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 Block: choice, list and abbreviations
Quick access
Block of choice
Block list Contraindications Contact us
(summary)

Application keys Ultrasound Complications Block Videos

Anesthetic vs.
Local anesthetic Ideal block conditions
Analgesic blocks
Understand Islam
Tourniquet pain Block timing Motor sparing

Block of choice for each region

Region Block of choice Alternative block
Upper limb
Clavicle SCP + CPF block
Shoulder Interscalene block ISO block
Arm & elbow +/- Intercostobrachial NB Infraclavicular block
Forearm & wrist Infraclavicular block Elbow block
Hand Forearm block +/- Musculocutaneous NB Walant

Lower limb

Hip Femoral NB Lumbar plexus or

Obturator NB +/- local infiltration
PENG + LFCN blocks
LFCN block
Knee & thigh Parasacral sciatic NB Adductor canal + IPACK
+/- Saphenous NB
Leg & ankle Popliteal block
+/- Femoral NB
Foot Ankle block +/- Femoral NB

Trunk (analgesic)

Breast + PECs1 block Mammary+ PECs1+

Thorax Paravertebral block (PVB) Serratus anterior blocks

Upper Abdomen Rectus/subcostal block

Inguinal region Transversalis plane block +/- Spermatic cord block QL1
Scrotal Scrotal + Spermatic cord blocks
Anal Ischiorectal fossa +/- local infiltration Pudendal NB
Back Erector spinae block
Block list
Upper limb Lower limb Trunk
Axillary block (AXB) Adductor canal block Erector spinae block (ESB)
Axillary nerve block Ankle block Intercostal nerve (IC) block
Clavipectoral fascia plane (CPF) block Femoral nerve block (FNB) Ilioinguinal, iliohypogastric (II) block
Elbow block Fascia iliaca block (FIB) Ischiorectal fossa
Median nerve (MN) block Intra-articular knee injection Mammary block
Radial nerve (RN) block IPACK Parasternal block
Ulnar nerve (UN) block Latreal femoral cut block(LFCN) Paravertebral block (PVB)
LCNF block LIA technique PECs1 block
MCNF block Lumbar plexus block (LPB) PECs2 block
Forearm block Obturator nerve block (ONB) Pecto-intercostal fascial (PIF) block
Median nerve (MN) block Obturator branch block Pelvic plexus (PP) block
Radial nerve (RN) block PENG block Pudendal nerve (PN) block
Ulnar nerve (UN) block Saphenous nerve block Penile block
Intercostobrachial nerve (ICBN) block Sciatic nerve block (SNB) QL (quadratus lumborum) block
Interscalene (ISB) Parasacral Rectus sheath (RS) block
Infraclavicular (ICB) subgluteal *Scrotal block
ISO block popliteal Serratus anterior block
Musculocutaneous nerve (MC) block supine popliteal approach Spermatic cord block
Superficial cervical plexus block SOFT block Subcostal block
Supraclavicular block (SCB) TAP block
Suprascapular nerve (SSN) block Transversalis plane block
Walant block Transverses thoracic plane (TTP)
block
LCNF & MCNF = Lateral and medial cutaneous nerve of the forearm,
*Scrotal block has not been published yet yet.

Abbreviations
Abbreviations e= with Pt = patient
// =parallel esp = especially Rt = right
+/- = plus or minus GA = General anesthesia S= syndrome
ant= anterior HD= hemodynamic SA= spinal anesthesia
BP= brachial plexus Inj= inject or injection SC= subcutaneous
b/c = because LA = local anesthetic Symp= sympathetic
bet= between LL= lower limb ttt= treatment
br= branch Lt= left US = ultrasound
cm= centimeters NS= nerve stimulator UL= upper limb
cut= cutaneous PNB = peripheral nerve block
DD= deferential diagnosis
 Introduction
Application keys

- The aim of this summary is to refresh your knowledge. Further readings of regional anesthesia related
articles & textbooks as well as practicing under supervision of experts are mandatory.

- For a certain surgical procedure, many nerve block techniques can be used. Similarly, a certain nerve
block may be performed using different approaches. However, we have mentioned our preferential
techniques/ approach as per our experience.

- All our preferential techniques are based on the usage of ultrasound (US). If the US is not available,
our preference will not be applicable.

-In this summary, unless stated, nerve blocks are described to provide anesthesia for upper and lower
limb surgeries and to provide analgesia for trunk surgeries.

- Some scenarios may need an expert hand.

Anesthetic vs. Analgesic blocks

- Nerve block can be used as a sole anesthesia (anesthetic block) or added to GA/SA for postoperative
analgesia (analgesic block).
- Some blocks may provide adequate analgesia, but not enough to provide anesthesia. In contrast,
anesthetic block, using long acting local anesthetic (LA), can provide adequate analgesia as well.

Analgesic block Anesthetic block (+/- sedation)

Unless contraindicated, all patients should receive nerve block. Anesthetic or
analgesic block choice is based on pt, surgery, experience of surgeon & anesthetist
- pt request to sleep - pt request to be awake
Indication - uncooperative pt (as kids, panic adult) - High-risk GA or SA.
- prolonged surgery time
- if the PNB cannot anesthetize all
dissected/ ischemic structures
To anesthetize ALL surgical and non-
To anesthetize all or some surgical pain
surgical (ischemic) pains
Block aim Example
- For forearm surgery with arm tourniquet, elbow block can provide analgesia but
musculocutaneous nerve block should be added to provide anesthesia.
- Femoral nerve block alone, can provide good hip and knee analgesia but not
anesthesia.
LA choice To achieve long duration To achieve rapid onset +/- long duration

Intraoperative ischemic (non-surgical) pain

Some non-surgically dissected structures (muscles/ligaments) may get ischemic pain because of
pressure or stretching. This pain requires the addition of nerve block, heavy sedation or GA.
For example:
- Tourniquet pain
- Back pain with prolonged supine positioning (need heavy sedation/GA).
- Stretching of psoas muscle during THA (treated with heavy sedation)
- Stretching of MCL during trimming/repair of medial meniscus (treated with ONB/ heavy sedation)
LBP = lumbar plexus block, MCL =medial collateral ligament, ONB = obturator nerve block, THA =total hip arthroplasty
Tourniquet Pain
- Usually occurs due to ischemic muscle pain.
- GA, spinal or proximal block controls this pain.
- When a distal block (elbow/popliteal) is used as sole anesthesia, it can compensate a distal applied
tourniquet (forearm/leg). However, when the tourniquet is applied proximally (arm / thigh), an
additional block for arm flexors / quadriceps is needed.
So, MC block (using lidocaine) is added to anesthetic elbow/ forearm block when arm tourniquet is
applied. Similarly FNB (using lidocaine) is added to anesthetic popliteal /ankle block when thigh
tourniquet is applied. [video1], [video 2]
Note skin can tolerate ischemia for more than 2 hr. So, unlike what is widely believed, there is no need
to block ICBN for arm tourniquet. [video]
ICBN=Intercostobrachial nerve, MC= musculocutaneous nerve, FNB= femoral nerve block

Cutaneous innervation
Innervations of the skin and subcutaneous (sc) tissue usually differ from the underlying muscle and
bone innervations. Therefore, to achieve complete anesthesia/analgesia, cutaneous innervation must
be blocked.

Note: - Fortunately, the cutaneous blocks can be replaced/ rectified with LA infiltration at the incision.
- Do not add cutaneous nerve block unless needed. So, if the surgery is in the medial aspect of
the forearm there is no need to block the LCNF. Similarly, sural and saphenous blocks are
not important to the big toe and lateral malleolus surgery, respectively.
- Do not add cutaneous br/nerve block if the feeding nerve/plexus is blocked. So, if MC, FNB,
and superficial cervical plexus are blocked, there will be no need for LCNF, saphenous, and
supraclavicular nerve blocks, respectively.
- Cutaneous innervation overlap is common

Region Skin Aspect Nerve supply Branch of

clavicle, upper chest and anterior
supraclavicular nerves superficial cervical plexus
shoulder
ICBN 2nd IC nerve
Arm Medial
medial cutaneous nerve of arm
medial cord
Medial medial
cutaneous nerve
Forearm Lateral lateral MC
of the forearm
Posterior posterior radial nerve
above the greater lateral branch subcostal nerve
Lateral hip
below trochanter
lateral (LFCN) lumbar plexus
Lateral
femoral
posterior posterior (PFCN) sacral plexus
Thigh cutaneous nerve
Anterior anterior
Medial medial
Femoral nerve
Leg Medial
saphenous nerve
medial
Foot
lateral Sural nerve Sciatic nerve
Scrotum pudendal, PFCN, II, and genitofemoral
Groin II and genitofemoral
gluteal cluneal nerves
ICBN=Intercostobrachial nerve, IC= intercostal, nerve, II=ilioinguinal and iliohypogastric, LFCN= lateral femoral cutaneous
nerve, MC= musculocutaneous, PFCN= posterior femoral cutaneous nerve
PNB indication & contraindications
Indication: All operated patients should receive nerve block (either anesthetic or analgesic), unless
there is an absolute or relative contraindication.

Safely applied high-risk high-risk

contra-indications Remarks
GA/SA /pain killer GA/SA Pain killers
Absolute pt refusal No block a
Infection at the site use an alternative block
of block technique/approach
Allergy to a LA use another LA b
motor sparing
Risk of nerve injury c, d
blocks
Risk of bleeding c, e
Relative
Risk of compartment No block
f
syndrome
Simple surgical use short use diluted
g
procedure acting LA long acting LA
Problematic
pt/surgeon
Avoid FNB & SNB or
early ambulation h, i
use short acting LA
Surgeon
motor sparing blocks
request early joint mobility +/- or classic blocks j
using short acting LA
a=pt refusal is the only absolute contraindication b= no cross sensitivity between amide LAs
c= nerve block should be performed only by expert
d= if the risk of nerve injury due to surgical cause, classic nerve block may be performed AFTER the surgery
e=superficial blocks are safer than deep blocks
f= for analgesia, diluted LA may allow early diagnosis of compartment syndrome
g= that outweighs block risks/benefits (as wire removal, ganglion excision, reduction of dislocation ..)
h=such as day care surgery
i= only FNB & SNB impair ambulation, so either avoid them or use short acting LA.
j= such as after joint surgery
GA/SA=general/ spinal anesthesia, FNB/ SNB= femoral / sciatic nerve blocks, LA= local anesthetics

High- risk GA/spinal/pain killer

High risk GA High risk SA

- hemodynamic instability - hemodynamic instability
- confirmed/suspected COVID - bleeding tendency.
- risk of (difficult intubation, aspiration, DVT) - pt with history of Backache, PDPH, urinary retention
- impaired lung, kidney or liver function High risk painkiller
- high ICT or IOP, epilepsy, stroke, carotid - allergy - PONV
stenosis - Renal / liver impairment - sever BA
BA= bronchial asthma, DVT=deep venous thrombosis, ICT= intracranial tension, IOP = intraorbital pressure,
PDPH= post dural puncture headache, PONV= postoperative nausea/ vomiting
Medications/ Equipment
1) Choice of Local anesthetic (LA)

According to desired block duration & availability:

-very rapid block recover (as in relative contraindicated): chloroprocaine
-Intermediate duration: lidocaine
-Long duration: ropivacaine, L- bupivacaine (Dexamethasone may be added for
further prolongation of duration).
-very long duration: add liposomal bupivacaine or insert a perineural catheter
Type
Of note a) except in low resource situations, we don’t recommend R-bupivacaine b/c
of its relatively higher risk of cardiac toxicity.
b) Block duration also varies according to nerve to be blocked and the used
approach. Hence, interscalene, infraclavicular and femoral blocks with
ropivacaine 0.5% have different durations of analgesia
According to desired onset.
-For analgesic block, rapid onset is not crucial and so low concentrations as
0.15% (or even less) of ropivacaine or L- bupivacaine can be used. Low
concentration does not shorten duration of analgesia and may allow early
diagnosis of compartment syndrome.

Concentration -For anesthetic block,

High LA concentration (and or adding lidocaine) is used to accelerate the onset
especially with delayed onset blocks (as sciatic and infraclavicular blocks)
However, to not exceed the safe dose when performing multiple blocks (as for
knee/hip surgery), the following anesthetic concentrations are recommended.
Sciatic block All other nerve blocks
ropivacaine, L- bupivacaine 0.5% 0.25%
lidocaine, chloroprocaine 1.5% 1%
Volume depends on the nerve to be blocked.
-Adrenaline: may be added (0.1mg per 20ml of LA) to decrease risk of toxicity. (but
some believe it may cause ischemic nerve injury)
Adjuvant
-Dexamethasone: perineural 8 mg prolongs block duration by 50% (off label route).
I.V is also effective.
-Others: better avoided
Injection a) around the nerve (peri-neural injection)
techniques b) within the fascial plane where LA can spread to the nerve (interfacial injection).

Maximum safe dose

With adrenaline Without adrenaline
ropivacaine and bupivacaine 3mg/kg
lidocaine 7mg/kg 4.5mg/kg
chloroprocaine 1000 mg (15mg/kg) 800 mg (12 mg/kg)
Of note: 1 ml of x% concentration contains 10 x mg. So 1 ml of ropivacaine 0.5% contains 5 mg of
ropivacaine
2) Ultrasound (US) machine

All blocks in this summary rely on US (video link) . Before block, take all safety precautions

1. Adjust Positions of the pt, probe, yourself and US machine.

Note: all operator positions described here are based on the supposition that the operator is Right-
handed
a) Pt & Probe: place the pt & probe as described for the desired
block. Place the probe with mark towards YOUR
LEFT (if not possible, upwards)
b) Yourself: place yourself in a way that you can hold the probe
with the left hand and the needle with the right
hand (without crossing hands)
Usually, you will stand on the same side of the
block (with a few exceptions).
c) US machine: place the machine in front of you (so you can
see the US screen without laterally tilting your
head)
2. Choose the probe: Two probes are usually used; linear for superficial blocks (< 4 cm depth) &
curved for deeper blocks

3. Scan the pt
When the probe moves around: a) its long axis (L) = tilt
b) its short axis (S) = rocking
c) its vertical axis (V)= rotation.
4. Choose the view

When the long axis of the probe is placed (A) parallel to

the short axis of the nerve this is called short axis view
but if placed (B) parallel to the long axis of the nerve this
is called longitudinal view

In short axis view, the adjacent structures (as vessels)

can be seen, so it is commonly used for PNB

5. Identify the landmark/nerve

-Vascular landmark in most blocks
-Bony landmark example ulnar and parasacral sciatic nerve blocks.
-Facial plane /muscles landmark: example obturator, suprascapular & trunk bocks
- Spot identification (rare): example radial & saphenous nerves

6. Activate Doppler
Switch on the Doppler (color) before
inserting the needle, to exclude any
vessels along the needle path.

In this image after activation of Doppler, a

neural like structure, appeared to be a
vessel.
7. Needle insertion
The needle can be inserted along:
a) the long axis of the probe, where its shaft & tip are visualized (In-plane
technique)
b) the vertical axis of the probe, where its tip position is identified by tissue
indentation (Out-of-plane technique)

To improve nerve visualization

- Use advanced US machine and settings
- Adjust the machine gain (brightness), dynamic range
- Use maximum possible pressure on the probe (but without
discomfort to the pt)
- Use the least possible machine depth (the most beneficial)
- In femoral and popliteal blocks, tilting the probe improves
nerve image resolution
The effect of caudal probe tilting
on sciatic nerve resolution in
To improve needle visualization:
popliteal fossa
-Needle: echogenic (but expensive)
Big size→ better resolution (but causes pt discomfort)
- Needle insertion point:
in-plane: * insert the needle 2cm away from probe (but this needs experience to keep
the needle within the same probe plane).
out-of-plane: * adjust the probe to have the nerve in the middle of the image
* Insert the needle flush to the middle of the probe
- Needle advancing (in/out of-plane):
Whenever the probe is tilted, the needle should be advanced with the same degree of tilt.
- Activate needle tracing (if available in the US machine software)
- Saline injection improves the tip identification

3) Needle choice

- Length: short needle (5 cm) for all upper limb blocks (except ICB), LFCN, ankle & saphenous blocks,
Long needle (8-12cm): for all other blocks (unless in very thin/pediatric pt)
Extra-long (15cm). for lumbar plexus & parasacral sciatic blocks in morbid obese
Of note: If superficial and deep blocks (as sciatic + saphenous blocks) are performed to the pt
→ use one long needle for both blocks
- Size: we use 21 G (5cm) for superficial blocks,
20 G (8-12cm) for deep/ interfacial blocks
18 G (8cm) for paravertebral block (PVB), trunk blocks (if pt under GA/SA)
- With extension (less-mobile injections)
- B Bevel for perineural injection. Normal bevel can be used for interfacial injection (as trunk blocks)
- Insulated (if electrical stimulation is planned). Not need for interfacial injection (as trunk blocks)
- Echogenic (better sonographic visualization, but more expensive)

4) Syringe/pressure device

For better detection of intraneural injection:

- Always use a 20 ml syringe.
- Try to use the same syringe brand
- Some experts recommend the use of injection-pressure device.
5) Nerve stimulator (NS)

Even with the use of the US, electrical stimulation may be needed as in:
a) Deep blocks to adjust the needle tip position (to avoid intraneural injection)
b) If uncertain nerve identification (as in old, obese, anatomical variation,... ..), add electrical
stimulation for confirmation (video link 56:37)

Of note: If the nerve block is performed under GA, be sure that the patient has not received
muscle relaxant if usage of NS is planned.

6) Perineural catheter

Technique:
- Under US-guidance, the usual epidural needle & catheter can be used
- After sterilization & draping (completely aseptic), perform single injection block. The LA forms a
hypoechoic area around the nerve.
- Insert the epidural needle and adjust its tip to the LA area.
- Advance the catheter and adjust its tip position under US guidance.
- Fluid injection improves tip identification.
- If needed, the catheter may be tunneled.
- Test dose is mandatory to exclude mal position.

- If PCA pump is available, we prefer to use bolus injection alone. (PCA=patient-controlled analgesia)

-limited indications b/c: a) numerous complications b) easier & safer alternatives

- Alternatives 1) Dexamethasone (prolongs duration of ropivacaine/L-bupivacaine)

2) Liposomal bupivacaine may provide analgesia for 2–3 days

7) Regional Anesthesia Cart contents:

N.B The block room/area must have: a monitor, an oxygen source, US machine, regional anesthesia
cart and nearby crash cart.

Drugs - LAs: ropivacaine, lidocaine with /without adrenaline, others LA, normal saline (for dilution)
- Sedatives: midazolam (prepared), propofol (ready), others may be used
- Adjuvant: dexamethasone
- For emergency: Intralipid, atropine (prefilled syringe), ….
- Others in a nearby crash cart (ephedrine, adrenaline, succinylcholine….
Equipment
For iv: cannula, alcohol swab, infusion line, 3-way, extension line, tourniquet, plaster
For LA preparation: syringes (3, 5, 10, 20 cc), disposable needles,
For block: Nerve stimulator, block needles (short, long, extra-long, insulated, echogenic, spinal,
epidural), marker, measurer, gloves (sterile & non), gauze (sterile & non), gel (sterile
& non), probe cover (sterile & non), alcohol spray, ECG electrodes
For catheters: catheters (stimulating & non-stimulating), sterilization (iodine, draping) and
incontinence sheet, tegaderm.
For emergency: crash cart should be nearby.
 Upper limb
Block choice
Clavicle

The clavicle is supplied by brachial plexus (BP). The overlying skin is supplied by the superficial
cervical plexus.

Anesthesia* ISB

Option 1 Option 2 (Video) Option 3

Analgesia sup cx plexus block
ISB Walant technique
+ CPF block
* When PNB is used as sole anesthesia with no access to airway. Some precautions should be taken
- Option 2&3 are reserved for simple procedure (as hardware removal) or pt who cannot tolerate
phrenic nerve block
- In some case reports, option 2 and 3 were used as sole anesthesia
CPF= clavi-pectoral fascia, ISB= interscalene block, sup cx = superficial cervical.

Shoulder

The shoulder joint and muscles are entirely supplied by the suprascapular nerve (SSN) and branches of
BP cords. The superficial cervical plexus shares in anterior skin innervations.

Option 1 Option 2 Option 3

Anesthesia* ISO block motor sparing blocks

ISB
/ analgesia + local infiltration at the port sites (only analgesic)

* When PNB used as sole anesthesia with no access to airway. Some precautions
should be taken. Video

^ Option 2 is reserved for pt who cannot tolerate phrenic block (respiratory or cardiac
Remarks
diseases).

Option 3 is reserved for pt with high risk of nerve injury or when early active shoulder
movement is requested.
ISB= interscalene block; ISO= infraclavicular-subomohyoid block, SSN= suprascapular.
^In these pts, SSN (+/- axillary nerve) block or modified ISB was commonly used. Unlike the former,
ISO block anesthetizes all shoulder innervations. Unlike modified ISB, ISO block spares phrenic nerve
in >95% of pt.
Arm & Elbow

The arm is supplied by the radial, musculocutaneous and axillary nerves. The medial skin aspect is
supplied by Intercostobrachial nerve (ICBN) & medial cutaneous nerve of arm (MCNF; branch of the
medial cord).

Of note: The axillary nerve supplies the deltoid muscle, deeper bone, and overlying skin and is
blocked by ISB, ICB or axillary nerve block but not with axillary block.
The ICBN is a thoracic nerve, therefore it is not blocked with any BP block

Many blocks can provide anesthesia/analgesia for arm surgery. We prefer:

anesthesia/
Option 1 Option 2 Remark
analgesia
-if the surgery is in the medial aspect of the
Upper arm ICB arm or elbow, add sc LA infiltration along the
skin incision or ICBN block.
ISB
- option 2 only if the pt cannot tolerate
phrenic block or to spare shoulder movement
Lower arm
ICB or axially block
and Elbow
-ICB may provide longer analgesia than
axially block
ISB= interscalene block; ICB= infraclavicular block; ICBN= Intercosto-brachial nerve, sc= subcutaneous

Forearm & wrist

- The forearm (& wrist) muscles and bones are entirely supplied by the ulnar, median & radial nerves.

- The medial (MCNF), lateral (LCNF), and posterior (PCNF) cutaneous nerves of the forearm are
branches of the medial cord, musculocutaneous and radial nerves, respectively and supply the
corresponding forearm skin aspects.

-Many blocks can provide anesthesia for forearm surgery. We prefer:

Forearm surgery Option 1 Option 2 Option 3

anesthesia ICB axially block (AXB) *Elbow block

analgesia Elbow block ICB

-ICB has lesser needle passes, higher success rate & longer duration of
analgesia than AXB (but ICB anesthetizes some shoulder movements)

- ICB & AXB have a relatively delayed onset, which can be accelerated by
increasing LA concentration, or adding lidocaine
Remarks
-Elbow block has a faster onset, spares the elbow movements but needs multiple
punctures.
* If elbow block is used as sole anesthesia & arm tourniquet is applied, MC block
(with lidocaine) should be added.
AXB= axially block, ICB= Infraclavicular block, MC= musculocutaneous nerve
Hand surgery

-The hand is entirely supplied by ulnar, median, and radial nerves. The ulnar nerve supplies the entire
medial aspect including the little finger (skin, muscles & bones).

Procedure site Block Remarks

A pure finger surgery ring block -if any of these blocks is used as sole
anesthesia & arm tourniquet is
applied, MC block (with lidocaine)
surgery purely in the medial aspect ulnar block
should be added.
- These blocks (including Forearm
Otherwise Forearm block block) spares hand motor activity
(video)
MC= musculocutaneous nerve
Block techniques
Inter-scalene block (ISB)

- Brachial plexus (BP) trunks run between scalenus

anterior (SA) and medius (SM) muscles.
- Sometimes the upper trunk passes within scalenus
anterior (video 1, video 2).
- ISB is simple, successful and safe, so it is our
standard technique for clavicle, shoulder and arm
surgeries, except in pt who cannot tolerate phrenic Diagrammatic cross section at level of C7.
nerve block where it is safer to replace ISB with ISO EJV= external jugular vein, SCM=
block (for shoulder) or ICB (for arm). sternocleidomastoid, TP= transverse process

Interscalene block (ISB) Video

LA: 15 ml (5 ml is used by expert successfully)
Equipment
Short needle / Linear probe
Semi setting*. for Lt ISB: you stand on the Lt side of the pt.
Pt & doctor positions*
for Rt ISB: you stand at the head end of the pt

Probe
position, 1) Place the probe horizontally in 2) Identify subclavian artery (SCA)
landmarks supraclavicular fossa, aiming caudally 3) identify the BP (divisions) above and lateral to the SCA.

Probe
manipulation 4) Follow BP cranially until transverse process of C6 or 7,
In-plane (but usually there is little room to insert the needle) *
Needle insertion*
out-of-plane is a more feasible
LA injection At one point beside the upper trunk BP (no need for needle repositions)
Successful block loss of shoulder abduction (patient cannot touch his scalp with his hand)
BP= brachial plexus, SA & SM = scalenus anterior & medius, SCM= sternocleidomastoid, VA= vertebral artery
* pt can be also placed in lateral position where the needle can be advanced using in-plane technique
Complications
The BP is almost sc, so always keep needle tip superficial. Most complications occur with excessive
needle advancement

A) Pneumothorax: -rare -occurs with too medial / inferior advancement of the needle
B) LA Spread to:
1) Superficial cervical plexus: allowing painless clavicle & shoulder surgery
2) Sympathetic chain and recurrent laryngeal nerve causing Horner syndrome and hoarseness
of voice, respectively. -Both have no consequences. - ttt: just patient assurance
3) Epidural and spinal: rare but fatal, occur with too medial advancement of the needle.
4) Brain: via vertebral artery injection. Avoid too medial/deep advancement of the needle.
5) Phrenic nerve: almost unavoidable (still occurs even with the use of 5ml LA)
It may occur with ISB, supraclavicular block & superficial cervical plexus (rare).
DD with pneumothorax
Confirmed with US (see figure below)
ttt: in healthy patient reassure the pt
in pt with limited respiratory function avoid ISB and supraclavicular blocks.
Of note: The ISB must NEVER be performed bilaterally.
If mistakenly performed bilaterally, mechanical ventilation will be required until the
fading of LA effect

Diaphragm Diaphragm
assessment assessment
Technique 1 Technique 2.

-Place the linear probe vertically on the mid-

-Place the curved probe vertically on the mid- clavicular line at 7th IC space and adjust the
maxillary line, adjust the probe (move probe (move superior or inferior)
superior/inferior & tilt) to identify the liver or -identify the diaphragm (deep to the intercostal
spleen, kidney & diaphragm muscles).
-Ask the pt to take a deep breath: No (or -Measure its thickness after normal expiration.
sluggish) movement of diaphragm = phrenic -Ask the pt to take a deep breath. On deep
block inspiration, normal diaphragm thickness
increases by more than 20%, if not phrenic
nerve is blocked.
Superficial cervical plexus block

- A purely cutaneous plexus lies deep in the sternocleidomastoid (SCM) muscle.

- Its branches emerge at the mid-posterior border of SCM to supply the skin of the scalp, the angle of
the mandible, neck, upper part of the chest & shoulder.
- indicated in clavicle, ear, neck, scalp surgery and rarely results in phrenic nerve block (Video).

Superficial cervical plexus block

Equipment Linear probe, Short needle, 5 -10 ml of LA
Pt position As Interscalene block

Probe position Horizontally (at mid posterior border of SCM)

Landmark Identify SCM
needle insertion In-plane technique (from lateral), inject LA deep to SCM

Successful block loss of sensation in the neck, skin overlying clavicle

SA & SM = scalenus anterior & medius, SCM= sternocleidomastoid
Clavipectoral fascia (CPF) plane block

- CPF lies between pec minor and subclavius.

- Technique: place the linear probe vertically at
mid-clavicular line to identify pec maj, min &
subclavius (sc)
LA (20 ml) is injected bet pec min & subclavius.
- This block is added to superficial cervical plexus
block to achieve analgesia of the clavicle
Diagrammatic sagittal section at level of BP cords
CPF is the green fascia

Supraclavicular block (SCB)

- At supraclavicular level, the brachial plexus (BP) lies
very superficial but very close to the pleura, which
could be injured (even with US guidance). SCB may
also result in phrenic nerve block.

-SCB can be always replaced by the safer interscalene

or infraclavicular block. So SCB, in our opinion, has no
role.
SCA= subclavian artery
Technique (Video 1:12:30)
-As ISB: place the probe horizontally in supraclavicular fossa, aiming caudally to identify subclavian
artery (SCA), the BP (above & lateral), pleura and first rib
- Note: the first rib is always at a level superficial to that of the pleura
-Tilt/rotate the probe to get the first rib just deep to the BP
- In this block it is mandatory to:
a) Switch on color Doppler before needle advancement to identify all vascular structures
b) Never advance the needle unless its tip is clearly seen
-Advance needle in-plane (lateral to medial) & inject LA superficial and deep to BP (between it & rib).
Infraclavicular blocks (ICB)

- The BP cords surround the 2nd part of the axillary

artery (deep to pectoralis minor).

- BP cords can be accessed with a needle inserted:

A) Inferior to clavicle (classic ICB approach)
B) Superior to clavicle (retro-clavicular or
posterior ICB approach). Needle then pass deep to
clavicle. This more horizontal needle pass allows
better resolution (relative to classic approach).

- ICB is a very successful block but has a relatively Diagrammatic sagittal section at level of BP cords
delayed onset, which can be improved by
increasing LA concentration and/ or adding lidocaine.

- Indications: shoulder surgery (part of ISO block), arm surgery (ISB is better option)
forearm surgery (ICB is our first choice)

Retro-clavicular ICB Video Classic ICB

Equipment 20 ml LA/ long needle/ Linear probe
Pt position Semi setting Semi setting with Arm 90, elbow 90
Stand on the lt side of the pt for lt side block,
doctor position
and at the head end of the pt for Rt side block
Probe position Vertical, just medial to the shoulder
- Rock the probe superiorly rotate cephalic end of the probe laterally

Landmarks

-Identify the axillary artery (AA).

-Identify brachial plexus (BP) cords: they
lie at 3,6,9 o’clock around the artery

AV= axillary vein, Pmaj= pec major, Pmin= Pec minor

- 3cm SUPERIOR to clavicle - superior to probe (inferior to clavicle)
needle insertion
-Advance it in-plane (behind the clavicle) -Advance it in-plane towards the artery
towards the artery
LA injection -10ml below the artery then 10 ml above*
-if part of ISO block, withdraw the needle
to sc to block the suprascapular nerve
Successful block loss of elbow flexion, extension
*Unless a huge LA volume is injected, single site injection results in a less success rate & delayed onset.
ISO and suprascapular (SSN) blocks

- All Shoulder joint innervations are branches of BP cords,

except the SSN which is a branch of upper trunk.

- Before it enters the suprascapular notch, the SSN runs deep

to inferior belly of omohyoid (IO). The IO lies superficial to
subclavian artery medially and deep to the trapezius (Tz)
laterally. sonographic anatomy

- ISO (Infraclavicular-SubomOhyoid) block is a combined ICB (retro-clavicular approach) and SSN

block (subomohyoid approach) using a single skin puncture.

- ISO block + LA infiltration (at the port sites) provide complete shoulder anesthesia/analgesia

- Indication: Shoulder surgery, as alternative to ISB in pt who cannot tolerate phrenic block (as pt with
respiratory or cardiac disease).

SSN block Video

If a part of ISO block: Retro-clavicular ICB is performed first, then

Equipment 5ml of LA / linear probe,

Probe As ISB ; horizontal in the supra-clavicular - identify the subclavian artery (SA)
position, fossa, anterior to the needle -Tilt probe anteriorly to identify IO; a vascular like
landmarks echogenicity, superficial to the artery
Manipulation -Adjust the probe to achieve longitudinal
view of IO (Note: IO thickness is variable)

-Follow the IO as lateral as possible.

Needle - in-plane technique (lateral to medial)

- If part of ISO block: at the end of ICB,
withdraw the needle to sc and redirect
needle tip (out-of-plane)

LA injection Deep to IO, as lateral as possible.

[IO= inferior belly of omohyoid, Tz= trapezius, Sr= serratus, Sc= subscapularis]

Successful block Weak external shoulder rotation.

Axillary block (AXB)

- All innervations of the upper limb surround the 3rd part of

the axillary artery (AA) except:
i) Musculocutaneous (MC) nerve runs within the
coracobrachialis (CB) muscle.
ii) Axillary nerve passes to quadrangular space.
iii) Intercostobrachial nerves (ICBN).
Note: Axillary block (AXB) does not block neither the axillary
nerve nor ICBN
-Indications: - lower arm, elbow & forearm surgery.
Diagrammatic cross section at the axilla,
- selective MC block (using lidocaine) may be
MN= median nerve, RN= radial nerve,
added to anesthetic elbow /forearm blocks UN= ulnar nerve.
when arm tourniquet is needed. Video Nerve locations are variant

Axillary block (AXB) (Video 1:34:22)

20 -30 ml of LA
Equipment
Linear probe / Short insulated needle #
Pt & doctor - Arm 90, elbow 90 -Stand on the lt side for Lt AXB &
positions at the head end of the pt for Rt AXB

Probe On axillary crease

landmarks Identify the axillary artery (AA), vein/ veins ^

- identify Musculocutaneous nerve

(MC): anterior to the artery, within
coracobrachialis #

needle - In-plane, anterior to probe

insertion

LA injection - 10 ml superficial to the artery

- 10 ml deep to the artery
- 5-7 ml around MC nerve

Assess each nerve separately (see elbow block)

Successful block
MC block = no elbow flexion.
^ Care, the veins are usually compressed by the probe
# MC location is variant so electrical confirmation may be needed

Intercostobrachial nerve (ICBN) block

- ICBN is the lateral branch of the 2nd intercostal nerve. - it is not blocked with any BP block
- It supplies the upper medial skin aspect of the arm. - its block is NOT needed for tourniquet pain.
Indication: ONLY for surgeries at the medial aspect of the arm (Video 1:39:00).
Technique -sc LA infiltration of the posterior axillary crease (ICBN may be visualized by US)
- PECs2, IC, or serratus anterior block opposite to T2.
-To simplify, ICBN block can be replaced by LA infiltration at the skin incision.
Elbow block

-The term “elbow block’ is usually referred to combined radial (RN), ulnar (UN) & median (MN) nerve
blocks around the elbow. MCNF or LCNF block is added ONLY if the skin incision is at their
corresponding skin aspect (innervation overlap is common). Video

Indication: forearm/wrist surgeries as:

a) Backup for incomplete proximal approaches
b) Sole anesthesia/analgesia. Unlike axillary block & ICB, elbow block has a faster onset & preserves
shoulder & elbow movement, however it requires multiple skin punctures.

Elbow Radial Ulnar Median

block nerve (UL) MCNF LCNF
nerve (RN) nerve (MN)
Video Video2
5-7 ml LA for each nerve
Equipment
Linear probe/ Short needle
Pt position, Probe position,
As described in the table below
manipulation, and marks
needle
In/out-of-plane
insertion
Loose of pain/cold sensation at
Successful
Anterior thumb medial Lateral
block Snuff box Little finger
base skin aspect of the forearm
- If elbow block is used as sole anesthesia and arm tourniquet is applied, add MC block (using
lidocaine).
Remark - If MC is blocked, there is no need to block its LCNF branch.
- MN, MCNF, UN can be blocked using a single puncture
MCNF /LCNF= medial / lateral cutaneous nerves of the forearm

RN block
At the spiral groove, the RN lies directly on the bone and gives the PCNF (posterior
Anatomy cutaneous nerve of the forearm). Slight distal, the RN lies anterior to the humerus

Probe -the pt’s arm rests on his chest, the probe is

position, placed on the lateral aspect of the arm, 4
fingers above the elbow

landmarks -the RN is identified anterior to the humerus,

where the nerve can be blocked.

- Only if the skin incision at posterior forearm, the RN

is followed and blocked at the spiral grove (where RN
rests directly on the bone).
 Probe position landmarks & Probe manipulation

Just proximal to the elbow, the UN passes superficially to the medial supracondylar ridge
(MSR) before it runs behind the medial epicondyle (MEC).

UN block

Just proximal to the identify the MSR - Follow UN slightly proximal

medial epicondyle UN is just superficial

-Identify the brachial

artery (BA)
MN block
-MN lies just medial to the
artery

MCNF
Block

On the elbow Spot identification (one or more nerves) in the sc, between the MN &
crease UN.

-Identify the cephalic vein

(CV).

LCNF - Inject LA deep to the CV

block (the nerve may be idetfied
deep to the CV)

- MN, MCNF, UN can be blocked using a single puncture

Forearm block

Indication: hand surgery. It is a block of choice as it preserves elbow & wrist movements. Video

Elbow block Radial Median Ulnar

Video nerve (RN) nerve (ML) nerve (UN)
5-7 ml LA for each nerve
Equipment
Linear probe/ Short needle
Probe
Horizontally at Mid-forearm level
position
Landmark

RN (superficial branch) lies MN lies between digitorum

lateral to radial artery (RA) superficialis and profundus UN lies just medial to the ulnar
R = radius artery(UA). U = ulna
needle
In/out-plane
insertion
Successful Loose of pain sensation at
block Snuff box Anterior thumb base Little finger
Technique Video
-If arm tourniquet is used, add MC block (using lidocaine).
Remark
- UN, MN, RN can be block using a single puncture using a long needle
*Sometimes the RN is not clear and so it is identified at the elbow and followed to the block level.
 Lower limb
Block choice
Iliac graft

The anterior iliac crest & overlying skin are supplied by the subcostal, II nerves which can be blocked
using QL/transversalis blocks.

Hip

- The hip joint and its muscles are supplied by branches of lumbar plexus; the femoral (the main
innervation), obturator, lumbosacral trunk (reach the hip through branches of sacral plexus) and
direct branches to psoas muscle.

-The lateral skin aspects below and above the greater trochanter are supplied by the lateral femoral
cutaneous nerve (LFCN) and the lateral branch of the subcostal nerve, respectively. The groin skin is
supplied by II and genital branch of the genitofemoral nerves and gluteal region with cluneal nerves.

- Hip anesthesia requires multiple blocks. Therefore, hip blocks are usually used to provide analgesia (
unless the pt has high-risk GA or SA)

Hip Analgesia Hip Anesthesia

# FNB + LFCNB
Option1 FNB +ONB + LFCNB + parasacral SNB
+/- parasacral SNB +/- ONB
Option2 LPB LPB + parasacral SNB
motor sparing blocks (PENG or QL1,
Option 3
LFCNB..)
-FNB (alone) can provide good (but not
complete) hip analgesia, while PENG block
To achieve anesthesia, you may need:
preserves motor power.
a) sc local infiltration to anesthetize the skin
- option 3 for pt with high risk of nerve injury,
incision above greater trochanter (for nail
or when early ambulation is needed (as in
femur, THA, hemiarthroplasty)
hip decompression)
Remarks b) deep sedation during *femur traction &
- In hip/ femur fractures,
hammering acetabular implant ^
In ER: FNB +ONB provide better
analgesia compared to PENG/ FIB
FNB / PENG are also used before spinal
anesthesia to allow positioning
# FNB +ONB + LFCNB is safer than LPB (esp in hemodynamically unstable pt)

- Start with SNB (b/c it has delayed onset), except with fracture, start with FNB / PENG
DHS= Dynamic hip screws, FIB= fascia iliaca block, FNB= femoral nerve block, LPB= lumbar plexus block, LFCNB= lateral
femoral cutaneous nerve block, ONB= obturator nerve block, QL= quadratus lumborum block, SNB= sciatic nerve block,
THA= total hip arthroplasty
*-Traction: FNB (but not LPB) does not provide psoas muscle relaxation, so during THA and hemiarthroplasty pt may get
discomfort with traction of the femur (to reduce its implant to acetabulum).
^-During Hammering of the acetabular implant (only in THA), the force is transmitted to sacroiliac and spine joints (which are
not anesthetized) causing pain. Therefore, deep sedation during this step is needed.
Knee and thigh

The knee joint and the surrounding muscles are innervated by femoral, sciatic & obturator nerves,
which are branched of lumbar and sacral plexuses.

The anterior aspect (in 30% pt) and the lateral knee skin aspects is supplied by the LFCN, while the
posterior aspect is supplied by PFCN.

Knee & thigh Anesthesia Analgesia

Block option 1 *SNB +FNB + ONB + LFCNB

SOFT block or
Option 2 LPB + SNB
FNB +/- *SNB +/- ONB +/- LFCNB
motor sparing blocks
Option 3 SOFT block+ LFCNB (ACB + LFCNB + a) ACLR: intra-articular injection
b) TKR IPACK block+ LIA
* We usually start with SNB as its onset is relatively delayed.

-LPB has many complications, so combined FNB + ONB + LFCNB is a safer alternative

- SOFT block is performed using a single skin puncture (less discomfort) in supine
position, but needs high experience & not in obese

-In TKA,
a) For anesthesia, we prefer parasacral SNB approach b/c it has high success rate,
rapid onset. For analgesia, popliteal approach is a better option to spare hamstring
muscle.
b) During hammering of the femur implant, the force is transmitted to hip, sacroiliac and
spine joints (which are not anesthetized) causing pain. Therefore, deep sedation
during his step is needed
C) Motor sparing blocks have lower quality of analgesia & so used only if early
Remarks
ambulation is requested.

-In above-knee amputation, we prefer parasacral approach to provide PFCN block.

- In ACLR using hamstring graft, a proximal SNB block (we prefer parasacral approach)
is needed to provide hamstring anesthesia/analgesia. Postop intra-articular can be
added for analgesia

- In knee scope.
a) FNB + SNB can provide anesthesia but ONB is needed to allows painless valgus
positioning (for medial meniscus trimming/repair)
b) intra-articular LA injection can provide adequate analgesia. In a few situations it can
be used as sole anesthesia.

- In pure patellar surgery, FNB alone is enough for anesthesia/analgesia

ACB= adductor canal block, ACLR= anterior cruciate ligament reconstruction, FNB= femoral nerve block, LIA= Local
infiltration anesthesia, LPB= lumbar plexus block, LFCNB= lateral femoral cutaneous nerve block, ONB= obturator nerve
block, PFCN: posterior femoral cutaneous nerve, SNB= sciatic nerve block, TKA= total knee arthroplasty
Leg and ankle

- The entire leg and ankle are supplied by the sciatic nerve, except their medial skin aspect, which is
supplied by the saphenous nerve (branch of femoral).

- Relative to the other proximal SNB block approaches, popliteal approach has a faster onset of leg /
ankle anesthesia.

anesthesia /
SNB popliteal classic approach
analgesia

*If sole anesthesia with If No thigh tourniquet but If difficult placing pt in

thigh tourniquet (video) surgery on medial aspect of lateral position
Remark the leg/ankle

add FNB (using lidocaine) add saphenous nerve block supine popliteal approach
FNB= femoral nerve block, SNB= sciatic nerve block

Distal foot

The foot is supplied by 3 Superficial nerves (start with letter S); saphenous, sural and superficial
peroneal and 2 other relatively deep nerves; posterior tibial and deep peroneal. Saphenous and sural
nerves are pure cutaneous

Distal foot
ankle block
anesthesia /analgesia

- Although it requires multiple punctures, ankle block has a faster onset of

distal foot anesthesia compared with the popliteal block.

-If thigh tourniquet is used, add FNB (using lidocaine) (video)

Remark
-Saphenous and/or sural block may not be needed according to surgery site.

- Even without motor block, ankle block causes loss of proprioception & pt
cannot walk properly postoperatively (Risk of fall).

-Note: the ankle region is not covered by ankle block.

FNB= femoral nerve block
 Block techniques
Lumbar plexus (LP) block = psoas block

- LP lies within psoas muscle (PM)

- LP gives the femoral, obturator, LFCN, genitofemoral,
ilioinguinal, iliohypogastric nerves & lumbosacral trunk.
Note: LP block anesthetizes only the former 3 nerves.
- Indication: hip & knee surgery (combined FNB + ONB + LFCN
is a safer alternative). Diagrammatic cross section. ES= erect
spinalis, QL= quadratus lumborum

Lumbar plexus block (LPB) Video1, Video 2

*30 ml of LA
Equipment long insulated needle (extra-long in morbid obese patients)
Curved probe, mark oriented laterally
Pt position lateral decubitus

Probe a) Place the probe horizontally, 3

position cm from midline, at the level of
iliac crest

b) Rock the probe medially to

identify the transverse process
(TP 3 or 4).

Probe c) Slid the probe cephalic or caudal to identify

manipulation the wave sign (outer lateral spine bone
& landmarks appears as a wave).
-The lumbar plexus (LP) lies just lateral to
vertebral body (blood vessels may be seen
close)

needle - better in-plane (medial to the probe)

insertion - Electrical stimulation is needed to adjust the
tip position

LA injection - do a carful aspiration.

- inject test dose (2ml of lidocaine) to exclude [PM= psoas major, QL= quadrates lumborum]
intrathecal injection
- loss of knee extension (don’t rely on loss of steady leg raise)
Successful
- marked weakness of hip adduction
block
- Loss of pinprick at lateral aspect of the thigh
- Epidural spread (common)→ hemodynamic instability according to spread level
- spinal /subdural spread was reported (may be fatal)
Specific
- Lumbar hematoma (especially in pt on anticoagulant). Avoid LPB in pt with coagulopathy.
Complications
- Renal hematoma (especially with high landmark approaches)
- Does not block obturator in 15%
* Some doctors believe that the use of 60 ml of LA spread to sacral plexus, therefore LPB alone (+local skin infiltration) may
be enough to provide anesthesia to hip and knee without SNB. However, we don’t recommend that because if
epidural/spinal/subdural spread occurred, it would be fatal.
Femoral nerve (FN) block

-In the thigh: FN runs lateral to the femoral artery (FA) &
supplies:
a) The hip and knee joints (main innervation)
b)The quadriceps muscle (the only extensor of the knee)
c) The skin: the anterior and medial aspects of the thigh, Diagrammatic cross section at inguinal crease.
the medial aspects of the leg and foot (via FN usually has a triangle shape (apex directed
its saphenous branch). laterally) & lies between 2 fascial layers
- Indication: hip, thigh & knee anesthesia /analgesia.
Below knee surgery, if thigh tourniquet is needed (only if nerve block was used as sole
anesthesia) for. In this case use short acting LA & no need to block the saphenous nerve

Femoral nerve block (FNB) Video

15 ml of LA
Equipment
Linear probe / long needle (short needle in thin patients)
Pt position Supine

Probe position On the inguinal crease

landmarks -Identify femoral artery (FA),

- The femoral nerve (FN) lies lateral to the artery

Probe manipulation - cephalic tilt improves FN resolution

- In-plane, from lateral

needle insertion to medial, toward the
apex of the FN,
between the 2 facial
layers

Successful blocks loss of knee extension / straight leg raise

Saphenous nerve (SpN) & adductor canal blocks

- Adductor canal is a space between 3 muscles: sartorius (SA), vastus

medialis (VM) & adductor longus (AL). It contains SpN, nerve to
vastus medialis and superficial femoral vessels (anatomy).

- SpN is a branch of femoral nerve. In the adductor canal, SpN gives Cross section at mid-thigh level
its infrapatellar branch which passes between sartorius & vastus
medialis to supply the knee & skin of upper 1/3 of the medial aspect of the leg.

- In the leg, SpN passes between sartorius & gracilis insertions to the sc tissue. A few cm distal, it runs
posterior to the saphenous vein. It supplies the medial aspects of the foot & lower 2/3 of the leg

- Based on the site of surgery, SpN can be blocked at adductor canal, leg, or ankle (this is described
later with ankle block).

SpN block At Adductor canal block Video 31:00 At leg Video 31:00
To block infrapatellar branch for:
Surgery at:
- TKA analgesia.
Indication - medial aspect of lower 2/3 of the leg
- Surgery at upper 1/3 of the medial
- medial aspect of ankle
aspect of the leg
10-15 ml of LA / Linear probe / Short needle
Equipment 5 ml LA/ Linear probe/ Short needle
(long needle /curved probe in obese)
Pt Position Supine, leg abducted or in figure of 4

horizontal,
horizontal on the posterior to the
Probe mid-thigh tibia
position

-Identify the SFA &SFV within the adductor -Spot identification of SpN in sc.
Landmarks
canal -Follow the nerve as proximal as possible

-around the
LA injection - around the nerve
artery.
-If SpN can’t be seen, just infiltrate sc 10 ml
of LA horizontally posterior to the tibia.

AL= adductor longus; NVM= nerve to vastus medialis, S= sartorius, SpN= saphenous nerve; SFA/SFV/SFVs =
superficial femoral artery/ vein / vessels; TKA= total knee arthroplasty, VM=vastus medialis.
Obturator nerve (ON) block

-ON supplies a) hip and knee joints (via its posterior branch)
b) all adductor muscles (note: adductor magnus and pectineus have double innervation)
c) almost no skin innervation.
- Indication: hip, thigh & knee surgeries & transurethral resection of bladder tumor (bilateral block).
-In a cross section along the inguinal crease, the fascia of
pectineus (P), adductor longus (AL) & brevis (AB) muscles
form a configuration resemble Y shape (Y sign).
-In a more proximal // cut (as in the figure): the Y sign still
appears but the muscles become thinner. The superior pubic
ramus (SPR) & obturator externus (OE) muscle appears deep
to lateral & medial fibers of pectineus, respectively. Both ON
branches lie between the pectineus and obturator externus,
medial to SPR.

Obturator nerve block (ONB) Video 1 , video 2

Equipment 10 ml LA / Linear probe / Short needle (long needle in morbid obese patients)
Pt position Supine, leg abducted or in figure of 4
Probe position On the inguinal crease

a) Identify Femoral artery, slide probe

landmarks
medially to identify the Y sign.
b) Identify the pectineus (P; between the
vessels (laterally) & Y sign (medially).
c) Follow pectineus proximally, by
Probe manipulation
cephalic tilting the probe, until a hyperechoic bony structure; the superior pubic ramus
(SPR), is visualized deep to pectineus muscle.
Needle insertion - out-of-plane
LA injection - deep to pectineus muscle, medial to SPR
marked decrease in adduction power. Complete loss of adduction will be achieved if
Successful blocks
accompanied with successful sciatic and femoral nerve blocks

Obturator articular hip branches block

These branches run directly on the SPR. Indications: chronic hip pain, motor sparing hip analgesia.
Block technique: same as the ONB, but the needle tip is directed to SPR as lateral as possible &
inject 5 ml of LA to minimize spread to the main obturator nerve.
Lateral femoral cutaneous nerve (LFCN) block

- At the inguinal crease, the LFCN runs lateral to

the sartorius muscle while the femoral artery
runs medial.

-LFCN supplies the lateral skin aspect of the

thigh (between greater trochanter until the Diagrammatic cross section at the inguinal crease
knee). In 30 % of pt, it also supplies the anterior -Note: the sartorius has a tapering medial end & curved
aspect. lateral end.

LFCN Block Video

5 ml LA
Equipment
Linear probe, Short needle
Pt position Supine
Probe position On the inguinal crease

landmarks a) Identify Femoral artery

b) identify the sartorius muscle (superficial & lateral to artery)

with a medial tapering end.

Probe
manipulation c) follow the sartorius
muscle laterally. At its
lateral curved border, LFCN
can be seen within a fascial
socket.
In some pt, there is more
than one nerve.
needle insertion
In/out-of-plane
Successful blocks Loss of pinprick at lateral aspect of the thigh

Fascia iliaca block (FIB)

- Fascia iliaca is the fascia covering iliacus muscle.

- LA injected deep to the fascia spreads to the
femoral nerve and LFCN (but not obturator).
- This block can be performed blindly so is valuable in Diagrammatic cross section at the inguinal crease
low resource situations. However, in presence of US,
the US guided FNB and LFCNB are so easy, provide a relatively more rapid onset, require less LA
dose, and can be performed using a single skin puncture.

-Technique: the US probe is placed vertically medial to the

anterior superior iliac spine. In this view, the arrangement
of abdominal, sartorius and iliacus muscles gives shape of
bowtie.
The LA (20 ml) is injected deep to the fascia iliaca
(between it and iliacus) Video 52:00.
N.B Injection superior to inguinal ligament may result in Diagrammatic sagittal section medial to
longer analgesia (compared with inferior injection) but also anterior superior iliac spine
does not block the obturator nerve.
PENG block (Pericapsular Nerve Group block)

-It blocks the innervations of anterior hip capsule.

-Indication: hip analgesia (alternative to FNB to preserve hip motor power).

PENG block Video 26:00

20 ml LA
Equipment
long needle, curved probe
Pt position Supine
Probe position On the inguinal crease (ie descending medially) as for FNB

landmarks a) Identify femoral artery & its deeper curved bone (femur neck)
Probe
manipulation b) Follow the bone slight cranial, until it becomes a continuous bone with 2 elevations:
anterior inferior iliac spine (AIIS) laterally & pectineus eminence (PE) medially.

c) identify psoas muscle (in the depression between the 2 elevations)

needle insertion Better in-plane (lateral to medial)

LA injection deep to psoas muscle (between the muscle & the bone)

Successful block No cutaneous/motor block. just loss of pain with hip movement
Sciatic nerve (SN)

Anatomy
-SN (main trunk) supplies: the hip joint, hamstring muscles and femur

-SN bifurcates into the common peroneal (CP) and tibial (T) nerves. They supply the posterior part of
the knee joint & almost all structures below the knee.

-The SN trunk/ branches are usually blocked at 4 levels; parasacral, subgluteal, popliteal & ankle,
giving varying distribution of anesthesia.

Parasacral approach (sacral plexus block)

The SN (& sacral plexus) originates in the pelvis, anterior
(deep) to piriformis (Pi). The SN exits the pelvis through the
greater sciatic foramen, just medial to posterior border of
ischium (PBI).

-In the parasacral approach, the SN is blocked in the pelvis

→ anesthesia of the entire sacral plexus

-Compared with the subgluteal approach, the parasacral has

a more rapid onset & higher success rate. Although it is Oblique longitudinal proximal SN view.
relatively deep, it is the easiest proximal US technique Gmax= gluteus maximus, Sg= sup gemellus
(especially in obese) b/c it is the only location where the
nerve is in direct contact with bone which is easily identified with US.

-Indication: hip, thigh & knee surgery (it is our approach of choice).

Parasacral SNB Video

20 ml of LA
Equipment Long insulated needle (extra-long in morbid obese)
A curved probe (mark oriented laterally)
Pt & probe positions landmarks

- Lateral decubitus -Identify PBI (a

curved bone)
- 4 fingers (8cm)
lateral to upper end of *-SN lies just
gluteal cleft, tilt the medial to PBI
probe slightly
caudally.

[Gmax& min= gluteus maximus & minimus, Pi= piriformis, PBI=

posterior border of ischium; S= sacrum; SN= sciatic nerve]
needle insertion Better out-of-plane, add electrical stimulation to adjust the needle tip position
Successful block Loss of knee flexion
* if the SN cannot be indetified (obese), direct the needle tip (with nerve stimulation) just medial to PBI.
Subgluteal approach
The sciatic nerve (SN) runs midway between the greater trochanter (GT) and the
ischial tuberosity (IT). It lies between the gluteus maximus (Gmax) superficially, the
quadrates femoris (QF) deep, with the common hamstring tendon (CHT) medially.

- Subgluteal SN block → anesthesia of hamstring muscle, posterior knee joint, below

knee +/- posterior skin of the thigh.

- Indication: thigh & knee surgery (parasacral approach is a better alternative).

Subgluteal SNB Video 1:09:10 & 1:14:00

20 ml of LA
Equipment Long insulated needle
Curved probe, mark oriented laterally
Pt position Lateral
Probe position between greater trochanter and ischial tuberosity.

landmarks

-The fascia of G max, QF and CHT muscles form a shape that resembles a rotated flute
glass.
-Identify Rotated flute glass sign.
-The SN lies in the center of the flute glass.
Out /in-plane
Needle insertion
add electrical stimulation to adjust the needle tip position
Successful block Loss of knee flexion
CHT= common hamstring tendon, Gmax= gluteus maximus, QF= quadrates femoris, SN= sciatic nerve
Popliteal block
- In the popliteal fossa, the SN bifurcates to common peroneal nerve (CP) and tibial nerve (T). The CP
runs laterally while the T accompanies the popliteal vessel (PVs).

-Popliteal block anesthetizes the posterior knee joint & almost all structures below knee.

-Indication: leg and ankle surgery,

knee arthroplasty analgesia (not anesthesia)

SNB Popliteal block Video

- 20-30 ml of LA
- delayed onset (so if used as sole anesthesia, use high ropivacaine concentration and
/or add lidocaine)
Equipment
we prefer long needle
Linear probe mark oriented laterally
Pt position Lateral decubitus

doctor position We prefer to stand on the front (not back) of the pt

Probe position On the popliteal crease, mark oriented laterally

landmarks -Identify Popliteal vein (PVs) & its

superficial tibial nerve (T).

Probe manipulation -Follow T cranially until it joins the

common peroneal nerve (CP).
A slight caudal probe tilt improves
image resolution.

Needle insertion -we prefer in-plane technique

LA injection -proximal, at, or distal to bifurcation

-we prefer to block each branch separately at the level of the popliteal crease
Successful block Loss of dorsal & planter foot flexion
Supine sciatic nerve blocks

In some situations (as pt under GA, or has fractures), you may need to block the SN in supine position.

SOFT, Supine popliteal, IPACK blocks allow SN/branches block in supine position. Video

Supine popliteal block

-Indication: leg and ankle surgery in pt who cannot be placed in lateral position (as with fracture, under
GA, …)
- can be combined with saphenous block using a single skin puncture (Video)

Supine popliteal block Video

Pt position Supine, slight ipsilateral tilt of the pelvis, leg in figure 4
Equipment 20-30 ml of LA, long insulated needle
Medial aspect scanning Posterior aspect scanning
better sciatic nerve image & easier identification
Remarks Tracing the needle is much easier
of the bifurcation level

Probe Curved probe on the medial aspect of the Linear probe on the popliteal crease (as medial
position thigh. as possible)

landmarks - identify the superficial femoral vessels

Probe - follow them distally until they pass into the - identify popliteal vessels (PVs). Tibial nerve
manipulation posterior compartment, as popliteal vessels (T) lies superficial to PVs
(PA, PV), to accompany the sciatic nerve (SN). -Follow the T proximally until it joins the
[Sa= sartorius, St= Semitendinosus, Bf= biceps common peroneal nerve (CP). A slight caudal
femoris, Vm = vastus medialis] tilt improves the image resolution.
in the medial aspect of the thigh (enough room to manipulate the needle)
Needle
insertion out-of-plane technique
in-plane technique.
adjust needle tip using electrical stimulation
Successful block - loss of plantar and dorsal flexions of the foot
SOFT block (Sciatic, Obturator and Femoral nerve block Technique)

-It is an advanced technique where the femoral (FN), obturator and sciatic (SN) nerves are blocked
using a single skin puncture (just medial to the femoral vein). The FN is blocked using short axis view,
but the needle is advanced from medial to lateral. While the SN is blocked using longitudinal anterior
view.

- Not for obese (BMI >30), Not for non-experts.

- Indications: Anesthesia /analgesia for thigh & knee surgeries

Longitudinal US & MRI SN views. The SN

runs deep to quadratus femoris (QF)
proximally and to adductor magnus (AM)
distally.
QF has a characteristic tapering inferior
end. Video

SOFT block
long needle, linear probe (for FNB & ONB), curved probe for SNB
Equipment
LA FNB (15 ml) & ONB (10ml), SNB (20 ml)
Pt position -Supine, slight ipsilateral tilt of the pelvis, leg in figure 4
Doctor position -Always on the Lt side of the pt

1-FNB: Linear probe is placed along the inguinal crease to

identify the femoral artery (FA), vein (FV) and nerve (FN).
Slid the probe until its medial pole is just above the FV. The
needle is inserted just medial to probe and advanced (in- 3- SNB: place the curved probe vertically,
plane) // skin for 1-2 cm, then tilt it towards the FN and inject inferior to the needle and tilt it medially to
15 ml of LA identify the sciatic nerve (SN) longitudinally
deep to the tapering end of QF.
2-ONB (as usual): Slid the linear probe medially (superior to -Redirect the needle tip (in-plane) and inject
the needle) to identify the pectineus. 20 ml of LA either:
- tilt it cranially to identify the SPR. a) deep to QF (for ACLR)
- Redirect the needle (out-of-plane) and inject 10 ml of LA b) deep to AM (for other knee surgeries)
deep to pectineus.
- loss of knee extension
Successful
-marked weakness of hip adduction,
block
- loss of knee flexion
//= parallel to, ACLR= anterior cruciate ligament reconstruction. AM= adductor magnus, FNB, ONB, SNB = femoral,
obturator, sciatic nerve block, QF= quadratus femoris; SPR= superior pubic rams.
IPACK block

IPACK= Infiltration between Popliteal Artery and Capsule of the Knee

- It blocks the genicular branches of the posterior knee capsule.

- Indication: analgesia for knee arthroplasty (added to adductor canal block). Both blocks, unlike the
SNB & FNB, spare motor power, but have a lower quality of analgesia.

Technique as supine popliteal block

(medial scanning). The curved probe is
placed on the medial thigh aspect, 1 finger
proximal to patella to identify the popliteal
vessels (PA, PV). 20-30 ml of LA is injected
between vessels & posterior shaft of femur.
Video 37:25 & 42:00

Knee Intraarticular (IA)block

- It blocks the knee joint only (but not the surrounding tissues)
- The knee joint has opioid receptors so opioid is usually added to LA
- advantage: simple, safe, early ambulation

Indication:
a) analgesia: for knee scope or ligament reconstruction. usually performed by surgeon
Note: LA may cause chondrocyte damage, so avoid continuous LA infusion
b) anesthesia for knee scope in pt with high-risk GA or SA with no available equipment for nerve block
(in areas with low resources)
- Note if intraarticular block is used as sole anesthesia in knee scope:
1) If pt got infection, the surgeon will blame you→ strict antiseptic
2) delayed onset → perform it 45 min before surgery
3) does not control pain with skin incision → add local infiltration at the port sites.
4) does not control valgus positioning associated pain → need additional sedation/ONB
5) does not control tourniquet pain →avoid tourniquet inflation or add heavy sedation

Technique:
- Carful antiseptic
- Linear US probe is placed horizontally just superior to patella
with a slight caudal tilt.
- with moving the patella, a narrow space (suprapatellar
recess, arrows) appears between the mobile quadriceps tendon
and the fixed articular tissues. The recess is clearer if there is
effusion as in the image
-Insert the needle in-plane (lateral to medial) & direct its tip the
suprapatellar recess
-Inject 30 ml of 0.5% ropivacaine (or L-bupivacaine) +10 mg
morphine+/- NSAID
Ankle block

- Indication: distal foot surgery

-Ankle block is usually referred to combined posterior

tibial (PTN), superficial (SPN) and deep peroneal nerve
(DPN) blocks. Saphenous (SpN) or sural (SuN) block is
added ONLY if the skin incision is at its skin distribution.

-The 3 nerve starts with letter (S) are Superficial & are
blocked with sc LA infiltration.
Diagrammatic cross section in the ankle: blue
- Ankle block carries risk of fall, even without motor light area= superficial fascia, DPA= dorsalis
block, b/c of loss of proprioception. pedis artery, PTA = posterior tibial artery

Ankle block Video 39:30 & 45:30

linear probe, Short needle, 5ml of LA (for each nerve)

-Place probe behind the medial

malleolus.
Posterior tibial - identify the posterior tibial artery (PTA).
nerve (PTN) - The PTN lies posterior to the artery.
-infiltrate 5 ml of LA around the nerve

- Deep & superficial peroneal & saphenous nerves can be blocked using a single
skin puncture.

Deep peroneal - place the probe above the dorsalis

nerve (DPN) pedis artery (DPA).
- insert the needle out-of-plane &
infiltrate LA at both sides of artery.

Superficial -Redirect the needle in sc, towards the

peroneal lateral malleolus & infiltrate LA in sc

Saphenous
-If needed, redirect the needle in sc towards medial malleolus & infiltrate LA in sc
nerve

-If needed, sc infiltration of LA

between lateral malleolus and
tendoachilles
Sural nerve
-The nerve can be seen with US in
few pt (beside the short saphenous
vein).
 Trunk
Trunk Pain transmission
Pains from the trunk wall (thorax, abdomen, pelvis and perineum) and partial layer of body cavities are
transmitted by somatic fibers. While pains from trunk organs and visceral layer of body cavities follow
autonomic fibers. These somatic and autonomic fibers join, in paravertebral space, to form the anterior
rami of the thoracic, lumbar and sacral nerves.

A) Trunk wall pain is transmission

Chest / breast Abdomen Inguinal Perineum

IC nerves Lower IC (7-11) nerves Subcostal and II nerves Pudendal nerve

IC= Intercostal; II= ilioinguinal & iliohypogastric

B) Trunk visceral pain transmission

Visceral pain is transmitted from the organ to a nearby plexus, then through splanchnic nerves, to
sympathetic chain or sacral plexus, then to the spinal cord.

Splanchnic
Region Organs Plexus→ Spine
nerve →
Cardiac & Cardio &
Chest Heart, lung and esophagus T1-4
pulmonary pulmonary
1) stomach, 1st part of duodenum, gall celiac greater T5-9
bladder, liver, pancreas, spleen

2) mid gut, kidney plexus, testes plexus, superficial lesser and

Abdomen ovary plexus (also supply tubes and mesenteric least Symp T10-12
broad ligament) Chain
inferior
3) hindgut (till mid-sigmoid) mesenteric lumber L1-3
HG → SHP→
lumbar
the part with peritoneal covering; roof of splanchnic L1-3
urinary bladder, uterine body
sacral
splanchnic
Pelvis PP
the part without peritoneal covering:
cervix, vagina (till hymen), rest of the Pelvic Sacral
bladder and male system, GIT distal to splanchnic plexus S2-4
mid-sigmoid (lower part of sigmoid, (para-symp)
rectum, anal canal till dentate line)
HG= hypogastric nerve, SHP= superior hypogastric plexus, symp= sympathetic, parasymp= parasympathetic,
PP= pelvic (=inferior hypogastric) plexus.
 General concepts for trunk blocks
A) Interfascial Injection: all trunk nerves (except II) are too small to be identified sonographically.
Therefore, instead of injecting LA around the nerve (perineural injection), the LA is injected within a
fascial plane, where it can spread to the desired nerve.
-The success of the Interfascial injection technique relies on:
1) accurate muscle/ fascial plane identification.
2) accurate needle tip positioning (bigger needle is better visualized,)
3) volume of LA: use high volume.

B) Block distribution: - the spread of LA is variable, so most of these blocks are more reliable for
analgesia (except PVB & II block can provide anesthesia).

C) Localized effect. Many nerves supply the trunk and each block spreads to a few nerves. Therefore,
multiple blocks are usually needed.

D) No visceral analgesia - all trunk blocks anesthetize thoracic/abdominal wall. Only PVB can
anesthetize visceral pain as well ( QL block and ESB are also claimed to
do so). Pelvic plexus block anesthetizes only pelvic viscera.

E) Unless stated, the following table is used for ALL trunk blocks.

Trunk block
20 ml of LA.
Equipment
-We prefer long needle for all blocks (Usually no need for B beveled or insulation)
- we use 20G needle for almost all blocks & 18G For PVB and blocks under GA
- curved probe for PVB, ESB, QL, PP & PN blocks (unless in very thin pt).
Probe
- linear probe for all other trunk blocks (unless morbidly obese pt).
- Prone for PVB & ESB - Lateral for unilateral QL and IC blocks
Pt position
- Supine for all other blocks
- In-plane safer in: PVB, IC, TTP blocks which are related to pleura
needle insertion
- in or out-of-plane for all other blocks
Successful block loss of sensation at corresponding dermatomes
IC= intercostal, ESB = erector spinae block, QL= quadratus lumborum, PP= pelvic plexus , PN=
Pudendal nerve, PVB= paravertebral block, TTP= transverses thoracic plane
 Chest (thorax & breast)
Block choice

- Visceral pain from the heart, lung and visceral pericardium & pleura is transmitted by sympathetic
fibers to T1-4 (can blocked by PVB)

- The entire chest wall (skin, muscle, rib, sternum and breast) medial and lateral to nipple line are
supplied by anterior and lateral branches of IC nerve, respectively

- The breast is innervated by IC 2-6 nerve. Some of the breast lymphatic drains to axilla.

- A small cephalic skin area of the breast/chest is supplied by supraclavicular nerves (superficial
cervical plexus).

- The breast rests on the pectoralis major muscle (w innervated by pectoral nerves). Other extrinsic
chest muscles (pectoralis minor, latissimus dorsi, serratus anterior, scapula attached muscles) are also
supplied by brachial plexus.

Lateral Posterior
Thoracic Sternotomy*
thoracotomy/ chest tube thoracic wall surgery
Option 1 PVB at incision level

Option 2 bilateral Mammary block IC block at incision level ESB at incision level

Medial to the nipple Lateral to the nipple Pectoral muscles

Breast
(Anterior branch) (Lateral branch) (Pectoral nerves)

Option 1 PVB at T4 + PECs1 block (video 0:30)

Parasternal, Mammary or PECs2 or

Option 2 PECs1 block
PIF block Serratus anterior block
- Option 1 can provide anesthesia or analgesia. Option 2 only analgesia
- Option 2: safer (for beginner), faster (doesn’t need positioning)
- PVB: is our standard technique (we think it is more reliable)
It anesthetizes chest wall and lung but reserved for expert operators.
In sternotomy: PVB should be performed at T4 level
Remark
In breast surgery:
thoracic/breast
- PECs1: is needed for almost all breast surgeries (except if very superficial)
analgesia
- for augmentation, the incision of is infra mammary, so PVB should be
performed at T5 level
- In long surgery (as bilateral /reconstructive surgery) → better add light GA
- For axially clearance → add ICBN /PECs2 block
- For flap surgery using latissimus dorsi → add posterior cord ICB or PECs2
IC= intercostal nerve, ICB= infraclavicular block, ICBN = Intercostobrachial nerve, ESB = erector spinae block,
PECs= pectoralis, PIF= pecto-intercostal facial block, PVB= paravertebral block
Paravertebral block (PVB)

- All somatic and visceral innervation of chest & upper

abdomen pass through the PV space. The space
bounded anteriorly with the pleura and posteriorly with
posterior membrane (PM), transverse process (TP) and
superior costotransverse (SCT) ligament.

- indication: thoracic & upper abdominal surgery (our technique of choice b/c it blocks viscera as well)
-Drawbacks: a) need lateral or prone positioning. b) risk of pleural injury (for expert only)
c) very painful block & heavy sedation is needed
- Alternative thoracic/ abdominal wall blocks are safer and easier (more superficial), but they do not
block the visceral pain
Paravertebral block (PVB) Video
Thoracic surgery: At Level of incision
depend on the surgery
level and laterality Upper abdomen surgery: T7 or T9
(site of skin incision and operated organs). Breast surgery: T4 or T5
20-30 ml (LA usually spreads 2 levels above & below the injection level)
Equipment Needle: 8 cm, 18G, echogenic or spinal with extension line for mobile-less injection
Curved probe (linear only in very thin pt).
Pt position We prefer prone (especially if bilateral), with a pillow under the chest
Horizontal technique Vertical technique
(standard, easier & more successful)
Doctor position Stand on operated side Stand on Lt side (pt’ head towards your Lt hand)
Probe position First placed vertically, para-median to count the IC spaces then positioned either:

Probe On the desired Vertical, just lateral to

manipulation IC space // to midline, and tilted
ribs laterally

Landmarks Identify: TP, pleura, posterior membrane Identify: TP (has rounded surface), pleura
and SCT ligament

Needle insertion In-plane lateral to medial In-plane caudal to cranial

between pleura and posterior membrane
Tip adjusted (deep to TP) between pleura and SCT ligament

Successful blocks loss of sensation at corresponding dermatomes

Technique Video Video
//= parallel, IC= intercostal, SCT= superior costotransverse ligament, TP=transverse process
Thoracic wall/ breast blocks

PECs1
It blocks pectoral nerves which are branches of brachial plexus (not IC
nerves). They supply the pectoralis major which is commonly cauterized
during breast surgery.

Lateral chest wall (PECs2 – Serratus) blocks

It blocks the lateral branch of intercostal (IC) nerve which pierces the IC
muscles & serratus anterior (Sr) at the mid-axillary level. It supplies the
chest wall and breast lateral to the nipple line. Serratus block may have a
better result

PECs1 PECs2 Serratus

Equipment, pt position, needle
Apply General block concepts
insertion & assessment, LA
Nerve to be
pectoral nerves lateral branches of IC nerves
blocked
-Breast surgery -Surgery at lateral breast /chest wall
Indication
-Pectoralis muscles repair flap breast reconstruction, axillary clearance, for ICBN block
Initial probe
as for ICB, to identify the axillary artery, pec maj and min
position vertical (on mid-axillary line).
Probe Rotate the probe Follow Pec minor to its lower
manipulatio horizontally lateral part
n

identify the serratus ant

Landmark a br of ATA can be seen muscle. It lies between ribs
Pec min
between Pec maj & min and skin.
superficial or deep to
LA injected between the 2 pec muscles deep to Pec min
serratus anterior muscle
*PECs2 spread to nerve to latissimus dorsi & ICBN
ATA= acromiothoracic artery, br= branch, IC= intercostal, ICB= infraclavicular block, ICBN= intercostobrachial
nerve Pec=Pectoralis, maj= major, min= minor
Medial chest wall (Parasternal, Mamary & PIF) blocks
PIF= Pecto-intercostal fascia
The intercostal (IC) nerve ends as an anterior branch which
pierces IC muscles & pectoralis major to supply the chest wall
medial to nipple line (the sternum, the breast tissue, IC muscles
& overlying skin).
The nerve can be blocked beside IMA (mammary block) or deep to pec maj (PIF and parasternal
blocks)
IC= intercostal, ICm= intercostal muscles, IMA= internal mammary artery, Pec maj= Pectoralis major
Mammary blocks Parasternal block PIF block
Equipment, pt position, LA
Apply General block concepts
needle insertion & assessment
-Nerve to be blocked. anterior branches of intercostal (IC) nerves
-Indication sternotomy / breast surgeries (medial to the nipple)

Probe position

horizontal at 4th IC space just lateral to sternum vertical, just lateral to the sternum

Landmark IMA Pec major, ICm Pec major

deep /above to the pec
LA injection just lateral to IMA Between Pec major & ICm
major
Complication Mammary: Better LA spread but risk of pericardial or IMA injury so ONLY for expert

Other: Intercostal (IC) / Transverses Thoracic Plane (TTP) blocks

-The IC nerve runs between internal intercostal (II) and the A sagittal section
transverses thoracic (TT) muscles
- In the IC block, the LA spread may be limited to the injected,
space & so it has limited indications (as chest tube insertion)

Technique: -the probe is placed vertically, at the desired level, on

the back (for IC block) or on the mid-clavicular line (for TTP
block).
-Identify the II & TT muscles
-LA injected between both muscles as cranial as possible (ie just
caudal to the cephalic rib).
 Abdomen /inguinal

Block choice

Innervation and Blocks

A) Abdominal organs innervated by sympathetic fibers. Only PVB can block thoracic sympathetic fibers.

B) Anterior abdominal wall can be divided, based on nerve supply, into 4 regions

Region Nerve supply Nerve course Main block

1 Run between RA & TA subcostal

anterior branches of
lower IC nerves Run between RA & its
2 rectus
posterior sheath

lateral branches of Run in TAP (between IO

3 TAP
lower IC nerves & TA).
Run anterior to QL, then
4 subcostal, II in transversalis plane, QL
then in TAP
PVB can replace all blocks above umbilicus
QL block can be replaced by transversalis, TAP or II block
Remarks -Transversalis and QL1 and blocks have almost the same injection point, but transversalis
doesn’t require QL identification.
-QL has longer analgesia than TAP or II block
IC= intercostal, IO= internal oblique, II= ilioinguinal/ iliohypogastric, QL= quadratus lumborum, RA= rectus
abdominis, TA= transversus abdominis, TAP= transversus abdominis plane

Laparoscopic surgeries
Based on the abdominal regions innervations, we prefer the following analgesic blocks

For midline port Bilateral RS/subcostal blocks

In lap sleeve Bilateral PVB T7
In lap choli (Bilateral PVB T9) or (RT PVB T9+ Lt RS/subcostal block
In lap appendix Bilateral RS blocks below umbilicus + LT transversalis block
- Blocks are mainly used for analgesia
- Multiple blocks are usually needed (we prefer to do it after induction of GA).
- block type/level depend on the port’s entry sites as described above
-The port positions vary according to surgery and surgeon.
-Adjust the RS block level according to the port incision level
Remarks
-PVB can replace all blocks above umbilicus (but needs positioning, experience).
-QL block can be replaced by transversalis (is almost a QL1), TAP or II block
-In lab OB/GY, PP block may be added
-Gas insufflation irritates the entire peritoneum, causes tachycardia (even without pain),
and impairs diaphragm movement (especially with Trendelenburg position)
/= or, PVB= paravertebral block, PP= pelvic plexus, QL= quadratus lumborum
Open abdominal /inguinal surgery
Based on the abdominal regions innervations, we prefer the following analgesic blocks
Surgery Suggested Blocks
Open cholecystectomy Rt PVB T9
Midline hernia (video) bilateral RS block (can be anesthetic)
Exploration bilateral RS block / Bilateral PVB (if above umbilicus)
Abdominoplasty
QL1
Iliac bone graft (video)
Open Inguinal surgery
QL 1
-hernia repair
(if used as sole anesthesia add Spermatic cord block )
-Radical orchiectomy -varicocele
Abdominal approach (include CS) bilateral QL block +/- bilateral PP
OB/GY
Vaginal approach Bilateral PP +/- bilateral pudendal blocks
-PVB anesthetizes the abdominal wall (above umbilicus) and many abdominal viscera
(stomach, gall bladder, liver, pancreas, spleen) but it needs positioning & experience.
Remark -QL can be replaced by transversalis, TAP, II block.
Transversalis block is almost QL1 but doesn’t require QL identification.
QL block lasts longer than TAP, II blocks
/= or, CS= caesarian section, II= ilioinguinal/iliohypogastric block, PP= pelvic plexus, PVB= paravertebral block,
QL= quadratus lumborum, RS= rectus sheath block.

Block techniques

Spermatic cord block

The spermatic cord enters the inguinal canal through the external ring and exits through the deep ring.
The cord transmits testicular innervation to superior mesenteric plexus to T10-11. Therefore, the
dissection of spermatic cord, testes or hernial sac results in a visceral pain that is not blocked with
abdominal wall blocks.
Indication: added to other blocks to provide anesthesia in:
A) the inguinal canal related surgery (as open inguinal hernia repair, radical
orchiectomy, varicocele)
B) the testicular surgery (as hydrocele)

Block Technique:
-identify the inferior epigastric artery (IEA) deep to rectus muscle and follow
the IEA until its origin from the external iliac artery (EIA).
- the spermatic cord passes superior to junction between IEA and EIA.
- traction/release of vas (at the scrotal neck) confirm the cord identification.
- rotate the probe to be perpendicular on the inguinal ligament and tilt it medially
- Insert the needle in-plane (caudal to cranial)
- After careful aspiration, inject LA around the cord at the deep ring.
Careful, do not puncture the herniated structure or vessels.
Note: - in obese pt, curved probe is needed
- Technique 2: the cord can be identified at the external ring and
followed laterally to be blocked at the deep ring
-LA spreads to genital branch of genitofemoral & ilioinguinal nerve.
- Surgeons usually perform this block under vision during the open
hernia repair.
Rectus & Subcostal blocks
As described in abdominal innervation:
-Subcostal block provides analgesia to Region 1
-Rectus sheath block provides analgesia to Region 2 (medial to nipple line)

A) Subcostal plane block B) Rectus sheath plane block

Video
Indications Region 1 incision Region 2 incision
Equipment, pt position, needle
General block concepts
insertion & assessment, LA

Probe position Just below & // to costal margin and along or crossing the nipple line
tilted laterally

Landmark identify: RA and TA muscles. 2 lines appear deep to RA.

posterior sheath is the superficial line
RA and its deep posterior sheath (below
LA injected between RA and its deeper TA umbilicus, inferior epigastric vessel can
be seen in this plane).
Technique Video
//= parallel, RA= rectus abdominis, TA= transversus abdominis, TAP= transversus abdominis plane, IO= internal
oblique, II= ilioinguinal/ iliohypogastric
TAP, transversalis & ilioinguinal iliohypogastric (II) blocks
A horizontal section diagram of abdominal wall.
-TA ends posteriorly at midclavicular line leaving the TF direct
deep to IO.
-TP (blue) is the space between IO & TF (posterior to TA),
-TAP (green) is the space between IO& TA
IO= internal oblique, QL= quadratus lumborum,
TA= transversus abdominis, TAP= transversus abdominis plane,
TF= transversalis fascia, TP= transversalis plane
Region 4 (inguinal) is supplied by the subcostal, II nerves. These nerves run anterior to QL, then within
the TP (lateral to QL), then within TAP
QL is the main block for region 4 (inguinal) but can be replaced by II,
transversalis or TAP block.
QL block lasts longer than TAP, II blocks
Transversalis block is almost QL1 but doesn’t require QL identification
D) Transversalis
C) TAP block II block
plane block
Video Video
Video
-Mid abdominal
Indications inguinal surgery
-inguinal surgery
Equipment, pt position, needle
General block concepts
insertion & assessment
a) Place the probe a) Place the
Probe position horizontally at the probe
& manipulation level of umbilicus between ASIS
lateral to nipple line & umbilicus

b) Identify IO (the
thickest muscle), EO
(above IO) & TA
(below IO)

c) follow the muscles

posteriorly, EO
become thicker & TA ends into transversalis plane
Landmarks

b) identify II nerves;
appear as Zorro eye cover close to ilium

c) Follow them slight lateral

Within TAP With TP

LA injection around the nerves, 5-10 ml is enough
(bet IO & TA) (bet IO & FT)
Technique Video
Complications LA may spread to femoral nerve
ASIS= anterior superior iliac spine, EO= external oblique; IO= internal oblique, II= ilioinguinal/ iliohypogastric,
TA= transversus abdominis, TAP= transversus abdominis plane, TF= transversalis fascia, TP= transversalis plane
Quadratus lumborum (QL) block
The subcostal & II nerves run anterior to QL then within the transversalis plane (lateral to QL)
- Indication: lower abdomen & inguinal surgery. It is also added for hip motor sparing analgesia.

QL block Video
Equipment 20 ml of LA, 12 cm needle, curved probe (except in very thin pt)

Lateral (easier, standard) Supine (Only if pt can’t be placed lateral)

Initially the probe is -the probe is placed

placed vertically, 4-5 cm lateral to midline. QL lies just horizontally on the loin.
between the ES and the kidney.it attaches cranially to last -The QL:
rib, caudally to iliac crest & medially (with slight medial tilt a) appears as Google
of the probe) to TP. location sign with its tip
attached to the TP.
b) hypoechoic relative to
surrounding muscles
c) with caudal probe tilt, QL becomes more superficial
and thinner.

After QL identification,
rotate the probe to be horizontal -After QL identification,
Adjust the probe to identify the TP. QL attaches to TP tip Slid the probe slightly medially and rock it medially to
create a room to insert the needle posterior to the
probe
needle insertion Better In-plane
In QL1,2,3,4 the LA was injected * lateral, posterior, antero-medial or within QL,
needle tip adjustment
respectively
Successful block Loss of groin sensation
ES = erector spinae, QL= quadratus lumborum, TP= transverse process
* QL1 is very similar to transversalis block
- QL thickness/ size is variable
 Perinium

Block choice

-The anal canal and vagina are divided (by white line and hymen) into pelvic and perineal parts, which
are supplied by pelvic plexus & pudendal nerve, respectively. Note: perianal skin is also supplied with
4th sacral nerve

-The penile skin and muscles are supplied by the pudendal nerve.

-The scrotum is supplied by pudendal, II, genitofemoral and posterior femoral cutaneous nerves. These
nerves cross in the sc of the scrotal crease to reach scrotum.

-The testicular / epididymis pain is transmitted via the spermatic cord to superior mesenteric to T10-11.

Perineal surgery Block

IRF block or PN block
Anal surgery
+ perianal skin infiltration
Penile surgery Penile block or PN block
Scrotal surgery scrotal block + Spermatic cord block
above hymen PP block
Vaginal
below hymen* PN block
IRF= Ischiorectal fossa PN= pudendal nerve PP= pelvic plexus.
Above blocks are commonly performed bilaterally unless the surgery is purely in one side.

Block technique

Penile block
It is a ring block at the sc tissue of the base of the penis to
block penile skin (not muscles). Penis has rich blood supply,
so carful aspiration is important, and hematoma is not
uncommon.

Scrotal block
The thigh is abducted and externally rotated. LA is infiltrated
sc along the crease (the green line; between the scrotum
and the inner thigh). Uni or bi lateral block depends on the
surgery site. It blocks the scrotum but not the testes.

Ischiorectal fossa block

The pudendal branches to the anus pass through the
ischiorectal fossa. Hence this block provides adequate anal
analgesia without temporary impotence (which usually
occurs with pudendal nerve block)
In the lithotomy position, 15-20 ml of LA is infiltrated bilaterally in the fossa which lies midway between
ischial tuberosity (IT) and anus.
Note: the fossa is just sc and so a short needle (3cm) is enough.
Pelvic plexus (PP) & Pudendal nerve (PN) blocks
- PP transmits all pelvic visceral pain (except the ovary). -PN is the main nerve to the perineum and
-PP lies between the rectum and Pi fascia on each side the covering skin.
(Rt & Lt) - In the gluteal region, the PN lies medial to
-PP is closely related to sacral plexus and branches of the pudendal vessels (PV), between SS
internal iliac vessels. So, its block is an advanced and ST ligaments.
technique not for
beginners

Gmax & Gmin= gluteus maximus & minimus, IS= ischial spine, PBI= posterior border of ischium, Pi= piriformis, PN&PV=
pudendal nerve & vessels, S= sacrum, SN = sciatic nerve. SS = sacrospinous ligament, ST= sacrotuberous ligament.

Pelvic plexus (PP) block Pudendal nerve (PN) block

Pt position Prone (if bilateral) or lateral decubitus (if unilateral)
30 ml ropivacaine 0.15% 5-10 ml of LA
Equipment
Curved probe, long insulated needle
Initial Probe -As parasacral SNB. horizontal at the upper end of the gluteal cleft, 4 fingers lateral
position to midline

landmarks - Identify: PBI, Pi muscle -Identify PBI. With a slight caudal slid of the
Probe -Rock the probe to identify the probe, PBI becomes a straight bone; the IS
manipulation rectum (hyperechoic surface) (slight rotate medial probe more cephalic// to
- identify the iliac vessels (use piriformis). -Identify:
Doppler). a) SS: hyperechoic line attaches to IS
b) ST: a more superficial hyperechoic line.
c) PV between the ST & SS ligaments (use
Doppler).
Needle insertion In-plane In /out plane
Electrical stimulation to avoid injury of sacral plexus to avoid intraneural injection
LA injection - between Pi muscle & rectum - medial to the vessels
Successful block No assessment Loss of perineal sensation
Specific -Injury of internal iliac vessel
Temporary impotence (inform the pt)
complication -urinary retention
*For episiotomy, obstetrician usually perform pudendal block using trans-vaginal landmark technique
Both blocks: a) similar scanning technique but different injection points & distribution of anesthesia.
b) usually performed bilaterally* c) can be combined (if needed) using a single skin puncture
 Back
The dorsal rami of the spinal nerves divide into 3 branches: lateral, intermediate, and medial. They
supply the back muscles & skin.
The medial branch supplies the facet joint, multifidus muscle & overlying skin (2cm Para midline).

Analgesia Remark
-For spine surgery as L4-5, we perform ESB at both TP4, TP5
erector spinae block (ESB)
-ESB anesthetizes back muscles & skin but neither spine nor disc
TP= transverse process

Erector spinae block (ESB)

-ES muscle lies directly posterior to transverse process (TP) of thoracic &
lumbar vertebra.

- Anatomically, ESB should block only the dorsal rami. However, it is claimed
that LA may spread to paravertebral space resulting in abdominal, thoracic &
even shoulder analgesia (based on block level). However in our experience it
relatively less effective

- Usually, it is not enough to provide anesthesia, and needs pt positioning (as PVB), but it is relatively
easier & safer (so better for beginners)

- Block level depends on the surgery site.

Equipment, LA, needle

Apply General block concepts
insertion & assessment
Pt position We prefer prone position with a pillow under the blocked region (chest or abdomen)

Curved/ linear: vertically 3 cm from midline.

Probe position
In lumbar region, it can be also placed horizontally.
thoracic vertical Lumbar vertical Lumbar horizontal

Landmark - Identify the transverse process (TP) & overlying erector spinae muscle (ES).
LA injection - between TP& ES.
- It is claimed to spread about 3-4 spaces above and below. But we prefer to inject at
Spread
multiple levels
ES= erector spinae muscle, QL= quadratus lumborum, TP= transverse process.
 Fundamentals
Motor sparing blocks
-Cutaneous and terminal articular nerve branches may be blocked selectively to spare motor fibers.

-indication: whenever motor weakness is undesirable as in:

1) surgery with high risk of nerve injury
2) for early ambulation/ physiotherapy (as in joint replacement, lower limb day case surgery).
Note:
- With no motor weakness, long acting LAs (as liposomal bupivacaine) are preferable.
- These blocks usually require multiple injections & are better performed under GA/spinal
anesthesia
- Unlike classic blocks, most of these blocks are weak analgesic (except Walant technique) so
they can’t be used as sole anesthesia and narcotics are usually needed.
- In joint replacement. We add classic blocks using lidocaine to motor-sparing techniques to
enhance immediate postoperative analgesia while limiting the duration of motor weakness (few hours).

WALANT /LIA block

Walant LIA
- In both techniques, a huge volume of diluted LA is infiltrated in different tissue planes by surgeon.
Upper limb anesthesia Knee arthroplasty analgesia
200 ml (1gm lidocaine, 375 mg bicarb, 1mg 150 mL (300 mg ropivacaine, 30 mg Ketorolac
adrenalin) and 0.5 mg adrenalin).
Walant= Wide-Awake Local Anesthesia No Tourniquet, LIA=local Infiltration Anesthesia.

Upper limb

a) Clavicle: sup cx plexus block+ CPF block or Walant technique

b) Shoulder surgery
a) classic block (ISB or ISO block) using short lidocaine
b) blocks with no motor block: ESB at T1
b) blocks with minimal motor block; selective suprascapular (SSN) block +/- axillary nerve
c) Skin/muscle: LA infiltration of them at the port/incision sites (by surgeon)
d) Joint; the shoulder is supplied mainly by 3 nerves; SSN, pectoral & axillary. Their articular
branches can be selectively blocked with LA injection around:
1) coracoid & coracoclavicular ligament
2) glenoid at 3 points; superior, anterior Glenoid (G) posterior view
and posterior can be obtained with the
placing curved/linear
c) Forearm/wrist surgery → selective probe just inferior to
forearm cutaneous nerve blocks (complete scapular spine the
motor sparing) or Elbow block (spares shoulder H= humerus,
& elbow movements) or Walant technique IST= infraspinatus tendon,
L= labrum

d) Hand surgery→ Forearm block (almost total motor sparing, video) or Walant technique
Lower limb

a) Hip surgery
1- classic blocks using short lidocaine (few hours motor block)
2- PENG block + LFCN block (for lateral hip skin) ± QL block ± Obturator nerve/ articular branches
block (obturator nerve block per say does not impair ambulation).

b) Knee surgery
1- classic blocks using short lidocaine
2 -a) skin incision: sc LA infiltration (by surgeon)
b) Joint: for knee scope: Intra-articular injection is very effective (opioid and NASID can be added)
for ligament reconstruction: Intra-articular + adductor canal block
for total knee arthroplasty: adductor canal block + IPACK block+ LIA

c) Distal foot surgery

Ankle block is almost motor sparing

Trunk

Most trunk blocks are associated with no or minimal motor weakness.

Block timing
-For anesthesia, block timing prior to surgery should be such that assessment and supplementation (if
needed) are possible.
- Even for analgesia, nerve blocks are better performed before induction (with a few exceptions).
After surgery,
Analgesic Before
After induction under After awaking the pt
blocks induction
anesthesia
- risk of nerve injury
Standard
-Uncooperative pt (operative cause)
Indication Almost all as C.S
-**Multiple blocks -failure of opioid/NSAID to
situations
control postop pain
Intraop
Yes Delayed @ No
analgesia
Surgery delay no Yes No

Pt positioning Easy Difficult

Block technique Easy Difficult *

Pt discomfort mild No Mod-severe

#
Paresthesia Yes No Not reliable
HD= hemodynamic
@ In a delayed onset block or short draping time, the skin incision may not be covered by nerve block (so
opioids may be needed)
* Surgical dissection & skin draping make some blocks technically impossible.
#
Paresthesia is alarming for intraneural injection (but not sensitive/ specific)
**As for laparoscopy.
Complications of PNB
Although PNB is a relatively safe technique, it may be fatal.
Monitoring, EARLY detection and EARLY management of PNB complications are critical.

1) Wrong site block

- It has a major medicolegal consequence

-Unlike GA or spinal, nerve block is usually unilateral.
- Wrong site block, unfortunately is not a rare complication.
-Appling “STOP before block” protocol is mandatory to avoid this mistake where the anesthetist &
assistant double check the surgical site mark & consents before sedation/block performance.

2) LA systemic toxicity (LAST)

- it is the most serious complication of PNB.

Causes

Occurs when LA exceeds certain plasma concentration as with:

a) direct IV LA injection: - Even small dose - Symptoms occur immediately.

(more common) - It may occur even after (-) ve aspiration or with the use of the US.

b) injection of an overdose of LA (symptoms occur within 30 min). This is affected by many factors:
1) the LA dose (= volume x concentration):
2) the site of injection. The higher absorption, the higher the risk of toxicity
iv> tracheal> intercostal> caudal> epidural > plexus >peripheral nerves > sc.
Ropivacaine 500mg was reported to be safe when injected for lumbar-sciatic block
3) Adrenaline: adding adrenaline to LA→↓LA absorption rate→↓LA plasma level
4) Hepatic activity: impaired liver function (as in old age, liver failure, enzyme inhibitor, reduced
hepatic blood flow) →↑ plasma level of amide LA
5) Carrier protein (AAG=alpha1-acid glycoprotein): ↓ AAG in neonate, pregnancy, acidosis →↑free
(unbounded) LA → LAST (even with injection of a safe dose).

Symptoms
- The first alarming symptoms are change in behavior, delusions, slurred speech, twitches then
circumoral numbness and tongue paresthesia, may progress to convulsion or coma.
- All types of cardiac arrhythmias & arrest may occur.
Ropivacaine and L-bupivacaine are 7 times safer than R-bupivacaine.

Of note: Peak plasma level is usually achieved within 30 mins after LA injection (unless LA was re-
injected). Careful patient monitoring, especially during these 30 mins is extremely
important.
Delusions of LAST may bother the pt (nightmares) for weeks. Therefore, we always use
midazolam premedication for anti-grade amnesia.
Management:
1) Prevention:
-use safe drugs: avoid R-bupivacaine if possible.
-use safe dose: keep in mind the factors above (site of injection, hepatic activity,…..)
-add adrenaline to LA (also works as iv marker) but some believe it may cause nerve injury
-switch on color Doppler to identify nearby vessels
-slow injection and frequent aspiration (every 5ml)
- during injection: listen to pulse rate/rhythm if it changes, stop injection & exclude iv injection

2) Early detection = Carful pt monitoring during and after block

3) Early management (once suspected do not wait for cardiovascular collapse):

a) intralipid (20%):150 ml bolus then 350 ml infusion.
if symptoms persist, another 500 ml can be used.
b) support CNS: if delusion, aggression or convulsion →propofol 50 mg increments,
c) support respiration.
Increase O2 flow rate (O2 mask & monitors must be applied BEFORE starting the block)
IF hypoventilation→ assist pt ventilation with ambu
Intubate the patient ONLY when unstable hemodynamically or inefficient ambu ventilation occurs
d) support CVS with IV fluids
if ↓BP, arrhythmias or cardiac arrest, treat them as needed except lidocaine.

Of Note. After stabilization of pt with LAST, pt can proceed for surgery when hemodynamically stable. If
the block is unsuccessful, add GA/SA and avoid repeating the block or any local infiltration of any kind.

3) Injury of nearby structures.

Its frequency has reduced with the use of US

a) Vascular injury (hematoma).

- Especially with:
- coagulopathy
- unintentional trauma of closely related vessels
- deep blocks: In general, superficial blocks have less risk of hematoma relative to deep blocks

-Only big hematoma (mostly due to surgery) can create high pressure leading to nerve damage, which
can be treated by evacuation as early as possible.

- Coagulopathy related guideline for spinal/epidural anesthesia is used for PNB; however, its use for
PNB is not based on clinical evidences.

-In our opinion, for patients with bleeding tendencies avoid blocks, unless have high-risks for GA/ Pain
killers, an expert can still perform all US guided single injection blocks except LPB. Use short-acting
LA for anesthetic blocks and diluted long-acting LA for analgesic blocks.
b) Pleural injury (pneumothorax):
-With supraclavicular block (but still occur with ISB, ICB,
thoracic PVB, IC block)

-Symptoms (usually delayed) include pleurisy, diminished air

entry, dyspnea and hypoxia.

-US can confirm the diagnosis & differentiate it from phrenic

block (video 1:20:19). A linear probe placed along the mid-
clavicular line to visualize the 2nd
-ttt: conservative (if <2 cm), or insertion of a chest tube intercostal space, In the M mode
image A) Being static, the chest wall
appears as multiple lines. B) While
c) Muscle injury: the dynamic sliding of the two layers
of pleura appears as dots. C) This
Due to hematoma or myopathy dynamic is lost with pneumothorax &
dots are replaced by lines
d) Injury of Abdominal viscera
This may occur with LPB (kidney), theoretically with TAP, QL and parasacral SNB block.

4) Nerve injury.

Causes
A) Operative causes
-Compression: tourniquets, retraction, wrong suture
-Direct trauma or diathermy: as LFCN injury with iliac crest grafting
-Stretching: bad positioning, knee valgus correction, tibial osteotomy, breast augmentation,
reversed shoulder replacement, joint dislocation or distention (fluid pump in shoulder
joint causes stretching of the MC nerve)
- hypo-perfusion: severe prolonged hypotension, hypothermia, or injury of a main feeding vessel

B) Postoperative causes: hematoma, compartment syndrome, tight dressing or brace

C) Anesthetic:
- pressure: intra-fascicular injection
- chemical: all LAs & adrenaline (in high concentrations) are chemically neurotoxic
- mechanical trauma: relative to short-beveled, long-beveled needles cause more frequent
nerve injury but always transient (4 wks)

D) Patient factor: Preexisting neurologic disorders (even subclinical), thoracic outlet, old age, male,
DM, atherosclerosis, chemotherapy →Careful preoperative assessment

Types of injury
Neuropraxia= myelin sheath damage with intact axon→ good recovery 4-6 weeks
Axonotmesis= Axonal disruption with intact myelin sheath → variable prognosis.
Neurotmesis: complete nerve disruption (axon& sheath) → poor prognosis (if occur need years)

Symptoms
Delayed block recovery or re-block after full recovery of neural function (up to 1 month)
sensory (paresthesia, pain,..etc) +/- motor weakness (but rarely pure motor).
Management
The key points of management are:

a) Prevention:
1) Careful preoperative & pre-block neurological assessment.

2) AVOID PNB if nerve injury is suspected as: -high risk pt -high risk surgery
-high risk surgeon (with varied levels of expertise).
3) If nerve injury is suspected but PNB is unavoidable (as high risk GA/spinal/pain killer):
a) PNB for anesthesia: use short agents LA (chloroprocaine)
b) PNB for postoperative analgesia:
1) Perform motor sparing blocks or
2) Perform block after surgery (to exclude occurrence of intraoperative nerve injury, though
delayed operative nerve injury may occur).

4) Avoid intraneural injection

a) avoid injection in the presence of:
-pain, paresthesia (high false +ve or - ve). -high resistance
- twitches with current < 0.2mA (if electrical stimulation is used).
b) by using US, identify the needle tip. If not possible (as in deep blocks), add electrical stimulation
c) some experts recommend the use of injection pressure device.
Note - the above precautions don't guarantee extra-neural injections.
- Recently, some studies showed that intra-neural (but extra-fascicular) is safe, however,
we still do not recommend intentional intra-neural injection.

b) Early detection
- Frequent postoperative neurological assessment (by trained nurse) to ensure block recovery.
- if the patient is discharged before the block recovery, he must be clearly instructed to come to ER if
the neural functions don’t fully recover within the duration of the used LA.
- Any unexplained delayed block → consider nerve injury. Anesthetists, surgeon and neurologist must
be included in immediate patient care to exclude any possibility of reversible causes.
- Even with full recovery of neural function, follow up of the patient for a month is required (for delayed
nerve injury).
C) Curative
- Doppler, CT or MRI may be needed to exclude surgical causes.
- Early correction (within few hours), such as removal of hematoma, wrong suture or relief of tight
dressing leads to a good prognosis.
- However, if the cause is uncorrectable, the prognosis will depend on the type of injury.
- Nerve conduction & EMG to determine the injury level. Repeat them after 4-6 w to determine the type
of injury.
- Assurance, physiotherapy and analgesics are important.
- If there is no improvement, nerve transplantation may be needed.

5) Spread of LA to nearby neural structure

Advantages: spread of: interscalene block to the superficial cervical plexus

Subgluteal SNB to posterior cutaneous nerve of the thigh
Parasacral SNB to the entire sacral plexus
Fascia iliaca block to LFCN
Disadvantages: spread of interscalene block to the phrenic nerve, brain, epidural and spinal space
spread of Lumbar plexus block to epidural and/or spinal space.
spread of II bock to femoral nerve
6) Failed block

-It is a common problem. It occurs with inaccurate placement of LA, inadequate LA volume or
concentration. Some patients may have genetic resistance to LA.

Block assessment
- When used as sole ANESTHESIA, EACH nerve block must be assessed separately. Successful block
of ALL nerves must be confirmed before shifting the patient to Operation Theater.
-Motor block (complete loss of motor function) usually achieved after sensory block (complete absence
of pin prick or cold sensation). Therefore, a complete motor block can confirm successful block of a
mixed nerve. While successful block of pure sensory nerve (as LFCN) relies on sensory
examination at its distribution (video)
-Unfortunately some analgesic fascial blocks (as ESB, IPACK and PENG ) has neither sensory nor
motor assessment

Management:
- Prophylactic: inject right LA in right position around right nerve under right condition (chain of success)
- If you have an incomplete block (before shifting a patient to OR), what to do?
a) Rescue (supplemental) block and reassess.
b) if risk of LAST → adding light GA is a safer alternative
-You MUST NOT rectify a failed (or incomplete) block with sedation under any circumstance.

7) Compartment syndrome.

- It was believed that PNB delays the diagnosis of compartment syndrome.

- However, recent evidence showed that nerve block using low concentration LA does not block
compartment inducing pain. On contrary, it may help in early diagnosis.
- Therefore, nerve block, using low concentration LA, is no longer a contraindication for cases with risk
of compartment syndrome.

8) Infection

- Especially in immunocompromised pt (DM, on chemotherapy, ….)

- For catheter insertion or immunocompromised pt: sterile gowns, sterile drapes, sterile gloves, sterile
probe cover and sterile gel are needed

- For a single injection: - wear clean gloves - disinfect the skin with alcohol
- cover US probe with clean cover - no need for drapes or gowns

9) Allergy of LA and local tissue toxicity

More for ester LA. No cross allergy between amide LA. if occurred, treated as usual.

10) Catheter related complications:

- all above + catheter dislodgment or sheared, drug injection errors, infection

- adjust its removal timing with the anticoagulant timing.
Ideal block conditions
Pre-anesthesia clinic

To exclude any contraindication,

Neurological
If any contraindication → avoid PNB unless high-risk GA or SA
examination
Document any neurological lesion
Assess Pt
in un-cooperative patient, blocks should be performed under deep sedation or GA
cooperation
Pt Education Facilitates easy conduction of nerve block

Before block

- to have enough time to perform, assess and

EARLY supplement (if needed) the block.
call of pt to OT -Unlike spinal anesthesia, PNBs usually last for long
duration (no hurry).

- STOP before block Double check surgical mark site & consents Regional anesthesia
cart
Apply O2, iv-line, basic monitors (ECG, BP, SPO2)
Sedation Midazolam (or propofol)
-clean equipment for single injection
Antiseptic -Sterile equipment for catheter insertion/
immunocompromised

During and after block

-Carful aspiration (see LAST)

- Slow injection.
Injection -Listen to pulse rate / rhythm. If it changes, stop injection &
exclude iv injection.
-Avoid intra-neural injection (see nerve injury)
-Hemodynamics Crash cart nearby
Monitor:
-Symptoms & signs of LAST for at least 30min after block.
If blocks are used as sole anesthesia, confirm successful block
Block
of all required nerves before shifting the pt to OR. (see failed
assessment
block)
Xcvxcv.
Intraoperative

1) Connect Capnography under the O2 mask

If the airway (AW)
2) use high O2 flow
is not accessible
3) Before draping, put the breathing circuit near the
(as shoulder and
patient’s head, so that in an emergency you can go under
clavicle surgery)
the drapes and control AW without un-sterilizing the Be ready to induce
Video
surgical field. GA
-Headphones (Quran or music),
-Warm: warm patient = warm feeling
Sedation - +/- Medications:(monitor breathing)
propofol, remifentanil (causes headache??)
- NEVER sedate pt with incomplete block
jkljkjkljljlj.

Postoperative

Postoperative follow up is not only important to the patient but to you as well. It gives you an idea
about the block duration, effectiveness, complication, etc
neural examination Frequent until full recovery of neural function
If catheter Check: infusion rate, skin infection, monitor of LAST

pt can be discharged with a blocked limb (or even with perineural catheter),
Discharge
but he must understand the required precautions.

After Discharge

neural
During surgical visits for 1 month to exclude delayed nerve injury
examination

﴾‫﴿وَما أُوتِيتُم ِم َن ال ِْع ْل ِم إِاَّل قَلِ ايًل‬

َ
﴾And of knowledge, you (mankind) have been given only
a little ﴿. Holy Quran :17:85
 Authors

Dr Ahmed Taha, MD
- Professor of anesthesia, Ain Shams
University, Cairo, Egypt (till 2021)
- Anesthesia Consultant, Reem Hospital,
Abu Dhabi, UAE

Email: ahmadtaha_1@yahoo.com

: massage me

Dr Manjusha Mohanan, MD
- Anesthesia Consultant, Healthpoint
Hospital, Abu Dhabi, UAE

Email: m.mohanan@healthpoint.ae