Advanced Nerve Blocks (Dr. Rao)
PENG Block
Bottom Line: New nerve block described in 2018. First new block to treat Pubic Ramus fractures and likely has better analgesia for hip fractures than Fascia Iliaca or Femoral nerve blocks.
-Easy to perform, Safe (away from any major vascular structure), high volume (20 - 40 cc) block
Pericapsular Nerve Group (PENG) block to treat pain by targeting the terminal sensory articular nerve branches of the femoral nerve (FN), obturator nerve (ON), and accessory obturator nerve (AON)
Motor Sparing Block: Blocking nociceptive nerve branches instead of motor branches will allow our orthopedic colleagues to perform a better motor function exam and allow patients to practice early range of motion, which is important for overall postoperative outcomes.
Motor sparing block especially important for pubic ramus fractures where ambulation status is weight bearing as tolerated.
Effective block for femoral neck fractures, intertrochanteric femoral fractures, pubic ramus fractures, acetabular fractures and hip dislocations
Any fractures of the femur beyond the intertrochanteric line will not be adequately anesthetized and may require alternative blocks such as the femoral nerve block or fascia iliaca compartment block
The curvilinear probe is used at an oblique angle parallel to the inguinal ligament (IL) with probe marker to the patient's right side.
Initially, the probe should be positioned inferior to the IL to identify the femoral head
Then the probe can be moved cranially until the anterior inferior iliac spine (AIIS) and iliopubic eminence (IPE) of the ilium are visualized. The femoral artery (FA), femoral nerve (FN), iliacus muscle (IM) and psoas tendon (PT) should be identified.
The target is the subfascial plane located underneath the psoas tendon (PT) and above the ilium.
A 20G or larger long spinal needle or echogenic nerve block needle is inserted in a lateral-to-medial approach until contact with the ilium is made underneath the psoas tendon.
Hydrodissection of the fascial plane using saline initially helps to visualize the correct location before injecting 20 CCs of long-acting anesthetic, such as ropivacaine or bupivacaine with epinephrine. The block has been shown to be effective with a lower concentration of local anesthetic such as 0.25% bupivacaine with epinephrine.
Interscalene Block by Dr. Rudnin
Indications: pain control after upper-extremity fractures (distal clavicle and humerus), alternative to procedural sedation for glenohumeral reductions, large abscess drainage, burns, deep wound exploration, and complex laceration repair
https://www.coreultrasound.com/interscalene-brachial-plexus-nerve-block/
Have the patient’s head turned to the contralateral side about 30 – 45 degrees. Place machine on opposite side of patient. Skin, transducer, and screen should all be within the same line of sight.
Start in the supraclavicular fossa with your transducer placed transversely. Find the subclavian artery and brachial plexus next to it
Follow the postero-lateral border of the SCM until the anterior and middle scalene muscles form.
Scan cephalad until you identify the C5, C6, C7 nerve roots (“stoplight sign”)
Approach in-plane view (ie. visualizing the entire needle length) lateral to medial in the interscalene groove. Inject ~ 20 cc of anesthetic near C5-7 with the anesthetic appearing as hypoechoic fluid extent of spread of anesthetic
Avoid vascular puncture by using color Doppler to identify vessels.
Avoid nerve injury by using non-cutting or spinal needle.
Anterior Serratus Block by Dr. Greenstein
Has been used effectively for the management of pain in the context of rib fractures and rib contusions
The block is effective in providing analgesia for lateral rib fractures but may be ineffective for anterior and posterior rib fractures
Unlike other nerve blocks that are classically thought to target a single nerve, the goal of the ultrasound-guided SAPB is to deposit a large volume of dilute anesthetic in a fascial plane.
Anechoic anesthetic fluid will slowly spread with patient respirations and anesthetize the interconnected lateral cutaneous branches of the thoracic intercostal nerves.
In a 30 mL syringe, place a mixture of 15 mL 0.5% bupivacaine and 15 mL normal saline. Connect the needle to the tubing and prime the circuit to ensure all air is removed.
A high-frequency linear transducer should be placed on the patient’s midaxillary line in the transverse plane, at the level of the fifth rib, with the indicator oriented toward the operator’s left
After cleaning the area under and around the transducer, place an anesthetic skin wheal (3–5 mL lidocaine with epinephrine) posterior to the transducer with the patient in a lateral decubitus position. Clean the area and apply a transparent dressing over the transducer.
Inject the skin wheal with an in-plane approach, always noting the needle tip. Once the visualized needle tip is located just above the serratus anterior muscle, aspirate to confirm lack of inadvertent vascular puncture and slowly inject 1–2 mL of anesthetic solution. Fluid placed in the fascial plane will immediately spread away from the needle tip and open the fascial plane.
Once the fascial plane is clearly opened, aspirate, then gently inject 2–3 mL of dilute anesthetic solution in a sequential manner until all 30 mL of dilute anesthetic is injected . Clinicians should be aware that onset of analgesia is often longer for planar blocks; expect 15–30 minutes before onset of the block
