1. Regional Anesthesia in the Outpatient Setting Ravindra V. Prasad, MD Department of Anesthesiology UNC School of Medicine

2. Review §3/30 – Ghia, Axillary Block §4/1 – Wilkes, Axillary Block §4/8 – Levin, SAB §4/14 – Klein, Lower Extremity Blocks §4/15 – Prasad, ???

3. Overview §Regional Anesthesia: general comments §Upper Extremity Blocks §Paravertebral Blocks §Neuraxial Blocks §Lower Extremity Blocks

4. Regional: advantages §Avoid GA complications §Less anesthetic required l faster wake-up? l quicker recovery? §Faster ambulation, faster discharge l N/V less common l post-op pain minimized

5. Regional: problems §Time §Equipment §Personnel §GA still backup plan §Skill l regional techniques l management of awake or LIGHTLY sedated patients

6. Block Placement §Monitoring §Emergency equipment and drugs should be readily available §Block equipment readied before starting §POSITIONING §SEDATION (preoperative, intraoperative) §Patient selection

7. Upper Extremity Blocks §Brachial Plexus Blocks §Peripheral Nerve Blocks l elbow l wrist §Bier Blocks

8. Brachial Plexus

9. Dermatome Distribution

10. Brachial Plexus Blocks §Indications: surgery of upper extremity §Approaches l Axillary l Infraclavicular l Supraclavicular l Interscalene (ISB)

11. ISB: technique §Equipment §Drugs §Technique

12. ISB: complications §Pneumothorax §Phrenic nerve paralysis §Horners syndrome §C6 root neuropathy (intraneural injection; root pinned against C6 tubercle)

13. Bier Block §Intravenous Regional Anesthesia (IVRA) §Described by Bier in 1908 §Intravenous injection of local anesthetics in an extremity isolated from the systemic circulation §A simple technique which is easy to perform §Widespread use in surgical cases of short duration

14. Bier Block: indications §Surgery of the extremities, especially hand and forearm §Surgery of short duration (less than 1 hour) §Soft tissue procedures (block is less dense than nerve blocks; may have pain if bony involvement)

15. Bier Block: contraindications §Disease processes or states l prolonged tourniquet times contraindicated (Sickle Cell Disease or Trait) l more susceptible to toxic effects of agents used (Heart Block) §Hypersensitivity/allergy to agents used §Patients with a painful extremity §Certain patient body habitus

16. Bier Block: technique §Equipment l tourniquet(s) with pressure gauge l rubber bandage (Martin, Esmarch) §Drugs l Local Anesthetics: Lidocaine 0.5% or Prilocaine 0.5% l Opioids l Ketorolac

17. Bier Block: mechanisms of action §Direct action at nerve endings §Diffusion into nerve trunks l Nerve trunks consist of fascicles covered with epineurium l Blood vessels contained within the epineurium l Capillaries within endoneurium extend intraneurally as vasa nervorum l Local anesthetic diffusion occurs from nerve core to the periphery

18. Bier Block: complications §Local anesthetic systemic toxicity l Premature tourniquet release, malfunctioning tourniquet l Leakage through intraosseous veins or ordinary veins §Direct tissue local anesthetic toxicity (neuronal, muscular, vascular injury ) §Ischemic injury (prolonged tourniquet time, excessive tourniquet pressure)

19. Bier Block: pearls §Tourniquet pain §Tourniquet deflation §Prolonged surgery §Lower extremity surgery

20. Paravertebral Blocks (PVB) §Paravertebral space §Spinal root emerges from intervertebral foramen, divides into dorsal and ventral rami and sympathetics §Unilateral motor, sensory, and sympathetic block

21. PVB Indications §Thoracic l thoracotomy l mastectomy l nephrectomy l cholecystectomy l rib fractures l post-thoracotomy pain l post-mastectomy pain §Lumbar: inguinal hernia

22. PVB: technique §Equipment §Drugs Technique l 2.5-3 cm lateral to spinous process, caudal and 1-2 cm deep to transverse process 4-5 ml local anesthetic §Variations

23. PVB: risks l Reported failure rate 10-15%

24. PVB: breast surgery §Block T1-T6: go lateral to C7-T5. §Greengrass: l Retrospective review, 156 blocks in 145 patients vs. 100 GA over 2-year period l 85% block alone l 91% block + local l 2.6% complication (4/156)

25. PVB vs. GA: breast surgery

26. PVB: inguinal hernia repair §Block T10-L2: go lateral to T10-L2 §Onset of surgical anesthesia 15-30 min

27. PVB: IH Repair, outcome §22 patients. 3 converted to GA l 1/3 had good block at emergence l failure rate 2-3/22 = 9-14% §Of 20 successful blocks l Onset of discomfort 14 11 hrs, first narcotic 22 18 hrs l 13 (65%) no incisional discomfort for at least 10 hrs after block l 3 (15%) epidural spread §Klein, SM Greengrass RA Weltz C Warner DS, 1998

28. PVB: inguinal hernia, satisfaction

29. SAB §Duration §Disadvantages §Advantages vs. epidural

30. Duration, SAB

31. Epidural §Duration §Disadvantages §Advantages vs. SAB

32. Duration, Epidural

33. Summary §Regional anesthesia is good §Use it!