NYSORA NEWSLETTER DECEMBER 2012

The DECEMBER 2012 NYSORA Newsletter

In this issue:

• A Letter from Your Editor
• Insider Tips on Infraclavicular Block
• Focus on Fascia Iliaca Block
• NYSORA Flash News
• Promotions
• Save 20% on Hadzic's Peripheral Nerve Blocks

A Letter from Your Editor

Dear NYSORA Newsletter reader,

Greetings from New York City and Happy Holidays. This December issue of the newsletter features some great practical insight on 2 of our favorite blocks—Infraclavicular and Fascia Iliaca. Please feel to add your thoughts via the link that follows each article. Additionally, don't forget that 2 NYSORA sponsored meetings are fast approaching—NYSORA ASIA and a joint NYSORA-UZ Leuven meeting in Belgium. More information is found below. We look forward to seeing you in the near future!

Best,
Clark Jaffe

Submit your research to the NYSORA Abstract Competition -- iPads for 1st, 2nd and 3rd prize
and Hadzic's Peripheral Nerve Blocks textbook for 4th and 5th prize.

Insider Tips for Ultrasound-Guided Infraclavicular Nerve Block
Jeff Gadsden, MD
Director of Regional Anesthesia
St. Luke's-Roosevelt Hospital Center
Assistant Professor of Clinical Anesthesiology
Columbia University College of Physicians and Surgeons
New York, New York

The infraclavicular nerve block is one of my personal favorites for upper extremity procedures. Following these five tips should help improve ease of performance and success rates with this versatile block.

Tip # 1: Position the arm at 90 degrees to the patient.

This is not always practical or feasible due to patient factors (i.e. pain fracture limiting movement). However, abducting the arm reliably brings the neurovascular structures closer to the surface, improving the sonographic image and reducing the distance the needle has to travel to reach the target structures. It may provide an additional safety advantage as well, as the distance from the skin to the pleura is not changed.

Tip # 2: Don’t position the transducer too medial or too lateral.

These errors result in difficulty identifying the neurovascular structures. The ideal location to place the transducer is just beneath clavicle, immediately medial to the coracoid process.

Tip # 3: "Rock" the transducer in a slightly cranial direction.

Since the needle will be traveling at a fairly steep angle in a cranial-to-caudal direction, tilting the ultrasound beam towards the head will improve needle visualization by rendering the beam slightly more perpendicular relative to the needle.

Tip # 4: Don't stress about seeing your needle--you won't.

Unless you're using specific echogenic needles, this block is too "steep and deep" to reliably see your needle throughout the procedure. Instead rely on deformation of the pectoralis major and minor muscles to guide your trajectory. Once assumed to be close to the fascia lining the deep surface of pec minor, start to use small boluses (e.g. 0.5-1 ml) of D5W or local anesthetic to "hydro-locate" your tip until it's positioned appropriately.

Tip # 5: Deposit all of the local anesthetic at the 6 o'clock location.

While it may be tempting to want to identify and separately block each of the lateral, medial and posterior cords, this is unnecessary. In our experience, the infraclavicular block has an extremely high success rate when 20-25 ml of local anesthetic are deposited immediately deep to the axillary artery (6 o'clock). Stay as close as you can to the artery, and take care not to advance beyond the 6 o'clock position.

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Focus on Fascia Iliaca Block for Total Hip Replacement
Dhiraj Jagasia, M.D.
Attending Physician
NYU Langone Medical Center
NYU Department of Anesthesiology
New York, New York

The fascia iliaca compartment block (FICB) can be used for analgesia after total hip replacement, as an alternative to a femoral nerve block (FNB), a lumbar plexus (psoas compartment) block, and epidural analgesia. All these techniques, as part of a multimodal analgesic regimen (acetaminophen, NSAIDs, possibly gabapentin or pregabalin), allow reducing the postoperative opioid requirements and the associated side effects.

Dalens initially described the FICB in children in 1990. An injection under the fascia iliaca will reach both the femoral nerve and the lateral femoral cutaneous nerve without any risk of intraneural injection, even in anesthetized patients. Subsequent studies demonstrated a slightly higher rate of blockade of the lateral femoral cutaneous block with the FICB than the FNB. In both cases, the obturator nerve is blocked only inconstantly, unless very high volumes are used. Complications are rare with the FICB and the FNB, especially when ultrasound guidance is used.

The psoas compartment block is very proximal and will reliably reach the obturator nerve in addition to the femoral and lateral femoral cutaneous nerve. However, it is a deep block with a much higher risk of severe complications (peritoneal breach, renal injury, retroperitoneal hematoma, epidural or intrathecal injection.) All these blocks of the lumbar plexus will not block the areas innervated by the sacral plexus, and patients can still complain of posterior pain.

Epidural analgesia is effective, but interferes with postoperative thromboprophylaxis. Moreover, it blocks both lower extremities, will typically require a urinary catheter, and necessitates frequent rate adjustments to avoid hypotension and insufficient analgesia. This explains why it has fallen somewhat out of favor.

To perform the fascia iliaca block, a linear array mid-frequency ultrasound probe is placed in a transverse orientation over the inguinal ligament, between the anterior superior iliac spine and the femoral artery. The femoral nerve, artery, and vein are appreciated medially, while the iliopsoas and sartorius muscles are visualized laterally. The probe is then turned 90 degrees (longitudinally) with the left now being cranial. By moving the probe cranially, the edge of the ilium can be seen as a bright white (hyperechoic) line towards the bottom of the ultrasound image. The muscle that is overlying this and descending into the pelvis along with the ilium is the iliacus muscle, covered by its fascia. As the probe is moved further cranially, the fibers of the femoral nerve were seen as bright white bands, while the fascia iliaca can be seen extending from the right of the image overlying the iliacus muscle. This can serve as the point of local anesthetic injection. Typically, for postoperative analgesia, 30mL of 0.2% ropivacaine or of 0.25% bupivacaine will be injected under the fascia iliaca. The spread can be seen in real time.

Further Reading
1. Candal-Couto JJ, McVie JL, Haslam N, Innes AR, Rushmer J. Pre-operative analgesia for patients with femoral neck fractures using modified fascia iliaca block technique. Injury. 2005; 36(4): 505-510
2. Foss NB, Kristensen BB, Bundgaard M, Bak M, Heiring C, Virkelyst C, Hougaard S, Kehlet, H. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized placebo-controlled trial. Anesthesiology. 2007; 106(4): 773-8
3. Monzon DG, Iserson KV, Vazquez JA. Single fascia iliaca compartment block for post-hip fracture pain relief. J Emerg Med. 2007; 32(3): 257-62

Click Here to Discuss this article at Anesthesiology Network

NYSORA FLASH NEWS

- Opinion poll on Axillary Brachial Plexus Block

Click here to view the poll >

- Discuss axillary brachial plexus block at the Anesthesiology Network

Click here to join the discussion >

- NYSORA-UZ Leuven Vesalius Research Project

View video >

NYSORA YouTube Channel

Keep up with the latest happenings.

Upcoming Meetings

- NWAC Bangkok. Do not forget to register early for NWAC (Networking World Anesthesia Convention), Bangkok, April 23-27, 2013

NWAC is a convention that has been branded the "The People's Anesthesia Meeting." With its unmatched educational program, networking sessions and unique humanities series - NWAC is the most liked meeting of anesthesiologists, where everyone feels at home.

Reviews of NYSORA's New Textbook
on Peripheral Nerve Blocks

SAVE 20% AT MCGRAW-HILL WEBSITE, www.mhpprofessional.com

From a recent review:
British Journal of Anaesthesia 109 (4): 652–4 (2012)

“The new edition builds on the success of the first edition. It does so by emphasizing the fundamental principles on which regional anaesthesia is based. Ultrasound can only be applied once these fundamentals are known and practiced, and the overall tone of the book reflects that. The author states that where best practice was not known, anatomy was emphasized, rather than recommend a block. We wholeheartedly recommend this book.”

Review from JAMA

The Journal of the American Medical Association had a very favorable review of the new NYSORA textbook in their July 18 issue. Here are a few excerpts. The full review is at http://jama.jamanetwork.com.

“The list of peripheral nerve blocks is substantial and covers upper extremity, lower extremity, and truncal nerve blocks. Although some clinicians will want to skip directly to the section dealing specifically with ultrasound-guided nerve blocks, readers should not overlook the chapters on nerve stimulation and surface landmark techniques; these dynamic chapters cover a significant amount of anatomical pearls relevant to ultrasound-guided techniques. Plenty of “Tips“ are located throughout each chapter. A short section discusses ultrasound basics and techniques for optimizing images. Readers new to the use of ultrasound will find these chapters particularly helpful.”

”There are an impressive number of regional anesthesia books on the market, and they all have their value. But when it comes to learning regional anesthesia, it's the subtleties of performing blocks that is key. No book comes closer to teaching the art of regional anesthesia than this one does. The previous edition was published in 2004, and a lot has been added to this edition. Apart from dedicating half the book to ultrasound techniques, whole sections are devoted to cadaver and ultrasound images and surface anatomy. In short, this is the only book one needs to learn and become proficient in performing regional anesthesia.”