Novocaine blockade

Tools: syringes with a capacity of 5 and 20 ml, a sterile jar for novocaine, an intramuscular needle, a thin, long needle, brushes for alcohol, iodine. All this is placed in a sterile tray.

Hands are washed with soap and running water, dried with a sterile napkin, treated (tanned) with 96% alcohol and put on sterile gloves. The surgical field is treated with alcohol and iodine.

For blockade, use 0.25% or 0.5% novocaine solution.

Vagosympathetic blockade

Indications: trauma chest, bronchospasm.

1. The patient is placed on his back with a bolster under his shoulder blades.

2. The head is thrown back and turned in the direction opposite to the blockade site.

3. The posterior edge of the sternocleidomastoid muscle is determined by palpation and a “lemon peel” is made approximately in its middle with a 0.25% novocaine solution.

4. Take a syringe with a capacity of 20 ml with a long needle, inject it at the same point and move the needle towards the spine until it stops cervical vertebra. Then the needle is moved back a little and 60 ml of a 0.5% novocaine solution is injected.

If the blockade is carried out correctly, then on the side of the blockade the Claude Bernard-Horner symptom will appear: narrowing of the palpebral fissure, dilation of the pupil, ptosis of the upper eyelid.

Complications.

Damage to the esophagus, trachea, and large vessels of the neck are rare and occur mainly as a result of gross violation of the blockade technique.

A sign of damage to the esophagus is a feeling of bitterness in the mouth when novocaine is administered; if the trachea is damaged, a cough, a feeling foreign body in the trachea in response to the administration of novocaine.

If the needle hits blood vessel, then blood appears in the syringe.

Perinephric block

Indications: intestinal paresis, renal colic.

1. The patient is placed on his healthy side with a bolster under the lumbar region.

2. The XII rib is determined by palpation and a “lemon peel” is made at the intersection of the lumbar muscles with the rib.

3. A long needle with a syringe with a capacity of 20 ml is inserted perpendicular to the surface of the body to a depth of 8-10 cm, sending a stream of novocaine in front. 120 ml of 0.25% novocaine solution is injected into the perinephric tissue.

Complication: damage to the renal parenchyma.

It is noted when the needle is inserted deeply. Blood appears in the syringe. It is necessary to move the needle back and make sure that it is in the correct position.

Case blockade

Indications: open fractures, traumatic amputations, frostbite of the extremities.

A “lemon peel” is made above the site of damage or inflammation and a long needle with a syringe is inserted into the bone. Having moved the needle back 1-2 cm, the fascial sheath is injected with a 0.25% solution of novocaine in an amount of 60 to 200 ml.

Intercostal blockade

Indications: rib fractures.

1. Treat the skin of the chest with alcohol and iodine.

2. The locations of rib fractures are determined by palpation.

3. Slightly distal to the fracture site, a needle is inserted along the lower edge of the rib, using a 0.5% novocaine solution, until it touches the rib. Then they “slip” from the rib, the needle is turned up and passed 0.5-1 cm, after which 10-15 ml of a 0.25% novocaine solution is injected.

If more than one rib is fractured, the next rib is blocked in the same way.

For multiple rib fractures along several anatomical lines, a paravertebral blockade is performed. The needle is inserted from behind along the paravertebral line, sequentially into the same intercostal spaces that correspond to the broken ribs.

Complications: getting into pleural cavity, if the needle is inserted deeply and is not oriented towards the edge of the rib.

A sign of this is air being sucked through the needle when the syringe is removed. If it gets into a vessel (blood appears in the syringe), you need to remove the needle a little and change the direction of injection.

BLOCK OF THE ROUND LIGAMENT OF THE LIVER

Indications:spicy pancreatitis, acute cholecystitis.

The blockade is carried out when the first medical care and further treatment. Its purpose is to block afferent nociceptive impulses in the area of ​​damage or inflammation of the pancreas and influence efferent impulses to reduce spasm of smooth muscles internal organs abdomen, ducts of the digestive glands, blood vessels.

Blockade eliminates paresis intestines, reduces exocrine pancreatic secretion glands, strengthens diuresis.

Information about the round liver ligament, see section “Umbilical vein”.

Patient position: on back.

Technique: strictly along the midline 3-4 cm above the navel, the skin is anesthetized through a thin needle. Change the needle to a thicker and longer one, which is used to pierce the linea alba of the abdomen. Preceding the advancement of the needle with a solution of novocaine, 250-300 ml of a 0.25% solution of novocaine or trimecaine is slowly injected into the tissue of the round ligament of the liver. The location of the needle tip corresponds to the attachment of the ligament to the anterior abdominal wall. Novocaine diffusely permeates not only the preperitoneal tissue and round ligament of the liver, but also bed gallbladder,

hepatoduodenal and hepatogastric ligaments, head of the pancreas (D.F. Bagovidov and T.I. Chorbinskaya, 1966;

I.N. Siparova and Yu.B. Martova, 1970).

Contraindications: the presence of scars in the epigastric region and right hypochondrium, hernia of the white line of the abdomen, intolerance to novocaine.

Indications: organ injuries abdominal cavity and retroperitoneal space, reflex anuria, dynamic intestinal obstruction, paresis of the gastrointestinal tract, hepatic-renal failure, renal colic, spasm and atony of the ureters, burns of the torso and lower limbs, blood transfusion shock, obliterating endarteritis, syndrome prolonged compression, trophic ulcers lower extremities.

Patient position: on the side, under the lower back, a cushion with a diameter of 15 cm is placed. The leg on which the patient lies is bent at an angle of 90° at the knee and hip joints, pulled towards the stomach; the top one is extended. Defining the end of the left index finger the most pliable place in the corner formed by the XII rib and the outer edge of the muscle that straightens the trunk, a nodule is formed through a thin needle with a 0.25% solution of novocaine. Through it, a long needle (up to 12 cm) with a syringe attached is directed strictly perpendicular to the skin into the tissue depth at 5-7 cm, sending an anesthetic solution in front of the needle. By passing the needle through the muscles and the posterior layer of the paramuscular fascia, the surgeon experiences tissue resistance. When the needle penetrates the perinephric cellular space, the solution begins to spread freely between the sheets of fascia. They catch the moment when drops of solution stop appearing from it: “dry needle” when removing the syringe. After making sure that no blood enters the syringe, inject 60-100 ml of a warm 0.25% novocaine solution. When a perirenal blockade is carried out correctly, the novocaine solution reaches the renal, solar, mesenteric plexuses, and splanchnic nerves, providing anesthesia. The patient must remain in bed for 1-2 hours (Fig. 59).

Fig- 59. Paransfr;1lnaya novocain blockade. I - point insertion of an injection needle; 2 - XII rib; 3 - kidney; 4 - long back muscle.

Errors and dangers: 1) if the needle is not advanced perpendicular to the surface of the skin, the needle may enter the abdominal cavity or intestinal lumen: when suctioning, gas with a fecal odor and intestinal contents will enter the syringe. The needle must be removed, and large doses of antibiotics must be injected through another into the perinephric tissue. wide range actions;

2) if the needle pierces the kidney parenchyma, the administration of novocaine becomes difficult, pain occurs, and novocaine mixed with blood comes out of the needle. The needle must be pulled back 1 cm. After repeated monitoring, you can continue administering the novocaine solution.

– injection of an anesthetic solution into the perinephric tissue for the purpose of pain relief in acute pain syndrome caused by pathology of the abdominal organs and surgical diseases requiring urgent diagnosis and treatment. Performed for acute pancreatitis, renal and hepatic colic, states of shock arising from abdominal injuries, blood transfusion shock and other urgent pathologies. Perinephric block is performed in treatment room after holding the minimum diagnostic studies. A long needle is inserted perpendicularly into the Lesgaft-Grinfelt triangle; approximately 60-100 ml of a 0.25% novocaine solution is required. Possible complications associated with needle penetration into the intestines or kidney.

Perinephric blockade was proposed by A.V. Vishnevsky in the 30s of the XX century, is one of the first novocaine blockades. Also called lumbar block. The range of indications for manipulation is quite wide, despite the possibility of complications. Perinephric blockade is performed in a hospital setting, less often on an outpatient basis, most often used in abdominal surgery. The procedure is also used in the field of urology in a complex of therapeutic measures for certain diseases of the kidneys and ureters and urgent conditions requiring urgent surgical intervention.

The advantage of perinephric block is that it wide application for many decades. Almost any specialist knows the technique of this manipulation. In addition, the procedure is largely universal and is performed for a range of indications in urology, abdominal surgery and gastroenterology. The equipment necessary for performing a perinephric block is available in every surgical and urological clinic. The disadvantages of manipulation include relatively high risk development of complications, therefore the need this method Treatment is always determined individually.

Indications and contraindications

Perinephric blockade is indicated in the case of renal and hepatic colic, abdominal injuries with subsequent development of shock, with a spastic state of the stomach and intestines and a sharply reduced tone of the hollow organs of the abdominal cavity. The procedure is performed for patients with acute pancreatitis, with dynamic intestinal obstruction, including in the case of differential diagnosis with obstructive. Perinephric blockade is prescribed for obliterating diseases of the vessels of the lower extremities and shock conditions of various natures: after blood transfusion, as a result of injuries to large muscles, for example, limbs, with large loss of blood, etc.

Perinephric blockade is contraindicated in terminally ill patients. Manipulation is not performed for confirmed tumors of the retroperitoneal space due to possible damage with subsequent spread of the process or bleeding. Perinephric blockade is carried out using a solution of novocaine, so the procedure is also contraindicated for patients with allergies to this anesthetic. Nervous excitement may become an obstacle to the blockade; in such cases, its need is determined individually. Manipulation should not be carried out in case of acute inflammatory processes on the skin at the injection site.

Preparation and methodology

Perinephric block in Moscow in most cases is performed for urgent or emergency indications, so preparation for the procedure is not required, or it is minimal. The absence of contraindications is specified. A survey radiography of the abdominal organs or ultrasound is prescribed. Blood is drawn for general and biochemical tests, the patient’s allergy history is clarified. A perinephric block is performed in a hospital treatment room by a urologist or surgeon. It is first required to obtain the written consent of the patient or his relatives for this manipulation.

Perinephric blockade is carried out with the patient lying on his healthy side, under which a cushion is placed. The lower leg is bent at the knee and hip joint, on the manipulation side, the leg should be straight. The procedure begins with intradermal anesthesia with a solution of 0.25% novocaine. The injection site for the anesthetic is the angle formed by the outer edge of the erector spinae muscle and the 12th rib. Perinephric blockade is carried out using a long needle 10-12 cm, which is inserted perpendicular to the injection site. The novocaine solution is added to the inserted needle. Periodically, the doctor slightly tightens the piston to timely diagnosis entering the vessel.

Entry into the retroperitoneal adipose tissue during a perinephric block is determined by the decrease in voltage required to inject the anesthetic solution. When the syringe is disconnected, the liquid does not flow back out of the needle. The needle oscillates in time with the movements of the diaphragm. Next, 60-100 ml of novocaine solution of 0.25% concentration, heated to a temperature of 36-37°C, is injected into the fiber. The final volume of anesthetic required for the procedure is determined individually by the specialist and largely depends on the degree of development of the retroperitoneal tissue. According to indications, the blockade is performed on one or both sides.

Features of the recovery period and complications

After the perinephric block, the patient continues to remain in the treatment room for the next 30-60 minutes. This period is necessary to assess the patient’s condition and the effectiveness of the procedure. Further management tactics depend on the purpose of the manipulation. If docking was required pain syndrome for renal colic, the patient can either be freed or is recommended to be hospitalized for appointment conservative therapy or planning an operation. Perinephric blockade within emergency surgery required in medicinal purposes, and for differential diagnosis of certain conditions. As a rule, after the procedure the patient is hospitalized.

Complications of perinephric block are relatively common. These include needle penetration into the parenchyma or vessels of the kidney, as well as into the intestinal lumen. In the first case, when removing the syringe, urine will flow out of the needle. If the needle ends up in the intestinal lumen, a characteristic intestinal odor will appear when the syringe is removed. In case of complications of perinephric blockade, high doses of broad-spectrum antibiotics are required to be administered into the perinephric tissue. The patient remains under medical supervision for several days to exclude signs of infection during the procedure.

Cost in Moscow

The price of the procedure is determined by the type medical institution and is usually higher in private clinics. The cost of a perinephric block in Moscow will depend on the volume of anesthetic used, since it is determined individually, taking into account the patient’s physique. The price includes the tools used, consumables and time spent in the treatment room. Since before performing a perirenal block, diagnostic measures, their implementation will also be included in the final cost of the manipulation. In addition, the price of perinephric blockade in Moscow is determined by qualifications medical personnel- doctor and nurse.

Indications: used to relieve pain, to treat trophic disorders, for disorders arterial blood supply, with fractured ribs, intercostal neuralgia.

Anesthetics used

• Novocaine 0.25% 250 ml.
• Novocaine 0.5% 50 ml.
• Novocaine 2% 10 ml.

Types of novocaine blockades

The following types of novocaine blockades are distinguished, which will be discussed below:

• intercostal block
• vagosympathetic blockade according to A. V. Vishnevsky
• perinephric block
• spermatic cord block
• blockade of the round ligament of the uterus

Necessary tools

• sterile tray
• two tweezers
• gauze wipes
• syringe 20 ml.
• injection needle for intramuscular injection
• 70% ethyl alcohol
• latex gloves
• novocaine

Intercostal novocaine blockade

Indications: rib fracture; intercostal neuralgia.
Sequencing:


3. Treat the skin of the intercostal space twice with a sterile gauze cloth on tweezers with alcohol.
4. Draw a solution of novocaine into the syringe.
5. Guide the needle along the lower edge of the rib, checking that the needle has not entered the vessel.
6. Introduce novocaine slowly.
7. Remove the needle and treat the needle insertion site with alcohol.
8. Remove rubber gloves, place in a container with a disinfectant solution

Indications: trauma in the chest area, after thoracotomy.
Sequencing.

2. Put on gloves.
H. Place a cushion under your shoulder blades so that your head is tilted back.
4. Turn your head to the side in the direction opposite to the blockade.
5. Extend the arm on the blockade side down along the body.
6. Treat the skin in the area of ​​the sternoclavicular muscle with alcohol 2 times.
The blockade is carried out by a doctor!
Observe the patient. When the blockade is performed correctly, it observes
narrowing of the face, narrowing of the pupil and palpebral fissure on the side of the blockade.

Perinephric novocaine blockade

Indications: injury and disease of the kidneys and perinephric tissue.
Sequencing.
1. Place the patient on his healthy side
2. Wear rubber gloves.
3. Place a cushion under the lumbar region.
4. Bend the leg on the healthy side at the hip and knee joints.
5. Extend the leg on the sore side along the body.
6. Extend the arm on the painful side upward.
7. Treat the area of ​​the vertebral costal angle twice with a sterile cloth and alcohol on tweezers.
The blockade is carried out by a doctor!

Blockage of the spermatic cord with novocaine

Indications: renal colic, trauma and diseases of the male genital organs
Sequencing:
1. Place the patient on his back.
2. Wear rubber gloves.
3. Treat the skin in the area of ​​the root of the scrotum twice with a sterile cloth and alcohol on tweezers.
4. Draw 5 ml of 2% novocaine solution into a syringe.
5. Inject novocaine subcutaneously into the root of the scrotum.

7. Remove rubber gloves, place in a container with a disinfectant solution
Pain relief occurs within 3-5 minutes.

Indications: renal colic, trauma and disease of the female genital organs.
Sequencing.
1. Place the patient on his back.
2. Wear rubber gloves.
3. Treat the skin in the area of ​​the inguinal fold near the pubis twice with a sterile napkin with
alcohol on tweezers.
4. Draw 5 mp of 2% novocaine solution into a syringe.
5. Inject novocaine subcutaneously into the area of ​​the inguinal fold near the pubis.
6. Remove the needle and treat the needle insertion site with alcohol.
7. Remove rubber gloves and place in a container with a disinfectant solution.
Pain relief occurs within 3-5 minutes.

Indications: operations on fingers.
Sequencing.
1. Place the patient in a comfortable position.
2. Wear rubber gloves.
3. Clean the brush twice with a sterile cloth and alcohol on tweezers.
4. Place a sterile bandage on the base of the finger.
5. Draw 5 ml of 2% novocaine solution into a syringe.
6. Apply novocaine subcutaneously along the inner surface of the finger from the DB~ sides.
7. After 3-5 minutes, carry out the operation without removing the sterile bandage from the base of the finger.

Novocaine blockades are widely used for the prevention and treatment of shock in cases of injuries to the chest, abdominal organs and other organs, as well as for extensive burns, peritonitis, and operations on the organs of the thoracic and abdominal cavities.

Cervical vagosympathetic blockade according to A.V. Vishnevsky Cervical vagosympathetic blockade is performed for chest injuries, traumatic brain injuries, and operations on the organs of the thoracic cavity. The patient is placed in a semi-sitting position or placed on the operating table on his back. A cushion is placed under the shoulders (shoulder blades). The head is turned in the opposite direction of the blockade. The hand is pulled down. From top edge of the thyroid cartilage, a line is drawn horizontally (conditionally) to the posterior edge (line) of the sternocleidomastoid muscle. At the intersection of the lines, infiltration anesthesia of the skin is performed. Then, strictly perpendicular to the surface of the skin, a long needle is passed deep into the tissue to the spine. As the needle advances, a 0.25% novocaine solution is injected. As soon as the needle comes into contact with the surface of the vertebral body, it is withdrawn 1.5 cm, then advanced the same distance to the anterior surface of the vertebral body and 30 to 50 ml of novocaine solution is injected for one side. In this case, the vagus and sympathetic nerves are blocked (Fig. 14).

Perinephric (lumbar) blockade is performed for injuries to the abdominal organs, after operations on the abdominal organs, for peritonitis, and extensive burns. The patient is placed on the opposite side of the blockade. A cushion is placed under the lower back. The injection is made in the corner between the 12th rib and the long back muscles, where the skin is anesthetized.

Perinephric block according to A.V. Vishnevsky Then take a long needle with a syringe and at the site of anesthesia, strictly perpendicular to the surface of the skin, insert it 10-20 cm deep into the tissue. As the needle moves, a 0.25% novocaine solution is injected. As soon as the needle enters the interfascial perinephric space, the reverse flow of novocaine stops when the syringe is removed from the needle. After this, 60-100 ml of a 0.25% novocaine solution is slowly injected into the perinephric tissue (it should have a temperature of 38-40 ° C). When performing a perirenal block, the rule must be observed - not a drop of liquid or a drop of blood from the needle (Fig. 15).

Presacral blockade is used for pelvic injuries. The patient is placed on his side or back with his hips adducted to his stomach. A needle is inserted between the coccyx and the anus, which is advanced towards the tip of the coccyx. As soon as the hand feels that the needle is piercing the densest tissue structure, they begin to inject a 0.25% solution of novocaine, while the needle is gradually moved deeper, focusing on the anterior surface of the sacrum. Novocaine is administered in 100-120 ml.

Case blockade Case blockade of the limbs is carried out with open and closed fractures bones. The patient can be in any position. In this case, a 0.25% solution of novocaine is injected above the fracture site into the corresponding fascial sheath surrounding the damaged bone. There is one such fascial receptacle on the thigh, and two on the shoulder. On the thigh, the injection is made along the outer or front surface (to the bone), and on the shoulder - along the back and front surfaces. Novocaine is injected into the fascial sheaths until pronounced resistance to the syringe piston appears. Typically, for a case blockade on the thigh, 200-300 ml of a 0.25% novocaine solution is required, and on the shoulder, 120-150 ml. The injected anesthetic, diffusing, gradually blocks the nerve trunks (Fig. 16).

A short novocaine blockade is carried out for various inflammatory processes. In this case, retreating 1-2 cm from the zone of hyperemia or infiltration (within healthy tissues), the skin is anesthetized, followed by advancing the needle under the base of the inflammatory focus. As the needle advances, a 0.25% solution of novocaine (preferably with antibiotics) is injected and 40-60 ml of novocaine is administered at the base of the lesion.

In addition to these, they also produce conduction blockades on the extremities (femoral, sciatic and other nerves), intrapelvic and retromammary novocaine blockades.