SLIGHTLY ADVANCING.  THIS SHOULD PLACE YOUR TIP AT THE 6 O'CLOCK POSITION OF THE ARTERY, WHERE YOU WILL DEPOSIT THE REMAINING 1/3 OF YOUR INJECTATE.

CATHETER PLACEMENT- SHOULD TAKE PLACE AT THE POSTERIOR CORD POSITION.  THIS WILL ENSURE EVEN SPREAD THROUGHOUT THE BRACHIAL PLEXUS.

INJECTATE

IF PLACING A CATHETER, USE 40 ML OF LIDOCAINE 2%, EPINEPHRINE 1:200,000, BICARBONATE 2ML.  THIS WILL ENABLE QUICK ONSET, AND ABOUT A 2 HOUR DURATION.  THE CATHETER CAN THEN BE BOLUSED WITH 4-8 ML AT A TIME.

RECOMMENDED POSTOPERATIVE INFRACLAVICULAR INFUSION RATES ARE: ROPIVICAINE 0.1% (OR BUPIVICAINE 0.1%)        8 ML/HOUR

IF NOT PLACING A CATHETER, USE ROPIVICAINE 0.5% 30 ML-40ML (IF USED FOR POST OPERATIVE PAIN).  IF A QUICKER ONSET IS DESIRED, ADD MEPIVICAINE 1.5% OR LIDOCAINE 2% WITH BICARBONATE (WITH OR WITHOUT 1:200,000 EPINEPHRINE) 20-40ML,  TOTAL VOLUME SHOULD NOT EXCEED 40 ML

DR. ROSENBLUM'S NOTE:

THIS IS ONE OF THE BEST LOCATIONS FOR A BRACHIAL PLEXUS CATHETER, AS IT IS USUALLY QUITE STABLE, AND BOLUSES WILL GIVE RELIABLE SPREAD TO ALL 3 OF THE CORDS AT THIS LEVEL.

  INDICATIONS  

 UPPER EXTREMITY SURGERY EXCLUDING SHOULDER SURGERY

ULTRASOUND TECHNIQUE

INJECTATE

ROPIVICAINE 0.5% 30 ML (IF USED FOR POST OPERATIVE PAIN).  IF A QUICKER ONSET IS DESIRED, USE MEPIVICAINE 1.5% OR LIDOCAINE 2% WITH BICARBONATE (WITH OR WITHOUT 1:200,000 EPINEPHRINE) 20-30ML, AND CONSIDER ADDING AT LEAST 10 ML OF ROPIVICAINE 0.5% OR BUPIVICIANE 0.25%-0.5% TO ENSURE THAT THE BLOCK WILL LAST UNTIL PACU DISCHARGE.

DR. ROSENBLUM'S NOTE:

 THIS BLOCK IS PREFERRED FOR SITUATIONS IN WHICH YOU NEED A QUICK ONSET.  DUE TO THE SIZE OF THE FIBERS IN THE AXILLA, ONSET IS USUALLY QUICKER THAN WITH MORE PROXIMAL BRACHIAL PLEXUS BLOCKS.  FOR THIS REASON IT ACCEPTABLE TO USE ROPIVICAINE 0.5% 30 ML FOR A FAIRLY QUICK ONSET, AND LONG DURATION.

MUSCULOCUTANEOUS NERVE BLOCK

 ULTRASOUND TECHNIQUE:

SLIDE YOUR PROBE SLIGHTLY CEPHALAD, AND DISTAL TO IDENTIFY THE  CORACOBRACHIALIS MUSCLE.

THE MUSCULOCUTANEOUS NERVE SHOULD BE VISIBLE WITHIN THE MUSCLE. 

MAKE ANOTHER SKIN WHEAL, AND INSERT A 50MM STIMIPLEX (OR 25G 1.5 INCH) NEEDLE INTO THE MUSCLE.  INJECT THE LOCAL ANESTHETIC SO THAT IT SURROUNDS THE NERVE.

 INDICATION

SURGERY OF THE LOWER EXTREMITY

ULTRASOUND TECHNIQUE

INJECTATE

DR. ROSENBLUM'S NOTE:

 INDICATIONS  

 KNEE SURGERY, ANTERIOR THIGH SURGERY, MEDIAL LOWER EXTREMITY SURGERY

ULTRASOUND TECHNIQUE

 OBTAIN A CROSS SECTIONAL VIEW OF THE FEMORAL ARTERY.  IDENTIFY THE FEMORAL NERVE LATERAL TO THE ARTERY.  USING AN IN PLANE APPROACH, INSERT A BLUNT BLOCK NEEDLE (OR TUOHY NEEDLE IF CONTINUOUS BLOCK IS DESIRED). 

INJECTATE

ROPIVICAINE 0.5% 30 ML (IF USED FOR POST OPERATIVE PAIN).  IF A QUICKER ONSET IS DESIRED, USE MEPIVICAINE 1.5% OR LIDOCAINE 2% WITH BICARBONATE (WITH OR WITHOUT 1:200,000 EPINEPHRINE) 20-30ML, AND CONSIDER ADDING AT LEAST 10 ML OF ROPIVICAINE 0.5% OR BUPIVICIANE 0.25%-0.5% TO ENSURE THAT THE BLOCK WILL LAST UNTIL PACU DISCHARGE.

DR. ROSENBLUM'S NOTE:

INDICATIONS:

SURGERY ON THE LOWER EXTREMITY 

ULTRASOUND TECHNIQUE:

 SCAN THE SUBGLUTEAL REGION, AND LOCATE THE NERVE AS IT TRAVELS DOWN THE LEG.  IDENTIFY THE SEMITENDONOSIS AND SEMIBEMBRINOSUS MUSCLES, AS THE NERVE IS USUALLY DEEP AND MEDIAL TO THE MUSCLE BODIES.

INJECTATE

ROPIVICAINE 0.5% 30 ML (IF USED FOR POST OPERATIVE PAIN).  IF A QUICKER ONSET IS DESIRED, USE MEPIVICAINE 1.5% OR LIDOCAINE 2% WITH BICARBONATE (WITH OR WITHOUT 1:200,000 EPINEPHRINE) 20-30ML, AND CONSIDER ADDING AT LEAST 10 ML OF ROPIVICAINE 0.5% OR BUPIVICIANE 0.25%-0.5% TO ENSURE THAT THE BLOCK WILL LAST UNTIL PACU DISCHARGE.

DR. ROSENBLUM'S NOTE:

THIS NERVE CAN BE DIFFICULT TO IDENTIFY IN OBESE PATIENTS.  A NERVE STIMULATOR IS RECOMMENDED, BUT MANY PATIENTS WHO REQUIRE SCIATIC NERVE BLOCKS (IE, PATIENTS WHO REQUIRE AMPUTATIONS- VASCULOPATHS, AND DIABETICS) WILL NOT TWITCH UPON APPROPRIATE STIMULATION.

POPLITEAL NERVE BLOCK

 INDICATIONS:  

 SURGERIES OF THE LEG DISTAL TO THE POPLITEAL FOSSA.

NEED FEMORAL NERVE (SAPHENOUS NERVE) SUPPLEMENTATION TO COVER THE MEDIAL ASPECT OF THE  LEG BELOW THE KNEE

ULTRASOUND TECHNIQUE:

IN THE PRONE POSITION, SCAN 6-9 CM ABOVE THE POSTERIOR CREASE OF THE KNEE.  IF THE NERVES ARE NOT VISUALIZED, CONSIDER STARTING HIGHER (DEEPER) AND IMAGING THE SCIATIC NERVE.  GOING MORE DISTALLY, THE BIFURCATION SHOULD BE OBSERVED.  IF THE SCIATIC NERVE CANNOT BE IDENTIFIED, THEN GO TO THE POSTERIOR KNEE TO IDENTIFY THE NERVES AFTER THEY BIFURCATED (USUALLY QUITE SUPERFICIAL).

INJECTATE

ROPIVICAINE 0.5% 10-20 ML (IF USED FOR POST OPERATIVE PAIN).  IF A QUICKER ONSET IS DESIRED, USE MEPIVICAINE 1.5% OR LIDOCAINE 2% WITH BICARBONATE (WITH OR WITHOUT 1:200,000 EPINEPHRINE) 10-20MLDR. ROSENBLUM'S NOTE: