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Pain management II: local and regional anaesthetic techniques
/content/chapter/10.22233/9781910443231.chap11
Pain management II: local and regional anaesthetic techniques
- Author: Tanya Duke-Novakovski
- From: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia
- Item: Chapter 11, pp 143 - 158
- DOI: 10.22233/9781910443231.11
- Copyright: © 2016 British Small Animal Veterinary Association
- Publication Date: April 2016
Abstract
The provision of local anaesthetic blocks prior to surgery, postoperatively or for critically ill or injured patients is a powerful tool for improving the quality of pain control. When performed correctly, there are observable benefits, such as anaesthetic-sparing properties and improved patient comfort. This chapter looks at the history of pain management, pharmacology and pharmacokinetics and local anaesthetic techniques.
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Figures
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11.1
Diagram of a nerve axon, showing an expanded view of a sodium channel in the open and closed state. © 2016 British Small Animal Veterinary Association
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11.1
Diagram of a nerve axon, showing an expanded view of a sodium channel in the open and closed state.
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11.2
Chemical structures of local anaesthetics from the ester group. Red circles indicate the ester linkage. © 2016 British Small Animal Veterinary Association
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11.2
Chemical structures of local anaesthetics from the ester group. Red circles indicate the ester linkage.
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11.3
Chemical structures of three commonly used amide local anaesthetic drugs. Red circles indicate the amide linkage. © 2016 British Small Animal Veterinary Association
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11.3
Chemical structures of three commonly used amide local anaesthetic drugs. Red circles indicate the amide linkage.
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11.7
A ‘splash’ block being applied on the surgical incision following closure of the linea alba in a dog. © 2016 British Small Animal Veterinary Association
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11.7
A ‘splash’ block being applied on the surgical incision following closure of the linea alba in a dog.
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11.8
(a) A diffusion wound catheter placed within the incision used for a hindlimb amputation in a dog. (b) Bupivacaine with bicarbonate was injected through the injection port (arrowed) attached to the catheter for postoperative pain control. © 2016 British Small Animal Veterinary Association
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11.8
(a) A diffusion wound catheter placed within the incision used for a hindlimb amputation in a dog. (b) Bupivacaine with bicarbonate was injected through the injection port (arrowed) attached to the catheter for postoperative pain control.
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11.9
(a–b) Use of a nerve stimulator and an insulated needle to perform accurate deposition of local anaesthetic around nerve bundles. These images show a RUMM block being performed with an older unit. New units have electrical current scales which are easier to use and proprietary insulated needles. (c) New model nerve stimulator (Stimpod, Mila International). © 2016 British Small Animal Veterinary Association
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11.9
(a–b) Use of a nerve stimulator and an insulated needle to perform accurate deposition of local anaesthetic around nerve bundles. These images show a RUMM block being performed with an older unit. New units have electrical current scales which are easier to use and proprietary insulated needles. (c) New model nerve stimulator (Stimpod, Mila International).
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11.10
(a) Diagram illustrating the needle positions to perform the auricular block in a dog. The positions are identical for the cat. (b) Auricular block for a dog undergoing a vertical ear canal ablation. (a, © Juliane Deubner, University of Saskatchewan, Canada; b, Courtesy of Marieke de Vries, Davies Veterinary Specialists, Higham Gobion, UK) © 2016 British Small Animal Veterinary Association
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11.10
(a) Diagram illustrating the needle positions to perform the auricular block in a dog. The positions are identical for the cat. (b) Auricular block for a dog undergoing a vertical ear canal ablation. (a, © Juliane Deubner, University of Saskatchewan, Canada; b, Courtesy of Marieke de Vries, Davies Veterinary Specialists, Higham Gobion, UK)
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11.11
Cervical paravertebral block being performed using the cranial–caudal approach in a dog about to undergo a humeral fracture repair. © 2016 British Small Animal Veterinary Association
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11.11
Cervical paravertebral block being performed using the cranial–caudal approach in a dog about to undergo a humeral fracture repair.
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11.12
Approaches to the paravertebral block. The green needle indicates the direction for the dorsal–ventral approach and the blue needles indicate the direction for the cranial–caudal approach. C = cervical; T = thoracic. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.12
Approaches to the paravertebral block. The green needle indicates the direction for the dorsal–ventral approach and the blue needles indicate the direction for the cranial–caudal approach. C = cervical; T = thoracic. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.13
(a) Diagram illustrating the direction of the needle to perform the brachial plexus block in a dog. The landmarks are the same for the cat. (b) This dog had a fractured radius/ulna and was difficult to handle. Following opioid administration and a brachial plexus block, the dog became friendly and appeared pain-free (
Duke et al., 1998
). C = cervical; T = thoracic. (a, © Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.13
(a) Diagram illustrating the direction of the needle to perform the brachial plexus block in a dog. The landmarks are the same for the cat. (b) This dog had a fractured radius/ulna and was difficult to handle. Following opioid administration and a brachial plexus block, the dog became friendly and appeared pain-free (
Duke et al., 1998
). C = cervical; T = thoracic. (a, © Juliane Deubner, University of Saskatchewan, Canada)
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11.14
Diagrams showing the needle positions for performing the RUMM block. (a) The radial nerve is blocked proximal to the elbow on the lateral surface. (b) The musculocutaneous, medial and ulnar nerves are blocked on the medial surface proximal to the elbow. The positions are identical for the cat. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.14
Diagrams showing the needle positions for performing the RUMM block. (a) The radial nerve is blocked proximal to the elbow on the lateral surface. (b) The musculocutaneous, medial and ulnar nerves are blocked on the medial surface proximal to the elbow. The positions are identical for the cat. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.15
(a) The radial nerve in a cat is blocked on the cranial surface of the forelimb, and (b) the median and ulnar nerves are blocked on the palmar surface of the forelimb. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.15
(a) The radial nerve in a cat is blocked on the cranial surface of the forelimb, and (b) the median and ulnar nerves are blocked on the palmar surface of the forelimb. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.16
The femoral nerve is blocked within the groin area as it crosses the femoral triangle. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.16
The femoral nerve is blocked within the groin area as it crosses the femoral triangle. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.17
The sciatic nerve is blocked between the cranial and middle third of a line connecting the greater trochanter and the ischiatic tuberosity. The tibial nerve is blocked deep to the gastrocnemius muscle and the common peroneal nerve is blocked as it passes caudal to the head of the fibula. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.17
The sciatic nerve is blocked between the cranial and middle third of a line connecting the greater trochanter and the ischiatic tuberosity. The tibial nerve is blocked deep to the gastrocnemius muscle and the common peroneal nerve is blocked as it passes caudal to the head of the fibula. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.18
(a) Cross-section of the spinal cord area depicting the divisions between the epidural and subarachnoid spaces. (b) Sagittal section of the lumbosacral area illustrating needle placement into the epidural space. L = lumbar; S = sacral. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.18
(a) Cross-section of the spinal cord area depicting the divisions between the epidural and subarachnoid spaces. (b) Sagittal section of the lumbosacral area illustrating needle placement into the epidural space. L = lumbar; S = sacral. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.20
Diagram illustrating the site for lumbosacral injection, indicated by the red circle. The horizontal blue dashed line illustrates the imaginary line joining the iliac crests, and the yellow dashed line marks the vertebral column. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.20
Diagram illustrating the site for lumbosacral injection, indicated by the red circle. The horizontal blue dashed line illustrates the imaginary line joining the iliac crests, and the yellow dashed line marks the vertebral column. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.21
An air bubble is introduced into the syringe to aid in detecting loss of resistance to injection into the epidural space. © 2016 British Small Animal Veterinary Association
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11.21
An air bubble is introduced into the syringe to aid in detecting loss of resistance to injection into the epidural space.
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11.22
A loss of resistance syringe for assessing placement of a spinal needle into the epidural space. © 2016 British Small Animal Veterinary Association
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11.22
A loss of resistance syringe for assessing placement of a spinal needle into the epidural space.
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11.23
A hanging drop of sterile saline or injectate can be placed on the hub of the needle; aspiration of the liquid indicates entry of the distal end of the needle into the epidural space. (Courtesy of Marieke de Vries, Davies Veterinary Specialists, Higham Gobion, UK) © 2016 British Small Animal Veterinary Association
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11.23
A hanging drop of sterile saline or injectate can be placed on the hub of the needle; aspiration of the liquid indicates entry of the distal end of the needle into the epidural space. (Courtesy of Marieke de Vries, Davies Veterinary Specialists, Higham Gobion, UK)
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11.24
(a) An epidural catheter and Tuohy needle. (b) The needle has a specially designed end to allow the cranial movement of the catheter. (c) Special patches with clips are available to fix the catheter to the skin. © 2016 British Small Animal Veterinary Association
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11.24
(a) An epidural catheter and Tuohy needle. (b) The needle has a specially designed end to allow the cranial movement of the catheter. (c) Special patches with clips are available to fix the catheter to the skin.
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11.25
Diagrams illustrating the needle positions for digital nerve blocks for (a) a cat and (b) a dog. The needle is inserted at the point of bifurcation of the nerves. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.25
Diagrams illustrating the needle positions for digital nerve blocks for (a) a cat and (b) a dog. The needle is inserted at the point of bifurcation of the nerves. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.26
(a) Placement of a catheter into a superficial vein and application of a tourniquet (not visible in this image) to perform an intravenous regional block in the hindpaw region of an anaesthetized dog for digit removal. (b) The leg is held above heart level for 5 minutes and the tourniquet is tightened until there is loss of a peripheral pulse distal to the tourniquet. Lidocaine is then injected through the pre-placed catheter. © 2016 British Small Animal Veterinary Association
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11.26
(a) Placement of a catheter into a superficial vein and application of a tourniquet (not visible in this image) to perform an intravenous regional block in the hindpaw region of an anaesthetized dog for digit removal. (b) The leg is held above heart level for 5 minutes and the tourniquet is tightened until there is loss of a peripheral pulse distal to the tourniquet. Lidocaine is then injected through the pre-placed catheter.
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11.27
(a) Placement of an intercostal nerve block in a dog undergoing a lateral thoracotomy. (b) Use of a diluted solution of bupivacaine to allow multiple injections around the intercostal nerves in a cat undergoing a median sternotomy. © 2016 British Small Animal Veterinary Association
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(a) Placement of an intercostal nerve block in a dog undergoing a lateral thoracotomy. (b) Use of a diluted solution of bupivacaine to allow multiple injections around the intercostal nerves in a cat undergoing a median sternotomy.
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11.28
Diagram illustrating the areas (red circles) where an intercostal block can be performed for a lateral thoracotomy incision (dashed line) or for chest drain placement. (© Juliane Deubner, University of Saskatchewan, Canada) © 2016 British Small Animal Veterinary Association
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11.28
Diagram illustrating the areas (red circles) where an intercostal block can be performed for a lateral thoracotomy incision (dashed line) or for chest drain placement. (© Juliane Deubner, University of Saskatchewan, Canada)
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11.29
Injection of bupivacaine through a pre-placed interpleural catheter for administration of an interpleural block in a dog after lateral thoracotomy. The incision is on the left side of the dog. © 2016 British Small Animal Veterinary Association
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11.29
Injection of bupivacaine through a pre-placed interpleural catheter for administration of an interpleural block in a dog after lateral thoracotomy. The incision is on the left side of the dog.