ASRA Guidelines
ASRA: this medication needs to be held for 5 days AND a normal INR prior to Neuraxial Block
What is Coumadin (warfarin)?
C8-T1 nerve roots are missed in this block
What is interscalene nerve block?
Hence it misses ulnar distribution
Sciatic nerve innervates all aspects of the foot except for this area.
What is the medial foot?
What are internal oblique and transversus abdominis?
Most common injured cranial nerves in dural puncture headache, causing diplopia.
What is CN VI (abducens neuropaxia)?
ASRA: initial dosing of Lipid Emulsion 20% in the event of a local anesthetic systemic toxicity (70kg or over)
Bolus 100 ml over 2-3 minutes
Infuse 250 ml over 15-20 minutes
These brachial plexus blocks spare the phrenic nerve
What are infraclavicular and axillary approach brachial plexus blocks?
This block covers the sensory articular branches of the sciatic nerve (popliteal plexus) without causing motor deficit.
What is IPACK block? IPACK: infiltration between the popliteal artery and capsule of the knee
These muscles are found on either side of the transversus process when performing a quadratus lumborum block.
What are psoas major and erector spinae muscles?
Opioids like Codeine and Tramadol are metabolized by this P450 enzyme. Rapid metabolizers are at risk of respiratory depression.
What is CYP2D6?
Others include hydrocodone and oxycodone.
Methadone is metabolized by CYP2B6.
ASRA: initial dosing of Lipid Emulsion 20% in the event of a local anesthetic systemic toxicity (< 70kg)
Infuse 0.25 ml/kg/min
This nerve innervates the lateral forearm.
What is musculocutaneous nerve?
Complications of quadratus lumborum block from needle trauma to surrounding structures
What are pneumothorax, renal hematoma and retroperitoneal hematoma (from nearby lumbar arteries)?
Also note, redistribution of local to lumbar plexus can cause motor block.
50 yo male 80 kg has thoracic epidural in place for rib fractures. He can be on these two anticoagulation medications to prevent DVT.
What are heparin and enoxaparin (Lovenox)?
Heparin 5000 units SQ q8h or q12h (verify aPTT); 7500 units SQ q8h or q12h; Heparin IV infusion
Enoxaparin (Lovenox): 40mg SQ daily
ASRA: this medication, at a high dose, needs to be held for 72 hours prior to neuraxial blocks
What is Xarelto (rivaroxaban)? What is Eliquis (apixaban)?
ASRA update, no longer use "therapeutic" or "prophylaxis", use "high" vs "low" dose
Low dose Xarelto/eliquis can be stopped for at least 36 hours prior to neuraxial block
This block covers lateral, medial and posterior cords of the brachial plexus.
What is infraclavicular nerve block?
This nerve controls the plantar flexion and inversion movements.
What is the tibial nerve?
These nerves are covered by the TAP block
What are intercostal nerves (T6-T12), lumbar spinal nerve L1 (iliohypogastric and ilioinguinal)?
70 yo female s/p epidural placement reports new back pain and lower extremity weakness. Diagnosis and treatment of this condition is best completed within this time period.
What is epidural hematoma?
12 hours
ASRA: medications to avoid in LAST
ASRA: Epinephrine dosing per kg in the case of LAST
Medications to avoid: local anesthetics, beta-blocks, calcium channel blockers, and vasopressin
Epinephrine < or = 1 mcg/kg in LAST
These blocks can be done for shoulder arthroplasty without affecting the phrenic nerve.
This muscle is the lateral boarder of the adductor canal.
What is vastus medialis?
Borders of the paravertebral space
What are vertebral body (medial), transverse process/superior costotransverse ligament (posterior), and pleura (anterolateral)?
Complete transection of the nerve (axons, endoneurium, perineurium and epineural connective tissue), treatment requires surgical intervention
What is neurotmesis?
Axonotmesis: axonal injury from crush or toxic injury, may lead to long-term disability
Neuropraxia: damage to myelin sheath, from stretching/compression, recovery takes weeks/months