Pt Refusal

Pt cognitive function

Infection or burn at injection sight

Concern for injury to nerves

Exisiting neurologic condition

LA allergy

Vascular grafts

Coagulopathy 

Increased Duration

Improves quality of block due to alpha 2 agonism

Decreased LA blood concentration

Worsening neurlogic injury- ischemia

Hypertension/Tachycardia 

Failure or incomplete block

LA toxicity or allergic reaction

Injury to nearby structures

Infection/Inflammation

Hematoma/Bleeding

Methemoglobinemia 

Disruption of neuronal vasculature

High end-neural pressures- high injection pressures

Addition of vasoconstriction agents

Exogenous compression- tourniquets 

Muscles of the pelvic region

Posterior abdominal wall

59 muscles of the lower limb

All the corresponding joints

Iliohypogastric

Ilioinguinal

Genitofemoral

Lateral Femoral Cutaneous

Obturator

Femoral 

Common Peroneal Nerve- lateral

Tibial Nerve- Medial 

Posterior thigh, most of lower leg, entire foot, part of the pelvis 

Superior Gluteal

Inferior Gluteal

Posterior Femoral Cutaneous

Pudendal 

Sciatic 

L4, L5, S1, S2, S3 

Motor Innervation of posterior thigh, all of the leg and foot 

Passes under the piriformis down the back of the thigh then branches into common peroneal and tibial 

Sural Nerve

Deep Fibular Nerve

Superficial Fibular Nerve

Medial Calcaneal branches 

Sensory innervation, via terminal branches in the lower leg and foot 

L2, L3, L4

Largest branch of the lumbar plexus 

Embedded in the groove between the psoas and the iliacus muscle, emerges beneath the inguinal ligament 

iliacus

pectineus and sartorius

muscle of anterior thigh "quads" except for tensor fascia lata 

Front and medial thigh

Below the knee medial leg/foot (saphenous)

articular branches of hip/knees joints 

Inguinal Ligament

Sartorius Muscle

Adductor longus 

"SAIL"

1 cm lateral to femoral artery 

15-20 mL, aspiration q 5 ml 

Must inject BELOW the fascia iliaca 

Onset time for 15 to 20 mins 

Visible twitch of quad muscle at 0.2-0.4 is most reliable response

Sartorius muscle is NOT reliable sign because it is outside femoral sheath 

25-30

Lateral Femoral Cutaneous

Obturator

Femoral 

Purely Sensory

10-15 mL

Find ASIS, 2 cm medial and 2 cm caudal 

Pop as its felt going through the fascia lata 

Dorsiflexion 

Eversion 

Plantar flexion

inversion 

Inject 20-30 mL of LA

Sciatic divides into common peroneal and tibial nerve 

Popliteal fossa crease, biceps femoris tendon, semitendinousus tendon

7cm up from crease and 1 cm over

Sciatic Nerve Block

Posterior Superior Iliac Spine

Greater Trochanter

Sacral Hiatus 

25-30 mL 

Tibial

Deep Peroneal 

Sural 

Saphenous

Superficial Peroneal 

Tibial Nerve divides into the posterior tibial and sural nerve 

Common peroneal nerve divides into superficial and deep peroneal nerves

Saphenous nerve only branch below the knee 

Anterior to the medial malleolus