ATLAS OF Regional Anesthesia - Doody another edition of our Atlas of Regional Anesthesia ... The first two editions of the Atlas ... as well as a variety of local anesthetic drugsAuthors:

ATLAS OF Regional Anesthesia

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Fourth Edition

David L. Brown, MD Professor of Anesthesiology

Cleveland Clinic Learner College of Medicine Chairman of Anesthesiology Institute

The Cleveland Clinic Cleveland, Ohio

IllustratIons by

Jo ann Clifford

ATLAS OF Regional Anesthesia


1600 John F. Kennedy Blvd.Ste 1800Philadelphia, PA 19103-2899

ATLAS OF REGIONAL ANESTHESIA ISBN: 978-1-4160-6397-1Copyright © 2010, 2006, 1999, 1992 by Saunders, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions.

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Authors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book.

Library of Congress Cataloging-in-Publication DataBrown, David L. (David Lee) Atlas of regional anesthesia / David L. Brown ; illustrations by Jo Ann Clifford and Joanna Wild King.—4th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4160-6397-1 1. Conduction anesthesia—Atlases. 2. Local anesthesia—Atlases. I. Title. [DNLM: 1. Anesthesia, Conduction—methods—Atlases. WO 517 B877a 2011] RD84.B76 2011 617.9′64—dc22

2010002699

Executive Publisher: Natasha AndjelkovicDevelopmental Editor: Julie GoolsbyPublishing Services Manager: Tina RebaneProject Manager: Amy NorwitzDesign Direction: Steven Stave

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Dedicated to

Kathryn, Sarah, Eric, Noah, and Cody

And you who think to reveal the figure of a man in words, with his limbs arranged in all their different attitudes,

banish the idea from you, for the more minute your description the more you will confuse the mind of the reader

and the more you will lead him away from the knowledge of the thing described. It is necessary therefore for

you to represent and describe.

LeonArdo dA VIncI

(1452–1519)

The Notebooks of Leonardo da Vinci, Vol. 1, Ch. III*

*Translator: edward Maccurdy

reynal & Hitchcock, new York, 1938




Contributors vii

Contributors

André P. Boezaart, MD, PhDProfessor of Anesthesiology and Orthopaedic Surgery, University of Florida College of Medicine; Chief of Division of Acute Pain Medicine and Regional Anesthesia; Director of Acute Pain Medicine and Regional Anesthesia Fellowship Program, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida

Ursula A. Galway, MDAssistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Staff Anesthesiologist, Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio

James P. Rathmell, MDAssociate Professor of Anaesthesia, Harvard Medical School; Chief of Division of Pain Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts

Richard W. Rosenquist, MDProfessor of Anesthesia and Director of Pain Medicine Division, Department of Anesthesia, University of Iowa School of Medicine; Medical Director of Center for Pain Medicine and Regional Anesthesia, Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa

Brian D. Sites, MDAssociate Professor of Anesthesiology and Orthopedics, Dartmouth Medical School, Hanover; Director of Regional Anesthesiology and Orthopedics, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Brian C. Spence, MDAssistant Professor of Anesthesiology, Dartmouth Medical School, Hanover; Director of Same-Day Surgery Program, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire




Preface to the Fourth Edition ix

Preface to the Fourth Edition Creating another edition of our Atlas of Regional Anesthesia demanded that we include the advances that are driving much of the change in regional anesthesia and pain prac-tices, and we have wisely chosen experts in our specialty to contribute to this edition. The first two editions of the Atlas were based on my experience in my practice; thankfully, as my academic practice grew, others came alongside me to add their knowledge and practical experience. The goal with this fourth edition remains the same as with the first edition—to teach physicians needing to learn regional anesthesia and pain medicine technical procedures these techniques as they are practiced by physicians who use them daily, incorporating the pearls learned from this daily practice.

I remain indebted to my three outstanding physician contributors to the third edition, Drs. André Boezaart,

James Rathmell, and Richard Rosenquist. Each has updated his contributions to this work. Additionally, two physicians helping to lead the revolution in ultrasound imaging in regional anesthesia have joined us, Drs. Brian Sites and Brian Spence. Their insights into the use of ultrasound will keep each of us focused on where our subspecialty is going. Finally, Dr. Ursula Galway has added her expertise in transversus abdominis plane block. Our artist for this edition remains Ms. Joanna Wild King; again she used her vision for simplification of images and concepts to improve on our technical messages.

I want to thank so many colleagues and patients across the country who share a belief that society as a whole ben-efits from physicians’ becoming more adept at regional anesthesia and pain medicine techniques, as we are able to treat both acute and chronic pain more effectively.

David L. Brown




Introduction xi

IntroductionThe necessary, but somewhat artificial, separation of anesthetic care into regional or general anesthetic tech-niques often gives rise to the concept that these two tech-niques should not or cannot be mixed. Nothing could be farther from the truth. To provide comprehensive regional anesthesia care, it is absolutely essential that the anesthesiologist be skilled in all aspects of anesthesia. This concept is not original: John Lundy promoted this idea in the 1920s when he outlined his concept of “balanced anesthesia.” Even before Lundy promoted this concept, George Crile had written extensively on the concept of anociassociation.

It is often tempting, and quite human, to trace the evolu-tion of a discipline back through the discipline’s develop-mental family tree. When such an investigation is carried out for regional anesthesia, Louis Gaston Labat, MD, often receives credit for being central in its development. Nevertheless, Labat’s interest and expertise in regional anesthesia had been nurtured by Dr. Victor Pauchet of Paris, France, to whom Dr. Labat was an assistant. The real trunk of the developmental tree of regional anesthesia con-sists of the physicians willing to incorporate regional tech-niques into their early surgical practices. In Labat’s original 1922 text Regional Anesthesia: Its Technique and Clinical Application, Dr. William Mayo in the foreword stated:

The young surgeon should perfect himself in the use of regional anesthesia, which increases in value with the increase in the skill with which it is administered. The well equipped surgeon must be prepared to use the proper anesthesia, or the proper combination of anes-thesias, in the individual case. I do not look forward to the day when regional anesthesia will wholly displace general anesthesia; but undoubtedly it will reach and hold a very high position in surgical practice.

Perhaps if the current generation of both surgeons and anesthesiologists keeps Mayo’s concept in mind, our patients will be the beneficiaries.

It appears that these early surgeons were better able to incorporate regional techniques into their practices because they did not see the regional block as the “end all.” Rather, they saw it as part of a comprehensive package that had benefit for their patients. Surgeons and anesthesiologists in that era were able to avoid the flawed logic that often seems

to pervade application of regional anesthesia today. These individuals did not hesitate to supplement their blocks with sedatives or light general anesthetics; they did not expect each and every block to be “100%.” The concept that a block has failed unless it provides complete anesthe-sia without supplementation seems to have occurred when anesthesiology developed as an independent specialty. To be successful in carrying out regional anesthesia, we must be willing to get back to our roots and embrace the con-cepts of these early workers who did not hesitate to supple-ment their regional blocks. Ironically, today some consider a regional block a failure if the initial dose does not produce complete anesthesia; yet these same individuals comple-ment our “general anesthetists” who utilize the concept of anesthetic titration as a goal. Somehow, we need to meld these two views into one that allows comprehensive, titrated care to be provided for all our patients.

As Dr. Mayo emphasized in Labat’s text, it is doubtful that regional anesthesia will “ever wholly displace general anesthesia.” Likewise, it is equally clear that general anes-thesia will probably never be able to replace the appropriate use of regional anesthesia. One of the principal rationales for avoiding the use of regional anesthesia through the years has been that it was “expensive” in terms of operating room and physician time. As is often the case, when exam-ined in detail, some accepted truisms need rethinking. Thus, it is surprising that much of the renewed interest in regional anesthesia results from focusing on health care costs and the need to decrease the length and cost of hospitalization.

If regional anesthesia is to be incorporated successfully into a practice, there must be time for anesthesiologist and patient to discuss the upcoming operation and anesthetic prescription. Likewise, if regional anesthesia is to be effec-tively used, some area of an operating suite must be used to place the blocks prior to moving patients to the main operating room. Immediately at hand in this area must be both anesthetic and resuscitative equipment (such as regional trays), as well as a variety of local anesthetic drugs that span the timeline of anesthetic duration. Even after successful completion of the technical aspect of regional anesthesia, an anesthesiologist’s work is really just begin-ning: it is as important to use appropriate sedation intra-operatively as it was preoperatively while the block was being administered.




Contents xiii

ContentsSECTION I: INTRODUCTION

Chapter 1:Local Anesthetics and Regional Anesthesia Equipment ... 3

David L. Brown with contributions from Richard W. Rosenquist, Brian D. Sites, and Brian C. Spence

Chapter 2:Continuous Peripheral Nerve Blocks ............................... 17

André P. Boezaart

SECTION II: UPPER EXTREMITY BLOCKS

Chapter 3:Upper Extremity Block Anatomy ..................................... 31

Chapter 4:Interscalene Block .............................................................. 41

David L. Brown with contributions from Brian D. Sites and Brian C. Spence

Chapter 5:Supraclavicular Block ........................................................ 49


Chapter 6:Infraclavicular Block ......................................................... 59

Chapter 7:Axillary Block .................................................................... 67


Chapter 8:Distal Upper Extremity Block .......................................... 73

Chapter 9:Intravenous Regional Block .............................................. 81

SECTION III: LOWER EXTREMITY BLOCKS

Chapter 10:Lower Extremity Block Anatomy ...................................... 89

Chapter 11:Lumbar Plexus Block ........................................................ 97

Chapter 12:Sciatic Block ..................................................................... 101

Chapter 13:Femoral Block .................................................................. 111


Chapter 14:Lateral Femoral Cutaneous Block................................... 121

Chapter 15:Obturator Block .............................................................. 125

Chapter 16:Popliteal and Saphenous Block ...................................... 129

Chapter 17:Ankle Block ...................................................................... 135

SECTION IV: HEAD AND NECK BLOCKS

Chapter 18:Head and Neck Block Anatomy ...................................... 141

Chapter 19:Occipital Block ................................................................ 147

Chapter 20:Trigeminal (Gasserian) Ganglion Block ......................... 151

Chapter 21:Maxillary Block ............................................................... 157

Chapter 22:Mandibular Block ........................................................... 161

Chapter 23:Distal Trigeminal Block................................................... 167

Chapter 24:Retrobulbar (Peribulbar) Block ...................................... 171

Chapter 25:Cervical Plexus Block ...................................................... 177

Chapter 26:Stellate Block ................................................................... 183

SECTION V: AIRWAY BLOCKS

Chapter 27:Airway Block Anatomy .................................................... 191

Chapter 28:Glossopharyngeal Block .................................................. 197

Chapter 29:Superior Laryngeal Block ................................................ 203

Chapter 30:Translaryngeal Block ........................................................ 207


xiv Contents

SECTION VI: TRUNCAL BLOCKS

Chapter 31:Truncal Block Anatomy ................................................... 213

Chapter 32:Breast Block ..................................................................... 217

Chapter 33:Intercostal Block .............................................................. 221

Chapter 34:Interpleural Anesthesia ................................................... 227

Chapter 35:Lumbar Somatic Block .................................................... 231

Chapter 36:Inguinal Block.................................................................. 239

Chapter 37:Paravertebral Block.......................................................... 245

André P. Boezaart and Richard W. Rosenquist

Chapter 38:Transversus Abdominis Plane Block .............................. 255

Ursula Galway

SECTION VII: NEURAXIAL BLOCKS

Chapter 39:Neuraxial Block Anatomy ............................................... 263

Chapter 40:Spinal Block ..................................................................... 271

Chapter 41:Epidural Block ................................................................. 285

Chapter 42:Caudal Block .................................................................... 301

SECTION VIII: CHRONIC PAIN BLOCKS

Chapter 43:Chronic and Cancer Pain Care: An Introduction and Perspective................................................................. 311

Chapter 44:Facet Block ....................................................................... 315

Chapter 45:Sacroiliac Block ............................................................... 327

Chapter 46:Lumbar Sympathetic Block ............................................ 335

Chapter 47:Celiac Plexus Block ......................................................... 339

Chapter 48:Superior Hypogastric Plexus Block ................................ 349

Chapter 49:Selective Nerve Root Block ............................................. 357

James P. Rathmell

Chapter 50:Intrathecal Catheter Implantation ................................. 365

James P. Rathmell

Chapter 51:Spinal Cord Stimulation.................................................. 375

James P. Rathmell

Bibliography ..................................................................... 385

Index ................................................................................. 391


Documents

ATLAS OF Regional Anesthesia - Doody another edition of our Atlas of Regional Anesthesia ... The first two editions of the Atlas ... as well as a variety of local anesthetic drugsAuthors: