PNBschool

01/13/2026

Extubation is a decision, not a reflex.

Objective recovery, adequate ventilation, and airway protection must align.

If criteria aren’t met, remaining intubated and transferring to PACU/ICU for continued ventilation and pacification is a safe, appropriate option—not a failure. A secure airway is always safe.

Ever try a Jackson Reese circuit?

Measure neuromuscular recovery. Delay when needed. Patient safety first.

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01/09/2026

Femoral Triangle vs Adductor Canal
What are you actually blocking?

One of the most common misunderstandings in lower-extremity regional anesthesia is treating the femoral triangle block and the adductor canal block as binary, nerve-specific techniques. In reality, these injections exist on an anatomic continuum.

Femoral Triangle Injection
• Targets femoral nerve branches, including the saphenous nerve and nerve to vastus medialis
• Produces reliable analgesia, but motor involvement is dose- and location-dependent
• Proximal spread and higher volumes may increase quadriceps weakness

Adductor Canal Injection
• Primarily targets the saphenous nerve, inconsistently the nerve to vastus medialis, and articular branches to the knee
• Designed to balance analgesia with preserved function
• Excessive volume or proximal injection may often convert this into a functional femoral triangle block

Key Takeaway: Volume Matters
They are fascial plane injections with3
• Larger volumes (≥15–20 mL)

➡️ may be motor involvement regardless of what the block is “called” if large volumes are used.

Clinical Pearl
If your “adductor canal block” causes quadriceps weakness, the issue is rarely the name of the block — its volume spread, total volume, and location.

Regional anesthesia outcomes are driven by anatomy + technique, not labels.

Follow PNBschool for practical, anatomy-driven regional anesthesia education that translates directly to better patient outcomes.

01/08/2026

How are things going up there?

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01/08/2026

How well do you really know interscalene block anatomy?

Take a look at this ultrasound image and quiz yourself before scrolling 👇

Question:
Which structure are you targeting for an effective interscalene block for a straight forward rotator cuff repair?

A️⃣ C6 nerve roots
B️⃣ Superior trunk
C️⃣ C8 nerve root
D️⃣ Phrenic Nerve

Key anatomy to identify before you inject:
• Anterior scalene
• Middle scalene
• Brachial plexus nerve roots
• Carotid artery & IJV (medial—danger zone)
• Any other vascular structures

💡 Pearl: Most “failed” ISBs are anatomy failures, not needle failures. If you can’t confidently identify the roots or before inserting the needle, stop and rescan.

⬇️ Drop your answer in the comments
⬇️ Save this for your next shoulder case
⬇️ Follow for daily regional anesthesia education

01/07/2026

LOCAL ANESTHETIC SYSTEMIC TOXICITY (LAST): A RARE EVENT — THAT DOESN’T MEAN YOU SHOULDN’T BE READY

LAST doesn’t happen often during ultrasound-guided nerve blocks, but when it does, it escalates fast. Every regional anesthesiologist should be able to recognize it early and respond immediately.

Key points to remember during nerve blocks:
• CNS symptoms often come first — agitation, tinnitus, metallic taste, seizures
• Cardiovascular collapse can follow rapidly
• Intravascular injection and cumulative dosing are the most common triggers

Prevention is everything
✔ Incremental injection
✔ Frequent aspiration
✔ Use the lowest effective dose
✔ Ultrasound guidance is not optional — it’s a safety tool

If you suspect LAST
STOP injecting.
Call for help.
Secure airway, breathing, circulation.
Start lipid emulsion therapy early — do not wait for cardiac arrest.

This is why pre-procedure planning, dose awareness, and team readiness matter just as much as needle visualization.

Save this post.
Share it with your trainees.
Review your LAST protocol before you need it.

Follow for practical, real-world regional anesthesia education focused on safety, consistency, and better blocks.

01/06/2026

STOP GUESSING WHICH TRANSDUCER TO USE. LET TARGET DEPTH GUIDE YOU.

One of the most common reasons regional blocks fail to look “clean” on ultrasound has nothing to do with skill—it’s transducer selection.

The rule is simple:

The decision is DEPTH, not habit.

Linear Transducer

Use it when your target is superficial
• High frequency = excellent resolution
• Best for nerves and vessels ≤ 4–5 cm
• Crisp needle visualization
• Poor performance once targets get deep

Curvilinear Transducer

Use it when your target is deep
• Lower frequency = better pe*******on
• Ideal for > 5–6 cm, obesity, or deep plexuses
• Wider field of view and better context
• Less sharp, but you can actually see the target

The One-Line Rule You Should Never Forget

Your target should live in the MIDDLE of the screen.
If it’s crushed at the bottom → wrong probe.
If it’s tiny at the top → wrong depth.

Correct probe selection =
• Better needle visualization
• Fewer passes
• Faster block procedure times
• Higher success rates

If this helped, follow PNBschool for practical, no-nonsense regional anesthesia education that actually improves your blocks.

01/05/2026

A quick LAST review!

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01/05/2026

AXILLARY BLOCK: CONSISTENT. RELIABLE. PREDICTABLE ANALGESIA.

If you want a high-reliability upper-extremity block, the axillary block continues to deliver—especially for distal arm surgery.

Where the Axillary Block Works Best

This block is ideally suited for surgery at or below the elbow, including:
• Hand and finger procedures
• Wrist surgery (carpal tunnel release, ORIF, tendon repair)
• Forearm surgery
• Distal radius and ulna fractures
• Soft-tissue procedures of the distal upper extremity

Why the Analgesia Is So Reliable

The axillary block is one of the most consistent brachial plexus blocks because:
• The median, ulnar, and radial nerves are anatomically separated and easily identified with ultrasound
• Local anesthetic spread is predictable when deposited circumferentially
• There is minimal diaphragmatic or respiratory risk, making it suitable for a wide patient population

When performed correctly, the axillary block provides dense sensory analgesia with excellent reproducibility, which is why it remains a workhorse for ambulatory hand and forearm surgery.

Practical Clinical Pearl

Block success depends on intentional nerve-by-nerve coverage. Treat the axillary block as three (sometimes four) individual injections, not a single-shot volume dump.

Take-Home Message

If your goal is dependable analgesia, high success rates, and predictable outcomes for distal upper-extremity surgery, the axillary block is one of the most reliable tools you can use.

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Follow PNBschool for practical, anatomy-driven regional anesthesia education.

01/03/2026

Keep it sterile!

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12/30/2025

3 ultrasound basics that immediately improve your block quality. Do these 3 things before you even think about picking up a block needle.

1️⃣ Set the correct depth
If your target is too deep, you lose resolution. Too shallow, and anatomy is cut off. Adjust depth so the nerve and surrounding structures fill the screen—precision starts with framing.

2️⃣ Optimize gain (not just brightness)
Over-gained images hide needle and tissue planes. Under-gained images miss subtle fascial layers. Balance overall gain so nerves, vessels, and fascia are clearly differentiated without washout. Make the darks darker and the lights lighter….(vascular structures are dark, bone/fascia are light)

3️⃣ Choose the right transducer
High-frequency linear probes for superficial targets. Lower-frequency or curvilinear probes for deeper structures. The wrong probe makes even good technique look bad.

Small adjustments. Big difference in image quality, needle visualization, and block success.

12/29/2025

You need to see it to block it.

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12/29/2025

Making Regional Anesthesia Easy Is a Cultural Decision

Every hospital says it values patient outcomes.
Fewer are willing to redesign culture to support them.

A strong regional anesthesia program is not built on individual skill alone.
It is built on intentional simplicity.

Hospitals that succeed with regional anesthesia do a few things exceptionally well:
• They standardize block selection instead of leaving it to personal preference
• They normalize education, not just for anesthesiologists, but for surgeons, nursing, and perioperative staff
• They remove mystique and variability from regional techniques
• They expect blocks as part of the perioperative plan—not as an optional add-on

When regional anesthesia becomes routine:
• Adoption increases
• Reliability improves
• Risk decreases
• Patient experience becomes predictable

The most effective programs I see are not the most complex.
They are the most aligned.

Making regional anesthesia easy is not about “dumbing it down.”
It is about designing systems that allow teams to perform at a high level—consistently.

That is culture by design.