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Pudendal nerve block

Key Points Patient selection plays a major role in performing the block; it is challenging with obese patients. Ultrasound experience is required to maximize the success rate of the block. Vascular injection is a risk if no spread is visualized with deposition of local anesthetics under ultrasound. Avoid contamination as the area of injection is close to the perianal area. Indications Perineal operations in both sexes.…

Ilioinguinal and iliohypogastric block

Key Points Identifying the different layers of the muscles is crucial because the peritoneum is the shiniest layer under the transversus abdominis muscle. When the bowels are seen under the peritoneum under ultrasound, the sliding sign appears in response to breathing. Loss of resistance when penetrating the different muscle layers can be felt as a pop. Extra caution is needed because the needle could advance accidentally…

Caudal block in pediatrics

Key Points Checking the anatomy with ultrasound before and during the procedure assures success. Because the sacrum is not fully ossified, it can still be penetrated by the ultrasound beams. Loss of resistance is not significant when placing an epidural because the sacrococcygeal ligament is softer in the pediatric population. The needle may be misplaced in the subcutaneous periosteal location or in the dural sac. Position…

Caudal block

Key Points In approximately 5% of adult patients, the sacral hiatus is nearly impossible to cannulate with needle or catheter. The tissue mass overlying the sacrum in some patients makes the technique difficult. The sacral hiatus lies at the tip of equilateral triangle that joins the poster superior iliac spines bilaterally. Caudal block can be performed in a lateral decubitus or a prone position. Volumes of…

Epidural block

Key Points Epidural block can be performed in cervical, thoracic, and lumbar regions of the vertebral column. Paramedian approach is the preferred technique for thoracic epidural, while median and paramedian approaches are suitable for lumbar epidural. T5–T6 interspace is the preferred position for thoracic epidural catheter insertion. The ligamentum flavum is congenitally absent in the midline in some people, which makes them prone to the dural…

Spinal block

Key Points Spinal anesthesia is unparalleled in that a small mass of local anesthetic can produce dense surgical anesthesia. Bupivacaine is the ideal drug for spinal anesthesia. Identification of the lamina at 1 cm lateral to the spinous process is very crucial for a successful paramedian approach. The use of a 25-gauge spinal needle is very helpful to avoid postdural puncture spinal headache. Taylor technique is…

Ultrasound-assisted neuraxial blocks

Key Points Prepuncture ultrasound scanning is helpful to determine the midline, the depth from the skin, the desired level, and rotation of the spine. There are limited outcome data on the real-time guidance with ultrasound for neuraxial blocks. The available evidence suggests that the use of ultrasound may improve the success rate from the first attempt, reduce the number of attempts, and improve patient comfort. The…

Subcostal transversus abdominal plane block

Key Points The subcostal transversus abdominal plane (TAP) approach is very useful for supraumbilical procedures. The most cephalad sensory dermatomal spread is T8. The bilateral continuous catheter infusion can be used in the upper abdominal surgeries where epidural analgesia is contraindicated or failed. The key for the success of this technique is the proper identification of the fascial plane between the transversus abdominis and rectus abdominis…

Transversus abdominis plane block (classic approach)

Key Points The transversus abdominis plane (TAP) block is a tissue plane block depending on adequate spread of local anesthetics through the plane—accordingly a minimum volume of 20 mL is usually needed for effective block. Frequent, small, incremental injections of saline while advancing the needle can identify the progress of the needle tip through the various tissue planes. When performed appropriately, the TAP block is very…

Paravertebral block

Key Points The thoracic paravertebral block, with or without catheter, can be used in lieu of thoracic epidural catheter for unilateral procedures and for breast surgeries. Pneumothorax is the major complication of this block. When performing the block and the injection, make sure the needle tip always remains visible in the plane. Indications Thoracic paravertebral catheter can be used in lieu of thoracic epidural analgesia for…

Serratus anterior block

Key Points Serratus anterior block is indicated for anterolateral chest wall incisions, targeting the lateral and postcutaneous branches of upper and middle thoracic dermatomes. The block has been used for different thoracoscopic and open chest wall incisions as well as chest tube placements and rib fractures. The long thoracic nerve is included in the serratus anterior block. Injection of the local anesthetic either superficial or deep…

PECS and Pecto-Intercostal blocks

Key Points Anterior chest wall blocks are used as alternatives to thoracic epidurals and paravertebral blocks for breast surgeries and procedures involving the anterior chest walls. Serratus plane blocks and supraclavicular blocks may be required for more extensive surgeries. Pectoralis major, pectoralis minor, and serratus anterior muscles are the main landmarks for the PEC blocks at the level of the fourth and fifth ribs. Bilateral pecto-intercostal…

Translaryngeal block

Key Points It is a useful block in providing topical anesthesia to the laryngotracheal mucosa innervated by branches of vagus nerve. Injection through the cricothyroid membrane results in the solution being spread onto the tracheal structures and coughed onto the more superior laryngeal structures. Air should be aspirated freely before injecting the local anesthetics. Perspective This block, like all airway blocks, can be useful in sedated,…

Superior laryngeal block

Key Points The superior laryngeal nerve is blocked at the lower border of the hyoid bone. A small 25-gauge, short needle is used to reduce the risk of intravascular or intralaryngeal injections. Perspective The superior laryngeal nerve block is one of the methods of providing airway anesthesia. Block of the superior laryngeal nerve provides anesthesia of the larynx from the epiglottis to the level of the…

Glossopharyngeal block

Key Points The distal branches of the glossopharyngeal nerve are located submucosally immediately posterior to the palatine tonsil, deep to the posterior tonsillar pillar. Glossopharyngeal blocks can be achieved from an intraoral approach or externally next to the styloid process. Bending the tip of the needle helps positioning the needle submucosally in posttonsillar be when performing the intraoral approach. Perspective Glossopharyngeal block is useful for anesthesia…