UPMC St. Margaret Nerve Block Rotation

Report
UPMC St. Margaret
Nerve Block Rotation
Guidelines for 1 month Block
Rotation
Staff
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Student Clinical Coordinator
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Co-coordinators
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Andy Miller, CRNA
Mary Lou Taylor, CRNA
Chief Anesthesiologist
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Rachel Gray, CRNA
Jay Roskoph, MD
PA/CRNP
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Bethany Mitchell, PA-C
Carolyn Garver, CRNP
First Day
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Please report to the OR lounge at 0600.
You will be given you access to the scrub
machine and provide you with an orientation
of our preoperative holding area.
If Rachel Gray, Andy Miller or Mary Lou
Taylor will orient you.
Overview and Expectations
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Become familiar with performing regional anesthesia
for a variety of orthopedic cases. Most of the training
will occur in the preoperative area using both
interactive and didactic techniques.
Create an understanding of the benefits and risks of
regional anesthesia
Become familiar with the fundamentals of regional
anesthesia
Become familiar with all anatomical landmarks
utilized in regional anesthesia
Objectives
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Describe specific anatomical landmarks for sciatic, femoral,
popliteal fossa, and lumbar plexus blocks.
Describe signs and symptoms of an intravascular injection and
the treatments for it
Describe regional anesthesia related procedures
Demonstrate an understanding of the medications used for
regional anesthesia
Perform regional anesthesia as directed by supervising
anesthesiologist
Assist with starting IVs and the positioning and monitoring of
patients receiving regional anesthesia
Review and follow departmental procedures and policies for
administration and management of anesthesia, documentation of
narcotics and emergencies
Give daily evaluations to the PA, CRNP or anesthesiologist
Sciatic Nerve Blocks
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This technique can be used for surgery and postoperative pain
management in patients undergoing a wide variety of lower leg,
foot, and ankle surgeries.
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It is particularly well-suited for surgery on the knee, calf, Achilles
tendon, ankle, and foot. It provides complete anesthesia of the leg
below the knee with the exception of the medial strip of skin, which
is innervated by the saphenous nerve. When combined with a
femoral nerve or lumbar plexus block, anesthesia of almost entire
leg is achieved.

A typical onset time for this block is 10-25 minutes, depending on
the type, concentration, and volume of local anesthetic used. The
first signs of blockade onset are usually reported by the patient in
the form of a feeling that the foot is "different" or an inability to
wiggle the toes. It can take up to 30 minutes for full sensory-motor
anesthesia to develop.
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Continuous infusion of 0.1 – 0.2 % Ropivacaine is maintained at 2-5
mL/hr after a bolus is given. This bolus is withheld until the patient
is out of surgery because they must be able to demonstrate full
plantar and dorsiflexion of the ankle.
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Complications and how to avoid them:
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Infection – aseptic technique is used
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Hematoma/vascular puncture – avoid deep needle or
multiple needle insertions; avoid in patients undergoing
anticoagulant therapy.
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References:
Chelly, J.E. (Ed.). (1999). Peripheral Nerve Blocks: A Color Atlas.
Wilikins.
Local anesthetic toxicity – avoid large volumes and doses
due to the close proximity of muscle beds.
Philadelphia: Lipincott, Williams and
Hadzic, A., Vloka, J.D. (2004). Peripheral Nerve Blocks Principles and Practice. New York: McGraw-Hill
Professional.
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Patients must be instructed on care of insensate extremity
and will need frequent repositioning.
SRNA Responsibilities
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Report to preop holding area every morning by 0600
to assist in setting up the block trays for the day
Start IVs for all patients receiving blocks. During
“down time” you may assist with other IVs as well
Fill out the block paper work for the chart and for
billing purposes on the block cart. Examples are
provided
Monitor the patient during and after the block,
recording BP, HR, pulse ox readings. Record any
sedation given.
Report off to the on-call anesthesiologist after all
blocks are completed
Please remember…
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An anesthesiologist MUST be present to
perform regional ansethesia
Make sure the cubicle is equipped with an
Ambu bag and the suction is functional
A time out must be completed with at least
two people including pt name, MR number
and laterality
Know the drugs, techniques, risks,
complications, anatomy and physiology
involved in the specific block
Additional Information
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The following is a study guide created by
Bethany Mitchell, PA-C. Please become
familiar with this before the first day of your
block rotation
Review your regional website for more
specifics on regional anesthesia
Femoral Nerve Blocks

This block is well suited for quadriceps muscle biopsy, knee
surgery (arthroscopy), quadriceps tendon repair and postoperative
pain management after femur and knee surgery. When combined
with the block of the sciatic nerve, anesthesia of the almost entire
lower extremity from the mid-thigh level can be achieved.
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The femoral nerve supplies motor fibers to the quadriceps muscle
(knee extension), the skin of the anteromedial thigh, and the medial
aspect of the leg below the knee and foot.
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The most common indications for this block include postoperative
analgesia after knee arthroplasty, ACL repair and femoral fracture
repair.
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Continuous infusion is initiated after a bolus of local anesthetic.
Ropivacaine 0.2% is routinely used for the infusion at a rate of 5-8
mL/hr.
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This nerve block not only affects sensory fibers of the femoral
nerve, but also some motor fibers. This results in quadriceps
weakness. The femoral nerve supplies muscular branches of the
iliacus and pectineus, and the muscles on the anterior thigh, except
the tensor fascie femoris.
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Complications of nerve block:
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Infection – aseptic technique is used; catheters are
removed 48-72 hours after insertion
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Hematoma/vascular puncture – stop advancing needle
when patient reports pain; if vein or artery is punctured
References:
pressure is applied before injecting solution at site.
Chelly, J.E. (Ed.). (1999). Peripheral Nerve Blocks: A Color Atlas.
Wilikins.
Philadelphia: Lipincott, Williams and
Hadzic, A., Vloka, J.D. (2004). Peripheral Nerve Blocks Principles and Practice. New York: McGraw-Hill
Professional.

Nerve injury – a nerve stimulator is used and a specific
muscle contraction is found; parasthesias are no longer
desirable.
Popliteal Fossa Nerve Block
Nerves Located in the Popliteal Fossa and their Motor
Functions
This
References:
Chelly, J.E. (Ed.). (1999). Peripheral Nerve Blocks: A Color Atlas.
Wilikins.
technique can be used for surgery and postoperative
pain management in patients undergoing a wide variety of
lower leg, foot, and ankle surgeries.
Continuous infusion is initiated after an initial bolus of local
anesthetic through the catheter. For this purpose, we routinely
use 0.2% ropivacaine (15-20 mL). The infusion is maintained
at 10 mL/hr or 5 mL/hr when a PCA dose is planned (5 mL).
Usually these patients are discharged the day after surgery
and are given disposable Stryker pumps. These pumps can
be adjusted to control the patient’s pain, usually running at 5-7
mL/hr.
Breakthrough pain in patients on continuous infusion is
always managed by administering a bolus of local anesthetic.
A typical onset time for this block is 10-25 minutes, depending
on the type, concentration, and volume of local anesthetic
used. The first signs of the onset of blockade are usually
reported by the patient. The foot "feels different" or an inability
to wiggle toes is reported. Sensory anesthesia of the skin with
this block is often the last to develop.
Complications and how to avoid them:
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Infection – Aseptic technique is used
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Local Anesthetic Toxicity – absorption of local anesthetic
from the popliteal fossa is slow because of the low
vascularity of the adipose tissue in the area
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Hematoma/vascular puncture – avoid medial redirection
of the needle to avoid the vascular sheath
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Nerve injury – do not inject if the patientif the patient
complains of pain or if stimulation at < 0.2 mA
Philadelphia: Lipincott, Williams and
Hadzic, A., Vloka, J.D. (2004). Peripheral Nerve Blocks Principles and Practice. New York: McGraw-Hill
Professional.
Lumbar Plexus Nerve Blocks
The
References:
Chelly, J.E. (Ed.). (1999). Peripheral Nerve Blocks: A Color Atlas.
Wilikins.
Philadelphia: Lipincott, Williams and
Hadzic, A., Vloka, J.D. (2004). Peripheral Nerve Blocks Principles and Practice. New York: McGraw-Hill
Professional.
Lumbar Plexus is made up of the nerve roots originating from
L1-L4. These roots go on to make up the genitofemoral nerve, lateral
femoral cutaneous nerve, femoral nerve, and obturator nerves.
This technique can be used for postoperative pain management in
patients undergoing hip, femur, and knee surgery.
Lumbar plexus blocks provide anesthesia or analgesia to the entire
distribution of the plexus, including the anterolateral and medial
thigh, the knee, and the saphenous nerve below the knee.
Continuous infusion is always initiated after an initial bolus of dilute
local anesthetic through the catheter. For this purpose, we routinely
use 0.2% ropivacaine (15-20 mL). The infusion is maintained at 10
mL/hr or 5 mL/hr when a PCA dose is planned (5 mL/q30 minutes).
Breakthrough pain in patients on continuous infusion is always
managed by administering a bolus of local anesthetic.
When the bolus injection through the catheter fails to result in
blockade after 30 minutes, the catheter should be considered
dislodged and it should be removed.
Complications and how to avoid them:
●
Infection – aseptic technique is used
●
Hematoma/vascular puncture – avoid use in patients on
anticoagualant therapy, avoid deep needle insertion
●
Local anesthetic toxicity – large volumes of long-acting
anesthetic should be avoided in elderly patients, frequent
aspiration necessary; avoid fast, forceful injecting
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Nerve injury – if stimulation occurs at <0.5 mA, withdraw
needle before injecting
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Hemodynamic consequences – every patient receiving a
lumbar plexus block should be monitored to the same extent
as a patient receiving an epidural since the anesthetic can
spread into the epidural space if the sheath is punctured.
Nursing Care
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Goals for Nerve Blocks:
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Decreased opioid use
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Improved mobility allowing for
improved participation in PT
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Improved patient satisfaction
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Shorter length of stay
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Types of pumps:
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Mechanical, programmable
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Rate can be changed according to order set based
on pain scores and sensory level
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Stop pump infusion every morning at least 2 hours
before scheduled physical therapy
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If no pump with patient who has a nerve block
catheter placed, notify anesthesia immediately.
Tubing, batteries, etc. located in PACU.
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After pump is discontinued, return to PACU for
cleaning.
Non-Mechanical
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Used for outpatients and short stay patients
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Rate can be adjusted based on pain level
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Pump can be left on for physical therapy because
patients are generally non-weightbearing
Nursing Duties:
Every 4 hours, every shift, or after activity:
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Monitor BP, Pulse, Respiratory rate, Neurological status and level of pain relief
Monitor sensory and motor function (It can take 24 hours after surgery for motor function to return)
Check dressing and site for leakage, swelling, redness or bleeding.
Check catheter for patency
Nurses can:
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Reinforce or change dressing if Regional anesthesia unavailable (sterile 4x4s can be placed under the dressing using sterile technique)
Remove catheter after the pump is empty (Stryker); an order must be given to discontinue the pump otherwise. Removal of entire
catheter with blue tip intact must be documented in Progress Notes in patient chart.
Notify Anesthesia if:
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Patient notes tinnitis, metallic taste or other signs of local anesthetic toxicity. Ropivacaine is used for continuous infusion due to its
lower risk of cardiac toxicity.
Excessive Sedation or change in neurological status
Systolic BP <90 mmHg
Inadequate pain relief (>5 of 10)
Leakage around the dressing site or if catheter has come out accidentally
Change in level of sensory status or motor function

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