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Failure to obtain a quadriceps muscle twitch on the first needle insertion is common, simply because the needle tip may pass between the two roots & thus stimulation is not obtained refl.in/95

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If hip flexion occurs (direct psoas stimulation) the needle is too deep. refl.in/98

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If the motor response is hamstrings contraction (L4 component to the sacral plexus) the needle is too medial or caudad.

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If there is contraction of the posterior abdominal wall (quadratus lumborum) the needle is too lateral. refl.in/98

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Injection inside dural sheath can result in tracking of the local anesthetic toward the epidural or subarachnoid space. Use >0.5mA only, to avoid needle placement within this sheath refl.in/95

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The Shamrock ultrasound guided technique

#wca2016

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Inadequate skin anesthesia despite the apparent timely onset of the blockade can occur. It can take up to 30 min for full sensory-motor anesthesia to develop. refl.in/95

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Spread of local to the epidural space may result in significant hypotension & occurs in up to 15% of patients. Monitor to the same extent as patients receiving epidural anesthesia refl.in/95

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Smaller volumes & concentrations can be used for analgesia (e.g., 20 mL); however, for surgical anesthesia, 30 mL is necessary to achieve a dense blockade of the entire lumbar plexus refl.in/95

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There is insufficient evidence to support the use of PCB combined with a sciatic nerve block and sedation as an alternative to GA or spinal anaesthesia for hip surgery. refl.in/97

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This block carries a higher risk of local anesthetic toxicity due its deep location & vicinity of muscles. For that reason, avoid high concentrations of long-acting local anesthetic. refl.in/95

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