dfsi drreddys workshop anasth.

1. Regional AnesthesiaRegional Anesthesia
for the Lower Limbsfor the Lower Limbs
Dr. Prakash Ambardekar
SeniorAnaesthesiologist
Dept of Anesthesia
SL Raheja Hospital, Mumbai

2. Diabetes Mellitus is not a simple endocrine disorder
1] Cardio-vascular system - Angina pectoris,
silent small to massive Myocardial Infarcts ,
varying degrees of cardiomyopathies,
varying types of Conduction blocks etc
may be accompanied with Hypertension
2] Reno-vascular system - Nephropathies leading to Chronic renal failure
3] Central nervous system –Secondary effects
4] Autonomic nervous system -Sympathetic & Parasympathetic systems
causing Autonomic Imbalance
5]Immunological system – suppression, prone to infections
Contd…

3. Diabetes Mellitus is not a simple endocrine disorder
6] Septicaemia - following infection affecting various systems
7] Fluid & Electrolyte status altered.
8] Pulmonary system – alters ventilation and perfusion
9] G. I. system – slows gastric emptying - aspiration
10] Skeleto-muscular system - fusion of upper cervical vertebrae
with limited neck movement,
if accompanied with obesity & short neck
Thus, in Diabetes, the selection of Anesthesia
becomes a tricky and highly skillful job.

4. Why regional anaesthesia ?
1] Ideal for day-care patients
2] Safety in high risk patients
3] No intra-op regurgitation & aspiration
4] No PONV
5] Minimal alteration in drug schedule
-specially in diabetics

5. Why regional anaesthesia ? Continued….
6] Minimal effects on vital parameters
7] Safer in emergency situations
8] Can be repeated frequently
9] Conscious & arousable patient
at the end of the surgery
10] Reduction in morbidity & mortality

6. Why not other modes of Anesthesia ??
General Anesthesia: [besides usual precautions]
a] Risk of Aspiration and PONV
b] Difficult intubations
c] Resistant hypotension which may last for longer time
d] Management of ischaemic changes and arrhythmias
e] Management of blood sugar

7. Why not other modes of Anesthesia ??
Spinal & Epidural Anesthesia
a] Prevention and management of hypotension
b] Cannot be repeated frequently
[ except in continuous epidural analgesia ]
especially for small but painful procedures.

8. Limitations
1] Surgical time limit is between
1-3 hrs.
2] Patient’s co-operation is must
3] Failure or partially acted block

9. Types of blocks
1] Sciatic & femoral nerve block
2] Sciatic nerve block in lower thigh
3] Leg block
a] low
b] mid
c] high
4] Field Block (small infected cysts, abscess,
carbuncles)

10. Pre-block preparation
Besides usual instructions….
Application of elastocrepe bandage
2-3 days prior to surgery
Advantages :-
• limb becomes soft & supple
• reduced oedema , improved limb
circulation
• pH of tissue fluid alters
Success rate improves

11. Pre-block preparation
Counseling the patient
regarding the procedure
and the expectation from the patient
(compliance and accurate replies
regarding paresthesia)

12. Lower leg block or modified ankle block
Deep peroneal nerve – can be
blocked by injecting
subcutaneously
3-5 mm along the lat border
of the shin with 2 ml 2%
xylocaine with 24 g 1.5 inch
needle

13. Lower leg block or modified ankle block
Post. Tibial nerve –
Blocked by injecting
3-5 ml 2% xylocaine
at the junction of proximal 1/3rd
with distal 2/3rd of medial
malleolus to calcaneum, where
normally pulsations of post.
Tibial artery is felt.

14. Sural nerve
Inject 2% xylocaine
between the tendoachilles
and the calcaneaum on
the lateral aspect
Lower leg block or modified ankle block

15. Ring block –
0.5 % xylocaine around the
leg to block cutaneous nerves
Lower leg block or modified ankle block

16. Calcaneal nerve block
2 Finger breadths
proximal to the
medial malleolus
Inject along the
direction of the nerve
Lower leg block or modified ankle block

17. Mid leg block
Anterior Tibial nerve
Inject 2- 4 ml 2% xylocaine
subcutaneously 5-7 mm along
the lateral border of the shin

18. Mid leg block
Posterior Tibial Nerve
Spinal needle no 23 G is inserted from the lateral side
of the leg over the ant. border of fibula going medially
downwards just to slip the interosseous border of tibia ,
advance 1-2 mm & deposit 8-10 ml 2% xylocaine

19. Mid leg block
Sural nerve
Inject 2 – 3 ml 2% xylocaine
along a line extended proximally
tangential to the lateral border
of the tendo achilles

20. Ring block
0.5 % xylocaine around the
leg to block cutaneous nerves
Mid leg block

21. High leg block
Anterior Tibial nerve
Inject 3-4 ml 2% xylocaine
5-10 mm deep lateral to the
upper end of shin

22. High leg block
Posterior Tibial nerve
2-4cm below the neck of the fibula
Lateral approach –
Spinal needle no 23 G is
passed from the lateral side
of the leg over the ant.
border of fibula going
medially downwards
just to slip the interosseous
border of tibia ,
advance 1-2 mm &
deposit 8-10 ml 2% xylocaine

23. Lateral Popliteal Nerve
2- 4 ml 2% xylocaine
injected around the
neck of fibula
High leg block

24. Ring block
0.5 % xylocaine around the
leg to block cutaneous nerves
High leg block

25. If patient has a pain-free leg,
then one may give sciatic nerve
block in the lower third of thigh alongwith
lat. Popliteal nerve block and ring block.
High leg block
An alternate technique -

26. Practice regularly
Your patience
The surgeons’ patience
The patients’ patience!
Steps to success with local blocks
Patients’ comfort
The surgeons comfort
Your comfort
AND SAFETY!!

27. In Diabetic Foot
Blocks are the way to
go!!