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Equipment and ultrasound

Equipment Needles, catheters, and syringes Effective regional anesthesia requires comprehensive knowledge of equipment—that is, the needles, syringes, and catheters that allow the anesthetic to be injected into the desired area. In early years, regional anesthesia found many variations in the method of joining needle to syringe. Around the turn of the century, Schneider developed the first all-glass syringe for Hermann Wülfing-Luer. Luer is credited with the…

Pharmacology of local anesthetics in pediatrics

Key Points Neonates and infants are more prone to developing systemic toxicity to local anesthetics (LAs), particularly amide LAs, compared with older children and adults. This is due to reduced plasma concentration of α 1 -acid glycoprotein with higher unbound fraction and decreased clearance of amide LAs. Higher baseline heart rates in neonates and infants predispose them to increased sensitivity for bupivacaine-induced cardiotoxicity compared with adults.…

Pharmacology

Regional anesthesia is a fast-growing field with application in a wide range of surgical procedures. Better technique with the help of ultrasound, better and safer local anesthetics, and better drug delivery systems for continuous anesthesia all helped in gaining the current status. Far too often, those unfamiliar with regional anesthesia regard it as complex because of the long list of local anesthetics available and the varied…

Regional Anesthesia in Resource-Constrained Environments

Introduction Regional anesthesia is a relatively low-cost and widely used technique in perioperative analgesia and anesthesia. To date, it has been primarily utilized in high-income countries (HICs) where regional anesthesia has been associated with reduced postoperative pain, reduced opioid requirements, as well as increased patient satisfaction, surgical pathway efficiency, and avoidance of general anesthesia. While each of these outcomes is also relevant in low- and middle-income…

Safety: Practical Techniques to Prevent Complications During Ultrasound-Guided Nerve Blocks

The goal of this chapter is to promote practical techniques that enhance safety during ultrasound-guided peripheral nerve block (PNB). Ultrasound-guided PNB can be performed with a level of precision and purpose that is not feasible with other techniques. Ultrasound imaging and guidance for PNB is unique among all the nerve localizing tools and monitors because the needle trajectory can be tracked and controlled, reducing the risk…

Stellate Ganglion Block (Cervicothoracic Sympathetic Ganglion Block)

Stellate ganglion blocks can be performed to treat sympathetically maintained pain (reflex sympathetic dystrophy, causalgia, complex regional pain syndromes). The stellate ganglion is the fusion of the inferior cervical and first thoracic sympathetic ganglia. Almost all the sympathetic innervation of the head, neck, and upper extremity travels via pathways through the stellate ganglion. The stellate ganglion is approximately 0.5 to 2.5 cm in size. Despite its name,…

Cervical Plexus Block

Introduction Anatomic Background The cervical plexus derives from the ventral rami of C1 to C4 and has two types of branches: muscular and cutaneous. Muscular branches include the phrenic nerve (C4 (C3 to C5); innervation: pericardium, diaphragm), the deep cervical ansa (loop formed from C1 to C3; innervation: supra- and infrahyoid muscles), and segmental branches from C1 to C4 (innervation: rectus capitis, longus colli and longus…

Transtracheal Block

Transtracheal block provides topical anesthesia of small branches of the recurrent laryngeal nerve that lines the tracheal lumen below the vocal cords. Because transtracheal injection usually elicits a strong cough reflex, local anesthetic also will distribute over the walls of the larynx and pharynx in the territory of the superior laryngeal nerve. This injection can improve conditions for awake fiberoptic intubation and upper endoscopy. The distance…

Neuraxial Block

Introduction In many patients, epidural and spinal blocks are routine procedures guided by loss of resistance and confirmation of free flow of cerebrospinal fluid, respectively. However, in patients with obesity or advanced age, these neuraxial blocks can be more challenging and may benefit from imaging guidance. Ultrasound can estimate the location and level of spinous interspaces. There also is evidence that ultrasound guidance improves the learning…

Pudendal Nerve Block in Children

Introduction The pudendal nerve is the major paired nerve of the perineum. It supplies sensation to the genitalia and perineal skin, and motor innervation to the external anal and external urethral sphincters. It is a branch of the sacral plexus (S2 through S4). With ultrasound, the nerve is most easily visualized in the pudendal canal, where it travels with the pudendal artery and vein. For adults,…

Thoracic Paravertebral Block

Introduction Thoracic paravertebral block (TPVB) is the technique of injecting local anesthetic alongside the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramina. This produces ipsilateral somatic and sympathetic nerve blockade in multiple contiguous thoracic dermatomes (segmental thoracic anesthesia) both above and below the site of injection. It is effective in treating acute and chronic pain of unilateral origin from the chest…