Download Update 11 - Update in Anaesthesia - WFSA

Update in Anaesthesia 59distribution of the saphenous nerveoccasionally extends down the medial sideof the big toe). the distribution of the sciatic nerve means thatit has fairly limited application as a block onits own and is most often combined with afemoral or 3-in-1 block.Combined sciatic and femoral or 3-in-1 block: with this combination pain relief andanaesthesia can be provided for almost anyinjury or operation from the upper thighdownwards.one area sometimes not covered is the upper,inner thigh, and possibly the posterior thigh.This may be a problem with tourniquetsapplied high on the leg and in this situationsome supplementary parenteral analgesia orsedation can be useful. it may be difficult to provide adequateanaesthesia for major hip surgery, althoughthe blocks described will provide goodpostoperative analgesia.Planning the dose of local anaesthetic and dealing withpossible side effectsThe above discussion will indicate that there are oftensituations in which one wishes to perform a combined sciaticand 3-in-1 block at the same time. This will necessitateusing large volumes of local anaesthetic and the total doseadministered may often be at the limit of recommendedsafe doses. It is important to be able to adjust theconcentration of the solution injected when using largevolumes, in order to keep the total dose at an acceptablelevel. See local anaesthetic, drugs and dosage page 56.Local complications of local anaesthetic blocks:The most important is damage to the nerve. Permanentnerve damage is very rare. It may be caused by accidentallyinjecting local anaesthetic within the nerve itself (intraneural)or by traumatising the nerve with the needle point. Twosigns of intraneural injection are severe pain on attemptedinjection and marked resistance to injection. (For thepatient to respond to the pain of intraneural injection he orshe must be awake, or only slightly sedated.) Either ofthese warning signs should prompt the operator to stopinjecting and reposition the needle. Intraneural injectionmay also be less likely if a short-bevel needle is used 1 .Paraesthesia is the “electric shock-like” feeling felt as thenerve is touched by the needle. It should be a warningsign that nerve damage may occur if the needle is insertedfurther.It is also possible to cause a haematoma by puncturing anartery with the needle - most commonly this will be thefemoral artery. This is rarely of any significance. If thefemoral artery is punctured then firm pressure applied tothe site for 5 minutes will minimise the haematoma.Performing the nerve blocks - patient preparationand techniquesWhen performing any of the blocks that are describedhere, the steps taken to safely prepare the patient shouldbe carefully followed.Preparing the patient Consent - explain the entire procedure to thepatient. This will help to relieve any anxiety andincrease co-operation.Fasting - if an elective procedure is planned, thenthe patient should be fasted similar to having a generalanaesthetic. This increases safety in the event that ageneral anaesthetic or resuscitation is required.Monitoring - the potential complications describedin the preceding section mean that monitoring isessential. If available, ECG and blood pressuremonitoring should be used. If sedation is plannedthen a pulse oximeter should also be used. In everycase, the most useful monitor is to maintain careful,continuous observation of the patient throughout.An assistant can be invaluable in helping with this.Intravenous access - because of the possiblecomplications, should be intravenous accesssecured before any block is performed. This alsoallows administration of intravenous fluids, sedativeagents and resuscitation drugs if required.Positioning - take care with positioning the patientfor the block and make sure they are ascomfortable as possible as this will make the blockeasier to perform.Identify the bony landmarks - these aredescribed in the anatomy section.Clean the site - the skin over the block site shouldbe cleaned with an antiseptic agent and surroundedwith sterile drapes. The operator should wash theirhands and wear sterile gloves.Perform the block!