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Regional Anesthesia for Anesthesiology Nursing Peripheral Nerve Blocks-Part 1

Regional Anesthesia for Anesthesiology Nursing Peripheral Nerve Blocks-Part 1 Jeffrey Groom, MS, CRNA, ARNP Clinical Associate Professor Anesthesiology Nursing Program School of Nursing – Florida International University. Peripheral Nerve Blocks. Brachial Plexus-Interscalene,Axillary

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Regional Anesthesia for Anesthesiology Nursing Peripheral Nerve Blocks-Part 1

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  1. Regional Anesthesia for Anesthesiology NursingPeripheral Nerve Blocks-Part 1 Jeffrey Groom, MS, CRNA, ARNPClinical Associate ProfessorAnesthesiology Nursing ProgramSchool of Nursing – Florida International University

  2. Peripheral Nerve Blocks • Brachial Plexus-Interscalene,Axillary • Bier Block- Upper Extremity • Awake Intubation-Tracheal Blocks • Eye Block- Retrobulbar

  3. PERIPHERAL BLOCKS GENERAL CONSIDERATIONS • PreOp Assessment same STANDARD of CARE • Examine block site • Medications ? Bleeding ? Infection ? • Patient Ed/Info and Consent • Back-up Plan • Documentation

  4. Peripheral Nerve Block SPINAL Epidural/PNB • Large volume • Outside-Sheath • Slow onset • Block varies with dose • Small volume • Direct-Sheath • Rapid onset • Total neural block

  5. PERIPHERAL vs. CENTRAL ADVANTAGESDISADVANTAGES • Segmental block • Slow onset = time to Rx side effects • Flexibility in density • Flexibility in duration • Less side effects • More technical & more failure • More time consuming • Greater LA volume- [>toxicity risk] • Faulty block

  6. RISKS ANATOMIC • PRIMARY – Direct Nerve Injury • SECONDARY - Associated Injury ie. pneumothorax, hematoma

  7. Lidocaine RISKS PLASMA Bupivacaine TOXICITY CNS Rx CV

  8. CONTRAINDICATIONS • ABSOLUTE • Patient Refusal • Sepsis or Infection at injection site • When blockade would hinder proposed surgical procedure

  9. CONTRAINDICATIONS • RELATIVE • Patient Appropriateness • Local Infection near injection site • CNS Disease • Prior block with difficulty

  10. PERIPHERAL NERVES • Nerve Fibers-A,B,C • Large,medium,small • Nerve Function • Motor • Sensory • Sympathetic • Unmyelinated vs. M DIFFICULT - - - - - - - - - EASY

  11. TECHNIQUE • Sterile Technique • Needles - 22ga / B-bevel Insulated Needles • Parasthesia • Nerve Stimulator – POS - Ground NEG - Needle TWITCH @ .5-1 mA

  12. Drug Dosage • VOLUME - spread related to volume • DENSITY - related to concentration • ONSET - rapid onset +/- NaHCO3 • DURATION - drug +/- EPI

  13. PreOP Preparation • SAME Routine - Standard of Care • PreOp Sedation/Narc’s ? • Monitors (EKG, BP, Pulse Ox) ? • Block Room or OR Room ? • Stimulator, Needles, Drapes • Emergency Equipment • Personnel and Communications

  14. Peripheral Block Technique • Position Patient - Locate Landmarks • Open Tray - Needles - Drugs • Baseline Vitals - Position Patient • Glove - Prep Patient • Draw up Drugs - Sterile Tray Setup • Localize Skin • Approach - Parasthesia vs Stimulator • Injection

  15. Peripheral Nerve Blocks • Cervical Plexus- superficial vs deep FOR: CAE, Bx, Neck • COMPLICATIONS: Phrenic, SAB/EPI, Artery, Cervical sympathectomy, Recurrent Laryngeal • 10 ml per process

  16. Peripheral Nerve Blocks • Brachial Plexus- Interscalene, Supraclavicular Axillary • Anatomy & Function • 20 - 40 ml Local • Complications

  17. AXILLARY - TRANSARTERIAL

  18. Prep the site Localize the site

  19. Palpate the artery Inject on both sides of the artery

  20. Peripheral Nerve Blocks • Bier Block- IVRegional Upper Extremity • Hep-Loc, 2x TQ • Esmarch Bandage • TQ SBP + 150 mmHg • Inject 50 ml .5% LIDO • TQ Pain - Deflate (+25min) Sequential

  21. Peripheral Nerve Blocks • Awake Fiberoptic Intubation- Tracheal Blocks • Glossopharyngeal • Superior Laryngeal • Transtracheal • Oral Topicalization & Prep • 2 - 3 ml LIDO CAUTION: Following topical & block pt is without airway reflexes!

  22. Laryngeal Innervation • The larynx and trachea are innervated by branches of the vagus nerve. The superior laryngeal nerve carries sensation from the base of the tongue and the inferior epiglottis to the vocal cords. The recurrent laryngeal nerve caries sensation distal to the vocal cords. • The superior laryngeal nerve travels inferior to the greater cornu of the hyoid bone and divides into internal and external branches. The internal branch pierces the thyrohyoid membrane with the laryngeal branch of the superior thyroid artery. • The muscles of the larynx are supplied by branches of the vagus nerve. The cricothyroid muscle is supplied by the external branch of the superior laryngeal nerve. All of the other intrinsic muscles of the larynx are supplied by the inferior laryngeal nerve, a continuation of the recurrent laryngeal nerve.

  23. + glycopyrrolate

  24. Peripheral Nerve Blocks • Eye Block- Retrobulbar Peribulbar • Anatomy • Analgesia • Complications - hemorrhage, OCR, CNS

  25. Assessing Block • ONSET- 5 - 10 minutes • POSITION • DENSITY- Sympathetics Sensory Motor

  26. COMPLICATIONS • HYPOTENSION- IV Fluid & Pressors • HEMATOMA – direct pressure • SYMPATHECTOMY- Treat symptoms • PostOP– Neuropathy-PNB may mask S&S

  27. DOCUMENTATION • Procedure: • Position and Monitors • Skin Prep • Landmarks & Approach • Skin Localization • Needles - type, guage, length • Puncture- #, +/- Blood, +/- Paresthesia • Nerve Stimulator • Drug- Concentration, dose, Lot Number

  28. QUESTIONS ?

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