Peripheral Nerve Block

Romina Alexis Pinson-Sulit, MD, DPBA, FPSA | December 11, 2021

Trans by: Cabalza, Matila, Tamacay

OUTLINE
I. Introduction VI. Equipment
II. Regional Anesthesia VII. Techniques
A. Benefits, Risks, and A. Landmark Based
Best Practice in Technique
Regional Anesthesia B. Nerve Stimulator –
B. Surgical Stress Guided
Response C. Ultrasound – Guided
III. Peripheral Nerve Blockade PNB
Figure 3. Epidural Technique Figure 4. PNB Technique
IV. Upper Extremity VIII. Basic Blocks Every
A. Brachial Plexus Anesthesiologist Should B. SURGICAL STRESS RESPONSE
B. Utz Guided Axillary Know
Brachial Plexus IX. References
Block X. Appendix
V. Lower Extremity
A. Lumbar Plexus
B. Sacral Plexus
C. Truncal Blocks

I. INTRODUCTION
• Peripheral nerve block is a type of regional anesthetic technique
wherein local anesthetic is delivered to a nerve to be able to
anesthetize or provide analgesia to a certain part of the body. [Dra.
Sulit]

II. REGIONAL ANESTHESIA

A. BENEFITS, RISKS, AND BEST PRACTICE IN REGIONAL
ANESTHESIA
• Regional anesthesia offers more than just pain relief!
→ Reduction in surgical morbidity and mortality, shorter length of Figure 5. Surgical Stress Response
hospital stay, lower costs of treatment, and better functional When a px undergo surgery, the moment the surgeon takes his scalpel to cut, then
the surgical stress response is activated. What happens to the body when the
outcome. [Barrie Fischer, MBChB, FRCA] stress response is activated? Of course, there is tissue damage, and then upon
• Regional techniques and outcome: What is the evidence? activation of this tissue damage, there is a release of proinflammatory cytokines
→ 141 RCTs, 9559 patients which causes pain, and then also local tissue damage would induce a systemic
response as well, so there is an increase in your cortisol, adrenaline and the
→ The largest meta-analysis of randomized controlled trials sympathetic response is fired, and this causes the myriad of complications/
(RCTs) comparing intraoperative neuraxial to general morbidities that our patients experience after surgery. For like example, after
anesthesia indicated a decrease in mortality [1.9 vs. 2.8%} surgery they can have ileus, they can have severe pain, they can have immobility,
[Marie N. Hanna, Jami D. Murphy, Kanupriya Kumar and Christopher L. Wu] then immobility will lead to pulmonary problems to cardiac problems as well. What
▪ CARDIOVASCULAR does RA do? Because of the superior analgesia that it offers, it attenuates,
meaning it inhibits the surgical stress response to surgery. Then we also say that
▪ PULMONARY local anesthetics have an inherent property to attenuate the surgical stress
▪ IMMUNOSUPPRESSION response. So, this is the benefit of doing RA technique on the patients, most
▪ EARLY REHAB important is the surgical stress response attenuation.
• What We Know...
WHAT WE OFFER WHEN WE DO RA IN OUR PATIENTS III. PERIPHERAL NERVE BLOCKADE
(Well-established short-term benefits) • Sole anesthetic (coupled with IV sedation)
✓ Superior postoperative analgesia • Postoperative analgesia
✓ Stress response attenuation • Supplement to GA to decrease anesthetic requirements
✓ Opioid sparing effect
Who can’t receive PNB?
✓ Avoids common side effects associated with systemic
anesthetic and analgesic agents • Low cognitive function
✓ Decreased rate of complications, and decreased odds of • Non-cooperative
ICU admission compared with GA alone • Bleeding problems
✓ Shorter hospital stay • Infection (especially in the area to be blocked)
Indications for PNB
• Pre-existing peripheral neuropathy
IV. UPPER EXTREMITY
A. BRACHIAL PLEXUS
• Upper extremity is one of the easiest to block because you only
have one plexus to study.
• Only the BRACHIAL PLEXUS that you need to study for upper
extremity block.
Figure 1. Spinal Technique Figure 2. Epidural Technique ***Figure 6. Roots, Trunks, Divisions, Cords, and Nerves of BP see appendix

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 B. UTZ GUIDED AXILLARY BRACHIAL PLEXUS BLOCK

Figure 7. Brachial Plexus

Interscalene Nerve Block

• For shoulder surgery, we do a interscalene nerve block. Insert
Figure 9. Axillary Nerve Block. (a) Axillary probe. (b) ultrasound
the needle in the interscalene groove so that you can block the
roots
• We use ultrasound because UTZ decreases the onset of local
• In the interscalene nerve block kase, the lower nerve root which anesthetic and of course safer for the patient and the
supplies the ulnar nerve, sometimes it is spared because of the anesthesiologist as well kasi you can see the nerves
location; it is very deep to the interscalene muscles so sometimes
• Hypoechoic structures (dark circles in the photo) are the vessels
the local anesthetics cannot penetrate
• Nerves are usually hyperechoic
• If we do an interscalene nerve block, there is sparing of the ulnar
nerve. That’s why this is only used for shoulder surgery or
V. LOWER EXTREMITY
proximal humeral surgeries
Supraclavicular Nerve Block A. LUMBAR PLEXUS
• Supraclav meaning above the clavicle and above this area,
divisions of the brachial plexus are blocked. This is called the
spinal of the upper extremity because all nerves are blocked
at this area.
Infraclavicular Nerve Block
• Below the clavicle
• You block the CORDS of brachial plexus
Axillary Nerve Block
• Block the CORDS of brachial plexus
• for surgeries of the elbow and forearm
Wrist Block
• Surgeries of the hand when you have fractures of your phalanges
• Radius-ulna surgery/ forearm surgery
• Wrist arthroplasty

Figure 10. Lumbar Plexus

Femoral Nerve Block

• Femoral nerve comes from L2-L4
• Posterior roots form the femoral nerve

Obturator Nerve Block

Figure 8. Wrist Block
• Anterior roots from the Obturator Nerve

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Total Knee Replacement Arthroplasty • Largest nerve in the body
• Done in any surgery below the knee warrants a sciatic nerve
block (e.g below knee amputation, fractures of the tibia, fibula,
foot injury)
• Leg is supplied by the sciatic nerve, except for the medial part
which is supplied by femoral nerve
• BKA (Below knee amputation)
→ If you do a BKA, you will have to do a saphenous block
because the saphenous nerve comes from the femoral nerve,
so that supplies the medial part of the leg
• Foot surgery

Figure 11. Total Knee Arthroplasty

• Most common procedures of the knee

• Top 3 most painful surgeries:
→ Thoracotomy
→ Total knee replacement
→ Mastectomy
• We do peripheral nerve blocks to these patients so that postop,
they will be able to undergo rehabilitation, they will be able to
ambulate immediately because of the analgesia that your block
will provide
• FEMORAL NERVE BLOCK is done in these patients.
Sometimes we leave a catheter on the femoral nerve so that
even post op, local anesthetic can still be infiltrated on the nerve

Figure 14. (a) Foot surgery (b) Below the knee amputation (BKA)

Figure 12. Femoral Nerve Block

• Femoral nerve is one of the most consistent nerve in the body;
doesn’t go anywhere. Very easy nerve to block. Supplies the
anterior portion of the thigh and lateral part of the thigh, and also
medial part of the leg Figure 15. Ultrasound technique. Blocking the sciatic nerve at level of popliteal
• Femoral nerve block is also used in surgeries of anterior and fossa. PA- popliteal artery; PV- popliteal vein
lateral thigh
• At the popliteal fossa, you will see the popliteal artery (refer from
B. SACRAL PLEXUS the UTZ picture above), and on top of popliteal artery, there are
2 nerves: the posterior tibial and common peroneal. This 2 nerves
Sciatic Nerve Block arise from the sciatic nerve
• Common peroneal nerve is usually in the lateral part
• If you move the probe upward towards the middle of the thigh,
then you can see that the posterior tibial and common peroneal
forms the sciatic nerve
• At this level, the sciatic nerve can be blocked and provide
analgesia/anesthesia to the lateral leg, posterior leg, anterior leg,
and foot

Figure 13 Sciatic Nerve

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 Ankle Block C. TRUNCAL BLOCKS

Figure 17. Thoracic Paravertebral Block.

Figure 16. Nerves of the foot.
Dr’s. note:
Dr’s. note: • This is just nice to know, these are very complicated blocks
• Ankle block on the other hand does not warrant an UTZ to do, your truncal blocks, usually we use truncal blocks to
because of the little nerves that you block for the foot. So, for supply analgesia to the area of the body, the chest, or the
foot surgery or surgery of the toes, then, an ankle block can abdomen when we do general anesthesia. So, they’re
be done. Pwede rin namang sciatic nerve but since you will supplements to general anesthesia when we do surgeries on
only be anesthetizing individual peripheral nerves of the foot the chest and the abdomen.
then sometimes if the surgery only warrants the innervation
of the toe, the big toe for example, then an ankle block will Transversus Abdominis Plane (TAP) Block
be better. • Deposit anesthetic between the fascia of two muscles
→ Internal oblique and transversus abdominis muscles
• Five nerves that you block when you perform an ankle
→ To block the intercostal nerves from T6-T12
block:
• For abdominal surgeries
1. Tibial nerve
→ Largest
→ Supplies the heal and medial side of the foot
2. Superficial peroneal nerve
→ Branch of common peroneal
→ Dorsal (top) portion of foot
3. Saphenous nerve
→ Branch of femoral nerve
→ Medial side of leg (only area of the leg that is not supplied
by sciatic nerve), ankle, and foot
4. Sural nerve Figure 18. TAP block.
→ Branch of posterior tibial nerve Dr’s. note:
→ Posterior lateral half of calf, lateral side of foot and 5th toe • For example, when we do a TAP block for patients who
5. Deep peroneal nerve undergo cesarean section, then this is depositing (arrow in
the image) local anesthetic between your internal oblique
Dr’s. note: and your transversus abdominis muscle. These are plane
• Like I said earlier, the medial part of the foot is supplied by blocks we deposit anesthetic in this fascial plane where the
the saphenous nerve from the femoral nerve intercostal nerves are embedded on.
• The lateral part is supplied by the sural nerve.
Paravertebral Nerve Block
• Simple mnemonics by doc:
→ suraL – Lateral • A very complicated block of the back
→ saphenous – no L = Medial • Can be used to anesthetize the chest area
• Provides analgesia to any surgeries for the chest
→ Mastectomy
→ CABG
Ilioinguinal/ Iliohypogastric nerve block
• Low TAP block, from L1-L2 of lumbar plexus
• Deposit anesthetic between internal oblique and transversus
abdominis muscles or xiphoid process and ASIS
• For herniorrhaphy and urologic surgery below inguinal area

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 IN SUMMARY:

WHAT SURGERIES AND PROCEDURES REQUIRE PNB?

- Any surgery from HEAD to FOOT

Nerve stimulator Stimulating needle

• Head – scalp block (neurosurgery), block of the face (ENT

procedures)
• Neck - Block of the sternocleidomastoid muscle (ENT
surgeries)
• Upper extremity blocks
Catheters Measures the pressure of
• Truncal blocks – surgeries of the chest, abdomen
• Ilioinguinal/ Iliohypogastric block injecting your local anesthetic
• Lower extremity blocks (for us to know that we are not
damaging the nerves

VI. EQUIPMENT
VII. TECHNIQUES

A. LANDMARK BASED TECHNIQUE

• Being abandoned technique
• Anatomy based
• Inserting a needle based on the landmark that you look for

Figure 20. Landmark technique.

Figure 19. Block room.
• Nerve stimulator B. NERVE STIMULATOR - GUIDED
→ Delivers current through the needle, stimulation results in
twitching of the muscle
• Catheters
→ For continuous nerve block
• Stimulating needle
→ To measure the pressure near the nerve, to know that we are
not inside the nerve. Deliver around the nerve (perineurium
only)

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 C. ULTRASOUND – GUIDED PNB
• Gold standard of ding PNB
• Allows us to see the nerve itself, the needle that we use to block
the nerve and the spread of the LA around the nerve
• Ultrasound-guided nerve blocks may result in not only higher
success but also in faster onset and progression of
sensorimotor block without an increase in block procedure time

VIII. BASIC BLOCKS EVERY ANESTHESIOLOGIST

SHOULD KNOW

INDICATION BLOCKS
Shoulder surgery Interscalene block
Elbow and forearm surgery Supraclavicular nerve block
Hand surgery Axillary/ wrist block
Hip surgery Lumbar plexus/ femoral
Knee surgery Femoral nerve block
Tibia and fibula Sciatic nerve block
Foot surgery Ankle block

IX. REFERENCES
• Dra. Romina Pinson-Sulit’s lecture
• Batch 2022 Trans

X. APPENDIX

Figure 6. Roots, Trunks, Divisions, Cords, and Nerves of Brachial Plexus

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