1. Josh Major Anesthesia Clerkship
Regional Nerve Blocks
Josh Major
Anesthesia Clerkship

2. History of Peripheral Nerve Block
1880’s: William Stewart Halstad and Richard John Hall describe injecting cocaine into peripheral sites during minor surgery
1914: Heinrich Braun describes techniques for every region of the body.
1922: Regional Anesthesia: It’s Technic and clinical Application written by Gaston Labot at the Mayo Clinic
Definitive regional anesthesia textbook for 30 years.

3. Indications for Regional Nerve Block
Pain control post-op associated with surgical procedures
Improved patient satisfaction due to decreased pain, opioid use and side effects and decreased incidence of sleep disturbance
Useful in patients in whom general anesthesia is contraindicated or prevent undesired effects

4. Contraindications Absolute Contraindications:
Infection at site of block
Patient refusal
Allergy to local anesthetic
Relative Contraindications:
Medical anticoagulation or coagulopathy in deeper nerve blocks

5. Types of Nerve Blocks
Single Shot: one time injection of local anesthetic to target nerve
Continuous Perineural Blockade: percutaneous insertion of a catheter directly adjacent to target nerves

6. Upper Extremity Blocks

7. Upper Extremity Blocks
Interscalene Block – Indication: Surgery or manipulation of the shoulder
Supraclavicular Block – Indication: Elbow, forearm and hand surgery
Infraclavicular Block – Indication: Provide anesthesia to the arm and hand
Axillary Block – Forearm and hand surgery

8. Lower Extremity Blocks

9. Lower Extremity Blocks
Femoral Nerve Block – Indication: Knee arthroscopy, femoral shaft fractures, total knee repair and ACL reconstruction
Obturator Nerve Block – Indication: Knee surgery, rarely blocked on it’s own
Sciatic Nerve Block – Indication: Can be used together with a femoral or saphenous block for any procedure below the knee that doesn’t need a thigh tourniquet
Inject large volume of anesthetic into the lumbar plexus

10. Choices of Local Anesthetic
Depends primarily on required duration of anesthesia
Different anesthetic drugs have varying durations
Blockade may last up to 24 hours
Epinephrine can be added to improve onset of action and prolong drug action

11. Major Nerve Block Drugs
Major Nerve Blocks
Drug with Epinephrine 1 : 200,000
Usual Concentration (%)
Usual Volume (mL)
Maximal Dose (mg)
Usual Onset (min)
Usual Duration (min)
Lidocaine
1-2
30-50
500
10-20
Mepivacaine
1-1.5
Prilocaine
600
Bupivacaine
225
20-30
Levobupivacaine
Ropivacaine
250

12. Ultrasound Guidance
Allows direct visualization of the nerve, needle, and anesthetic distribution
Commonly used as an adjunct to regional anesthesia techniques
Can be useful in decreasing complications
Facilitates placement of blocks in patients with challenging anatomy

13. Complications Block Failure Perineural Hematoma Infection Nerve Injury
Intravascular Injection
Intraneural Injection
Excessively Dense Block

14. References
Miller, M.D., Eriksson, L.I., et al. (eds.). Miller’s Anesthesia, 7th Edition. Philidelphia: Churchill Livingston 2009.