Dr Anuradha Pandey

Dr Anuradha Pandey

CONSULTANT Anaesthesiologist

Mayom hospital

Dr Anuradha Pandey

Fundamental to the success of regional anesthesia is the correct positioning of the needle tip in the perineural sheath, prior to injection of local anesthetic

Dr Anuradha Pandey

Brief introduction Indications and contraindications preparation Facial nerve blocks Scalp nerve blocks

Dr Anuradha Pandey

Dr Anuradha Pandey

Explain the procedure Informed consent Emergency cart preparation Sedation if needed Position of patient Well lit room Cooperative patient practice

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Facial loco-regional anaesthesia

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

FACE Trigeminal nerve blocks

Orbit and contents, sphenoid sinus, eyelids, anterior two thirds of scalp

Ophthalmic nerve block

Forehead Supraorbital nerve block and supratrochlear nerve block

Upper jaw, maxillary antrum, distribution of infraorbital nerve

Maxillary nerve block

Lower eyelid, upper lip, temple, lateral aspect of the nose

Infraorbital nerve block

Dr Anuradha Pandey

-inferior alveolar nerve (branch of mandibular) -often anesthetized in dental procedures – lower jaw -numbs to mental nerve (branch of the IAN)-superior alveolar nerve (branch of the maxillary) -numbs the upper jaw

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

S.o- SupraorbitalS.t.- supratrochlearI.t- Infratrochlear

Dr Anuradha Pandey

Imp-To avoid keratitis- ophthalmic division Itself

not block, so only the suproptic br.

is Blocked.

Technique:-

-2 ml LA injected at supraoptic notch

which located on supraoptic

ridge Above pupil .

-Insert needle lateral to supraorbital foramen

Direct needle medially, parallel

to brow, toward nose Infiltrate

mid-two thirds of lower edge

of eyebrow.

-Inject just above bone level.

-Redirect needle if paresthesia

or sharp pain.

Dr Anuradha Pandey

Supraorbital Medial edge of Cornea

Infra orbital: Above first maxillary premolar

Mental Nerve: Inferior to the second premolar

Dr Anuradha Pandey

Ask the patient to look straight

Draw a straight line from the centre of the cornea

Dr Anuradha Pandey

Supratrochlear block- 1 ml of LA at Superior medial cornerOf orbital ridge

Sensation to the skin of the upper eyelid,forehead, ant. Scalp and part of nose.

Dr Anuradha Pandey

Landmark - superior orbital rim

Dr Anuradha Pandey

Procedure-

Location-

- IOF approx. 1 cm below orbit

and usually located with a needle

-Inserted about 2 cm lateral to

Nasal Ala and directed superiorly ,

and slightly laterally

-Blocked with 2 ml

of LA .

-Anesthesia to lower eyelid, lateral

inferior nose and lower lip

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

• Advance needle,bevel toward bone• Approx 1.5 cm deep

Dr Anuradha Pandey

Dr Anuradha Pandey

- With the patient's mouth slightly opened,- An 8- to 10-cm 22-gauge needle is inserted

between the zygomatic arch and the notch of the mandible

- After contact with the lateral pterygoid plate (at about 4-cm depth), the needle is partially withdrawn and angled slightly superiorly and anteriorly to pass into the pterygopalatine fossa.

- Anesthetic (4–6 mL) is injected once paresthesias are elicited. Both the maxillary nerve and the pterygopalatine ganglia are anesthetized by this technique.

Dr Anuradha Pandey

Dr Anuradha Pandey

Mandibular branch (V3) – This supplies the lower jaw; it exits via the foramen ovale, and its branches are the:-

lingual, Auriculo temporal, inferior alveolar, Buccal , and mental nerves The ophthalmic and maxillary nerves

are purely sensory. The mandibular nerve has sensory and motor functions

Dr Anuradha Pandey

Dr Anuradha Pandey

- This procedure is undertaken with the patient's mouth slightly opened.

- An 8- to 10-cm 22-gauge needle is inserted between the zygomatic arch and the mandibular notch.

- After contact with the lateral pterygoid plate, the needle is partially withdrawn and angled slightly superiorly and posteriorly toward the ear.

- Anesthetic (4–6 mL) is injected once paresthesias are elicited.

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Trigeminal nerve block can be accomplished either via the classic approach (guided by the anatomic landmarks) or with the help of imaging (guided by fluoroscopy or computed tomography [CT]

Preparation of the skin- with iodophor or povidone-iodine and draped. A skin wheal is raised with a local anesthetic

.

Dr Anuradha Pandey

Classic approach The patient is placed in a supine position with the head

in a neutral position and the eyes staring straight ahead. The key anatomic landmark—a point 2-3 cm lateral to the angle of the mouth on the side to be blocked—is marked.

A 22-gauge 10-cm long spinal needle is inserted here and advanced upward toward the mandibular condyle

This plane should be in line with the pupil as the patient’s eyes stare ahead, and the trajectory should be cephalad toward the external auditory meatus.

At a depth of 4-6 cm, the greater wing of the sphenoid at the base of the skull is contacted. The needle is withdrawn and redirected more posteriorly so as to enter the foramen ovale. It is then advanced 1-1.5 cm.

Paresthesia at the mandible is elicited, followed by paresthesia in the maxilla and orbit

Dr Anuradha Pandey

Dr Anuradha Pandey

Agents Used For Scalp infiltration. Vasoconstricting agents may be added to LA to control bleeding with

added advantage of prolongation of the anesthetic action. AGENTS

.

50/50 mixtures of lidocaine and bupivacaine may provide the most optimal anesthetic.

There is no report on the use of ropivacaine in this indication. However, with a 0,2 %, concentration, it should be as effective as bupivacaine. Furthermore, its intrinsic vasoconstrictor effect allows to avoid epinephrine.

Short Acting:•Lidocaine, which can be given as 1% or 2% mixtures. Epinephrine 1:1000 may be added to both 1% and 2% solutions•Lidocaine -300 mg (3-4 mg/kg in children) without epinephrine, the maximum dose is 500 mg (7 mg/kg).with epinephrine

• Long-acting -Sensorcaine, 0.25% or 0.5% bupivacaine

• Bupivacaine- 175 mg (2mg/kg) in an adult, is increased to 225 mg (3mg/kg) when mixed with epinephrine

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Anterior scalp block-by blocking V1( supra orbital and supra trochlear ) and V2 ( zygomaticotemporal)

Posterior- greater and lesser occipital nerve

Lateral-greater auricular nerve Cervical plexus and zygomatico

temporal –brow block

Dr Anuradha Pandey

scalp is innervated by branches of the trigeminal and cervical nerves.

These nerves can be anesthetized as they penetrate the scalp.

They become subfascial along a line that encircles the head (like a skull-cap). This line passes just above the tragus and through the glabella and occiput.

A wheal should be raised in the subdermal plane along this line. About 10 ml of lidocaine is required every few centimetres.

Dr Anuradha Pandey

Scalp Block Insert 1 peripheral IV line LA given at 16 points and about 3ml at each point ( 2 points in each

nerve since both nerves are blocked bilaterally) 1)Back of head- Greater and Lesser Occipital nerve- patient sitting

with head resting forward at the time of this Block After this patient is made to lie down 2) Greater auricular nerve- 1.5 cm posterior to the tragus 3) Auriculotemporal nerve- between tragus and superficial temporal

artery 4) Zygomaticotemporal- halfway down the line joining tragus to the

outer corner of the eye 5) Supraorbital nerve 6) Supratrochlear nerve 7) Sternomastoid muscle- Midpoint of the posterior border

Steps- Pre operative Psychological PreparationManagement goals- Adequate sedation, Analgesia , Airway, respiratory & hemodynamic control

Dr Anuradha Pandey

• ANATOMYGreater occipital nerve arises from the dorsal primary

ramus of the second and third cervical nerve.  It gives sensation to the medial portion of the posterior scalp.  

The lesser occipital nerve arises form the ventral primary rami of the second and third cervical roots and give supply to the cranial surface of the pinna and adjacent scalp.

Dr Anuradha Pandey

GREATER OCCIPITAL NERVE BLOCK TECHNIQUE The patient is usually positioned in the sitting position with the

head either vertical or slightly flexed. The nerve is relatively easy to locate along the superior

nuchal line,where it lies medial to the occipital artery, bilaterally. The pulsation of the occipital artery is easy to

palpate. Assistant provides support for the head anteriorly. The scalp is prepped with alcohol. A mixture of local anesthetic and steroid is used, usually 2%

lidocaine with either triamcinolone 10 to 20 mg or betamethasone 2 to 4 mg for a total volume of 3 mL of injectate.

Usually a 25 G needle, either 5 ⁄8 inch or 1 1⁄2inch, can be used depending on the size of the patient.The needle is directed at 90 degrees toward the occiputuntil a bony endpoint is obtained. Aspiration is important to prevent intravascular injection, and in the case of a history of a cranial defect, to prevent injection into the cerebrospinal fluid.

Dr Anuradha Pandey

1.0 cc is injected around the nerve and an additional 1.0 cc on either side of the nerve. When the needle is withdrawn, pressure should be maintained over the site of injection to both bathe the nerve trunk with the mixture and to achievehemostasis as the scalp has a rich vascular supplyThe lesser occipital nerves may be

included by injecting more of the local anesthetic/steroidmixture lateral to the greater occipital injection along the superior nuchal line

Dr Anuradha Pandey

Complications As with any nerve block, bleeding, infection, and nerve damage are

possible. Allergic reaction to the anesthetic. Eccchymosis can result from dissection of the local anesthetic into

the loose areolar tissue of the eyelid. Puncture of the angular vein causing a hematoma

Dr Anuradha Pandey

Back of the ear- lesser occipital and greater auricular nerve block

Area to the rear of the pinna

The innervation of this region comes from the lesser occipital nerve and the great auricular nerve.

After previously separating the pinna, inject 3-4 ml whilst the needle moves through the posterior sulcus.

Dr Anuradha Pandey

22 gauge needle is neededProcedure steps Disinfect the skin with an alcohol swab. Insert the needle anteriorly and

superiorly to the tragus. Aspirate and inject 3-4 mL of anesthetic. insert needle Zygomatico temporal nerve and greater

auricular nerve can be blocked With a single prick

Dr Anuradha Pandey

Landmarks- Midpoint between mastoid process and

chassaignac tubercle ( upper border of cricoid cartilage ) or midpoint between origin and insertion of SCM with patient in supine position and drug is infilterated at the posterior boarder of SCM

3-5 mm of LA is injected, needle is inserted perpendicular and directed superiorly and inferiorly and well infilterated with 10 ml of drug

Careful with phrenic nerve blockage

Dr Anuradha Pandey

Dr Anuradha Pandey

Dr Anuradha Pandey

Signs and Symptoms of Lidocaine Toxicity Blood Lidocaine Levels(ug/mL ) Signs and Symptoms 1–5= Tinnitus, lightheadedness,

circumoral numbness, diplopia, metallic taste in the mouth

5–8 =Nystagmus, slurred speech, localized muscle twitching, fine tremors

8–12= Focal seizure activity, which may progress to tonic-clonic seizures

20–25= Respiratory depression which can lead to c

Dr Anuradha Pandey

Anatomical landmark History of drug allergy Correct technique and positioning of

needle Use fresh drugs in each patient Look for signs of toxicity-cvs and cns

including circumoral numbness, disorientation, yawning, tachycardia

Dr Anuradha Pandey

Regional Anesthesia in Head and Neck SurgerSOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology

http://emedicine.medscape.com/article Atlas of Interventional Pain Management By Steven D. Waldman New York School Of Regional

Anaesthesia(Nysora.com)

Presentation Prepared By

Dr Anuradha Pandey

For