PERIPHERAL NERVE BLOCKS

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PERIPHERAL NERVE BLOCKS

• R1 ???

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• Regional anesthesia? ???? ??
• needle delivery technique
• perineural sheath? ???? ??
• nerve stimulatior
• elicitation of paresthesia
• ? ? ultra sound, doppler,
• sensory nerve stimulationetc.?? ?? ?

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INDICATION

• Choice of anesthesia
• - risk? benefit? ??
• type of surgery
• surgeons preference
• experience of anesthesiologist
• physiological and mental state of the patient

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? ?

• Less immunosuppressive than GA
• Less postop. nausea vomiting, aspiration,
• malignant hyperthermia
• Hemodynamically compromised pt.
• or too ill to tolerate GA? ??

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? ?

• Systemic toxicity of local anesthetics
• Chronic paresthesia nerve damage
• Respiratory failure( phrenic n.blockade)
• Seizure ( intraarterial inj.)

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RELATIVE CONTRAINDICATION

• Uncooperative patient
• Bleeding diathesis
• Infection
• Local anesthetic toxicity
• - anesthetic? ?? ?? ?? ???? ??
• (eg, bilateral axillary nerve blocks)
  
• Peripheral neuropathy
• - contralateral phrenic n.palsy? ?? ??
• ipsilateral interscalene n. block? ??

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CHOICE OF ANESTHETIC

• Time to onset
• Duration of action
• Degree of sensory vs motor block
• Cardiac toxicity

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PLACEMENT OF THE BLOCK (1)

• ??? holding area? procedure room? ??
• - ??? monitoring system? resuscitation ?? ??
• ???? ?? intravascular inj.?? ??
• systemic toxicity??
• - peak blood level? ???? ?????
• delayed toxicity? ??
• - aspiration of the syringe
• - 3mL test dose of anesthetic with 1200,000
• or 1400,000 epinephrine
• - heart rate? baseline?? 20?? ??? ???
• intravascular inj.??

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PLACEMENT OF THE BLOCK (2)

• Common local anesthetic solution
• - lidocaine 1.52
• - mepivacaine 2
• - bupivacaine 0.5
• - levobupivacaine0.5
• - ropivacaine0.5
• Post op. analgesia more dilute solution

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PREMEDICATION

• Benzodiazepine, opioid
• - anxiety ??, pain threshold??
• Sedation? ??? practioner? ?? ??
• - nerve stimulator??? deep sedation??
• Supplemental oxygen??? ??

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FIELD BLOCK

• ????? ?? ?? local anesthetic?
• single or mult. Inj.
• - Supf.cervical block
• - to supplement axillary braqchial plexus
• ankle blokcs
• - Minor,supf. surgery

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FIXED ANATOMIC RELATIONSHIPS

• Brachial plexus axillary artery ? ??
• Mucocutaneous n.
• coracobrachialis m.? body ??
• Intercostal n.
• rib? inf.border? ??
• (????? vein,artery,nerveVAN)
• Femoral n.
• neurovascular bundle?? ??
• (lateral???? nerve,artery, vein,
• empty space, lymphatics NAVEL)

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ELICITATION OF PARESTHESIAS

• Needle? sensory n.? ?? ?? ? paresthesia
• ??
• - perineural ?? intraneural ?? ??? ??
• perineural inj.
• -brief accentuation of the paresthesia
• intraneural inj.
• hydrostatic injury-gtintense,searing pain
• Blunt bevel needle? ??
• - blunt tip, smaller cutting edge
• - nerve? ???? piercing? ????
  

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NERVE STIMULATION

• Needle tip? low level eletrical current
• (0.16.0mA)? ??
• - motor n.? ??? specific m.??
• -needle? ????? ???? ??? ??
• Optimal positioning? 0.5mA???
• evoked contration???
• 1-2mL? local anesthetic? ???
• evoked reponse ???

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SOMATIC BLOCKADE OF THE UPPER EXTREMITY
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ANATOMY OF THE BRACHIAL PLEXUS - 1

• C5T1? ant.primary
• division
• 3trunk? ant.middle
• scalene m.??? ??
• - sup.trunk? C5C6
• - mid.trunk?C7
• - inf.trunk? C8T1
• trunk? 1st rib? lateral
• border?, clavicle ???
• ??
• - ant. post. division
• - clavicle??? ??? ?
• ?? 3?? cord?

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ANATOMY OF THE BRACHIAL PLEXUS - 2

• Lat. cord
• - sup. mid. trunk?ant.
• division
• -median n.?lat.branch
• musculocutaneous n.
• Med. cord
• - inf.trunk? ant. division
• - median n.? medial br.
• ulnar n.
• Post. cord
• - ?? cord? post.division
• - axillary n. radial n. cord?
• pectoralis m.? lat.border??
• ???? terminal n.??

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TECHNIQUES FOR BRACHIAL PLEXUS BLOCK (1)

• Brachial plexus? ??? ?? fascial sheath?
• intervertebral foramen?? upper arm??
• ???? ? sheath??? injection? ??
• BPB? ???
• Interscalene approach
• - shoulder, arm, forearm? optimal
• - C57dermatome? ??, but C8T1?? ???
• -gt ulnar n.distribution? ?? procedure? ???

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TECHNIQUES FOR BRACHIAL PLEXUS BLOCK (2)

• Axillary approach- elbow hand ? procedure
• - C7T1dermatome? ??
• - ulnar n.
• -gt shoulder, upper arm C56 procedure? ???
• Supraclavicular,infraclavicular approach
• - even distribution
• - arm,forearm and hand procedure? ??

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INTERSCALENE BRACHIAL PLEXUS BLOCK (1)

• ANATOMY
• - trunk???
• ant. mid. scalene m. ??,
• cricoid cartilage level
• TECHNIQUE
• - ??? supine, contralateral? 30? head rotation
  ??
• ? ? interscalene groove?
• ??,?? SCM. ant. scalene m. ?? groove?
• ???? ??? ??

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INTERSCALENE BRACHIAL PLEXUS BLOCK (2)

• 22-gauge,1.5in B bevel needle??
• - skin? ????, ?? medial, caudal direction
• ?? paresthesia or evoked muscle
  contraction
• ??? ??? ??
• - nerve stimulator???
• phrenic n. activity -gt too anterior
• trapezius m.activity -gt too posterior

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INTERSCALENE BRACHIAL PLEXUS BLOCK (3)

• COMPLICATION
• - incidental block
• - stellate ganglion -gt Horner's syndrome
• (myosis, ptosis, anhidrosis)
• - phrenic n. -gt dyspnea
• - recurrent laryngeal n -gt hoarseness
• - intra-arterial inj. into vertebral a.
• -gtseizure?? (??? brain??? ??)
• - venous inj.
• - slower onset of CNS toxicity
• - epidural, subarachnoid, subdural
• - close proximity of cervical intervertebral
  foramen
• - pneumothorax

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SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK (1) - 1

• ANATOMY
• - ant.scalene m.?
• lat.border??
• brachial plexus?
• first rib? clavicle???
• ?? axilla? ??

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SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK (1) - 2

• TECHNIQUE
• - ??? supine, contralateral?
• 30? head rotation
• - interscalene groove? ??
• ?? ?? ?? (subclavian a.
• pulse???? ????) ? ?
• - 1.5in B bevel needle????
• subclavian a. ?????
• caudal direction inj.
• (skin? flat? ???)

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SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK (2)

• COMPLICATION
• - relatively high incidence (1-6) ?
• pneumothorax ??
• - Hemothroax
• - Horners syndrome
• - Phrenic n. block

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INFRACLAVICULAR BRACHIAL PLEXUS BLOCK (1)

• CORACOID
• APPROACH
• - arm? ??? ????
• - coracoid process
• ????, ????
• 2cm medial,
• 2cm caudal??
• floor? ???? insert

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INFRACLAVICULAR BRACHIAL PLEXUS BLOCK (2)

• CLASSIC APPROACH
• - supine,procedure side?? ??? ?? ??? operative
• limb? abduction to 90
• clavicle? midpoint?? 2cm
• caudal direction?? 45?
• angle? axillary a. pulsation?
• ?? ????
• - 4 inch 21gauge (nerve stimulator needle?
  insulated)
• ? ??, hand? motor activity
• ??

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INFRACLAVICULAR BRACHIAL PLEXUS BLOCK (3)

• COMPLICATION
• - pneumothorax
• - hemothorax
• - chylothorax (left sided block)
• - supraclavicular approach?? ?? ????
• ??

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AXILLARY BRACHIAL PLEXUS BLOCK (1) - 1

• ANATOMY
• - subclavian a.? clavicle?
• ?? ??
• -gt axillary a.
•     -gt ? ???? trunk?
• ant. post. division??
• pectoralis minor m.?
• lateral border?? cord?
• large terminal branch??
• ??

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AXILLARY BRACHIAL PLEXUS BLOCK (1) - 2

• ANATOMY
• - musculocutaneous n.?
• axilla?? ?? brachial
• plexus? sheath? ?? 
• costobrachialis m.?? ??
• - plexus? sheath? fascial
• septum? ??? ?? ??
• ???? ?????? ??
• ? ??  patchy" anesthesia
• ? ??-gtincomplete spread
• of local anesthetic within the
• plexus sheath

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AXILLARY BRACHIAL PLEXUS BLOCK (2)

• TECHNIQUE
• - supine position with the arm abducted,
• the elbow flexed at 90
• Transarterial technique
• - axilla? high(proximal) area?? axillary a.?
• pulse? palpation
• -gt immobile technique"?? 22gauge, 1.5inch
  B-bevel
• needle inj. aspiration -gt blood? ???? blood
• aspiration? ?? ??? needle? ????? ??,
• ????? 40ml? ?? (sheath?? septa ?? ?
• ???? ??? needle? artery? ?? anterior 20ml,
• posterior 20ml? ??? ???? clinician? ??)

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AXILLARY BRACHIAL PLEXUS BLOCK (3)

• ELICITATION OF PARESTHESIA TECHNIQUE
• - single, specific or multiple paresthesia? ???
  ?
• ?? needle? axillary a.???? ?? 
• -gt plexus sheath?? septation? ?? ??? ???
• ulnar, median, radial n. distribution ???
  ?? ???
• ? ??? ?? -gt total 40ml? local anesthetic??

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AXILLARY BRACHIAL PLEXUS BLOCK (4)

• NERVE STIMULATOR TECHNIQUE
• - 2inch 22gauge insulated stimulating needle?
  ????
• ?? identified?? 0.5mA??? stimulation? ???
• ?? ???? 1mL? local anesthetic? ????
• motoractivity? ???? ?? ???? negative
• aspiration??

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AXILLARY BRACHIAL PLEXUS BLOCK (5)

• COMPLICATION
• - very low complication rate
• -gtproviding intravascular injection is avoided
• but, multiple sites ? ?? repeated elicitation
  of
• paresthesia? postoperative neuropathy?
  incidence? ?????? ??.
• hematoma, infection? rare

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MIDHUMERAL BRACHIAL PLEXUS BLOCK

• All four major nerves of the arm can be blocked
  separately at the level of the midhumerus.
• - nerve stimulator? ??
• - similar success rate to classic axillary
  block
• but, the onset of the blockade is slower

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PERIPHERAL NERVE BLOCKS OF THE ARM
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INTERCOSTOBRACHIAL MEDIAL BRACHIAL CUTANEOUS
NERVES

• Block proximal to the axilla for shoulder surgery
  or for any upper extremity procedure that
  involves use of a pneumatic tourniquet(medial
  brachial cutaneous nerve often leaves the sheath
  just below the clavicle)
• -gt may be missed with the axillary block
• -gt prevent pain from an arm tourniquet
• Intercostobrachial nerve
• -gt T2
• medial brachial cutaneous nerve
• -gt C8 T1
• gtfield block -gt 5mL local anesthetic

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RADIAL NERVE(1)

• - used to supplement an incomplete brachial
  plexus blocks
• ANATOMY
• - brachial plexus? post.cord br.? humerus? ??
  ???? triceps m.? innervation
• -. Humerus? musculospiral groove? ?? elbow
• ? lateral? ?? -gt terminal sensory br arm?
• lateral cutaneous n., forearm? post.
  Cutaneous n.
• elbow? lat.epicondyle?? supf. deep br.? ??
• Deep br. -gt forearm? extensor group? innervation
• Supf. Br-gt radial a.? ?? ?? dorsal wrist?
  radial aspect, lateral 3 2/1? dorsal aspect?
  innervation

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RADIAL NERVE(2)

• TECHNIQUE
• At the upper arm
• - radial n.? musculospiral groove?? triceps two
  head??? ??-gt??? lat. Epicondyle??? line?? radial
  n.??-gtepicondyle?? proximal 24cm?? needle
  inj.-gtbone? contack?? 0.5cm???? 5ml inj.

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RADIAL NERVE(3)

• At the elbow
• - antecubital space?? biceps tendon? ??? flexion
  crease? needle inj.-gt direction supf.to radial
  head toward the lat. epicondyle

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RADIAL NERVE(3)

• At the distal forearm
• - ulnar styloid level?? thumb? lat.side???
  sensory br.? radial a.? flexor carpi radialis
  tendon??? ?? -gt? ??? inj.
• COMPLICATION
• - Radial a. inj. intraneural inj.

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MEDIAN NERVE(1)

• anatomy
• brachial plexus? lat. med. cords?? ??
• - brachial a.? medial ???? ??-gt antecubital
  space?? biceps tendon insertion site? ?? wrist
  finger flexor m.?? motor br.??-gt prox.wrist
  flexion crease?? palmaris longus tendon? ?? ????
  carpal tunnel? ??

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MEDIAN NERVE(2)

• at the elbow
• - biceps tendon insertion??? medial ??? brachial
  a.? ???? medial?? inj.-gt med. Epicondyle? ??-gt
  paresthesia or wrist flexion or periosteum
  contact??(??? ?? ??)

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MEDIAN NERVE(3)

• At the wrist
• - ???? wrist flexion? ?? palmaris longus tendon?
  ??? medial?? inj.

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ULNAR NERVE(1)

• Anatomy
• - brachial plexus? medial cord? ??
• - axillary brachial a.? medial side? ??
• -gt med. Condyle? arcuate lig.??? ??
• -gt mid forearm?? flexor digitorum profundus
  flexor carpi ulnaris??? ??
• -gt wrist ? flexor carpi ulnaris tendon? lateral,
  ulnar a.? medial ?? ??

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ULNAR NERVE(2)

• At the elbow
• - arcuate lig.? proximal ?? one finger??? needle
  inj.

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ULNAR NERVE(3)

• At the wrist
• - ulnar a.? ?? medial side or flexor carpi
  ulnaris ? lat. Side? inj.

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DITAL NERVES

• Insert at the medial and lateral aspects of the
  base of the selected digit
• - periosteum? ?????.
• ??? vasoconstrictor(epinephrine)? ?? ????? ???

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INTRAVENOUS REGIONAL ANESTHESIA OF THE ARM(Bier
block)

• 4560? ??? ??? ??( eg, carpal tunnel release)
• - ??? intravenous catheter? ???? arm? double
  pneumatic tourniquet? ???.
• -gt catheter? 0.5lidocaine (25ml for forearm,
  50ml for arm, 100ml for thigh)? 23?? ??? ??
• -gt ?? 510?? ?? ??

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SOMATIC BLOCKADE OF THE LOWER EXTREMITY
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ANTOMY

• Femoral n L2L4
• Obturator n.- L2L4
• Lateral femoral n.- L1L3
• Sciatic n. L4S3

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LUMBAR PLEXUS(PSOAS)BLOCK(1)

• ANATOMY
• - Lumbar plexus? the fascis of the psoas
  muscle(ant.to the plexus)? the fascia of the
  quadratus laborum(post. to the plexus)? ?? ??????
  psoas compartment? ????

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LUMBAR PLEXUS(PSOAS)BLOCK(2)

• Technique
• - insert to the psoas compartment(7090mm)
• -gt quadriceps motor response??
• -gt epidural space? ???? loss of resistance?
  ????

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FEMORAL NERVE THREE-IN-ONEBLOCK(1)

• -gt ant. Thigh, knee, medial foot? ??
• ANATOMY
• - psoas m.? ?? thigh?? femoral a.? lat.inguinal
  lig.? ????? ??-gt quadriceps, sartorius, pectineus
  m.? motor br.? ??
• -gt medial ant.thigh? sensory br. ??(psoas m.??
  inguinal lig.????? sheath? encased)

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FEMORAL NERVE THREE-IN-ONEBLOCK(2)

• Technique
• - inguinal lig.? ???? midpoint?? femoral a.?
  ????, femoral a.? 2cm lateral ? inj.
• Femoral n. obturator n., lat. Femoral cutaneous
  n.? ??? block??? ????, ?? ??? ??

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FASCIA ILIACA BLOCK(1)

• Fascia iliaca compartment
• - space bordered by the fascia iliaca(ant.) and
  iliopsoas muscle(post)
• -gt femoral nerve,lat.femoral cutaneous,
  obturator n. genitofemoral n.? fascia?????
  ????????? ??? compartment block
• -gt two pops fascia lata, fascia iliaca
• -gt nerve stimulator ??? ????
• -gt hip, thigh, knee surgery? ??

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FASCIA ILIACA BLOCK(2)
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LATERAL FRMORAL CUTANEOUS BLOCK

• ANATOMY
• - L23 lumbar plexus?? ?? psoas m.? ?? iliacus
  m.? ?? anterolaterally?? ??
• TECHNIQUE
• - ant.sup. Iliac spine?? 2cm meddistal site?
  inj.
• -gt needle? sheath? ????(pop)? ???? ?? fascia
  lata
• lat. Thigh? skin, m.biopsy, skin graftetc.

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OBTURATOR NERVE BLOCK

• ANATOMY
• - obturator foramen? ?? ??
• sensory innervation to the medial thigh and
  hip
• motor innervation to adductor m. of thigh
• TECHNIQUE
• - pubic tubercle?? 1.5cm lat. 1.5cm
  inf.??-gtsup.pubic ramus? ?? ???? ??, bone
  contact? lat.caudal direction?? 24cm ? ??(to
  enter the obturator foramen)-gt adductor motor
  response??

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SCIATIC NERVE BLOCK(1)

• Sciatic nerve
• - originate from the lumbosacral plexus(L4-5
  S1-3) -gt sensory innervation to the post.hip
  capsule and knee
• -gt motor to the hamstring, all the
  lower extremity m. distal to the knee

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SCIATIC NERVE BLOCK(2)

• POSTERIOR APPORACH
• - lat. decubitus ?? ??? hip? knee? flexion
• -gt great trochanter? prominence?? post.sup.iliac
  spine?? line? ?? midpoint?? ???? caudal???
  46cm??? ???? inj.

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SCIATIC NERVE BLOCK(3)

• Lithotomy approach
• - supine position?? knee? 90?flexion, hip?
  90120? flexion? great trochanter? ischial
  tuberosity?? midpoint?? skin? ???? inj.

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SCIATIC NERVE BLOCK(4)

• Anterior apporach
• - hip? flexion?? ????
• - supine position?? ??? ?? ext.rotation? femoral
  a.? 2cm medial ???? needle? lesser trochanter? ??
  ??

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POPLITEAL BLOCK(1)

• ANATOMY
• - sciatic n.? popliteal fossa(lat.??? biceps
  femoris tendon, medial ??? semitendinosus
  semimembranosus tendon? ??) ?? tibial n.? common
  peroneal n.? ??

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POPLITEAL BLOCK(2)

• Posterior approach
• prone position
• - popliteal fossa is identified as a triangle
• -gt ?? biceps femoris
• -gt ?? semitendinosus semi membranosus
• -gt ?? popliteal crease
• - apex?? 1cm??,1cm lat?? inj.

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POPLITEAL BLOCK(3)

• Lateral approach
• suposition
• - patella ? sup.notch?? proximal 1012cm??
  vastus lateralis? biceps femoris m.???
  intertendinous groove? ?? -gt 30? ???? ?? -gt
  distal ankle, foot, toes? motor response??

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SAPHENOUS NERVE BLOCK

• ANATOMY
• - femoral n.? terminal extension, medial aspect
  of the lower leg( knee? medial malleolus??)?
  sensory innervation
• -gt tibial tuberosity? ???? subcutaneously
  infiltrate
• Popliteal block ? ???? ??

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ANKLE BLOCK(1)

• ANATOMY
• saphenous n. (femoral n.? terminal br.)
• anteromedial foot?
  supf.sensory innervation        
•  medial malleolus
  ?? ??? ??
• deep peroneal n. ( common peroneal n.? br.)
• toe extensor m.?
  innervation , dorsal foot? medial? sensory
• medial malleolus??
  flexor hallucis longus? lateral? ??
• supf. peroneal n. (common peroneal n.? br)
  dorsal foot? sensory innervation
•          lateral malleolus??
  extensor digitorum longus? lateral? ??
• posterior tibial n. (tibial n.? br.)
  medial malleolus? ??? post. tibial a. ?? ??
•          ???? ???(lateral ??
  ??)? sensory innervation
• sural n. (tibial n.? br.) Achilles tendon?
  lateral malleolus??? ??
•          lateral foot?
  sensory innervation

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ANKLE BLOCK(2)

• TECHNIQUE
• - deep peroneal n. block
• -gt intermalleolar line?? extensor digitorum
  longus ?  extensor hallucis longus tendon??? ??
• - supf. peroneal n. saphenous n. block -gt
  deep peroneal n. inj. Site?? lat. malleolar ? ??
  subcutaneous infiltration
• - saphenous n. block
• -gt deep peroneal n. inj. site?? med.
  malleolar? ?? subcutaneous infiltration
• - post. tibial n. block
• -gt medial malleolus ???? post. tibial a.
  pulse? ???? needle? inj.
• - sural n. block
• -gt lateral malleolus? Achilles tendon ???
  subcutaneous infiltration

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SOMATIC BLOCKADE OF THE TRUNK
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SUPERFICIAL CERVICAL PLEXUS BLOCK(1)

• ANATOMY
• - cervical plexus(C1-C4)? SCM m. ?? platysma
  m.?? ??
• - jaw, neck, occiput and chest, shoulder
  close to clavicle? sensory innervation

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SUPERFICIAL CERVICAL PLEXUS BLOCK(2)

• TECHNIQUE
• supine position, SCM? post. border? ??
  1/3??? needle? inj.-gt SCM? post. border? ??
  cephalic ???? ??? ? needle? ?????? subcutaneous
  infiltration
• -gt needle? 180? ??? SCM? post. border? ??
  caudal ???? inj.? ? ?? needle? ??????
  subcutaneous infiltration

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INTERCOSTAL BLOCK(1)

• ??????? ? ??? ??
• To supplement general anesthesia
• For postoperative analgesia following thorasic
  and upper abdominal surgery
• For relief of pain associated with rib fx.,
  herpes zoster, and cancer

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INTERCOSTAL BLOCK(2)

• ANATOMY
• - thorasic spinal n.?? ???? ? rib? ???? artery,
  vein? ?? ??(nerve? ?? ?? ??)
• TECHNIQUE
• - lateral decubitus or supine?? ?? mid or post.
  axillary line?? rib? ??? inj. -gtaspiration?? ?
  3-5ml? ????? ??
• COMPLICATION
• - intravascular inj.
• pneumothorax

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PARAVERTEBRAL NERVE BLOCKS(1)

• Spinal nerve? intervertebral foramina?? ???? two
  rami? ??, ?? smaller posterior ramus? back and
  neck? skin? muscle? innervation
• - thorasic paravertebral space?
• post.- sup.costotransverse lig.
• anterolaterally- parietal pleura
• medially vertebra and intervertebral foramen
• sup. inf. heads of the ribs

78
PARAVERTEBRAL NERVE BLOCKS(2)

• TECHNIQUE
• - sitting position? C7 ? prominence??
• ? spinous proc.?? lat.2.5cm ??(inj. Point)
• - needle insertion? transverse proc.? contact??
  ???? ?? ???? ??-gt? ???? ? 1cm ? ????
  (costovertebral lig.??? pop? ????? ??.

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INGUINAL NERVE BLOCK(1)

• ANATOMY
• - ilioinguinal n., iliohypogastric n. - L1 or
  T12?? ??
• iliohypogastric n.
• - lateral br. - hip buttock?
  lateral sensory innervation
• - ant. br. - lower abdomen?
  innervation
• ilioinguinal n. -gt inguinal canal? ??
•         male scrotum, penis, medial thigh?
  sensory innervation
•          female labia, mons pubis? innervation

80
INGUINAL NERVE BLOCK(2)

• ?? ant. sup. iliac spine? 2cm medial??
  transversalis abdominis m. internal oblique m.?
  ??
• - genitofemoral n. - L1 and L2?? ??
• - femoral br femoral a.? ?? ??
• inguinal lig.???
  cutaneous sensation
•             - genital br. inguinal canal? ??
• male scrotum
• female labium major? innervation

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INGUINAL NERVE BLOCK(3)

• TECHNIQUE
• - ant. sup. iliac spine? medial 2cm????
  needle? skin? ???? inj.
• -gt fascia ?? ??? ????? ??
• genitofemoral n.? genital br.? pubic
  tubercle? lateral? 2-3ml? local anesthetic ??
• femoral br.? inguinal lig.?? ??? subcutaneous
  inj.

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PENILE BLOCK

• ANATOMY
• - pudendal n. -gt dorsal n. of penis bilaterally
  -gt Bucks fascia? ??? dorsal ventral br.??
• Fan-shaped field block
• - penis? base? 24cm lat.?? inj.
• - more extensive surgery? ??, Bucks fascia?
  1030 130 ???? ???? inj.(epinephrine ??)