caite.info - Download as PDF File .pdf), Text File .txt) or read online. MAS ( Clinical Research) Associate Professor of Anesthesia Stanford University. Section I: Anesthetic Equipment & Monitors Section IV: Regional Anesthesia & Pain Management Morgan & Mikhail's Clinical Anesthesiology, 6e. Morgan and Mikhail's Clinical Anesthesiology PDF 5th Edition It is a must-have book for all anesthesia students/trainees and practitioners.
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Morgan & Mikhail's Clinical Anesthesiology, Fifth Edition 25 Anesthesia for Thoracic Surgery 29 Renal Physiology & Anesthesia Department of Anesthesia. Texas Tech University Health Sciences Center. School of Medicine. Lubbock, Texas. Morgan & Mikhail's. New York. 5th edition | Morgan & Mikhail's CLINICAL ANESTHESIOLOGY John F. xiii 1 The Practice of Anesthesiology 1 section Anesthetic Equipment & Monitors 2 The Operating Available at: caite.info Appendix_L. pdf.
Examples include younger pediatric patients and some developmentally delayed individuals. The International Edition is not available in North America. If surgical anesthesia is desired for the entire shoulder. Retrospective data collection began in Once an acceptable muscle response is identified.
The interscalene groove should not be confused with the groove between the sternocleidomastoid and the anterior scalene muscle. The external jugular vein often crosses the interscalene groove at the level of the cricoid cartilage.
Even 1 mL of local anesthetic delivered into the vertebral artery may induce a seizure. The ventral rami of C5—C8 and T1 form the brachial plexus. The interscalene groove is palpated using the nondominant hand. If surgical anesthesia is desired for the entire shoulder.
If bone transverse process is contacted. For an out-of-plane technique. After the skin is anesthetized. A motor response of the diaphragm indicates that the needle is placed in too anterior a direction.
After careful aspiration for nonappearance of blood. Aspiration of arterial blood should raise concern for vertebral or carotid artery puncture. Nerve Stimulation A relatively short 5-cm insulated needle is usually employed. For both techniques. Figure 46— The brachial plexus and anterior and middle scalene muscles should be visualized in cross-section Figure 46— The carotid artery and internal jugular vein may be seen lying anterior to the anterior scalene muscle.
The brachial plexus at this level appears as three to five hypoechoic circles. Interscalene perineural infusions provide potent analgesia following shoulder surgery. Ultrasound A needle in-plane or out-of-plane technique may be used. Sparing of distal branches. For an in-plane technique. It may be helpful to have the patient turn slightly laterally with the affected side up to facilitate manipulation of the needle.
It has seen a resurgence in recent years as the use of ultrasound guidance has theoretically improved safety. Ultrasound image of the brachial plexus in the interscalene groove. A longer block needle 8 cm is usually necessary. The supraclavicular block does not reliably anesthetize the axillary and suprascapular nerves. Depending on visualized spread relative to the target nerve s.
The needle tip and shaft should be visualized during the entire block performance. Supraclavicular perineural catheters provide inferior analgesia compared with infraclavicular infusion and are often displaced due to a lack of muscle mass to aid catheter retention.
Light blue shading indicates regions of variable blockade. The first rib should also be identified as a hyperechoic line just deep to the artery. The subclavian artery should be easily identified.
The brachial plexus appears as multiple hypoechoic disks just superficial and lateral to the subclavian artery Figure 46— After careful aspiration for the nonappearance of blood. A linear. Ultrasound image of the brachial plexus in the supraclavicular fossa. Pneumothorax and subclavian artery puncture.
Ultrasound The patient should be supine with the head turned 30o toward the contralateral side. The skin is anesthetized. Pleura may be identified adjacent to the rib. The needle is inserted lateral to the transducer in a direction parallel to the ultrasound beam.
Nearly half of patients undergoing supraclavicular block will experience ipsilateral phrenic nerve palsy. Abducting the arm 90o improves axillary artery imaging. The axilla is also a suboptimal site for perineural catheter placement because of greatly inferior analgesia versus an infraclavicular infusion. Infraclavicular Block cords provides excellent anesthesia for procedures at or distal to the elbow Figure 46— Optimal needle positioning is between the axillary artery and the posterior cord.
The axillary artery pulse should be palpated and its location marked as a reference point. At this level. The subclavian artery and brachial plexus run deep to the coracoid process and can be found approximately 2 cm medial and 2 cm caudad to it.
A relatively long needle is inserted 2—3 cm cephalad to the transducer. Axillary Block At the lateral border of the pectoralis minor muscle.
Local infection. Local anesthetic spread should be visualized surrounding the plexus after careful aspiration and incremental injection. The axillary. All of the numerous axillary block techniques require the patient to be positioned supine. Ultrasound With the patient in the supine position. There are few contraindications to axillary brachial plexus blocks.
As the brachial plexus traverses beyond the first rib and into the axilla. Site-specific risks of the infraclavicular approach include vascular puncture and pneumothorax although less common than with supraclavicular block. It is often prudent to avoid this approach in patients with vascular catheters in the subclavian region. Insertion of a perineural catheter should always be in the same location posterior to the axillary artery.
The axillary artery and vein are identified in crosssection Figure 46—18B. The medial. Nerve Stimulation The patient is positioned supine with the head turned to the contralateral side.
Because the axilla is highly vascularized. A high-frequency linear transducer will. Three randomized. An acceptable motor response is finger flexion or extension at a current less than 0.
Use a small curvilinear probe in a parasagittal plane to visualize the brachial plexus. Ultrasound image of the brachial plexus surrounding the axillary artery. The red dot indicates the location of local anesthetic deposition. A total of 30—40 mL of local anesthetic is typically used. Once an acceptable muscle response is identified.
Although a single injection of 40 mL may be used. Axillary n.. Medial brachial cutaneous n. The musculocutaneous nerve elbow flexion is separate and deep within the coracobrachialis muscle. The needle is then slightly advanced until blood aspiration ceases.
Injection can be performed posteriorly. With the arm abducted and externally rotated. Nerve Stimulation Again the nondominant hand is used to palpate and immobilize the axillary artery. Transarterial Technique This technique has fallen out of favor due to the trauma of twice purposefully penetrating the axillary artery along with a theoretically increased risk of inadvertent intravascular local anesthetic injection. A 2-in. The nondominant hand is used to palpate and immobilize the axillary artery.
Musculocutaneous n. Radial n. Axillary v. Median n. Subcutaneous tissue Skin Intercostobrachial n. Coracobrachialis m. Brachial plexus Ulnar n. Triceps m. Axillary a. Patient positioning and needle angle for axillary brachial plexus block.
Biceps m. Ten milliliters of local anesthetic is then injected around each nerve including the musculocutaneous. It enters the arm and runs just medial to the brachial artery Figure 46— As it enters the antecubital space. Ultrasound Using a high-frequency linear array ultrasound transducer. Brachial a. The needle is inserted superior lateral to the transducer and advanced inferiorly medially toward the plexus under direct visualization.
Median Nerve Block The median nerve is derived from the lateral and medial cords of the brachial plexus. Biceps tendon C. Just distal to this point. The brachial plexus can be identified surrounding the artery Figure 46— Flexor carpi radialis Palmaris longus Flexor digitorum superficialis Flexor digitorum profundus Palmar branch Palmar digital nerves Blocks of the Terminal Nerves minal nerve.
Axillary artery. Brachioradialis m. A short gauge needle is inserted just medial and deep to the palmaris longus tendon. If ultrasound is used.
To block the median nerve at the wrist. Brachialis m. Skin Subcutaneous tissue Biceps m. At the level of the proximal wrist flexion crease. To block the median nerve at the elbow. To block the ulnar nerve at the level of the elbow. With ultrasound. The nerve is frequently palpable just proximal to the medial epicondyle. Ulnar n. Ulnar Nerve Block The ulnar nerve is the continuation of the medial cord of the brachial plexus and maintains a position medial to the axillary and brachial arteries in the upper arm Figure 46— Medial epicondyle Arcuate ligament Ulnar a.
The needle is inserted just medial to the artery Figure 46—29 and 3—5 mL of local anesthetic is injected. At the distal third of the humerus. To block the ulnar nerve at the wrist. At the wrist. Flexor carpi ulnaris Biceps tendon Flexor digitorum profundus Palmar branch Dorsal branch Palmar retinaculum Median n.
In the mid-forearm. Flexor carpi radialis m. Radial a. Ulnar a. To block the radial nerve at the elbow. A short gauge insulated needle is inserted just lateral to the tendon and directed toward the lateral. Terminal sensory branches include the lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm.
After exiting the spiral groove as it approaches the lateral epicondyle. The deep branch remains close to the periosteum and innervates the postaxial extensor group of the forearm.
Radial Nerve Block The radial nerve—the terminal branch of the posterior cord of the brachial plexus—courses posterior to the humerus. The superficial branch becomes superficial and follows the radial artery to innervate the radial aspects of the dorsal wrist and the dorsal aspect of the lateral three digits and half of the fourth.
The musculocutaneous nerve is the terminal branch of the lateral cord and the most proximal of the major nerves to emerge from the brachial plexus Figure 46— Lateral Brachialis m. Musculocutaneous Nerve Block A musculocutaneous nerve block is essential to complete the anesthesia for the forearm and wrist and is commonly included when performing the axillary block. Medial Biceps Median n. Using a short gauge needle.
This nerve innervates the biceps and brachialis muscles and distally terminates as the lateral antebrachial cutaneous nerve.
Lateral epicondyle Radial n. Dorsal Palmar. Deep branch Posterior interosseous n. Lateral epicondyle Flexor carpi radialis m. Superficial branch epicondyle Figure 46—31 until wrist or finger extension is elicited. Ultrasound may be used at the level of the wrist or mid-forearm to identify the radial nerve just lateral to the radial artery. Sensory innervation of each finger is provided by four small digital nerves that enter each digit at its base in each of the four corners Figure 46— The insertion of the biceps tendon is identified.
Digital Nerve Blocks Digital nerve blocks are used for minor operations on the fingers and to supplement incomplete brachial plexus and terminal nerve blocks. Ultrasound may be used to confirm the location of the musculocutaneous nerve in the coracobrachialis muscle or between this muscle and the biceps see Figure 46— Simple infiltration may be used.
A small-gauge needle is inserted at the medial and lateral aspects of the base of the selected digit. The extremity is elevated and exsanguinated by tightly wrapping an Esmarch elastic bandage from a distal to proximal direction. It supplies cutaneous innervation to the medial aspect of the proximal arm and is not anesthetized with a brachial plexus block Figure 46— An 8 Intravenous regional anesthesia. Intercostobrachial Nerve Block The intercostobrachial nerve originates in the upper thorax T2 and becomes superficial on the medial upper arm.
Anesthesia is usually established after 5—10 min. Patients usually tolerate the distal tourniquet for an additional 15—20 min because it is inflated over an anesthetized area.
Addition of a vasoconstrictor epinephrine has been claimed to seriously compromise blood flow to the digit. Tourniquet pain usually develops after 20—30 min. The proximal tourniquet is inflated. The patient should be supine with the arm abducted and externally rotated. Even Intravenous Regional Anesthesia a Bier block.
Starting at the deltoid prominence and proceeding inferiorly. Three major nerves from the lumbar plexus make contributions to the lower limb: Femoral Nerve Block The femoral nerve innervates the main hip flexors. The posterior femoral cutaneous nerve S1—3. These provide motor and sensory innervation to the anterior portion of the thigh and sensory innervation to the medial leg.
The posterior thigh and most of the leg and foot are supplied by the tibial and peroneal portions of the sciatic nerve. It lies within the psoas muscle with branches descending into the proximal thigh. Slow deflation is also recommended to provide an additional margin of safety. The sacral plexus arises from L4—5 and S1—4. The lumbar plexus is formed by the ventral rami of L1—4.
The term 3-in-1 block refers to anesthetizing the femoral. A femoral nerve block alone. Femoral nerve blocks have a relatively low rate of complications and few contraindications. Its most medial branch is the saphenous nerve. Just lateral to the artery and deep to the fascia iliaca. Fascia Iliaca Technique The goal of a fascia iliaca block is similar to that of a femoral nerve block.
Without use of a nerve stimulator or ultrasound machine. The femoral artery and femoral vein are visualized in cross-section. The needle is advanced through the sartorius muscle. Nerve Stimulation With the patient positioned supine.
The needle is inserted parallel to the ultrasound transducer just lateral to the outer edge. The needle is advanced until it is seen penetrating the fascia iliaca. Local anesthetic is injected. Once the inguinal ligament and femoral artery pulse are identified. Ultrasound A high-frequency linear ultrasound transducer is placed over the area of the inguinal crease parallel to the crease itself. As the needle passes through the two layers of fascia in this region fascia lata and fascia iliaca.
A short gauge block needle is inserted and directed laterally. A field block is performed with 10—15 mL of local anesthetic. Once the needle has passed through the fascia iliaca. The lateral femoral cutaneous nerve L2—3 departs from the lumbar plexus. This block usually anesthetizes both the femoral nerve and lateral femoral cutaneous nerves.
As there are few vital structures in proximity to the lateral femoral cutaneous nerve. It may be anesthetized as a supplement to a femoral nerve block or as an isolated block for limited anesthesia of the lateral thigh. Sartorius muscle. Ultrasound image of the femoral nerve. It emerges inferior and medial to the anterior superior iliac spine to supply the cutaneous sensory innervation of the lateral thigh. Lateral Femoral Cutaneous Nerve Block The lateral femoral cutaneous nerve provides sensory innervation to the lateral thigh see Figure 46— The patient is positioned supine or lateral.
Two centimeters distal to the junction of the middle and outer thirds.
After identification of the pubic tubercle. Redirecting laterally and caudally. The obturator nerve contributes sensory branches to the hip and knee joints. This nerve exits the pelvis and enters the medial thigh through the obturator foramen. Obturator Nerve Block A block of the obturator nerve is usually required for complete anesthesia of the knee and is most often performed in combination with femoral and sciatic nerve blocks for this purpose.
Posterior Lumbar Plexus Psoas Compartment Block surgical procedures involving areas innervated by the femoral. Following careful aspiration for the nonappearance of blood. These include 10 Posterior lumbar plexus blocks are useful for. The needle is advanced posteriorly until bone is contacted Figure 46— Obturator n.
Femoral nerve. Femoral n. Contact pubic tubercle 1. The midline is palpated. A long The posterior superior iliac spine is then palpated and a line is drawn cephalad. Modern posterior lumbar plexus blocks deposit local anesthetic within the body of the psoas muscle. The needle is advanced in an anterior direction until a femoral motor response is elicited quadriceps contraction. If available. Lumbar plexus Spinal cord procedures on the hip.
The patient is positioned in lateral decubitus with the side to be blocked in the nondependent position Figure 46— The lumbar plexus is relatively close to multiple sensitive structures Figure 46—48 and reaching it requires a very long needle.
Lumbar nerve roots emerge into the body of the psoas muscle and travel within the muscle compartment before exiting as terminal nerves see Figure 46— A line is first drawn through the lumbar spinous processes. If the transverse process is contacted. Saphenous Nerve Block The saphenous nerve is the most medial branch of the femoral nerve and innervates the skin over the medial leg and the ankle joint see Figure 46— Local anesthetic volumes greater than 20 mL will increase the risk of bilateral spread and contralateral limb involvement.
The needle should never be inserted more than 3 cm past the depth at which the transverse process was contacted. Distal Saphenous Technique The medial malleolus is identified.
The posterior femoral cutaneous nerve is variably anesthetized as well. Proximal Saphenous Technique A short block needle is inserted 2 cm distal to the tibial tuberosity and directed medially. Trans-Sartorial Technique The saphenous nerve may be accessed proximal to the knee.
A line is drawn from the greater trochanter to the PSIS. A long needle is inserted from medial to lateral in-plane or angled cephalad outof-plane and 5—10 mL of local anesthetic deposited within this fascial plane.
A high-frequency linear probe is used to identify the junction between the sartorius. The greater trochanter. If sacral plexus or posterior femoral cutaneous nerve anesthesia is required.
Ultrasound may be used to identify the saphenous vein near the tibial tuberosity. Posterior Classic or Labat Approach The patient is positioned laterally with the side to be blocked in the nondependent position. When this occurs. The needle is advanced through the gluteal muscles a motor response of these muscles may be encountered until plantar.
Before proceeding with this block. An anterior approach can be technically challenging but offers an alternative path to the sciatic nerve.
A local anesthetic volume of 25 mL provides surgical anesthesia. It can be accessed from the anterior thigh just medial to the lesser trochanter. Lateral or prone positioning may present a challenge for some patients requiring a sciatic nerve block ie. A long cm insulated needle is inserted at an angle perpendicular to all planes to the skin Figure 46— Nerve stimulation—With the patient positioned supine.
Anterior Approach After leaving the sciatic notch. A second line is drawn parallel to the first that traverses the greater trochanter intertrochanteric line. Often with this approach. Both bony structures should be visible in the ultrasound field simultaneously.
Gluteal muscles are identified superficially. From the midpoint of this line. Ultrasound—With the patient positioned supine and the leg externally rotated. If sciatic nerve block is being combined with a femoral block and ambulation is desired within the local anesthetic duration. Ultrasound—Using the same positioning and landmarks Figure 46— In many patients the landmarks are more easily identified. Through this point a long cm insulated needle is inserted directly slightly cephalad until foot plantarflexion or inversion is elicited dorsiflexion is acceptable for analgesia.
It is advanced through. Once the needle passes through the gluteus muscles with the tip next to sciatic nerve. Subgluteal Approach A subgluteal approach to the sciatic nerve is a useful alternative to the traditional posterior approach.
With the sciatic nerve at a more superficial location. The triangular sciatic nerve should be visible in cross-section just deep to this layer in a location approximately midway between the ischial tuberosity and the greater trochanter.
The elliptical. Using a long cm needle. For an out-of-plane ultrasound-guided sciatic block. The femur. Popliteal Approach 12 Popliteal nerve blocks provide excellent coverage for foot and ankle surgery. Common peroneal n.
Sciatic n. The popliteal vein is lateral to the artery. The major site-specific risk of a popliteal block is vascular puncture. Cephalad to the flexion crease of the knee.
Semimembranosus m. Sural n. Tibial n. The upper popliteal fossa is bounded laterally by the biceps femoris tendon and medially by the semitendinosus and semimembranosus tendons. The sciatic nerve divides into the tibial and common peroneal nerves within or just proximal to the popliteal fossa Figure 46— The tibial nerve continues deep behind the gastrocnemius muscle.
If bone femur is contacted. Nerve stimulation posterior approach —With the patient in the prone position. When the needle is positioned in proximity to the sciatic nerve. Having the patient flex the knee against resistance facilitates recognition of these structures. An insulated needle 5—10 cm is advanced until foot plantarflexion or inversion is elicited dorsiflexion is acceptable for analgesia.
For posterior approaches. The sciatic nerve is approached by either a posterior or a lateral approach. Ultrasound—With the patient positioned prone. The needle entry point is 1 cm caudad from the apex.
Nerve stimulation lateral approach —With the patient in the supine position and the knee fully extended. For lateral approaches. Using a high-frequency linear ultrasound transducer placed in a transverse orientation.
A volume of 30—40 mL of local anesthetic is often required for single-injection popliteal—sciatic nerve block.
Ankle Block For surgical procedures of the foot. Since this block includes five separate injections. If surgical anesthesia is desired. Excessive injectate volume and use of vasoconstrictors such as epinephrine must be avoided to minimize the risk of ischemic complications.
Five nerves supply sensation to the foot Figure 46— For analgesia alone. These maneuvers are often more technically challenging. The needle is advanced in the ultrasound plane. Ultrasound-guided popliteal sciatic blocks may be performed with the patient in the lateral or supine positions the latter with leg up-raised on several pillows.
Soleus m. Deep peroneal n. The deep peroneal nerve runs in the anterior leg after branching off the common peroneal nerve. Superficial peroneal n. It supplies superficial sensation to the anteromedial foot and is most constantly located just anterior to the medial malleolus.
The sural nerve is a branch of the tibial nerve and enters the foot between the Achilles tendon. It is located behind the posterior tibial artery at the level of the medial malleolus and provides sensory innervation to the heel. The superficial peroneal nerve. Popliteus m. Tibialis anterior m. It enters the ankle just lateral to the extensor digitorum longus and provides cutaneous sensation to the dorsum of the foot and toes.
The posterior tibial nerve is a direct continuation of the tibial nerve and enters the foot posterior to the medial malleolus. Extensor hallucis longus m. Peroneus longus muscle cut Extensor digitorum longus m. Tibialis posterior m. It provides innervation to the toe extensors and sensation to the first dorsal webspace.
Peroneus longus and brevis m. Gastrocnemius m. Flexor hallucis longus m. The needle is withdrawn and redirected from the same location in a medial direction. The posterior tibial nerve may be located by identifying the posterior tibial artery pulse behind the medial malleolus. A short. It is helpful to identify and avoid the external jugular vein. To target the sural nerve. At the junction of the upper and middle thirds. The patient is positioned supine with the head turned away from the side to be blocked.
To block the deep peroneal nerve. The dorsalis pedis pulse is often palpable here. It supplies sensation to the jaw.
The sternocleidomastoid muscle is identified and its lateral edge marked. Continuing from this insertion site. All five injections are required to anesthetize the entire foot. The cervical plexus is formed from the anterior rami of C1—4.
With the advent of ultrasound guidance. An additional 5 mL of local anesthetic is infiltrated subcutaneously. Intercostal Block Intercostal blocks provide analgesia following thoracic and upper abdominal surgery. A small-gauge needle is inserted at the inferior edge of each of the selected ribs. Following aspiration. The intercostal block has one of the highest complication rates of any peripheral nerve block due to the close proximity of the intercostal artery and vein intravascular local anesthetic injection.
With the patient in the lateral decubitus or supine position.
The intercostal nerves arise from the dorsal and ventral rami of the thoracic spinal nerves. These blocks require individual injections delivered at the various vertebral levels that correspond to the area of body wall to be anesthetized.
Branches are given off for sensation in a single dermatome from the midline dorsally all the way to across the midline ventrally. They exit from the spine at the intervertebral foramen and enter a groove on the underside of the corresponding rib. The needle is turned to advance it in a caudad direction. The major complication of thoracic injections is pneumothorax.
Each spinal nerve emerges from the intervertebral foramina and divides into two rami: Unlike the intercostal approach. Ventral hernias require bilateral injections corresponding to the level of the surgical site.
In the thorax. Paravertebral Block Paravertebral blocks provide surgical anesthesia or postoperative analgesia for procedures involving the thoracic or abdominal wall. From the midpoint of the superior aspect of each spinous process. Hypotension secondary to sympathectomy can be observed with multilevel thoracic blocks. With the patient seated and vertebral column flexed. For inguinal hernia repair.
Paravertebral blocks usually require individual injections delivered at the various vertebral levels that correspond to the area of body wall to be anesthetized. The thoracic paravertebral space is defined posteriorly by the superior costotransverse ligament.
The difficulty with this technique is that the depth of the transverse process is simply estimated. Contact transverse process 1. Upon contact with the transverse process. Inject 5 mL of local anesthetic at each level.
Using ultrasound to gauge transverse process depth prior to needle insertion theoretically decreases the risk of pneumothorax. The transverse process. Some practitioners use a loss-of-resistance syringe to guide placement. It is helpful to visualize the needle in-plane as it passes through the costotransverse ligament and observe a downward displacement of the pleura as local anesthetic is injected.
The paravertebral space may be approached from a caudal-to-cephalad direction parasagittal or a lateral-to-medial direction transverse. Ultrasound An ultrasound transducer with a curvilinear array is used. At each level 5 mL of local anesthetic is injected.
Traditional Technique A pediatric Tuohy needle 20 gauge is inserted at each point and advanced perpendicular to the skin Figure 46— The patient is ideally positioned in lateral decubitus.
Transversus Abdominis Plane Block The transversus abdominis plane TAP block is most often used to provide surgical anesthesia for minor. Ultrasound With a linear or curvilinear array transducer oriented parallel to the inguinal ligament. For hernia surgeries. Potential complications include violation of the peritoneum with or without bowel perforation.
Needle placement should be between the two fascial layers of these muscles. For part of their course. Mariano ER. Fredrickson MJ. Reg Anesth Pain Med Benninger B: Anatomic basis to the ultrasound-guided approach for saphenous nerve blockade. Hadzic A editor: Salinas F. Part I: Understanding the basic principles of ultrasound physics and machine operations.
Heil JW. McGraw-Hill Medical. Anesth Analg Loland VJ. Oxford University Press. Chan VW. Horn JL. Brull R. Perlas A. Ilfeld BM. J Ultrasound Med Ilfeld BM: Continuous peripheral nerve blocks: A review of the published evidence. Part II: A pictorial approach to understanding and avoidance. Ultrasound guidance improves the success of sciatic nerve block at the popliteal fossa.
Coimbra C. Ultrasound guidance versus electrical stimulation for femoral perineural catheter insertion. Reg Anesth Pain Med. Simons M: Brachial plexus examination and localization using ultrasound and electrical stimulation: A volunteer study. Muscles appear as striated hypoechoic structures with hyperechoic layers of fascia at their borders. Anesthesiology Hebl JR. Sandhu NS. Pitsch T. Choquet O: Approaches to the lumbar plexus: Artifacts and pitfall errors associated with ultrasound-guided regional anesthesia.
Ultrasound-guided transversus abdominis plane catheters and ambulatory perineural infusions for outpatient inguinal hernia repair. Sites BD. Mariano ER: Ultrasoundguided perineural catheter insertion: Three approaches.
A long cm needle is inserted in-plane just lateral posterior to the transducer and advanced. Lennon RL editors: Although there is no clear evidence that exposure to trace amounts of anesthetic agents presents a health hazard to operating room personnel.
True anaphylaxis due to anesthetic agents is rare. The incidence of latex anaphylaxis in children is estimated to be 1 in The use of gloves. Of the preventable incidents. The relative decrease in death attributed to respiratory rather than cardiovascular damaging events has been attributed to the increased use of pulse oximetry and capnometry.
Anesthetic mishaps can be categorized as preventable or unpreventable. Many anesthetic fatalities occur only after a series of coincidental circumstances. Muscle relaxants are the most common cause of anaphylaxis during anesthesia. Malpractice occurs when four requirements have been met: All anesthesia practitioners.
A lawsuit may be filed. Although memories fade. A duty is established when the practitioner has an obligation to provide care doctor—patient relationship. When a patient has an unexpectedly poor outcome. This chapter reviews management approaches to complications secondary to anesthesia and discusses medical malpractice and legal issues from an American USA perspective. It is often not possible to predict which cases will be pursued by plaintiffs! Litigation may be pursued when it is clear at least to the defense team that the anesthesia care conformed to standards.
Often years pass before litigation proceeds to the point where the anesthesia provider is asked about the case in question.
Readers based in other countries may not find this section to be as relevant to their practices. Should an adverse outcome lead to litigation. That said. Appropriate documentation in the patient record is helpful. When unexpected events occur. Following review by expert consultants. As previously noted. In this instance. Causation is established. When a claim is meritorious. Anesthesiology staff should carefully explain the risks and benefits of the anesthesia options available to the patient.
Once delivered. The litigation process begins with the delivery of a summons indicating that an action is pending. It must never be forgotten that the tort system is designed to be adversarial. When an adverse outcome occurs.
Malpractice insurers will hire a defense firm to represent the anesthesia staff involved. The practitioner may or may not be able to participate in this decision depending upon the insurance policy. Informed consent does not consist of handing the patient a form to sign.
More commonly. In some systems usually when everyone in a health system is insured by the same carrier. When applying for licensure or hospital appointment. The patient grants informed consent following a discussion of the risks and benefits.
One should not discuss elements of any case with anyone other than a risk manager. Preparation for defense begins before an injury has occurred. False testimony can lead to criminal charges of perjury. Some policies have a clause that disallows the practitioner from admitting errors to patients and families.
Informed consent requires that the patient understand the choices being presented. Injuries can be physical. Failure to do so can lead to adverse consequences. Being sued is stressful. Providing testimony can be stressful. Should the case not settle. This is natural and should not be a source of anxiety for the defendant.
If the award is so egregiously large that it is inconsistent with awards for similar injuries. Following empanelment. Each attorney is able to strike a certain number of jurors from the pool because they perceive an inherent bias. Expert witnesses will attempt to define what the standard of care is for the community. Many anesthesia providers will not want to settle a case because the settlement must be reported.
Following discovery. One should remember that an adverse judgment may arise from a case in which most anesthesiologists would find the care to meet acceptable standards! When a case proceeds to trial. Each attorney attempts to educate the jurors—who usually have limited knowledge of healthcare physicians and nurses will usually be struck from the jury —as to the standard of care for this or that procedure and how the defendants did or did not breach their duty to the patient to uphold those standards.
At times. Most defense attorneys will advise their clients to answer questions as literally and simply as possible. Many cases will settle during the course of the trial. Also during this period. After the attorneys conclude their closing remarks. Obligatory small talk often occurs among the attorneys and the court reporters. Once a case is in the hands of a jury.
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Mackey ,John D. Wasnick Pages: Paperback Brand: At the same time it has retained its value for coursework, review, or as a clinical refresher. This Sixth Edition has been extensively revised to reflect a greater emphasis on critical care medicine, enhanced recovery, and ultrasound in anesthesia practice. Key features that make it easier to understand complex topics: If you want to download this book, click link in the next page 5. Thank You For Visiting. You just clipped your first slide! Clipping is a handy way to collect important slides you want to go back to later.
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