Novocaine blockade: perinephric, intercostal, spermatic cord. Technique of manipulation. Medical equipment necessary for emergency care Perinephric novocaine blockade indications technique

Indications: renal hepatic colic, cholecystitis, biliary dyskinesia, pancreatitis, dynamic intestinal obstruction, obliterating endartermitis (initial stage), shock in severe injuries of the lower extremities.

Technique: The patient is positioned on the healthy side; a cushion is placed under the lower back. The needle is inserted at the apex of the angle formed by the XII rib and the outer edge of the rectifier muscle (Fig. 69). After intradermal anesthesia, a long needle (up to 14 cm) connected to a syringe is inserted perpendicular to the surface of the body. With light, constant pressure on the syringe plunger, a solution of novocaine is sent in front of the needle. The needle passes through the muscles, the posterior layer of the renal fascia and enters the perinephric tissue, which is determined by the “sinking” of the piston when novocaine enters the loose tissue and by the cessation of reverse flow of the solution from the needle when the syringe is removed from it. 60-80 ml of 0.25% novocaine solution is injected into the perirenal tissue on one side, and the renal plexus is initially blocked, due to the fact that it has a close connection with the autonomic plexuses (celiac, superior and inferior mesenteric, aortic) reflexively these plexuses are also included. In addition, novocaine spreads through the connections of the perinephric cellular space into the para-aortic space and directly approaches and affects these autonomic plexuses. The blockade is performed on one or both sides.

Rice. 69. Point of administration of novocaine when performing perinephric blockade according to A.V. Vishnevsky.

Complications: damage to the kidney parenchyma and the introduction of novocaine under its own capsule, damage to the vessels of the kidney, penetration of the needle into the lumen of the ascending or descending colon. If blood appears in the needle, it is necessary to slightly pull the needle back until the blood flow stops and continue administering novocaine.

Projections of arteries and nerves of the perineum

Internal genital vessels and pudendal nerve (a., v.pudenda interna et n.pudendus) is projected along the medial edge of the ischial tuberosity (they have a direction from back to front and somewhat from the outside to the inside) (Fig. 70).

Rice. 70. Projections of the internal genital vessels and the pudendal nerve.

Intrapelvic blockade according to Shkolnikov-Selivanov

Indications: prevention and control of shock in injuries of the pelvic bones and lower extremities.

Technique: on the side of the injury, 1 cm medially from the anterior superior iliac spine, after anesthesia of the skin, a needle 14-15 cm long is inserted, directing it from front to back to the inner surface of the iliac wing and 400-500 ml of 0.25% novocaine solution is injected ( Fig. 71). The solution enters the tissue where the branches of the lumbar and sacral plexuses pass.

Complications: damage to the large or small intestine.

Pudendal nerve block. (n.Pudendus).

Indications: surgical interventions in the perineum and posterior vaginal wall, surgical treatment of perineal wounds.

Rice. 71. Point of administration of novocaine during blockade according to Shkolnikov-Selivanov.

Technique: after anesthesia of the skin, a long needle is inserted 1.5-2.0 cm inward from the ischial tuberosities and advanced into the depths of the ischiorectal fossa (Fig. 72), sending portions of novocaine in front of the needle. 50-60 ml of 0.25% novocaine solution is injected into each hole, in the fiber of which the branches of the pudendal nerve pass.

It is injected within the fascial sheath of the kidney, where it penetrates the perinephric fatty tissue and affects the renal nerve plexus (Fig. 10).

Rice. 10. Scheme of right-sided lumbar (perinephric) blockade: 1 - left kidney; 2 - right kidney; 3 - longissimus dorsi muscle; 4 - iliocostal muscles; 5 - thoracic vertebra; 6 - haze position

When producing the blockade, the rules of asepsis and antiseptics are strictly observed. In large animals, Vir or Bobrov needles are used for injection.

For the lumbar block, use a 0.25% novocaine solution heated to body temperature, which is prepared using a 0.45% sodium chloride solution or a modified Ringer's solution (see preparation of novocaine solutions).

The average dose for horses and cattle is 1 ml of 0.25% novocaine solution per 1 kg of animal weight. If indicated, the blockade is repeated after 6-7 days.

Technique of lumbar blockade in horses according to I. Ya. Tikhonin. The blockade is performed on a standing horse, fixed in a machine. Novocaine solution can be injected from both the right and left sides. A one-stage bilateral lumbar blockade, according to some authors, gives better results than a unilateral one.

With a right-sided blockade, the needle is inserted perpendicular to the skin in the space between the last rib and the transverse costal process of the first lumbar vertebra or between the 17th and 18th ribs, at a distance of 8-10 cm from the midline of the back (at the outer edge of the longissimus dorsi muscle). The needle insertion depth is 8-10cm.

On the left side, the needle is inserted into the space between the last rib and the anterior edge of the transverse costal process of the 1st lumbar vertebra, at a distance of 5-6 cm from the free end of the process towards the midline of the body and to a depth of 5-6 cm, depending on the breed and horse fatness.

After the needle is inserted to the required depth, the mandrin is removed from it and a test infusion of the solution is performed using a 10- or 20-gram syringe. When the needle is positioned correctly, the novocaine solution enters the perinephric tissue under light pressure on the syringe piston. Completely free entry of the solution indicates that it enters the peritoneal cavity. When introducing the solution intramuscularly or into the kidney parenchyma, the hand experiences significant resistance. The appearance of blood indicates penetration of the needle into the kidney parenchyma or into the lumen of a blood vessel.

After making sure that the needle is in the correct position, begin injecting the intended amount of novocaine solution. For injection, use a Janet syringe or a device designed by I. Ya. Tikhonin.

Technique of lumbar blockade in cattle according to M. M. Senkin. The blockade is performed on the right side. The needle is inserted in the space between the last rib and the transverse process of the 1st lumbar vertebra or between the transverse processes of the 1st and 2nd lumbar vertebrae, retreating 1.5-2 cm from the free ends of the processes to the midline of the body, downward and slightly inward . The depth of needle insertion depends on the age and fatness of the animal and is usually 8-11 cm. After puncturing the skin, the needle initially moves relatively easily, when passing the initial tendon of the right leg of the diaphragm and the outer fascia of the kidney, the resistance increases, and the hand sometimes feels a slight crunch, and then the needle again moves freely by 1.5-2 cm.

The novocaine solution should flow completely freely with light pressure on the syringe plunger.

Technique of lumbar blockade in sheep and goats according to V. G. Martynov. The blockade is performed on the right side. The needle is inserted between the transverse costal processes of the 1st and 2nd lumbar vertebrae, retreating 1-1.5 cm from their free ends to the midline of the body. After the needle touches the edge of the transverse costal process, it is displaced and further advanced 1.5-2 cm in depth. The dose for a single injection in sheep and goats is 40-60 ml of a 0.25% novocaine solution.

Technique of lumbar blockade in dogs according to I. I. Magda. For a left-sided blockade, the needle is inserted at the level of the end of the transverse costal process of the second lumbar vertebra, and for a right-sided blockade - at the level of the first lumbar vertebra. At the indicated points, the needle is inserted in a vertical direction until it stops at the edge of the transverse costal process, then it is displaced from the bone and immersed another 0.5-1 cm. The dose depends on the size of the dog and is equal to approximately 25-100 ml of a 0.25% solution novocaine

Indications. Lumbar novocaine blockade is relatively widely used in veterinary practice. It is recommended for the following diseases in animals:

· infected wounds - to prevent wound infection;

· ulcers and long-term non-healing wounds;

· acute aseptic and purulent inflammatory diseases - hemolymphatic extravasation, phlegmon, furunculosis, post-castration edema, acute rheumatic inflammation of the hooves, etc.;

· bovine papillomatosis;

· verrucous dermatitis and purulent pododermatitis;

· colic in horses due to dynamic or paralytic obstruction - flatulence, enteralgia, blockages of the thick section;

· initial stages of toxemia, tympany and overfeeding in cattle;

· atony of the proventriculus in ruminants;

· enterocolitis in horses and cattle;

· retention of placenta in cows and goats;

· purulent endometritis;

· catarrhal form of canine distemper;

· epizootic lymphangitis.

Indications for this blockade for diseases of the abdominal and pelvic cavities:

Infected long-term non-healing wounds and ulcers, acute aseptic and purulent inflammatory diseases (hemolymphatic extravasation, phlegmon, furunculosis, post-castration edema, rheumatic inflammation of the hooves), papillomatosis, verrucous dermatitis and purulent pododermatitis, colic in horses (flatulence, enteralgia, blockages of the thick section), initial stages of toxemia, tympany and overfeeding in cattle, atony of the proventriculus, enterocolitis, retention of placenta in cows and goats, purulent endometritis, catarrhal form of canine distemper, epizootic lymphangitis.

With this method, a solution of novocaine is injected into the fascial sheath of the kidney, where it penetrates the perinephric fatty tissue and affects the renal nerve plexus.

Lumbar (perinephric) blockade in horses according to I.Ya. Tikhonin.

Blockade technique.

When performing a blockade, the rules of asepsis and antiseptics are strictly observed.

For injection, use Beer, Bobrov needles or injection needles 10-12 cm long with mandrels, 1.5-2 mm thick with an end sharpened at an angle of 45 degrees.

• The blockade is performed on a standing horse, fixed in a machine.
• Novocaine solution can be injected from both the right and left sides.
• For a right-sided blockade, the needle is inserted perpendicular to the skin in the space between the last rib and the transverse costal process of the first lumbar vertebra or between the 17th and 18th ribs, at a distance of 8-10 cm from the midline of the back (at the outer edge of the longissimus dorsi muscle) (drawing).
• The depth of needle insertion is 8-10 cm.

1 – left kidney; 2 – right kidney; 3 – longissimus dorsi muscle; 4 – iliocostal muscle.

• On the left side, the needle is inserted into the space between the last rib and the anterior edge of the transverse costal process of the 1st lumbar vertebra at a distance of 5-6 cm from the free end towards the midline of the body and to a depth of 5-6 cm, depending on the breed and fatness horses.

1. After preparing the surgical field, it is advisable to use a thin needle to make an intradermal injection and infiltrate the underlying tissues with a 0.25-0.5% solution of novocaine.
2. Then a puncture of the skin is made with a Beer or Bobrov needle. The needle insertion point should be in the middle of the intercostal space.
3. An injection needle with a mandrel is inserted into the resulting hole perpendicular to the skin and advanced to the required depth.
4. Then the mandrel is removed from it and a test infusion of the anesthetic solution is performed. When the needle is positioned correctly, the novocaine solution enters the perinephric tissue under light pressure on the syringe piston. Completely free entry of the solution indicates that it enters the abdominal cavity. When introducing the solution intramuscularly or into the kidney parenchyma, the hand experiences significant resistance. The appearance of blood indicates penetration of the needle into the kidney parenchyma or into the lumen of a blood vessel.
5. After making sure that the needle is in the correct position, begin injecting the required amount of novocaine solution.

For injection, use a Janet syringe.

BLOCK OF THE ROUND LIGAMENT OF THE LIVER

Indications:spicy pancreatitis, acute cholecystitis.

The blockade is carried out during first aid 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 the smooth muscles of the internal organs of the abdomen, ducts of the digestive glands, and 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 gall bladder bed

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: injuries of the abdominal organs 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 trunk and lower extremities, transfusion shock, obliterating endarteritis, syndrome prolonged compression, trophic ulcers of the 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. Having determined with 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% novocaine solution. 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 broad-spectrum antibiotics must be injected through another into the perinephric tissue;

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, shock conditions resulting from abdominal trauma, blood transfusion shock and other urgent pathologies. Perinephric block is performed in the treatment room after a minimum of 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 are associated with the needle getting 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, and is 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 perirenal block is its widespread use over 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 a relatively high risk of complications, so the need for this particular method of 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 one. 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 can 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, and the patient’s allergy history is determined. 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 leg on the bottom is bent at the knee and hip joint; on the side of the manipulation, 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 for timely diagnosis of entry into 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 it was necessary to relieve pain due to renal colic, the patient can either be free, or he is recommended to be hospitalized to prescribe conservative therapy or plan surgery. Perinephric blockade as part of emergency surgery is required both for therapeutic purposes and for the 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 of 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 instruments used, consumables and time spent in the treatment room. Since diagnostic measures are required before performing a perinephric block, their implementation will also be included in the final cost of the manipulation. In addition, the price of a perinephric block in Moscow is determined by the qualifications of medical personnel - a doctor and a nurse.