Place of conduction anesthesia in the classification
Regional anesthesia is designed to numb a specific part of the body without affecting the entire organism. Depending on the level and route of administration, several types of regional anesthesia are distinguished:
- Conduction anesthesia (nerve conduction block).
- Intravascular (includes intravenous and intra-arterial routes).
- Intraosseous.
- Spinal (subarachnoid).
- Epidural.
Within the study of conduction anesthesia, spinal and epidural anesthesia are often classified as its subtypes. According to the target structure, the method is divided into blocks of nerve trunks, nerve plexuses, and nerve ganglia (paravertebral anesthesia).
Lukashevich-Oberst finger anesthesia
This technique is used for anesthesia during finger surgeries (treatment of felon, wound debridement, tumor removal). The goal is to block the digital nerves running along the lateral surfaces of the phalanx.
Execution Technique:
- A tight rubber tourniquet is applied to the base of the finger.
- The puncture site is located on the dorsal surface of the proximal phalanx, distal to the applied tourniquet.
- The physician sequentially anesthetizes the skin and subcutaneous tissue.
- The needle is advanced deep into the tissues until bone contact is felt.
- The solution is injected in the immediate vicinity of the nerve trunks. To achieve this, the needle is shifted first to one lateral side of the bony phalanx and then to the other.
- Dosage: 2–3 ml of a 1–2% local anesthetic solution on each side of the finger.
Intercostal anesthesia
This technique is indicated for rib fractures. If there are multiple fractures, the procedure is repeated for each damaged rib. The puncture is performed proximal to the injury—a few centimeters away from the fracture site towards the spine.
Assay steps:
- Skin anesthesia: the solution is injected intradermally to form a "lemon peel" wheal.
- Access: the needle is inserted strictly perpendicular to the fractured rib until it touches the bone.
- Main block: the needle must be withdrawn by 2–3 mm, the soft tissues shifted with its tip, and advanced toward the lower edge of the rib. After sliding off its surface, 3–5 ml of anesthetic (1–2% solution) is injected perineurally.
- Additional infiltration: without fully removing the needle, return it to the outer surface of the rib. Then, by sliding off, advance it toward the upper edge and inject another 2–3 ml of the drug.
- The needle is carefully withdrawn.
Kulenkampff brachial plexus block
This type of anesthesia is indicated for various surgical procedures on the upper extremity. Proper positioning and orientation according to anatomical structures are required for successful execution.
Patient position and landmarks: The patient lies in a supine position. The head must be turned away from the injection site. The arm hangs freely off the table—this is necessary to lower the clavicle as much as possible. The main landmarks are the midpoint of the clavicle along its upper edge and the pulsation of the subclavian artery. The brachial plexus itself is projected lateral to the artery.
Algorithm:
- Local skin anesthesia is performed.
- A long needle without a syringe attached is inserted 1 cm above the clavicle, lateral to the vessel pulsation point.
- The needle is directed upward, sliding along the upper edge of the first rib toward the spinous processes of Th I-II (the first two thoracic vertebrae).
- The criterion for correct placement is a "shooting" pain in the patient, indicating contact with a nerve trunk.
- It is mandatory to check for the absence of blood in the needle. If blood appears, it means a vessel has been hit—the needle must be withdrawn and redirected.
- When in the correct position, 30–35 ml of a 1% solution is injected. The effect develops within 10–15 minutes.
Briefly: answers to topical questions
Which specific nerves are blocked during Lukashevich-Oberst finger anesthesia?
During Lukashevich-Oberst conduction anesthesia, the digital nerves running along the lateral surfaces of the finger are blocked. To achieve adequate anesthesia, the local anesthetic is injected in the immediate vicinity of these nerve trunks. The technique requires applying a rubber tourniquet to the base of the finger. Then, on the dorsal surface of the proximal phalanx distal to the tourniquet, a needle is inserted, advanced until bone contact, and moved alternately to each side of the bony phalanx, injecting 2–3 ml of procaine or lidocaine solution on each side.
What complications can occur during a Kulenkampff brachial plexus block?
During a Kulenkampff brachial plexus block, which is performed via the supraclavicular approach, the following complications may arise:
- Blood vessel puncture — diagnosed when blood appears from the needle. In this situation, it is necessary to withdraw the needle and change the insertion angle;
- Pneumothorax — caused by the risk of injuring the pleural dome, which projects into the base of the scalene-vertebral triangle directly in the manipulation zone.
Which local anesthetics are used for conduction anesthesia?
For conduction anesthesia, local anesthetics belonging to the groups of esters and substituted acid amides are used. The following drugs are used in clinical practice:
- Procaine (novocaine) — an ester group representative;
- Trimecaine — an amide drug;
- Bupivacaine (Marcaine) — an amide drug;
- Mepivacaine (Isocaine) — an amide drug;
- Articaine (Ultracaine) — an amide drug;
- Ropivacaine — an amide drug;
- Lidocaine (Xycaine) — a universal amide-type local anesthetic suitable for all types of anesthesia.
What structures are blocked during paravertebral anesthesia?
During paravertebral anesthesia, nerve ganglia are blocked. In the classification of regional anesthesia types by target structure, this method is designated as an independent category—anesthesia of nerve ganglia. The procedure is based on the general principle of conduction anesthesia, in which a local anesthetic solution is administered perineurally (around the nerve structure) or endoneurally (directly into its thickness) to temporarily block nerve impulse conduction in a specific topographic area.
During an intercostal block, remember the direction of needle slippage: first toward the LOWER edge of the rib (main dose 3–5 ml), then toward the UPPER edge (additional dose 2–3 ml).
Class and exam questions
What is the difference between endoneural and perineural administration?
During perineural administration, the solution is distributed in the tissues around the nerve trunk, while during endoneural administration, the drug is injected directly into the thickness of the nerve itself.
What does the appearance of blood from the needle mean during Kulenkampff block?
This indicates entry into a blood vessel, most likely the subclavian artery. It is necessary to immediately withdraw the needle and adjust its direction.
Where is the injection point located in Lukashevich-Oberst anesthesia?
The puncture is performed on the dorsal surface of the proximal (main) phalanx of the finger, strictly distal to the previously applied rubber tourniquet.
What else to study on this topic
- Topographic anatomy of nerve trunks on the lateral surfaces of the fingers.
- Location of the neurovascular bundle along the inferior border of the rib.
- Specifics of drug selection: differences between procaine and lidocaine.
- Potential complications of accidental intravascular injection of an anesthetic.
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