ANESTHESIA 5

5. For intravenous regional anaesthesia

Perpheral Nerve Block
Upper Extremity
The most common LA's employed are 1% to 1.25% lidocaine or mepivacaine epinephrine for 2- to 4-hour duration of surgical block. Longer blockade (but slower onset) is achieved with 0.5% bupivacaine, levobupivacaine, or ropivacaine with epinephrine, which provide 4 to 12 hours of surgical block.

The technique of IVRA.
An intravenous catheter is placed in the hand, a tourniquet (usually a double cuff) is applied to the arm, the limb is exsanguinated by elevation and wrapping with an elastic bandage, and the proximal tourniquet is inflated well above arterial pressure. The bandage is removed and a dilute LA solution, usually 40 to 50ml of 0.5% lidocaine, is injected into the catheter. The LA gains access to nerves through the blood vessels supplying those nerves, and anesthesia occurs in 10 to 15 minutes and remains as long as the tourniquet is inflated.

Substances used are for local anesthesia:
a) Cocaine is used essentially for topical anaesthesia and thus
for operations in the nasal cavity in a concentration ranging
from 4-20%.
b) Procaine (Novocaine) the substance was introduced in 1905 and
is not effective topically but is much less toxic than
cocaine.
It can be used for subcutaneous infiltration in a 0.5%
solution; 2% solution is required for nerve blocks.
c) Lignocaine (Xylocaine) 0.5% solution is used for local
infiltration. 1-2% for nerve block. The relative advantages
and disadvantages of procaine and lignocaine can be
appreciated.
Lignocaine it is apparent, provides longer duration of
anaesthesia, however, has a lower maximum dose.

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REGIONAL ANESTHESIA LOWER LIMB

LOWER LIMB

Lumber plexus block (LPB) is performed from a posterior approach with a translumber, paravertebral needle placed to stimulate the plexus. A volume of 25 to 30 ml of LA provides adequate block.

An anterior approach to LPB is described at the groin with placement of the needle into the femoral nerve sheath and injection of 25 to 30 ml of LA.

The surgical requirements and ability to position a patient in the lateral position determine which approach is chosen. One or both halves of the nerve are identified, and 20 to 40 ml of LA injected to achieve blockade. The classic approach deep to the gluteal muscles is easily made at the same time.

Ankle block is a reliable technique that can used as sole anesthetic or for postoperative analgesia for procedures on the foot. The nerves to the foot diverge below the knee, and five separate nerve branches must be blocked for complete anesthesia as shown in. the entire ankle block requires 20 to 25 ml of LA.

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ANESTHESIA LOCAL REGIONAL

5.4 REGIONAL ANAESTHESIA
Technique used for the interruption of sensory pathways involves
the use of local anaesthetic agents at different sites in the
nervous system and can be used -

1. On mucosal surfaces
2. for subcutaneous infiltration
3. for nerve blocks

UPPER LIMB

Brachial plexus blocks above the clavicle include inter-scalene (ISB) and supraclavicular is performed at the level of the C6 transverse process, and 30 ml of LA is injected between the fascia of the anterior and middle scalene muscles after identification of the C5-C6 nerve roots. Rapid anesthesia of the superficial cervical plexus and upper toots of the brachial plexus ensures, so the technique is particularly well suited for shoulder procedures.

Brachial plexus blocks below the clavicle include infraclavicular (IFCB) and axillary (AXB) blocks.

The median nerve is located just medial to the brachial artery pulse, 2 to 3 cm proximal to the elbow flexion crease, and the radial nerve is located as it courses around the lateral supracondylar ridge of the humerus 3 to 4 cm proximal to the elbow crease. Each blocked with 5 to 10 ml of LA.

Wrist block of the three peripheral nerves is performed with 3 to 5 ml of LA per nerve, as shown. Finally, digital block can be performed for individual fingers with non-epinephrine-containing LA just distal to the metacarpophalangeal joint.

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AIRWAY DELIVERY SYSTEM

5.3 GENERAL ANAESTHESIA
The inhalation agent for anesthesia, is in most instances delivered
through an endotracheal tube

Short term barbiturates (pentothol) injected, into a vein intravenously.

This is referred to as induction, and enables the introduction
of the endotracheal tube with the help of direct laryngoscope


The tube is then connected with an anesthesia machine

5.3.1 TECHNIQUE
The dose of anesthetic to be given to any patient by inhalation
cannot be calculated based on milligrams of anesthetic per
kilogram body weight.

* In addition, there is a problem of maintaining sufficient
ventilation.
* Both these objectives are obtained by frequent clinical
examination of the patient so as to ensure sufficient level
of anaesthesia and adequate ventilation.
* The mixture of the anesthetic agent, and oxygen is adjusted
to provide sufficient anesthesia, without causing excess
depression of the central nervous system, by observing the
effect on reflexes.
* The ideal state to be maintained is a plane of anesthesia
in the 3rd state.
The ideal plane will depend upon the surgical procedure to
be performed.
* In all events, 4th stage, a stage of over dosage is to be
avoided.
These reflexes are listed, and the stages indicated, in the
Table.

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