1. Infraorbital Nerve Block
Santhanam Suresh, MD, FAAP
Director of Research, Department of Pediatric Anesthesia
Professor of Anesthesiology and Pediatrics
Northwestern University’s Feinberg School of Medicine
Children’s Memorial Hospital
Chicago, Illinois

2. SKILL COMPONENTS Pre-operative Preparation Strategy of Procedure
Infraorbital Block
(Single Shot)
SKILL COMPONENTS
Pre-operative Preparation
Strategy of Procedure
Preparation
Position
Procedure
1. Injection
2. Monitoring
Clean up
Handling Post-op Adverse Events

3. Preoperative prep: CONSENT
Infraorbital Block
(Single Shot)
Component 1:
Preoperative prep: CONSENT
Steps:
How to obtain consent.
Video – InfraorbitalConsent.mov

4. Strategy of Procedure Component 2:
Infraorbital Block
(Single Shot)
Component 2:
Strategy of Procedure
Steps:
Choice of local anesthetic solution
3. Dose of local by weight
4. Confer with surgeon
Bupivacaine 0.25% w/ 1:200,000 epinephrine:
Lidocaine can be used instead to facilitate initiation of feeding and minimize duration of block.

5. Strategy of Procedure Anesthetic Dose: Component 2:
Infraorbital Block
(Single Shot)
Component 2:
Strategy of Procedure
Steps:
Choice of local anesthetic solution
3. Dose of local by weight
4. Confer with surgeon
Anesthetic Dose:
0.5 mL (infants) to 1.5 mL (older children and adolescents) for Infraorbital Block

6. Strategy of Procedure Component 2: Discuss with Surgeon:
Infraorbital Block
(Single Shot)
Component 2:
Strategy of Procedure
Steps:
Choice of local anesthetic solution
3. Dose of local by weight
4. Confer with surgeon
Discuss with Surgeon:
- Discuss risk of intravascular injection and hematoma formation
- Stress potential for numbness in upper lip
- Stress to caregivers in PACU about potential for child biting
upper lip if dentition is present

7. Prepare for block Component 3: Steps: Get materials
Infraorbital Block
(Single Shot)
Component 3:
Prepare for block
Steps:
Get materials
Identify surface landmarks
Prep the patient
Seen here:
27 gauge needle
bent at 70°
3 mL syringe
Ruler
Marker
Not seen:
Bupivacaine .25% with 1:200,000 epinephrine
Sterile dry gauze
Sterile field area
Rolling cart/MAYO tray

8. Prepare for block Component 3:
Infraorbital Block
(Single Shot)
Component 3:
Prepare for block
Steps:
Get materials
Identify surface landmarks
Prep the patient
photo of betadeine prep
The external landmark is an imaginary line that passes through the pupil, the supraorbital foramen, the infraorbital foramen, and the mental foramen.

9. Prepare for block Component 3:
Infraorbital Block
(Single Shot)
Component 3:
Prepare for block
Steps:
Get materials
Identify surface landmarks
Prep the patient
Palpate the floor of the orbital rim from midline laterally until infraorbital notch is felt. Mark injection site at infraorbital foramen.

10. Prepare for block Component 3:
Infraorbital Block
(Single Shot)
Component 3:
Prepare for block
Steps:
Get materials
Identify surface landmarks
Prep the patient
Markings should be about 2 centimeters from the midline.

11. Patient Position for block
Infraorbital Block
(Single Shot)
Component 4:
Patient Position for block
Steps:
Supine position
Patient should be supine, with the head on a pillow or soft donut to prevent movement.

12. Procedure for block Component 5:
Infraorbital Block
(Single Shot)
Component 5:
Procedure for block
Steps:
Injection
- Insertion
- Aspiration
Monitoring
- Watch EKG
Needle should be inserted into the subsulcal groove until it reaches proximal to the intraorbital foramen. A finger should be placed externally to prevent needle from moving cephalad into the globe of the eye.

13. Procedure for block Component 5: Steps: Injection - Insertion
Infraorbital Block
(Single Shot)
Component 5:
Procedure for block
Steps:
Injection
- Insertion
- Aspiration
Monitoring
- Watch EKG
see video – InfraorbitalProcedure.mov
Video of injection.

14. Procedure for block Component 5:
Infraorbital Block
(Single Shot)
Component 5:
Procedure for block
Steps:
Injection
- Insertion
- Aspiration
Monitoring
- Watch EKG
Aspirate for possible heme. Inject while palpating—the local anesthetic should be felt under your finger.

15. Procedure for block Component 5:
Infraorbital Block
(Single Shot)
Component 5:
Procedure for block
Steps:
Injection
- Insertion
- Aspiration
Monitoring
- Watch EKG
Train yourself to look at the EKG for increasing heart rate and blood pressure.

16. Handling post-operative adverse events
Infraorbital Block
(Single Shot)
Component 7:
Handling post-operative adverse events
Steps:
Lipid Rescue
Lipid Rescue:
Lipid Infusion Therapy is an apparently effective treatment for the most devastating complication of regional anesthesia: cardiovascular collapse from local anesthetic overdose. The Lipid Sink Theory explains the effect by postulating that the lipophilic local anesthetics are absorbed into the infused lipid, thus preventing their toxic effect on the tissue. Recent research suggests that there may be another mechanism for effect.
Rx:
“20% Intralipid: 1.5 mL/kg as an initial bolus, followed by 0.25 mL/kg/min for minutes. Bolus could be repeated 1-2 times for persistent asystole. Infusion rate could be increased if the BP declines.