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Anesthetic techniques: reGionAl ● 193 branch of the femoral nerve). When combined with a lumbar plexus block, it can provide complete anesthesia to the entire leg. Ankle Block Five nerves supply sensation to the foot (Figure 13.10). Four of the five nerves are branches of the sciatic nerve, while one is a branch of the femoral nerve. The saphenous nerve (branch of the femoral nerve) provides sensation to the anteromedial aspect of the foot. It can be blocked by infiltrating local anesthetic just anterior to the medial malleolus. The deep peroneal nerve provides sensation to the dorsal medial aspect of the foot and the webspace between the first two digits. It can be blocked by infiltrating local anesthetic lateral to the dorsalis pedis artery. The superficial peroneal nerve provides sensation to the dorsum of the foot and all five digits. It can be blocked by administering a subcutaneous wheal of local anesthetic from the anterior border of the tibia to the lateral malleolus. The sural nerve provides sensation to the lateral aspect of the foot. It can be blocked by injection of local anesthetic just lateral to the Achilles tendon, toward the lateral malleolus. Finally, the posterior tibial nerve provides sensation to the heel. The nerve can be blocked by injection of local anesthetic posterior to the medial malleolus. Approximately 5–8 mL of local anesthetic is injected for each nerve. Table 13.4 provides a summary of lower extremity peripheral nerve blocks. Intravenous Regional Anesthesia (Bier Block) A Bier block is a fairly simple block to perform and can produce profound anesthesia and analgesia. It is often used for short surgical procedures of the hand or forearm (e.g., carpal tunnel). A peripheral intravenous line is started and a double pneumatic tourniquet is placed on the arm. The arm is exsanguinated and the proximal cuff on the double tourniquet is inflated. Approximately 25–50 mL of 0.5% lidocaine is injected into the IV and the IV is removed. If the patient begins to complain about tourniquet pain, the distal cuff can be inflated and the proximal cuff deflated. If the surgical procedure is extremely short, the tourniquet must still be left in place for at least 20 min to avoid rapid systemic absorption of a high concentration of local anesthetic. Due to concern of inadvertent early tourniquet deflation and systemic absorption, long-acting local anesthetics, such as bupivacaine, are not recommended for intravenous regional blocks.
194 ● AnesthesiA student survivAl Guide Table 13.4 Summary of lower extremity nerve blocks. Type of nerve block Femoral Anterior thigh; knee; medial aspect of lower leg (saphenous nerve) Lumbar plexus (Psoas) Sciatic (posterior approach) Sciatic (lateral approach) Indications Anatomical landmarks hip; anterior thigh; knee; medial aspect of lower leg (saphenous nerve) Posterior thigh; below the knee surgery (except saphenous nerve distribution) Below the knee surgery (except saphenous nerve distribution) 1 cm lateral to palpation of femoral artery along the inguinal ligament 5 cm lateral from the spinous process (midline) at the level of iliac crest Posterior superior iliac spine (Psis); sacral hiatus; greater trochanter. A line bisecting the midpoint of the Psis and greater trochanter to intersect with a line drawn from greater trochanter to sacral hiatus Average needle depth Potential complications 3–5 cm intravascular injection; miss obturator and lateral femoral cutaneous nerves 6–8 cm epidural spread; intravascular injection; retroperitoneal hematoma; needle trauma to kidney 5–7 cm intravascular injection; nerve injury Between vastus lateralis 6–8 cm intravascular injection, and biceps femoris nerve injury, will miss muscles, contact femur, posterior thigh then change needle angle approx. 45° (tourniquet pain) Ultrasonography The use of ultrasound in regional anesthesia has increased in popularity over the past few years. As more research is done, ultrasound may ultimately prove to be safer, faster, and more effective than the paresthesia or neurostimulation techniques. Ultrasound emits high-frequency sound waves, which are reflected back when they encounter different types of tissue. Different tissues have different degrees of echogenicity and thus reflect the sound waves at different speeds. The resulting image provides varying shades that helps distinguish the tissue types. Nerves can be seen as round, oval, or triangular shaped structures and can be hyperechoic (light) or hypoechoic (dark). For example, nerves visualized above the diaphragm tend to be hypoechoic, while those below the diaphragm
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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30 ● AnesthesiA student survivAl
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Anesthesia Equipment and Monitors B
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AnesthesiA eQuiPment And mOnitOrs
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Page 204 and 205: Table 13.1 Risks of neuraxial anest
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Pneumothorax Uncommon, but may spon
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COMMON INTRAOPERATIVE PROBLEMS ●
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Table 16.3 Common intraoperative dy
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Table 16.3 (continued) Problem Diff
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Systems Physiology and Anesthetic S
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Chapter 20 Physiology and Anesthesi
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PhysioloGy And AnesthesiA for Gener
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Anesthesia for Urological Surgery P
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AnesthesiA for uroloGicAl surGery
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Physiology and Anesthesia for Pedia
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PhysioloGy And AnesthesiA for PediA
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Table 22.6 Common pediatric emergen
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Physiology and Anesthesia for Elder
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PhysioloGy And AnesthesiA for elder
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Chapter 24 Ambulatory Surgery and O
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AmbulAtOry Surgery ANd Out-Of-Or (O
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Perioperative Acute and Chronic Pai
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PerioPerAtive ACute And ChroniC PAi
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Chapter 27 Postoperative Anesthesia
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POstOPerAtive AnesthesiA CAre unit
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Introduction to Critical Care Bever
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introduction to criticAl cAre ● 4
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SVR = [(MAP - CVP)/CO] ´ 80 introd
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● ● ● ● ● introduction to
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Chapter 29 Professionalism, Safety,
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ProfessionAlism, sAfety, And teAmwo
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Chapter 30 Quality Assurance, Patie
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QuAlity AssurAnce, PAtient And Prov
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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