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OXFORD MEDICAL PUBLICATIONS Regional Anaesthesia, Stimulation, and Ultrasound Techniques Oxford Specialist Handbooks published and forthcoming General Oxford Specialist Handbooks A Resuscitation Room Guide Addiction Medicine Day Case Surgery Perioperative Medicine, 2e Pharmaceutical Medicine Postoperative Complications, 2e Renal Transplantation Oxford Specialist Handbooks in Anaesthesia Anaesthesia for Medical and Surgical Emergencies Cardiac Anaesthesia Cardiothoracic Critical Care Neuroanaesthesia Obstetric Anaesthesia Ophthalmic Anaesthesia Paediatric Anaesthesia Regional Anaesthesia, Stimulation, and Ultrasound Techniques Thoracic Anaesthesia Oxford Specialist Handbooks in Cardiology Adult Congenital Heart Disease Cardiac Catheterization and Coronary Intervention Cardiac Electrophysiology and Catheter Ablation Cardiothoracic Critical Care Cardiovascular Computed Tomography Cardiovascular Magnetic Resonance Echocardiography, 2e Fetal Cardiology Heart Failure, 2e Hypertension Inherited Cardiac Disease Nuclear Cardiology Pacemakers and ICDs Pulmonary Hypertension Valvular Heart Disease Oxford Specialist Handbooks in Critical Care Advanced Respiratory Critical Care Oxford Specialist Handbooks in End of Life Care End of Life Care in Cardiology End of Life Care in Dementia End of Life Care in Nephrology End of Life Care in Respiratory Disease End of Life in the Intensive Care Unit Oxford Specialist Handbooks in Neurology Epilepsy Parkinson’s Disease and Other Movement Disorders Stroke Medicine Oxford Specialist Handbooks in Oncology Practical Management of Complex Cancer Pain Oxford Specialist Handbooks in Paediatrics Paediatric Dermatology Paediatric Endocrinology and Diabetes Paediatric Gastroenterology, Hepatology, and Nutrition Paediatric Haematology and Oncology Paediatric Intensive Care Paediatric Nephrology, 2e Paediatric Neurology, 2e Paediatric Radiology Paediatric Respiratory Medicine Paediatric Rheumatology Oxford Specialist Handbooks in Pain Medicine Spinal Interventions in Pain Management Oxford Specialist Handbooks in Psychiatry Child and Adolescent Psychiatry Forensic Psychiatry Old Age Psychiatry Oxford Specialist Handbooks in Radiology Interventional Radiology Musculoskeletal Imaging Pulmonary Imaging Thoracic Imaging Oxford Specialist Handbooks in Surgery Cardiothoracic Surgery, 2e Colorectal Surgery Gastric and Oesophageal Surgery Hand Surgery Hepatopancreatobiliary Surgery Neurosurgery Operative Surgery, 2e Oral and Maxillofacial Surgery 2e Otolaryngology and Head and Neck Surgery Paediatric Surgery Plastic and Reconstructive Surgery Surgical Oncology Urological Surgery Vascular Surgery Oxford Specialist Handbooks in Anaesthesia Regional Anaesthesia, Stimulation, and Ultrasound Techniques Edited by Dr Paul Warman Dr Barry Nicholls Consultant Anaesthetist Leeds General Infirmary Leeds Teaching Hospitals NHS Trust Leeds and Honorary Senior Lecturer University of Leeds Leeds Consultant in Anaesthesia and Pain Management Musgrove Park Hospital Taunton and Somerset NHS Foundation Trust Taunton Dr David Conn Consultant Anaesthetist Royal Devon and Exeter Hospital Royal Devon and Exeter NHS Foundation Trust Exeter and Honorary University Fellow University of Exeter Medical School 1 Mr David Wilkinson Physicians’ Assistant (Anaesthesia) Royal Devon and Exeter Hospital Royal Devon and Exeter NHS Foundation Trust Exeter 3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 204 The moral rights of the authors have been asserted First edition published 204 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 98 Madison Avenue, New York, NY 006, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 204930094 ISBN 978–0–9–955984–8 Printed in Great Britain by Ashford Colour Press Ltd, Gosport, Hampshire Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work. v Foreword For a (large) pocket-sized handbook, this new addition to the Oxford Handbook series contains an impressive range and depth of information about regional anaesthesia, a sub-specialty of anaesthesia, which has truly come of age in recent years. The current popularity of regional anaesthesia can be attributed to three main factors: advances in nerve location technology, especially the application of ultrasound guidance; recognition of the central importance of anatomy in achieving safe and successful results; and a better understanding of the potential benefits and limitations of regional anaesthesia in the management of surgical anaesthesia, postoperative analgesia, and other causes of acute pain. The very experienced editors of this practical and informative book are well placed to attract an impressive array of authors and to ensure that these three fundamental principles are used as a consistent framework throughout the book. The result is a very readable approach to all the techniques described, literally from head to toe. The expertise, enthusiasm, and common sense of all the contributors are clearly communicated throughout the text, enhanced by the excellent diagrams and ultrasound pictures. It would be unusual to agree with the details of every technique, as described, in an instructional textbook. While I might take a different view on some of the nuances of practice, I can commend the book as a comprehensive and authoritative guide for the novice. It will also stimulate the more experienced practitioners to question their own practice and encourage debate to continue the evolution of regional anaesthesia for the benefit of the next generation. It is a privilege to be asked to write a foreword for such an instructive book, if only because it has allowed me to update my knowledge base prior to its general release. More importantly it allows me to pay tribute to the many contributors who, during their working lifetimes, have worked hard to ensure that regional anaesthesia has found its proper place in modern anaesthetic practice. Barrie Fischer Dr H B J Fischer Worcestershire, UK vi Preface The purpose of this handbook is to provide clinicians with an easy access to the art and science of regional anaesthetic techniques. We believe we have provided the reader with a practical guide, in the familiar format of the Oxford Handbook series, combined with aspects of a larger reference text, in a handy pocket-sized book. We have deliberately included both landmark or peripheral nerve stimulator-guided techniques and ultrasound techniques to provide a complete clinical guide. Anatomy features strongly throughout the chapters as it remains the cornerstone of good clinical regional anaesthesia, whether using an ultrasound or a peripheral nerve stimulator, and indeed the legendary Alon P. Winnie remarked ‘Regional anesthesia is simply an exercise in applied anatomy’. The first section covers a wide range of topics on the background of regional anaesthesia. There is an amusing and enlightening chapter on the history of regional anaesthesia. There are chapters covering the basic science of physiology of pain, pharmacology of drugs, physics and use of ultrasound, and peripheral nerve stimulators. Whilst maintaining a strong science base, we have tried to make these chapters as clinically relevant as possible and have useful clinical tips on the practice of regional anaesthesia and frequent summaries of published evidence. There are also sections to deal with risks and complications of regional anaesthesia. Included in this section are some more advanced techniques of wound and nerve catheters and paediatric regional anaesthesia. The remainder of the book provides detailed descriptions of almost all conceivable regional anaesthetic techniques over the whole of the body. The obvious upper and lower limb blocks are there, with descriptions of all common approaches. Unlike some pocket guides we have included head and neck blocks and ophthalmic regional anaesthesia. We have also covered trunk blocks, those of both the chest, including the increasingly popular paravertebral blocks, and of the abdominal wall; such as TAP and rectus sheath blocks. Each chapter provides a representation of the complexity of the block, the indications, contraindications, and complications. There is an overview of the anatomy with frequent diagrams to illustrate. The step-bystep ‘hands on’ guides of the blocks are again complemented with diagrams to aid understanding and to help the practice of block performance and of course ultrasound images of the appropriate anatomy. There are frequent helpful clinical tips and hints throughout. Although familiar to many, we have included a section describing central neuraxial techniques. Although the basics of the practical techniques are covered, there is perhaps more of a focus on the use of these techniques in certain situations and there is a chapter to describe and illustrate the emerging skill of spinal ultrasonography in regional anaesthesia. There are many contributors to the text of the book; all are clinical anaesthetists with an enthusiasm and passion for regional anaesthesia. Many of them will be familiar names from the ‘aristocracy’ of regional anaesthesia in this country, teaching and preaching on national and international stages PREFACE over many years of dedication. Our thanks to them all for their expert contributions and their forbearance on bringing this book to publication. The text and images have been checked, but we apologies in advance for any errors (or differing points of view) and would welcome your feedback, comments, and corrections. Whilst we hope that this handbook provides an invaluable guide and reference, it is not a substitute for the proper study, training, practice, and mentorship to attain proficiency in the safe and effective delivery of regional anaesthesia to your patients. Paul Warman David Conn Barry Nicholls David Wilkinson Reference . Winnie AP, Håkansson L (eds) (993). Plexus Anesthesia. Vol  (3rd edn). Philadelphia: WB Saunders. vii viii Acknowledgements and dedications I would like to acknowledge the kind assistance of the Anatomy Department at the University of Leeds. My thanks to Barry Nicholls and David Conn for their teaching, guidance, and friendship. I dedicate this book to my wife, Claire, who makes everything possible and to my children Harry and Barnaby who make everything worthwhile. —PW For the support and training shown to me by teachers and friends Dr Edmund J Charlton and Dr Angus Pridie. —BN To Sherdil Nath, Angus Pridie, and Barry Nicholls, who are the reason I practise regional anaesthesia. Also to Clare, who keeps me sane. —DC For IAW and AMR. —DW ix Contents Contributors xii Symbols and Abbreviations xv Part  General Considerations  2 3 4 5 6 7 8 9 0  2 3 4 5 A brief history of regional anaesthesia The physiology of acute pain Local anaesthetics and additives Local anaesthetic toxicity Peripheral nerve location using nerve stimulators Basic physics of ultrasound Principles and practice of ultrasound-guided regional anaesthesia Risks, benefits, and controversies of regional anaesthesia Regional anaesthesia in patients taking anticoagulant drugs Preparation and care of the awake patient during surgery Wound infiltration and catheter techniques Dermatomes and myotomes Paediatric regional anaesthetic techniques Peripheral nerve catheters Training and assessment in regional anaesthesia 3  25 37 49 6 79 97 7 27 33 39 49 69 77