Infraorbital Nerve Block Santhanam Suresh MD FAAP Director

Infraorbital Nerve Block Santhanam Suresh, MD, FAAP Director of Research, Department of Pediatric Anesthesia Professor of Anesthesiology and Pediatrics Northwestern University’s Feinberg School of Medicine Children’s Memorial Hospital Chicago, Illinois

Infraorbital Block (Single Shot) SKILL COMPONENTS 1. Pre-operative Preparation 2. Strategy of Procedure 3. Preparation 4. Position 5. Procedure 1. Injection 2. Monitoring 6. Clean up 7. Handling Post-op Adverse Events

Component 1: Infraorbital Block (Single Shot) Preoperative prep: CONSENT Steps: 1. How to obtain consent.

Component 2: Infraorbital Block (Single Shot) Strategy of Procedure Steps: 1. Choice of local anesthetic solution 3. Dose of local by weight 4. Confer with surgeon Bupivacaine 0. 25% w/ 1: 200, 000 epinephrine: Lidocaine can be used instead to facilitate initiation of feeding and minimize duration of block.

Component 2: Infraorbital Block (Single Shot) Strategy of Procedure Steps: 1. Choice of local anesthetic solution 3. Dose of local by weight 4. Confer with surgeon Anesthetic Dose: 0. 5 m. L (infants) to 1. 5 m. L (older children and adolescents) for Infraorbital Block

Component 2: Infraorbital Block (Single Shot) Strategy of Procedure Steps: 1. Choice of local anesthetic solution 3. Dose of local by weight 4. Confer with surgeon Discuss with Surgeon: - Discuss risk of intravascular injection and hematoma formation - Stress potential for numbness in upper lip - Stress to caregivers in PACU about potential for child biting upper lip if dentition is present

Component 3: Infraorbital Block (Single Shot) Prepare for block Steps: 1. Get materials 2. Identify surface landmarks 3. Prep the patient Seen here: • 27 gauge needle bent at 70° • 3 m. L syringe • Ruler • Marker Not seen: • Bupivacaine. 25% with 1: 200, 000 epinephrine • Sterile dry gauze • Sterile field area • Rolling cart/MAYO tray

Component 3: Infraorbital Block (Single Shot) Prepare for block Steps: 1. Get materials 2. Identify surface landmarks 3. Prep the patient The external landmark is an imaginary line that passes through the pupil, the supraorbital foramen, the infraorbital foramen, and the mental foramen.

Component 3: Infraorbital Block (Single Shot) Prepare for block Steps: 1. Get materials 2. Identify surface landmarks 3. Prep the patient Palpate the floor of the orbital rim from midline laterally until infraorbital notch is felt. Mark injection site at infraorbital foramen.

Component 3: Infraorbital Block (Single Shot) Prepare for block Steps: 1. Get materials 2. Identify surface landmarks 3. Prep the patient Markings should be about 2 centimeters from the midline.

Component 4: Infraorbital Block (Single Shot) Patient Position for block Steps: 1. Supine position Patient should be supine, with the head on a pillow or soft donut to prevent movement.

Component 5: Infraorbital Block (Single Shot) Procedure for block Steps: 1. Injection - Insertion - Aspiration 2. Monitoring - Watch EKG Needle should be inserted into the subsulcal groove until it reaches proximal to the intraorbital foramen. A finger should be placed externally to prevent needle from moving cephalad into the globe of the eye.

Component 5: Procedure for block Steps: 1. Injection - Insertion - Aspiration 2. Monitoring - Watch EKG Video of injection. Infraorbital Block (Single Shot)

Component 5: Infraorbital Block (Single Shot) Procedure for block Steps: 1. Injection - Insertion - Aspiration 2. Monitoring - Watch EKG Aspirate for possible heme. Inject while palpating—the local anesthetic should be felt under your finger.

Component 5: Infraorbital Block (Single Shot) Procedure for block Steps: 1. Injection - Insertion - Aspiration 2. Monitoring - Watch EKG Train yourself to look at the EKG for increasing heart rate and blood pressure.

Component 7: Infraorbital Block (Single Shot) Handling post-operative adverse events Steps: 1. Lipid Rescue: Lipid Infusion Therapy is an apparently effective treatment for the most devastating complication of regional anesthesia: cardiovascular collapse from local anesthetic overdose. The Lipid Sink Theory explains the effect by postulating that the lipophilic local anesthetics are absorbed into the infused lipid, thus preventing their toxic effect on the tissue. Recent research suggests that there may be another mechanism for effect. Rx: “ 20% Intralipid: 1. 5 m. L/kg as an initial bolus, followed by 0. 25 m. L/kg/min for 30 -60 minutes. Bolus could be repeated 1 -2 times for persistent asystole. Infusion rate could be increased if the BP declines.