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Compendium of Regional Anesthesia
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Foundations1. Histology of peripheral nerves and light microscopy14 Topics
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1.1 Organization of the peripheral nervous system
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1.2 Neurons
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1.3 Schwann cells
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1.4 Classification of nerve fibers
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1.5 Myelinated nerve fibers
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1.6 Unmyelinated nerve fibers
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1.7 Connective tissue investments of peripheral nerves
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1.8 Epineurium
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1.9 Perineurium
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1.10 Endoneurium
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1.11 The central-peripheral transition region
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1.12 Vascular supply of peripheral nerves
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1.13 Age-related changes in peripheral nerves
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1.14 Response of peripheral nerves to injury
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1.1 Organization of the peripheral nervous system
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2. Functional Regional Anesthesia Anatomy20 Topics
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2.1 Anatomy of Peripheral Nerves
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2.2 Connective Tissue
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2.3 Communication Between the Central Nervous System and Peripheral Nervous Systems
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2.4 Spinal Nerves
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2.5 Dermatomes, Myotomes, and Osteotomes
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2.6 Thoracic and Abdominal Wall
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2.7 Nerve Plexuses
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2.8 The Cervical Plexus
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2.9 The Brachial Plexus
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2.10 The Lumbar Plexus
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2.11 The Sacral Plexus
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2.12 Innervation of the Major Joints
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2.13 Shoulder Joint
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2.14 Elbow Joint
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2.15 Hip Joint
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2.16 Knee Joint
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2.17 Wrist and Hand
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2.18 Ankle and Foot
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2.19 Autonomic Component of Spinal Nerves
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2.20 Suggested Readings
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2.1 Anatomy of Peripheral Nerves
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3. Local Anesthetics: Clinical Pharmacology and Selection31 Topics
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3.1 Nerve conduction
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3.2 Mechanism of Action of Local Anesthetics
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3.3 Structure-Related Clinical Properties of Local Anesthetics
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3.4 Pharmacological Properties of Local Anesthetics
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3.5 Site of Injection
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3.6 Nerve Factors: Anatomical Characteristics of Nerve Fibers
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3.7 Differential Sensitivity of Nerve Fibers to Local Anesthetics
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3.8 Types of Local Anesthetics
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3.9 Ester-Linked Local Anesthetics
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3.10 2-Chloroprocaine
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3.11 Cocaine
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3.12. Procaine
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3.13 Tetracaine
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3.14 Amide-Linked Local Anesthetics
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3.15 Lidocaine
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3.16. Mepivacaine
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3.17 Prilocaine
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3.18 Bupivacaine
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3.19 Levobupivacaine
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3.20 Ropivacaine
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3.21 Additives to Local Anesthetics
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3.22 Vasoconstrictors
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3.23 Opioids
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3.24 Clonidine
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3.25 Dexmedetomidine
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3.26 Dexamethasone
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3.27 Other Adjuvants
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3.28 Selecting Local Anesthetics for Peripheral Nerve Blocks
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3.29 Mixing Local Anesthetics
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3.30 Extended-Release Formulations of Local Anesthetics
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3.31 Suggested Reading
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3.1 Nerve conduction
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4. Multimodal Analgesia: Pharmacologic Interventions and Prevention of Persistent Postoperative Pain10 Topics
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5. Equipment for Peripheral Nerve Blocks16 Topics
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5.1 Induction and Block Room
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5.2 Cardiovascular and Respiratory Monitoring During Application of Regional Anesthesia
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5.3 Regional Anesthesia Equipment Storage Cart
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5.4 Peripheral Nerve Block Trays
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5.5 Nerve Block Needles
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5.6 Needle Gauge
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5.7 “Echogenic” Needles and Tip Tracking Systems
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5.8 Ultrasound Machines
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5.9 Sterility
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5.10 Transducer Covers and Gel
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5.11 Injection Pressure Monitoring
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5.12 Continuous Nerve Catheters
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5.13 Securing Perineural Catheters
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5.14 Infusion Pumps
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5.15 Nerve Stimulators
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5.16 Suggested Readings
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5.1 Induction and Block Room
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6. Electrical Nerve Stimulation18 Topics
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6.1 Basics of Electrical Peripheral Nerve Stimulation
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6.2 Ohm’s Law
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6.3 Impedance and Constant-Current Source
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6.4 Coulomb’s Law, Electric Field, and Current Density
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6.5 How Nerve Stimulation Works
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6.6 Threshold Level, Rheobase, and Chronaxie
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6.7 Needle-to-Nerve Distance
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6.8 The Role of Nerve Stimulation in Conjunction with Ultrasound-Guided Nerve Blocks
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6.9 Limitations of Peripheral Nerve Stimulation
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6.10 Nerve Stimulation and Interference with Pacemakers and Defibrillators
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6.11 Stimulating Needles
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6.12 Clinical Use of Peripheral Nerve Stimulation
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6.13 Basic Settings and Implications
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6.14 Electrode Localization
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6.15 Using Peripheral Nerve Stimulation as a Localization Tool Without Ultrasound Guidance
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6.16 Troubleshooting
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6.17 Suggested Readings
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Appendix: Glossary of Physical Parameters
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6.1 Basics of Electrical Peripheral Nerve Stimulation
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7. Optimizing an Ultrasound Image7 Topics
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8. Indications for Peripheral Nerve Blocks6 Topics
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9. Regional Anesthesia & Nerve Injury3 Topics
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10. Assessment of Neurologic Complications of Regional Anesthesia10 Topics
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10.1 Barriers to Recognition of Postoperative Neurologic Injury
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10.2 Barriers to Neurologic Evaluation of a Postoperative Neurologic Complication
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10.3 Mechanisms of Injury
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10.4 Neuraxial Complications
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10.5 Treatment and Prognosis of Neurologic Complications of Neuraxial Procedures
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10.6 Peripheral Nerve Injury
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10.7 Postsurgical Inflammatory Neuropathies
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10.8 The Role of Electrophysiology in Evaluating Postoperative Nerve Injuries
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10.9 Conclusion
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10.10 References
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10.1 Barriers to Recognition of Postoperative Neurologic Injury
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11. Local Anesthetic Systemic Toxicity and Allergy to Local Anesthetics18 Topics
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11.1 Mechanisms of LAST
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11.2 Special Populations and the Risk of Local Anesthetic Systemic Toxicity
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11.3 Newborns
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11.4 Elderly Patients
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11.5 Renal Disease
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11.6 Liver Disease
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11.7 Heart Failure
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11.8 Pregnancy
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11.9 Symptoms and Diagnosis
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11.10 Prevention
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11.11 Limiting Intravascular Injection and Systemic Uptake
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11.12 Management
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11.13 Specific Cardiopulmonary Resuscitation
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11.14 Lipid Therapy: Mechanism
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11.15 Allergy to Local Anesthetics
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11.16 Symptoms and Diagnosis
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11.17 Management
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11.18 Suggested Readings
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11.1 Mechanisms of LAST
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Head and Neck Nerve Blocks12. Nerve Blocks of the Face13 Topics
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12.1 Trigeminal Nerve
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12.2 Superficial Trigeminal Nerve Blocks
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12.3 Block of the Frontal Nerve (Supraorbital and Supratrochlear Branches)
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12.4 Block of the Infraorbital Nerve
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12.5 Block of the Mental Nerve
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12.6 Ultrasound-Guided Technique for Superficial Trigeminal Nerve Blocks
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12.7 The Maxillary Nerve Block
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12.8 The Mandibular Nerve Block
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12.9 Regional Block of the Nose
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12.10 Regional Blocks of the External Ear
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12.11 Greater Occipital Nerve Block
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12.12 Scalp Block
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12.14 References
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12.1 Trigeminal Nerve
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13. Regional and Topical Anesthesia for Awake Endotracheal Intubation11 Topics
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13.1 Introduction
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13.2 Sensory Innervation of the Airway
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13.3 Topical Anesthesia
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13.4 Application Techniques
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13.5 Regional Anesthesia Techniques
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13.6 Landmark Technique Glossopharyngeal Nerve Block
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13.7 Ultrasound-Guided Techniques
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13.8 Sedation Techniques
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13.9 Preferred Technique for Performing an Awake Fiber-Optic Intubation
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13.10 Summary
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13.11 Recommended Readings
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13.1 Introduction
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14. Regional Anesthesia for the Eye13 Topics
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14.1 Indications & Quick facts
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14.2 Anatomy
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14.3 Sensory & motor block
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14.4 Key surgical considerations
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14.5 Technique: Sub-tenon's eye block
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14.6 Technique: Retrobulbar eye block
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14.7 Technique: Peribulbar eye block
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14.8 Technique: Topical anesthesia
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14.9 Technique: Subconjunctival anesthesia
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14.10 Technique: Oculoplastic blocks
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14.11 Local anesthetic choice
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14.12 Complications
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14.13 Tips
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14.1 Indications & Quick facts
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15. Ultrasound-Guided Cervical Plexus Block11 Topics|1 Quiz
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Neuraxial Anesthesia and Other Special Techniques16. Neuraxial Anatomy9 Topics
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17. Spinal anesthesia11 Topics
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17.1 Indications and Quick facts
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17.2 Anatomy
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17.3 Mechanism of action
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17.4 Pharmacology
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17.5 Indications
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17.6 Contraindications
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17.7 Sensory & motor block for specific surgeries
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17.8 Technique of Lumbar Puncture
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17.9 Ultrasound-guided spinal anesthesia technique
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17.10 Local anesthetic dosing for different indications
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17.11 Complications
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17.1 Indications and Quick facts
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18. Epidural anesthesia15 Topics
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18.1 Indications & Quick facts
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18.2 Anatomy
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18.3 Mechanism of action
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18.4 Pharmacokinetics
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18.5 Pharmacodynamics
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18.6 Indications
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18.7 Indications - Lumbar epidural anesthesia
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18.8 Indications - Thoracic epidural anesthesia
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18.9 Indications - Uncommon medical disorders and clinical scenarios
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18.10 Contraindications
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18.11 Technique - Thoracic and Lumbar Epidural Block
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18.12 Technique - Cervical Epidural Block
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18.13 Local Anesthetic Choice and Dosing
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18.14 Problem-solving
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18.15 Complications and common side effects
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18.1 Indications & Quick facts
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19. Combined Spinal-Epidural Anesthesia23 Topics
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19.1 Introduction
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19.2 Clinical applications of CSE
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19.3 Advantages of CSE
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19.4 Epidural Volume Extension: A Modification of the CSE
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19.5 Sequential CSE
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19.6 CSE for High-Risk Patients
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19.7 Functional Anatomy Related to CSE
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19.8 Technique
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19.9 Needle-Through-Needle Technique
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19.10 Separate Needle Technique
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19.11 Comparison of Techniques
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19.12 Techniques to Improve the Success and Safety of CSE
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19.13 Drugs for CSE
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19.14 Complications and Concerns of the CSE Technique
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19.15 Complications Associated With Spinal Migration of the Epidural Catheter or Intrathecal Administration of Epidural Drugs
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19.16 Hypotension
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19.17 Neurological Injury
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19.18 Postdural Puncture Headache
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19.19 Complications Related to Labor Analgesia
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19.20 Equipment
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19.21 Controversial Topics in CSE Technique
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19.22 Summary
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19.23 References
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19.1 Introduction
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20. Caudal Anesthesia12 Topics
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20.1 Introduction
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20.2 Anatomic Considerations
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20.3 Indications for Caudal Epidural Block
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20.4 Technique of Caudal Epidural Block
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20.5 Ultrasound-Guided Caudal Block
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20.6 Characteristics of Caudal Epidural Block in Adults
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20.7 Caudal Block for Labor Analgesia
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20.8 Indications for Caudal Epidural Analgesia in Children
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20.9 Applications of Caudal Epidural Block in Acute and Chronic Pain Management
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20.10 Complications Associated With Caudal Epidural Block
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20.11 Summary
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20.12 References
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20.1 Introduction
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21. Pediatric Spinal Anesthesia & Analgesia8 Topics
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22. Pediatric Epidural Anesthesia & Analgesia21 Topics
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22.1 Anatomy and Physiological Implications
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22.2 Local Anesthetics for Epidural Anesthesia in Children
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22.3 Adjuvants for Epidural Anesthesia in Children
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22.4 Complications Associated with Epidural Anesthesia
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22.5 Epidural Block for Pediatric Surgery: Techniques
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22.6 Aspiration and Test Dose
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22.7 Radiographic Methods
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22.8 Epidural Stimulation Test (Tsui Test) and Epidural ECG Technique
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22.9 Ultrasound-Guided Techniques
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22.10 Epidural Approaches
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22.11 Caudal Epidural Analgesia: Single-Injection Technique
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22.12 Choice of Needle for Caudal Analgesia
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22.13 Technique for Performing a Single-Injection Caudal Epidural Block
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22.14 Confirmation of Correct Local Anesthetic Distribution
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22.15 Caudal Epidural Analgesia: Continuous Technique
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22.16 Lumbar Epidural Anesthesia
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22.17 Lumbar-to-Thoracic Epidural Approach
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22.18 Thoracic Epidural Analgesia
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22.19 Thoracic Epidural Analgesia: Midline Approach
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22.20 Postoperative Epidural Infusion Management
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22.21 References
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22.1 Anatomy and Physiological Implications
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23. Mechanisms and management of failed spinal anesthesia7 Topics
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24. Postdural Puncture Headache35 Topics
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24.1 History and Current Relevance
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24.2 Pathophysiology
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24.3 Clinical Presentation and Characteristics
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24.4 Onset
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24.5 Presentation
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24.6 Associated Symptoms
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24.7 Risk Factors
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24.8 Patient Characteristics
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24.9 Procedural Details
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24.10 Prevention
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24.11 General Measures
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24.12 Spinal Technique
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24.13 Epidural Technique
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24.14 Measures to Reduce the Risk of PDPH After ADP
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24.15 Stylet Replacement
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24.16 Subarachnoid Saline
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24.17 Intravenous Cosyntropin
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24.18 Limiting/Avoiding Pushing
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24.19 Intrathecal Catheters
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24.20 Epidural Saline
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24.21 Epidural Opiates
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24.22 Prophylactic Epidural Blood Patch
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24.23 Diagnostic Evaluation
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24.24 Treatment
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24.25 Time
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24.26 Supportive Measures
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24.27 Pharmacologic Therapies
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24.28 Epidural Therapies
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24.29 Epidural Saline
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24.30 Epidural Blood Patch
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24.31 Alternative Treatment Options to EBP
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24.32 Persistent or Recurrent PDPH
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24.33 When to Seek Further Consultation
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24.34 Summary
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24.35 References
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24.1 History and Current Relevance
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25. Diagnosis and Management of Spinal and Peripheral Nerve Hematoma9 Topics
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26. Intravenous regional anesthesia for upper and lower extremity7 Topics
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27. Intra-articular and Periarticular Infiltration of Local Anesthetics8 Topics
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27.1 The Concept of Local Infiltration Analgesia
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27.2 Evidence-based Information on Efficacy and Safety of Local Infiltration Analgesia
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27.3 Potential and Documented Pros and Cons of Local Infiltration Analgesia and Alternatives
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27.4 Local infiltration analgesia for hip arthroplasty
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27.5 Local infiltration analgesia for knee arthroplasty
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27.6 LIA in total knee arthroplasty
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27.7 LIA in total hip arthroplasty
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27.8 References
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27.1 The Concept of Local Infiltration Analgesia
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Blocks for the Upper Extremity28. Interscalene Brachial Plexus Block9 Topics|1 Quiz
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29. Supraclavicular Brachial Plexus Block9 Topics|1 Quiz
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30. Infraclavicular Brachial Plexus Block9 Topics|1 Quiz
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31. Costoclavicular Brachial Plexus Block7 Topics
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32. Shoulder Block10 Topics|1 Quiz
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33. Axillary Brachial Plexus Block9 Topics|1 Quiz
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34. Nerve Blocks Above the Elbow9 Topics
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35. Wrist Block10 Topics|1 Quiz
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Nerve Blocks for the Lower Extremity36. Sonography of the Lumbar Paravertebral Space and Considerations for Ultrasound-Guided Lumbar Plexus Block4 Topics
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37. Fascia Iliaca Block9 Topics|1 Quiz
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38. The Hip Block8 Topics
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39. Femoral Nerve Block9 Topics|1 Quiz
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40. Saphenous Nerve Block at the Adductor Canal8 Topics
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41. Popliteal Sciatic Nerve Block9 Topics|1 Quiz
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42. IPACK Block9 Topics
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43. Ankle Block13 Topics|1 Quiz
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43.1 Indications & Quick facts
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43.2 Anatomy
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43.3 Sensory & motor block
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43.4 Landmarks & patient position
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43.5 Technique
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43.6 Tibial nerve block
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43.7 Deep peroneal nerve block
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43.8 Superficial peroneal nerve block
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43.9 Sural nerve block
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43.10 Saphenous nerve block
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43.11 Local anesthetic choice
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43.12 Tips & algorithm
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43.13 Video
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43.1 Indications & Quick facts
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44. Tibial Nerve Block at the Level of the Ankle8 Topics
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45. Deep peroneal nerve block at the level of the ankle8 Topics
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46. Superficial Peroneal Nerve Block at the Level of the Ankle8 Topics
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47. Sural Nerve Block at the Level of the Ankle8 Topics
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48. Saphenous Nerve Block at the Level of the Ankle8 Topics
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49. Genicular Nerve Blocks13 Topics
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49.1 General Considerations
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49.2 Limitations
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49.3 Specific Risks
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49.4 Anatomy
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49.5 Ultrasound View
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49.6 Distribution of Analgesia
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49.7 Block Preparation
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49.8 Local Anesthetic
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49.9 Patient Positioning
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49.10 Technique - Initial Transducer Position and Scanning Technique
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49.11 Needle Approach and Trajectory
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49.12 Flowchart
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49.13 Suggested Readings
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49.1 General Considerations
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Abdominal & Thoracic Wall Blocks50. Pectoralis and Serratus Anterior Plane Blocks11 Topics|1 Quiz
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51. Transversus Abdominis Plane (TAP) Blocks11 Topics|1 Quiz
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51.1 Indications & Quick facts
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51.2 Anatomy
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51.3 3D-Anatomy
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51.4 Sensory & motor block
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51.5 Landmarks & patient position
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51.6 Subcostal TAP block
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51.7 Lateral TAP block
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51.8 Posterior TAP block
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51.9 Ilioinguinal-iliohypogastric block (Anterior TAP)
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51.10 Local anesthetic choice
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51.11 Tips & algorithm
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51.1 Indications & Quick facts
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52. Quadratus Lumborum Plane Blocks10 Topics|1 Quiz
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53. ESPB8 Topics
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54. Rectus Sheath Block9 Topics
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55. Paravertebral Block8 Topics
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RA for Specific Surgical Procedures56. Carpal Tunnel Release2 Topics
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57. Total Shoulder Arthroplasty2 Topics
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58. Total Hip Arthroplasty2 Topics
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59. Total Knee Arthroplasty2 Topics
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RA in Patients with Specific Considerations60. Obstetric Regional Anesthesia31 Topics
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60.1 Physiologic Changes of Pregnancy
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60.2 Changes in the Cardiovascular System
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60.3 Changes in the Respiratory System
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60.4 Metabolic Changes
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60.5 Changes in the Gastrointestinal System
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60.6 Endocrine Changes Influencing Plasma Volume, Blood Composition, and Glucose Metabolism
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60.7 Altered Drug Responses in Pregnancy
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60.8 Placental Transfer of Local Anesthetics
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60.9 Risk of Drug Exposure: Fetus Versus Newborn
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60.10 Anesthesia for Labor and Vaginal Delivery
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60.11 Systemic Analgesia
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60.12 Regional Analgesia Techniques
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60.13 Epidural Analgesia
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60.14 Spinal Analgesia
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60.15 Combined Spinal–Epidural Analgesia
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60.16 Paracervical Block
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60.17 Paravertebral Lumbar Sympathetic Block
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60.18 Pudendal Nerve Block
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60.19 Anesthesia for Cesarean Section Delivery
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60.20 Advantages of Regional Anesthesia in the Obstetric Patient
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60.21 Spinal Anesthesia
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60.22 Lumbar Epidural Anesthesia
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60.23 Local Anesthetic Choices
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60.24 Anesthetic Complications
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60.25 Regional Anesthesia in Complicated Pregnancy
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60.26 Preeclampsia-Eclampsia
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60.27 Antepartum Hemorrhage
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60.28 Preterm Delivery
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60.29 Non-obstetric Surgery in the Pregnant Woman
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60.30 Summary
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60.31 References
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60.1 Physiologic Changes of Pregnancy
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61. Regional Anesthesia & Cardiovascular Disease16 Topics
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61.1 The Cardiovascular Effects Of Regional Anesthesia
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61.2 Lumbar Epidural Anesthesia
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61.3 Intrathecal Anesthesia
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61.4 Thoracic Blocks (Paravertebral and Intercostal)
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61.5 Upper Extremity Regional Anesthesia and Cardiac Disease
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61.6 Brachial Plexus Block
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61.7 Lower Extremity Regional Anesthesia and Cardiac Disease
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61.8 Regional Anesthesia and Cardiac Surgery
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61.9 The Patient With Cardiac Disease Presenting For Noncardiac Surgery
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61.10 The Patient with Hypertension/Left Ventricular Hypertrophy
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61.11 The Patient with Ischemic Heart Disease
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61.12 The Patient with Valvular Heart Disease Regurgitant Valvular Disease
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61.13 Stenotic Valvular Disease
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61.14 The Adult Patient with Congenital Heart Disease
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61.15 Summary
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61.16 References
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61.1 The Cardiovascular Effects Of Regional Anesthesia
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62. Perioperative Regional Anesthesia in the Elderly14 Topics
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62.1 Physiologic Changes Associated With Aging and Considerations for Regional Anesthesia/Analgesia
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62.2 Nervous System Function
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62.3 Cardiovascular Function
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62.4 Pulmonary Function
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62.5 Pharmacokinetic and Pharmacodynamic Changes in the Elderly
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62.6 Multimodal Drug Therapy and the Elderly
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62.7 Physiology and the Perception of Pain in the Elderly and Clinical Implications
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62.8 Assessment of Pain in Older Cognitively Impaired Patients
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62.9 Considerations for the Use of Peripheral Regional and Neural Block in Elderly Patients
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62.10 Epidural Anesthesia and Analgesia
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62.11 Intrathecal Opioid Analgesia
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62.12 Regional Anesthesia and Analgesia Using Peripheral Nerve and Nerve Plexus Block
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62.13 Summary
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62.14 References
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62.1 Physiologic Changes Associated With Aging and Considerations for Regional Anesthesia/Analgesia
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63. Regional Anesthesia in Patients with Trauma12 Topics
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63.1 Management of Acute Pain in Patient with Trauma
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63.2 The Role of Regional Anesthesia in Trauma
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63.3 Continuous Peripheral Nerve Blocks in Patients with Trauma
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63.4 Regional Analgesia in the Emergency Department and Prehospital Settings
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63.5 Specific Injuries: Hip Fractures
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63.6 Specific Injuries: Fractured Ribs
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63.7 Specific Injuries: Digital Replantation
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63.8 Regional Anesthesia for Shoulder Reduction
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63.9 Regional Anesthesia for Burns
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63.10 Acute Compartment Syndrome Considerations
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63.11 References
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63.12 Summary
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63.1 Management of Acute Pain in Patient with Trauma
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64. Regional Anesthesia in Anticoagulated Patients5 Topics
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65. ERAS Protocols
Lesson 53, Topic 7
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53.7 Tips & algorithm
Lesson Progress
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- A high-frequency linear transducer can be used for thoracic levels, whereas a low-frequency curved array transducer may be better suited for lumbar injections or obese patients, where the erector spinae layers are deeper (greater depth than 4cm).
- A caudad-to-cranial direction or out-of-plane needle insertion can be used
- When pleura is imaged at any time: The transducer is placed too lateral. Slide medially until the transverse processes are identified and the pleura is no longer seen.
- Keep in mind at all times: ESPB is a fascial plane technique – therefore a volume-dependent block for success. Regardless, be mindful of the total dose of local anesthetics keeping in mind the risk of local anesthetic systemic toxicity and resuscitative measures should it occur.
- For a continuous technique, first, inject 5 mL of local anesthetic to create a space in which the catheter can then be advanced.
