First Aid Perioperative Ultrasound Acute Pain Manual For Surgical Procedures Jinlei Li Editor Wei Jiang Editor Nalini Vadivelu Editor

Full download test bank at ebookmeta.
com
First Aid Perioperative Ultrasound Acute Pain

Manual for Surgical Procedures Jinlei Li Editor
Wei Jiang Editor Nalini Vadivelu Editor
For dowload this book click LINK or Button below
https://ebookmeta.com/product/first-aid-
perioperative-ultrasound-acute-pain-manual-for-
surgical-procedures-jinlei-li-editor-wei-jiang-
editor-nalini-vadivelu-editor/
OR CLICK BUTTON
DOWLOAD EBOOK
Download More ebooks from https://ebookmeta.com

More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Anesthesiologist s Manual of Surgical Procedures 6th

Edition Richard A Jaffe Md Phd Editor Clifford A
Schmiesing Md Editor Brenda Golianu Md Editor
https://ebookmeta.com/product/anesthesiologist-s-manual-of-
surgical-procedures-6th-edition-richard-a-jaffe-md-phd-editor-
clifford-a-schmiesing-md-editor-brenda-golianu-md-editor/
The Acute Management of Surgical Disease Martin D.

Zielinski (Editor)
https://ebookmeta.com/product/the-acute-management-of-surgical-
disease-martin-d-zielinski-editor/
Ophthalmology Clerkship A Guide for Senior Medical

Students Contemporary Surgical Clerkships Emily Li
Editor Colin Bacorn Editor
https://ebookmeta.com/product/ophthalmology-clerkship-a-guide-
for-senior-medical-students-contemporary-surgical-clerkships-
emily-li-editor-colin-bacorn-editor/
Atlas of Interventional Orthopedics Procedures:

Essential Guide for Fluoroscopy and Ultrasound Guided
Procedures 1st Edition Christopher J. Williams Md
(Editor)
https://ebookmeta.com/product/atlas-of-interventional-
orthopedics-procedures-essential-guide-for-fluoroscopy-and-
ultrasound-guided-procedures-1st-edition-christopher-j-williams-
Ultrasound Guided Procedures and Radiologic Imaging for
Pediatric Anesthesiologists [Team-IRA] [True PDF] Anna
Clebone (Editor)
https://ebookmeta.com/product/ultrasound-guided-procedures-and-
radiologic-imaging-for-pediatric-anesthesiologists-team-ira-true-
pdf-anna-clebone-editor/
Textbook of Dermatologic Ultrasound Ximena Wortsman

(Editor)
https://ebookmeta.com/product/textbook-of-dermatologic-
ultrasound-ximena-wortsman-editor/
Aortic Dissection and Acute Aortic Syndromes Frank W

Sellke Editor Joseph S Coselli Editor Thoralf M Sundt
Editor Joseph E Bavaria Editor Neel R Sodha Editor
https://ebookmeta.com/product/aortic-dissection-and-acute-aortic-
syndromes-frank-w-sellke-editor-joseph-s-coselli-editor-thoralf-
m-sundt-editor-joseph-e-bavaria-editor-neel-r-sodha-editor/
Micro LEDs (Volume 106) 1st Edition Hongxing Jiang

(Editor)
https://ebookmeta.com/product/micro-leds-volume-106-1st-edition-
hongxing-jiang-editor/
Absolute Breast Imaging Review Multimodality Cases for

the Core Exam Lucy Chow Editor Bo Li Editor
https://ebookmeta.com/product/absolute-breast-imaging-review-
multimodality-cases-for-the-core-exam-lucy-chow-editor-bo-li-
editor/
First Aid
Perioperative
Ultrasound
Acute Pain Manual for Surgical
Procedures
Jinlei Li · Wei Jiang
Nalini Vadivelu Editors
123
First Aid Perioperative Ultrasound
Jinlei Li • Wei Jiang
Nalini Vadivelu
Editors
First Aid
Perioperative
Ultrasound
Acute Pain Manual for Surgical
Procedures
Editors
Jinlei Li Wei Jiang
Department of Anesthesiology Shanghai Jiaotong University
Yale University Shanghai Sixth People’s Hospital
New Haven, CT, USA Shanghai, China
Nalini Vadivelu
Department of Anesthesiology
Yale University
New Haven, CT, USA
ISBN 978-3-031-21290-1 ISBN 978-3-031-21291-8 (eBook)

https://doi.org/10.1007/978-3-031-21291-8
© The Editor(s) (if applicable) and The Author(s), under exclusive license to
Springer Nature Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by
the Publisher, whether the whole or part of the material is concerned, specifically
the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting,
reproduction on microfilms or in any other physical way, and transmission or
information storage and retrieval, electronic adaptation, computer software, or by
similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service
marks, etc. in this publication does not imply, even in the absence of a specific
statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and
information in this book are believed to be true and accurate at the date of
publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with
regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature

Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
Part I Ultrasound Guided High-Yield Perioperative

Regional Anesthesia
Safe Practice of Ultrasound Guided Regional

Anesthesia �� 3
Tae S. Lee and Yan H. Lai
Sonographic Image of Head and Neck Regional
Anesthesia �� 19
Shenyuan Zhou and Wei Jiang
Sonographic Image of Upper Extremity Regional
Sonographic Image of Lower Extremity Regional
Sonographic Image of Thoracic Spine and Chest
Regional Anesthesia �� 79
Sonographic Image of Lumbar-Sacral Spine
and Abdomen Regional Anesthesia�� 89
v
vi Contents
Part II Evidence-Based Utilization of Opioid

and Non-opioid Analgesics
Acetaminophen��107
Kristin Brennan and Henry Liu
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) ��127
Kaivon Sobhani, Jinlei Li, and Milaurise Cortes
Anticonvulsants��139
Efime Popovitz, Jinlei Li, and Nalini Vadivelu
Muscle Relaxants ��147
Clara Pau
Antidepressants��159
Tolga Suvar
Alpha-2 Adrenergic Agonists��169
Michael Guan, David Fanelli, Thomas Verbeek,
Dennis J. Warfield Jr., and Henry Liu
Ketamine ��195
Sukhman Shergill and Nalini Vadivelu
Methadone��207
Jackson Condrey, Andrew Klein, and Carey Brewbaker
Buprenorphine, Buprenorphine/Naloxone
(Suboxone)��221
William F. Barrett and Carey Brewbaker
Complimentary Non-pharmacological
and Non-opioid Options��239
Christopher D. Wolla and Tara Kelly
Part III Acute Pain Management Protocols

for Surgical Procedures
Acute Pain Management Protocol

for Cranial Procedures��261
Shane M. Barre and Sanjib Das Adhikary
Contents vii
Acute Pain Management Protocol for Ophthalmic

Procedures��291
Rahul M. Dhodapkar, Andrew Jin, and Ji Liu
Acute Pain Management Protocol for Neck
Procedures��313
Alex Yu, Samuel DeMaria Jr., and Shane Dickerson
Acute Pain Management Protocol for Proximal
Upper Extremity: Shoulder and Proximal
Humerus Procedures ��331
Marcelle Blessing
Acute Pain Management Protocol for Distal
Upper Extremity: Elbow, Wrist and Hand Procedures��349
Olga Salianski, Margaret Griesemer, and Jinlei Li
Acute Pain Management Protocol for Pelvic,
Hip and Proximal Femur Procedures��367
Nicole Hollis and Katelyn Glines
Femur, Proximal Tibia/Fibula and Knee Procedures ��389
Janet Hong and Yan H. Lai
Tibia/Fibula, Ankle and Foot Procedures��403
Benjamin Allen Howie, Victor Yu, Jinlei Li,
and XueWei Zhang
Acute Pain Management Protocol for Unilateral
and Bilateral Chest/Thoracic Procedures��429
Dena Danji, Jacob A. Lambert, and Matthew B. Ellison
Acute Pain Management Protocol for Breast
Procedures, with and Without Reconstruction ��447
Daniel Amor, Jordan Abrams, and Yan H. Lai
Acute Pain Management Protocol for Cardiac
Procedures��459
Justin Walker, Rushil Bose, Ashley Jordan,
and Dennis J. Warfield Jr.
viii Contents

Acute Pain Management Protocol for Gastrointestinal
Procedures��475
Tolga Suvar and Henry R. Govekar
Acute Pain Management Protocol for Urological
Procedures: Kidney, Bladder, Prostate��487
Poonam Pai, Jordan Abrams, and Yan H. Lai
Acute Pain Management Protocol
for Biliary-Hepatic, Spleen, Pancreatic Procedures ��503
Elizabeth Cooney Reyes, Claire Marie Bentley,
Hong Wang, and Pete Pelletier

Acute Pain Management Protocol for Hernia Repair:
Umbilical, Inguinal, Femoral Hernia ��521
Rutuja Sikachi and Yan H. Lai
Acute Pain Management Protocol in Major
Vascular Procedures��533
Ailan Zhang and Jeff L. Xu
Acute Pain Management Protocol in Minor
Vascular Procedures��575
Ashley Shilling, Matthew Thames, and Michael Glick
Acute Pain Management Protocol for Spine
Procedures��585
Jennifer Mardini, Shayann Ramedani, and Sonal Sharma
Must-Known Special Considerations for Acute
Pain Management in Pediatric Patient Population��599
Jodi-Ann Oliver, Lori-Ann Oliver,
and Bartlomiej Bartkowiak
Pain Management in Geriatric Patient Population��623
Thomas Halaszynski
Pain Management in Trauma and Non-OR Patients��643
Brett Simmons and Nicole Hollis
Index��655
Contributors
Jordan Abrams, MD Department of Anesthesiology, Periopera-

tive and Pain Medicine, Mount Sinai West and Morningside Hos-
pitals, New York, NY, USA
Sanjib Das Adhikary, MD Department of Anesthesiology and
Perioperative Medicine, Penn State Health Milton S. Hershey
Medical Center, 500 University Dr., Hershey, PA, USA
Daniel Amor, MD Department of Anesthesiology, Perioperative
and Pain Medicine, Mount Sinai West and Morningside Hospi-
tals, New York, NY, USA
Shane M. Barre, DO Department of Anesthesiology and Periop-
erative Medicine, Penn State Health Milton S. Hershey Medical
Center, 500 University Dr., Hershey, PA, USA
William F. Barrett Department of Anesthesia and Perioperative
Medicine, Medical University of South Carolina, Charleston, SC,
USA
Bartlomiej Bartkowiak Department of Anesthesiology, Yale
University School of Medicine, New Haven, CT, USA
Claire Marie Bentley Department of Anesthesiology, West Vir-
ginia University, Morgantown, WV, USA
Marcelle Blessing Yale-New Haven Hospital, New Haven, CT,
USA
ix
x Contributors
Rushil Bose Department of Anesthesiology and Perioperative

Medicine, Penn State Health Milton S. Hershey Medical Center,
Hershey, PA, USA
Kristin Brennan UPMC Harrisburg, Riverside Anesthesia Asso-
ciates, Harrisburg, PA, USA
Carey Brewbaker Department of Anesthesia and Perioperative
USA
Jackson Condrey Department of Anesthesia and Perioperative
USA
Milaurise Cortes, MD Department of Anesthesiology, Yale New
Haven Hospital, New Haven, CT, USA
Dena Danji Department of Anesthesiology, West Virginia Uni-
versity, School of Medicine, Morgantown, WV, USA
Samuel DeMaria Jr Department of Anesthesiology, Periopera-
tive and Pain Medicine, Icahn School of Medicine at Mount Sinai,
New York, NY, USA
Rahul M. Dhodapkar Department of Ophthalmology and Visual
Science, Yale School of Medicine, New Haven, CT, USA
Shane Dickerson Department of Anesthesiology, Cooperman
Barnabas Medical Center, Livingston, NJ, USA
Matthew B. Ellison Department of Anesthesiology, West Vir-
ginia University, School of Medicine, Morgantown, WV, USA
David Fanelli Department of Anesthesiology and Perioperative
Medicine, Milton S. Hershey Medical Center, Penn State Univer-
sity College of Medicine, Hershey, PA, USA
Michael Glick University of Virginia Health System, Charlot-
tesville, VA, USA
Katelyn Glines Department of Anesthesiology, West Virginia
University, Morgantown, WV, USA
Contributors xi
Henry R. Govekar Division of Colon and Rectal Surgery,

Department of Surgery, Rush University Medical Center, Chi-
cago, IL, USA
Margaret Griesemer Rush University Medical Center, Chicago,
IL, USA
Michael Guan Department of Anesthesiology and Perioperative
Medicine, Milton S. Hershey Medical Center, Penn State Univer-
sity College of Medicine, Hershey, PA, USA
Thomas Halaszynski Yale University School of Medicine, New
Haven, CT, USA
Nicole Hollis Department of Anesthesiology, West Virginia Uni-
versity, Morgantown, WV, USA
Janet Hong, DO Department of Anesthesiology, Perioperative
Benjamin Allen Howie Department of Anesthesiology, Yale
New Haven Hospital, New Haven, CT, USA
Wei Jiang Department of Anesthesiology, Shanghai Jiaotong
University Affiliated Sixth People’s Hospital, Shanghai, China
Andrew Jin Department of Ophthalmology and Visual Science,
Yale School of Medicine, New Haven, CT, USA
Ashley Jordan Department of Plastic and Reconstructive Sur-
gery, Geisinger Medical Center, Danville, PA, USA
Tara Kelly Department of Anesthesiology and Perioperative
USA
Andrew Klein Department of Anesthesia and Perioperative
USA
Yan H. Lai, MD, MPH, FASA, CBA, L.Ac Department of
Anesthesiology, Perioperative and Pain Medicine, Mount Sinai
West and Morningside Hospitals, New York, NY, USA
xii Contributors
Jacob A. Lambert Department of Anesthesiology, West Virginia

University, School of Medicine, Morgantown, WV, USA
Tae S. Lee, MD Department of Anesthesiology, Perioperative
Jinlei Li, MD, PhD Department of Anesthesiology, Yale New
Anesthesiology, Yale University, New Haven, CT, USA
Henry Liu Department of Anesthesiology and Critical Care,
Perelman School of Medicine, University of Pennsylvania, Phila-
delphia, PA, USA
Ji Liu Department of Ophthalmology and Visual Science, Yale
School of Medicine, New Haven, CT, USA
Jennifer Mardini Department of Anesthesiology and Periopera-
tive Medicine, Penn State Health Milton S. Hershey Medical Cen-
ter, Hershey, PA, USA
Jodi-Ann Oliver Pediatric Division, Department of Anesthesiol-
ogy, Yale University School of Medicine, New Haven, CT, USA
Lori-Ann Oliver Acute Pain and Regional Anesthesia Division,
Department of Anesthesiology, Yale University School of Medi-
cine, New Haven, CT, USA
Poonam Pai, MD, MS Department of Anesthesiology, Periop-
erative and Pain Medicine, Mount Sinai West and Morningside
Hospitals, New York, NY, USA
Clara Pau Department of Anesthesia, Hackensack University
Medical Center, Hackensack, NJ, USA
Pete Pelletier Department of Anesthesiology, West Virginia Uni-
Efime Popovitz Department of Anesthesiology, Yale University
School of Medicine, New Haven, CT, USA
Contributors xiii
Shayann Ramedani Penn State College of Medicine, Penn State

Health Milton S. Hershey Medical Center, Hershey, PA, USA
Elizabeth Cooney Reyes Department of Anesthesiology, West
Virginia University, Morgantown, WV, USA
Olga Salianski Department of Anesthesiology, Yale New Haven
Hospital, New Haven, CT, USA
Sonal Sharma Department of Anesthesiology and Perioperative
Hershey, PA, USA
Sukhman Shergill Department of Anesthesiology, Yale Univer-
sity School of Medicine, New Haven, CT, USA
Ashley Shilling University of Virginia Health System, Charlot-
tesville, VA, USA
Rutuja Sikachi, MD Department of Anesthesiology, Periopera-
tive and Pain Medicine, Mount Sinai West and Morningside Hos-
pitals, New York, NY, USA
Brett Simmons Department of Anesthesiology, West Virginia
University, Morgantown, WV, USA
Kaivon Sobhani, MD Department of Anesthesiology, Yale New
Tolga Suvar, MD Department of Anesthesiology and Pain Medi-
cine, Rush University Medical Center, Chicago, IL, USA
Matthew Thames University of Virginia Health System, Char-
lottesville, VA, USA
Nalini Vadivelu Department of Anesthesiology, Yale University,
New Haven, CT, USA
Department of Anesthesiology, Yale University School of Medi-
cine, New Haven, CT, USA
Thomas Verbeek Department of Anesthesiology and Periopera-
tive Medicine, Milton S. Hershey Medical Center, Penn State
University College of Medicine, Hershey, PA, USA
xiv Contributors
Justin Walker Department of Anesthesiology and Perioperative

Hershey, PA, USA
Hong Wang Department of Anesthesiology, West Virginia Uni-
Dennis J. Warfield Jr. Department of Anesthesiology and Peri-
operative Medicine, Milton S. Hershey Medical Center, Penn
State University College of Medicine, Hershey, PA, USA
Department of Anesthesiology and Perioperative Medicine, Penn
State Health Milton S. Hershey Medical Center, Hershey, PA,
USA
Christopher D. Wolla Department of Anesthesiology and Peri-
operative Medicine, Medical University of South Carolina,
Charleston, SC, USA
Jeff L. Xu Division of Regional Anesthesia and Acute Pain Man-
agement, Department of Anesthesiology, Westchester Medical
Center/New York Medical College, Valhalla, NY, USA
Alex Yu Department of Anesthesiology, Perioperative and Pain
Medicine, Icahn School of Medicine at Mount Sinai, New York,
NY, USA
Victor Yu Department of Anesthesiology, Yale New Haven Hos-
pital, New Haven, CT, USA
Ailan Zhang Division of Regional Anesthesia and Acute Pain
Management, Department of Anesthesiology, Westchester Medi-
cal Center/New York Medical College, Valhalla, NY, USA
XueWei Zhang Department of Anesthesiology, Yale New Haven
Hospital, New Haven, CT, USA
Shenyuan Zhou Department of Anesthesiology, Shanghai Jiao-
tong University Affiliated Sixth People’s Hospital, Shanghai,
China
Part I
Ultrasound Guided High-Yield
Perioperative Regional Anesthesia
Safe Practice of Ultrasound
Guided Regional Anesthesia
Tae S. Lee and Yan H. Lai
Case Stem As a regional anesthesiology fellow, you are meeting

your first patient of the day in the preoperative holding area.
Patient is a 61-year-old man with a BMI of 18 (weight of 45 kg)
presenting for elective total shoulder arthroplasty (TSA) for treat-
ment of his primary osteoarthritis. His past medical history
includes hypertension, diabetes, coronary artery disease with
a drug-eluting stent placed 1 year earlier, Wolf-Parkinson-White
syndrome, and emphysema secondary to a 30-pack year smoking
history. He also has a history of polysubstance abuse, and success-
fully tapered off of methadone completely just this past year. His
medications include Aspirin 81 mg, Clopidogrel (which he had
stopped 7 days ago), Atorvastatin, Amlodipine, Metformin,
Insulin, Carvedilol, and Albuterol. His electrocardiogram was
notable for left anterior hemiblock and pathologic Q waves in the
anterior distribution. A recent stress echocardiogram demon-
strated left ventricular hypertrophy, moderate pulmonary hyper-
tension, an ejection fraction of 35%, and multiple areas of
reversible ischemia. On exam, patient was noted to have a malla-
mpati III airway, small mouth opening, and limited cervical exten-
T. S. Lee · Y. H. Lai (*)

Department of Anesthesiology, Perioperative and Pain Medicine,
Mount Sinai West and Morningside Hospitals, New York, NY, USA
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature 3

Switzerland AG 2023
J. Li et al. (eds.), First Aid Perioperative Ultrasound,
https://doi.org/10.1007/978-3-031-21291-8_1
4 T. S. Lee and Y. H. Lai
sion. He is interested in regional anesthesia in order to avoid

opioids given his history of substance abuse. You are also made
aware of the fact that he will not be expected to participate in
physical therapy until postoperative day 1.
Key Question 1
What peripheral nerve blocks (PNBs) can be performed for this
patient? Compare and contrast single-shot versus continuous
methods. Which technique do you believe is best suited for this
patient?
PNBs can generally be administered by one of two possible tech-
niques: a one-time injection (i.e. “single-shot” or SSPNB) of local
anesthetic (LA), or a continuous infusion of LA via a percutaneously
placed catheter (CPNB). Each technique has distinct advantages and
disadvantages that should be carefully considered and thor-
oughly discussed with both the patient and the perioperative team.
CPNBs involve infusion of LA to a target nerve or nerve plexus
in an attempt to extend the benefits of SSPNB. CPNBs offer sev-
eral distinct advantages, particularly in the postoperative period.
Advantages of CPNBs are summarized in Table 1 based on a
plethora of research validating CPNBs in various surgical models,
particularly those related to orthopedics [1–3].
Despite these many advantages, CPNBs are also associated
with some drawbacks that have prevented them from being used
routinely. Catheter specific complications include [4–6]:
• Dislodgement (up to 15% of all catheters, 5% with ISB

catheters) [4]
• Infections
Table 1 Advantages of continuous peripheral nerve blocks (CPNBs) relative

to single-shot peripheral nerve block
• Superior and prolonged postoperative analgesia
• Reduced supplemental opioid consumption and opioid related adverse
effects
• Improved postoperative rehabilitation/ambulation
• Reduced length of hospital stay and expedited discharge to home
• Improved patient satisfaction
Safe Practice of Ultrasound Guided Regional Anesthesia 5
• Local anesthetic systemic toxicity (LAST), and LA induced

myo- and neurotoxicity
• Increased incidence of falls (with femoral CPNB due to resul-
tant quadricep muscle weakness [7])
Indications for CPNB tend to vary between different institutions,

but generally include palliative management (i.e., non-operative
femoral neck fractures) and circumstances in which systemic opi-
oids should be minimized or avoided entirely (i.e., substance
abuse, opioid-induced hyperalgesia). Our patient has a longstand-
ing history of opioid abuse and it would undoubtedly be in his
best interest to minimize systemic opioids in the perioperative
period with CPNB. CPNBs can also provide adequate pain con-
trol to ensure that patient can tolerate aggressive physical therapy
(PT) on postoperative day 1 (POD1).
Case Stem At the end of your preoperative discussion with the

patient, you collectively agree to perform an ultrasound-guided
interscalene nerve catheter (US-ISB). After obtaining informed
consent, you set up an ultrasound machine at the bedside. You
recall and confirm that the patient is having a right-sided proce-
dure, and so you place the ultrasound machine on the left side of
the patient’s stretcher.
Key Question 2
During your preparation for the US-ISB catheter, a visiting medi-
cal student asks you what equipment/medications he/she
could help gather?
A principal means of delivering safe and effective local and
regional anesthesia involves maintaining a practice aimed at
avoiding adverse outcomes and preventing known complications.
Achieving this goal generally requires consistency on the part of
the anesthesiologist when it comes to preparation and basic setup
for every case.
Standard American Society of Anesthesiologist (ASA) moni-
tors, such as pulse oximetry, electrocardiography, and non-
invasive blood pressure measurement should be utilized for any
type of anesthetic, and regional anesthesia (RA) is no exception.

These monitors are crucial given that neuraxial and peripheral
nerve blocks are generally performed in patients who have
received some degree of sedation, both for improved procedural
conditions as well as for patient comfort. Over sedation and its
undesirable sequelae, including hypoventilation, airway obstruc-
tion, and hypoxemia, can be easily avoided with steadfast moni-
toring of oxygenation and ventilation.
Patient sedation while performing PNB has been shown to be
beneficial for numerous reasons. Sedation reduces procedural
pain and recall of the procedure, which in turn has resulted in
increased patient satisfaction during block performance and
greater tolerance of nerve blocks [8]. Furthermore, sedation with
benzodiazepines or propofol increases the seizure threshold,
thereby potentially reducing the risk for neurotoxic sequelae asso-
ciated with systemic toxicity [9]. Table 2 outlines a number of
medications that are frequently used for sedation in regional anes-
thesia. Doses are titrated to patient comfort while ensuring that
patients maintain levels of consciousness that are necessary for
communication and cooperation.
Although the use of ultrasound has significantly mitigated the
risk of severe LAST by allowing direct visualization of vascular
structures and injectate, the risk has not been completely elimi-
Table 2 Sedatives for regional anesthesia
Onset General IV drug

Drug (min) dose range Benefits and complications
Midazolam 1–2 1–4 mg Significant anxiolysis,
anterograde amnesia.
Synergistic with opioids in
causing respiratory depression
Fentanyl 3–5 25– Significant analgesia, respiratory
100 micrograms depression
Ketamine Variable 5–20 mg Significant analgesia with
minimal respiratory depression
Propofol <1 10–50 mg Hypnosis with significant
respiratory depression
nated [10]. Therefore, emergency drugs and resuscitation equip-

ment should always be readily available when administering any
regional anesthetic to obtain timely control of the airway, stabilize
vital signs, and treat both cardiotoxic and neurotoxic effects of
LAST. Resuscitation equipment and emergency medications are
shown in Table 3.
All PNBs require some mode of nerve localization to ensure
that the injectate/catheter is deposited in the correct location adja-
cent to the target nerve. SSPNB are performed with insulated
needles (to conduct electrical stimulus for nerve stimulation) or
echogenic needles (for ultrasound guidance) of different lengths
and diameters (see Fig. 1). Shorter, larger-diameter needles allow
for better handling and manipulation, whereas longer, smaller-
diameter needles offer less control and are more easily distorted
when traversing different layers of tissues (muscles, subcutaneous
tissues, fascial layers, etc.); however, these longer, smaller-
diameter needles are often required simply to perform deeper
blocks that would otherwise be out of reach.
Case Stem You summarize the patient’s pertinent medical his-

tory and airway exam to the medical student. You show the medi-
cal student the equipment you have gathered thus far, including
18-gauge continuous block needle system, chlorhexidine prepara-
Table 3 Resuscitation equipment and emergency medications for regional

anesthesia
Resuscitation equipment Emergency medications
• Self-inflating bag-mask • Induction agent (i.e., Propofol should be
ventilation device (i.e., avoided in LAST)
Ambu bag) • Succinylcholine
• Suction • Atropine
• Oxygen-supply with face • Ephedrine vs. Phenylephrine
mask • Glycopyrrolate
• Endotracheal tube(s), oral • 20% Intralipid (ideally, together with
airways, nasal airways LAST protocol for use and necessary
• Laryngoscopes equipment to draw up the medication)
(Macintosh and Miller
blades)
• Defibrillator
Fig. 1 18-gauge insulated CPNB needle with stimulation wire
tion, sterile drape, skin adhesive (i.e., Dermabond), transparent

dressing, sterile ultrasound transducer covers, and sterile ultra-
sound gel (see Fig. 2).
Key Question 3
The medical student states that he has never seen a PNB per-
formed before, and asks how the ultrasound machine is able to
produce accurate and clinically useful images.
Fig. 2 CPNB supplies: (Upper left counterclockwise) PNB tray (sterile

drape, syringes, etc.…), chloroprep impregnated tegaderm, dermabond seal-
ant, small tegaderm, sterile gloves, CPNB needle kit with catheter, sterile
ultrasound cover
UG is used in conjunction with anatomic landmarks to locate

targeted nerves. Ultrasound imaging enables direct visualization
of:
• Needle and its relation to muscles, bones, blood vessels, and

other nerves
• LA distribution during and after injection.
Ultrasound waves are a type of acoustic energy that are gener-

ated when piezoelectric crystals within an ultrasound transducer
vibrate at high frequency in response to an alternating current.
When placed in contact with skin via a conductive gel, the
transducer transmits the rapid vibrations that then propagate
sound waves longitudinally into the body, reflect off tissue inter-
faces, and back to the receiver part of the same transducer. When
ultrasound waves return to the transducer, the piezoelectric crys-
tals will vibrate again, thereby transforming acoustic energy

into electrical energy and generating a clinically useful ultra-
sound image [11].
When passing through any given medium, an ultrasound wave
is subject to several interactions at tissue interfaces including
reflection, refraction, and attenuation [11]:
• Reflection: Acoustic impedance (resistance to passing of ultra-

sound waves) between the two media account for degree of
reflection
• Refraction: sound waves change direction with different acous-
tic velocities
• Attenuation: acoustic energy is progressively lost as sound
waves travel deeper into tissue. Attenuation can degrade image
quality to the point where performing a nerve block would be
impractical, or even unsafe
• Certain functions the ultrasound machine, such as increasing
gain, can artificially increasing the signal intensity from a spe-
cific or all points in the field.
• Resolution is the ability to distinguish between two separate
objects
Case Stem Shortly before you begin the block, you discover that
the ultrasound machine is not functional and so you opt to per-
form the interscalene nerve catheter using peripheral nerve stimu-
lation.
Key Question 4: What Is Peripheral Nerve Stimulation

(PNS) and How Does It Assist in Nerve Localization?
PNS is a nerve localization technique that uses an insulated block
needle to deliver low-intensity (up to 5 mA), short-duration
(0.05–1 ms) electrical stimuli to elicit predefined responses (i.e.,
twitch in a specific muscle or muscle groups vs. sensory responses
in the form of paresthesias within certain dermatomes) in order to
locate a target nerve/plexus prior to injecting local anesthetic [12].
The overall goal of this technique is to approximate the needle
(and thus, LA delivery) and nerve as much as possible without
violating essential neural structures (such as intraneural fascicles).

Both needle trauma and LA toxicity caused by intraneural injec-
tions could potentially be associated with transient and/or perma-
nent nerve damage. Successful use of PNS is dependent on a
strong foundational knowledge in anatomy and a comprehensive
understanding of electrophysiology.
PNS incorporates several different principles of electrophysi-
ology. Stimulation of nerve fibers occurs when a delivered charge
to a nerve result in a change in transmembrane voltage (i.e., dif-
ference between intracellular and extracellular voltage) that is
greater than the threshold to generate an action potential or series
of action potentials along the nerve fiber. The peripheral nervous
system consists of various types of nerve fibers, each of which can
be distinguished by its diameter, as well as by its degree of
myelination. In general, the speed of impulse propagation of
action potentials is greater/threshold of excitability is lower in
myelinated, large-diameter fibers (i.e., Aα motor fibers), whereas
the speed of impulse propagation of action potentials is lower/
threshold of excitability is higher in non-myelinated, small-
diameter fibers (i.e., C fibers) [13].
When operating the nerve stimulator, the starting amplitude/
current that is used depends on the projected depth of the target
nerve. An initial amplitude of 1 mA is appropriate for superficial
nerves (i.e., upper extremity nerves), whereas amplitudes of 1.5–
3.0 mA may be required for deeper nerves (i.e., paravertebral or
lower extremity nerves). After the intended muscle response is
observed, current is gradually decreased while simultaneously
advancing the block needle until the observed motor response is
elicited with a current of 0.2–0.5 mA at 0.1 ms stimulus duration.
At this point, 1–2 mL of local anesthetic is injected as a test
dose to observe for timely termination of the muscle twitch, fol-
lowed by injection of the remaining volume of local anesthetic
[13].
Case Stem As you begin positioning the patient to perform the

block, the surgeon pulls you aside and quietly requests something
“long acting” for the patient because he anticipates that the proce-
dure may take slightly longer than usual and that the patient may
be in a significant amount of pain.
Key Question 5: What Factors Are Involved When Choosing

LA to Administer for Any Peripheral Nerve Block?
When performing regional anesthesia, the anesthesiologist must
decide on not only the specific LA agent to be used, but also the
volume, concentration, and dose to be administered. These deci-
sions are generally based on the desired outcomes of block onset,
duration, density and degree of motor blockade, and adverse
effects. In turn, the desired characteristics of specific LA agents
is dependent on clinical circumstances. For example, motor
blockade is beneficial when a peripheral nerve bock serves as a
sole surgical anesthetic or when prolonged postoperative analge-
sia is needed. However, motor blockade would be unattractive
when a patient is expected to participate in PT in the early post-
operative period or if adequate neurological exam/sensory
assessment recovery is immediately following the conclusion of
surgery [14].
• Onset dependent on proximity to nerve (likely most important

factor). Other factors include total LA dose (not LA volume or
concentration), as well as the hydrophobicity of specific LA
used [14].
• Potency dependent on lipophilicity of LA, which facilitates LA
penetration through the axon [14].
• Duration of action influenced primarily by rate of clearance of
LA. Other factors include hydrophobicity (hydrophobic LA
have longer duration) and the total LA dose (larger LA
doses produce longer blocks) [14].
• General guidelines for maximum LA doses are shown in
Table 4 [14].
Case Stem With US not functioning, you decided it would be

safer to place a US-ISB SSPNB using the nerve stimulator with
30 mL of 0.5% Ropivacaine and a 22-gauge insulated block
needle. As you are manipulating the block needle, the patient
Table 4 Local anesthetic properties [14]

Duration of Maximum Maximum
Onset Action Dose Without Dose with Epi
Anesthetic (minutes) (hours) Epi (mg/kg) (mg/kg)
2% lidocaine 10–20 2–8 4.5 7
1.5% 10–20 2–10 5 7
mepivacaine
0.2% 15–30 5–15 3 3.5
ropivacaine
0.5% 15–30 4–24 3 3.5
ropivacaine
0.25% 15–30 5–25 2.5 3
bupivacaine
0.5% 15–30 5–30 2.5 3
bupivacaine
suddenly complains of shooting pain down his arm. You imme-

diately reposition the needle until the intended muscle response
is elicited with a current of 0.3 mA. You confirm that the
patient’s paresthesias have subsided, and inject the
LA. Following block placement, TSA is completed by the sur-
geon without event, and you transfer the patient to the recovery
room. During your routine postoperative phone call with the
patient the following day, he endorses slightly decreased sensa-
tion in the extremity.
Key Question 6: What Are the Complications Associated

with Peripheral Nerve Blocks?
Fortunately, serious complications of PNBs are exceedingly rare
when proper techniques and equipment are utilized; however,
when they do occur, these complications can be potentially devas-
tating for both patient and provider. Therefore, it is imperative
that patients be presented with the necessary information to fully
comprehend the risks associated with peripheral nerve blocks and
to participate in informed decision making. Serious complications
of PNBs that should be discussed prior to procedure include
bleeding, catheter infection, nerve injury, and LAST.
• Inadvertent puncture of neighboring vascular structures during

PNB can result in perineural hematoma formation. Hematomas
can cause compression of nerves and lead to neurologic
sequelae.
• Bleeding in non-compressible areas (especially with deeper
blocks) can rarely occur, sometimes requiring surgical decom-
pression. As such, it is often wise to avoid performing periph-
eral nerve blocks in non-compressible areas for patients with
abnormal coagulation profiles. Anticoagulation guidelines for
PNBs do exist but extend beyond the scope of this discussion.
• Infection risk for SS PNBs is minimal whereas bacterial colo-
nization of CPNB is higher-ranging between 7.5 and 57%.
Nevertheless, colonization rarely leads to systemic infection,
with overall risk of infection ranging between 0 and 3.2% [15].
Femoral and axillary nerve catheters are associated with the
highest rates of colonization, while rates of colonization of
popliteal catheters are low [15]. Other independent risk factors
for PNC infection include intensive care unit (ICU) admission,
trauma, immunocompromised states (i.e., diabetes), indwell-
ing catheters for >48h, male sex, and the absence of antibiot-
ics.
• Nerve injury:
–– Rare occurrence with exact incidence that remains contro-
versial and highly variable across studies.
–– Persistent symptoms of nerve injury (i.e., pain, tingling, or
paresthesia) can be as high as 8–10% in the days following
the block [16].
–– Majority of symptoms are transient (days to less than 6
months). Permanent symptoms range between 0.015 and
0.09% [17].
–– Historically associated with intraneural injection but con-
troversial evidence
• LAST:
–– Can be caused by inadvertent injection of LA into blood
vessels or delayed uptake of LA by small veins (via indwell-
ing CPNBs or catheter migration, for example) [18].
–– Highly variable clinical presentation:

Mild: tinnitus, perioral numbness, metallic taste
Severe: Seizure, coma, respiratory depression, and car-
diovascular collapse (i.e. hypertension vs. hypotension,
tachycardia vs. bradycardia, arrhythmias, and arrest).
–– Guidelines for prevention and treatment of LAST will be
discussed in later chapters.
1 Summary
• PNB may be performed as SS PNB or infusion of LA via peri-

neural catheters (CPNB)
• CPNBs allows prolonged analgesia and have been successfully
used in numerous settings
• Emergency drugs and resuscitation equipment should always
be readily available when administering any regional anes-
thetic in the event of acute complications
• Peripheral nerve localization techniques include direct visual-
ization via ultrasound guidance and/or electrical nerve stimu-
lation to observe for motor responses
• Thorough understanding of ultrasound physics and technique
is necessary to prevent serious adverse effects, such as hemor-
rhagic/infectious complications and LAST.
Common Pitfalls
• Failure to adequately explain the indications/risks/benefits/

alternatives of PNB may limit patients’ ability to make
informed decisions.
• Failure to follow-up with ambulatory patients discharged with
CPNBs may cause delays in diagnosis/treatment of complica-
tions.
• Failure to consider all perioperative circumstances when
selecting LA for a given procedure may lead to block failure
or other unexpected complications.
Clinical Pearls
• Although the use of ultrasound has significantly reduced the
risk of complications, this risk has not been completely elimi-
nated.
• Under the appropriate clinical circumstances, CPNBs can be
an effective way to extend analgesia, facilitate earlier and
dynamic PT, and reduce overall hospital costs.
• When utilizing ultrasound guidance, it is imperative to select
the appropriate transducer and settings for a given procedure.
• While peripheral nerve stimulation can be an alternative to
ultrasound for nerve-localization, it can also be used to con-
firm ultrasound findings.
References
1. Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral
nerve block compared with single-injection peripheral nerve block: a sys-
tematic review and meta-analysis of randomized controlled trials. Reg
Anesth Pain Med. 2012;37(6):583–94. https://doi.org/10.1097/
AAP.0b013e31826c351b.
2. Ilfeld BM. Continuous peripheral nerve blocks: an update of the pub-
lished evidence and comparison with novel, alternative analgesic modali-
ties. Anesth Analg. 2017;124(1):308–35. https://doi.org/10.1213/
ANE.0000000000001581.
3. Vorobeichik L, Brull R, Bowry R, Laffey JG, Abdallah FW. Should con-
tinuous rather than single-injection interscalene block be routinely
offered for major shoulder surgery? A meta-analysis of the analgesic and
side-effect profiles. Br J Anaesth. 2018;120(4):679–92. https://doi.
org/10.1016/j.bja.2017.11.104.
4. Marhofer D, Marhofer P, Triffterer L, Leonhardt M, Weber M, Zeitlinger
M. Dislocation rates of perineural catheters: a volunteer study. Br J
Anaesth. 2013;111(5):800–6. https://doi.org/10.1093/bja/aet198.
5. Bomberg H, Bayer I, Wagenpfeil S, Kessler P, Wulf H, Standl T, et al.
Prolonged catheter use and infection in regional anesthesia: a retrospec-
tive registry analysis. Anesthesiology. 2018;128(4):764–73. https://doi.
org/10.1097/ALN.0000000000002105.
6. Nouette-Gualain K, Capdevila X, Rossignol R. Local anesthetic ‘in-situ’
toxicity during peripheral nerve blocks: update on mechanisms and pre-
vention. Curr Opin Anaesthesiol. 2012;25(5):589–95. https://doi.
org/10.1097/ACO.0b013e328357b9e2.
7. Ilfeld BM. Single-injection and continuous femoral nerve blocks are

associated with different risks of falling. Anesthesiology. 2014;121:668–
9. https://doi.org/10.1097/ALN.0000000000000358.
8. Jlala HA, Bedforth NM, Hardman JG. Anesthesiologists’ perception of
patients’ anxiety under regional anesthesia. Local Reg Anesth. 2010;3:65–
71. https://doi.org/10.2147/lra.s11271.
9. Horikawa H, Tada T, Sakai M, Karube T, Ichiyanagi K. Effects of mid-
azolam on the threshold of lidocaine-induced seizures in the dog-
comparison with diazepam. J Anesth. 1990;4(3):265–9. https://doi.
org/10.1007/s0054000040265.
10. Sites BD, Taenzer AH, Herrick MD, Gilloon C, Antonakakis J, Richins J,
et al. Incidence of local anesthetic systemic toxicity and postoperative
neurologic symptoms associated with 12,668 ultrasound-guided nerve
blocks: an analysis from a prospective clinical registry. Reg Anesth Pain
Med. 2012;37(5):478–82. https://doi.org/10.1097/
AAP.0b013e31825cb3d6.
11. Gray AT. Ultrasound-guided regional anesthesia. Current state of the art.
Anesthesiology. 2006;104(2):368–73. https://doi.org/10.1097/00000542-
200602000-00024.
12. Chapman GM. Regional nerve block with the aid of a nerve stimulator.
Anaesthesia. 1972;27(2):185–93. https://doi.
org/10.1111/j.1365-2044.1972.tb08195.x.
13. Gadsden JC. The role of peripheral nerve stimulation in the era of
ultrasound- guided regional anaesthesia. Anaesthesia. 2021;76(Suppl
1):65–73. https://doi.org/10.1111/anae.15257.
14. Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses
of local anesthetics: a multifactorial concept. Reg Anesth Pain Med.
2004;29(6):564–75. https://doi.org/10.1016/j.rapm.2004.08.003.
15. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous
peripheral nerve blocks. Anesthesiology. 2009;110(1):182–8. https://doi.
org/10.1097/ALN.0b013e318190bd5b.
16. Fredrickson MJ, Kilfoyle DH. Neurological complication analysis of
1000 ultrasound guided peripheral nerve blocks for elective orthopaedic
surgery: a prospective study. Anaesthesia. 2009;64(8):836–44. https://
doi.org/10.1111/j.1365-2044.2009.05938.x.
17. Malchow RJ, Gupta RK, Shi Y, Shotwell MS, Jaeger LM, Bowens
C. Comprehensive analysis of 13,897 consecutive regional anesthetics at
an ambulatory surgery center. Pain Med. 2018;19(2):368–84. https://doi.
org/10.1093/pm/pnx045.
18. Vasques F, Behr AU, Weinberg G, Ori C, Di Gregorio G. A review of
local anesthetic systemic toxicity cases since publication of the American
Society of Regional Anesthesia recommendations: to whom it may con-
cern. Reg Anesth Pain Med. 2015;40(6):698–705. https://doi.org/10.1097/
AAP.0000000000000320.
Sonographic Image of Head
and Neck Regional Anesthesia
1 Ultrasound Image of Superficial Cervical

Plexus
1.1 High Frequency Probe; Short-Axis
Probe position: transverse over the midpoint of the sternocleidomastoid muscle
S. Zhou · W. Jiang (*)

Department of Anesthesiology, Shanghai Jiaotong University Affiliated
Sixth People’s Hospital, Shanghai, China
© The Author(s), under exclusive license to Springer Nature 19

Switzerland AG 2023
J. Li et al. (eds.), First Aid Perioperative Ultrasound,
https://doi.org/10.1007/978-3-031-21291-8_2
20 S. Zhou and W. Jiang
SCM: sternocleidomastoid muscle; IF: investing fascia; PVF: prevertebral

fascia; SCP: superior cervical plexus; M:medial; L:lateral
2 Ultrasound Image of Cervical Root
Probe position: horizontal plane, transverse on neck, superior to c lavicle

Sonographic Image of Head and Neck Regional Anesthesia 21
SCM: sternocleidomastoid muscle; M: medial; L: lateral
Probe position: horizontal plane, transverse on neck, superior to clavicle

SCM: sternocleidomastoid muscle; M:medial; L:lateral

SCM: sternocleidomastoid muscle; AT of TP: anterior tubercle of transverse

process; PT of TP: posterior tubercle of transverse process; M:medial; L:lateral

SCM: sternocleidomastoid muscle; ASM: anterior scalene muscle; PT of TP:

posterior tubercle of transverse process; M:medial; L:lateral
3 Ultrasound Image of Great Auricular

Nerve

SCM: sternocleidomastoid muscle; GAN: great auricular nerve; A: anterior;

P: posterior
4 Ultrasound Image of Lesser Occipital

Nerve

SCM: sternocleidomastoid muscle; SC: splenius cervicis; MC: musculus

capitis; GAN: great auricular nerve; A:anterior; P:posterior
5 Ultrasound Image of Greater Occipital

Nerve
Probe position: horizontal plane, transverse just inferior to the h airline

SsCM: semispinalis capitis; IObCM: obligus capitis inferior muscle; GON:

greater occipital nerve; L:lateral; M:medial
6 Ultrasound Image of Superior Laryngeal

Nerve
6.1 High Frequency Probe; Long-Axis
Probe position: parasagittal plane, longitudinal just inferior to the mandibula

SHM: sternohyoid muscle; THM: thyrohyoid muscle; THM: thyrohyoid

membrane; SLN: superior laryngeal nerve; SLA: superiro laryngeal artery
7 Ultrasound Image of Cricothyroid

Membrane
Probe position: horizontal plane, transverse on middle aspect of neck

Another random document with
no related content on Scribd:
stages of human development, the time is past when the war system
can serve the highest ends of civilization. It is an anachronism in the
modern world. It has become a drag upon the moral progress of the
race. By an ethical necessity the day of its abolition approaches. At a
time not remote, as history reckons time, the common conscience of
the world will brand war between civilized nations as the greatest of
crimes, and will regard the nation that assaults another with intent to
commit general slaughter as a criminal nation—as a common enemy
of the human race. In that coming and better age men will look with
the same incredulous amazement upon our infernal engines and
devices for wholesale man-killing that we of this age look upon “the
iron virgin of Nuremberg” and the other medieval instruments of
torture in the museums of Europe.
To many this optimistic forecast, in the face of the prevailing war
spirit and the ever-growing armaments of the nations, may seem
oversanguine and incredible. But to think despairingly of the future
argues a failure to discern what is really most significant in the
international situation to-day. The most significant thing in the
ongoings of life at Rome on that memorable day of the year 404 of
our era which saw the last gladiatorial combat in the Colosseum was
not that, four hundred years after the incoming of Christianity with its
teachings of the sanctity of human life, gladiators fought on the
arena to make a holiday for Rome; the significant thing was the
protest made by the Christian monk Telemachus and sealed by his
787
martyr death, for that announced the birth into the Roman world
of a new conscience, and that, through an ethical necessity, meant
the speedy abolition of “the human sacrifices of the amphitheater.”
And so to-day the significant thing is not that nineteen hundred
years after the advent of a religion of peace and good will among
men, gladiator nations still wet the earth with fratricidal blood; the
significant thing is the constantly growing protest against it all, for
that announces the birth into the modern world of a new international
conscience, and that, through an ethical necessity like that which
abolished forever the bloody sacrifices of the Colosseum, means the
certain and speedy abolition of war as a crass negation of human
solidarity and brotherhood, and a venturous denial of a moral order
of the world and the sovereignty of conscience.
FOOTNOTES
1
Henry T. Buckle, History of Civilization in England (1891), vol. i,
chap. iv. For a trenchant criticism of Buckle’s contention that
there has been no progress in morals during historic times, see
article entitled “The Natural History of Morals,” North British
Review for December, 1867.
2
For a discussion of the economic theory, see Edwin R. A.
Seligman, The Economic Interpretation of History, 2d ed.
3
Social Evolution (1894), p. 307.
4
Ralph Barton Perry, The Moral Economy (1909), p. 254.
5
Immanuel Kant, Critique of the Practical Reason; cited by
Fisher, History of the Christian Church (1888), p. 623.
6
“It is probable indeed that every movement of religious reform
has originated in some clearer conception of the ideal of
human conduct, arrived at by some person or persons.”—T. H.
Green, Prolegomena to Ethics, 5th ed., p. 361.
7
Prolegomena to the History of Israel, tr. Black and Menzies
(1885), p. 472; summing up the moral teachings of the prophet
Amos.
8
Wake, The Evolution of Morality (1878), vol. ii, p. 4;
Westermarck, The Origin and Development of the Moral Ideas
(1906), vol. ii, p. 743; T. H. Green, Prolegomena to Ethics, 5th
ed., p. 237; George Harris, Moral Evolution (1896), p. 79.
9
T. H. Green, Prolegomena to Ethics, 5th ed., p. 240.
10
“We cannot explain morality without going to objective morality,
which is expressed in the customs and laws, in the moral
commands and judgments, conceptions and ideals of the race”
(Frank Thilly, “Friedrich Paulsen’s Ethical Work and Influence,”
The International Journal of Ethics for January, 1909, p. 150).
And so Wundt: “The original source of ethical knowledge is the
moral consciousness of man, as it finds objective expression in
the universal perceptions of right and wrong, and further, in
religious ideas and in customs. The most direct method for the
discovery of ethical principles is, therefore, the anthropological
method. We use this term in a wider sense than is customary,
to include ethnic psychology, the history of primitive man and
the history of civilization, as well as the natural history of
mankind” (Ethics: the Facts of the Moral Life, tr. Gulliver and
Titchener (1908), p. 19). Cf. also Westermarck, The Origin and
Development of the Moral Ideas (1906), vol. i, pp. 158 ff.
11
“An ideal is essential to the very existence of morality.”—
George Harris, Moral Evolution (1896), p. 54.
12
“The history of moral ideals and institutions, though hitherto
ignored by moralists, seems to me the most important topic in
the whole realm of ethics.”—Schurman, The Ethical Import of
Darwinism (1887), p. 201.
13
S. Alexander, Moral Order and Progress (1889), p. 354. The
same thought is expressed by the writer of “The Natural
History of Morals,” North British Review for December, 1867:
“The earth is a moral graveyard ... and our virtues and vices
will, in turn, be but fossils which the eye of science shall
curiously scan, and they will finally crumble into dust, from
which the moral harvests of the future shall spring.”
14
Lecky, History of European Morals, 3d ed., vol. i, p. 154.
15
“Effective ideals are elicited by circumstances. But they are not
created by them. It is a prejudice of modern sociology, a
prejudice which sociology has taken over from biology, to try to
explain the inner by the outer.”—G. Lowes Dickinson, “Ideals
and Facts,” Hibbert Journal for January, 1911, p. 266.
16
“The growth of intellectuality, considered as breadth of view
and competence of personal judgment, carries with it normally
growth in sensitiveness of feeling and rightness of ethical
attitude.”—Baldwin, Social and Ethical Interpretation in Mental
Development (1897), p. 397.
17
See Chapter XVIII. “The activity of a free people creates a
great number of social relations from which arise new duties
and new rights; so that liberty is not less favorable to the
development of morality than to that of letters, arts, and
sciences, of all the noble interests and high faculties of our
nature.”—Denis, Histoire des théories et des idées morales
dans l’antiquité (1879), t. i, p. 10.
18
Principles of Economics, 2d ed., p. 1. “It is not Christianity but
industrialism that has brought into the world that strong sense
of the moral value of thrift, steady industry, punctuality in
observing engagements, constant forethought with a view to
providing for the contingencies of the future, which is now so
characteristic of the moral type of the most civilized nations.”—
Lecky, The Map of Life (1900), pp. 53 f.
19
The Moral Ideal, new and revised edition, p. 19.
20
“Doubtless the ethical life of the world has suffered much from
religion, but it owes to religion immeasurably more than it has
suffered from it. Faulty enough indeed the influence has been,
but the ethical life of the world has on the whole been greatly
reënforced and purified by its religions.”—William Newton
Clarke, The Christian Doctrine of God (1909), p. 13.
21
“Morality is the endeavor to realize an ideal” (George Harris,
Moral Evolution (1896), p. 54). Not to miss the import of this
dictum emphasis must be laid on the word “endeavor”; for, in
the words of Professor Green, morality must be regarded “as
an effort, not an attainment” (Prolegomena to Ethics, 5th ed.,
p. 301).
22
Meditations, tr. Long, xi, 18.
23
“There is nothing more modern than the critical spirit which
dwells upon the difference between the minds of men in one
age and in another; which endeavors to make each age its
own interpreter, and judge what it did or produced by a relative
standard.”—James Bryce, The Holy Roman Empire, 8th ed.,
p. 261.
24
Prolegomena to Ethics, 5th ed., p. 291.
25
After long observation of the life of the uncivilized races of
Polynesia, Alfred Russel Wallace records as his opinion that
“savages act up to their simple code at least as well as we act
up to ours” (The Malay Archipelago, vol. i, p. 139). “Many
strange customs and laws obtain in Zululand, but there is no
moral code in all the world more rigidly observed than that of
the Zulus” (Russell Hastings Millward in National Geographic
Magazine for March, 1909, p. 287).
26
“The larger morality which embraces all mankind has its basis
in habits of loyalty, love, and self-sacrifice which were originally
formed and grew strong in the narrow circle of the family or the
clan.”—W. Robertson Smith, The Religion of the Semites, 2d
ed., p. 54.
27
The Religion of the Semites, 2d ed., p. 274. Cf. Judges ix. 2; 2
Sam. v. 1.
28
Dudley Kidd, Savage Childhood (1906), p. 74. See also
Clifford, Lectures and Essays (1901), vol. ii, p. 79, on the “tribal
self.”
29
W. Robertson Smith, The Religion of the Semites, 2d ed., p.
267. See also Coulanges, The Ancient City, bk. ii, chap. ix.
30
Before this stage in civilization has been reached, religion is a
hindrance to the widening of the moral sympathies; for in
earlier stages “a man is held answerable to his god [only] for
wrong done to a member of his own kindred or political
community; ... he may deceive, rob, or kill an alien without
offense to religion; the deity cares only for his own kinsfolk” (W.
Robertson Smith, The Religion of the Semites, 2d ed., pp. 53
f.).
31
It should be carefully noted that this is very different from
saying that his life is immoral. To pronounce it immoral would
be like pronouncing immoral the life of the child, in whom the
sense of right and wrong has not yet arisen. The savage is a
child not only in intellect but also in moral feeling. As Bagehot
says, “We may be certain that the morality of prehistoric man
was as imperfect and as rudimentary as his reason” (Physics
and Politics (1873), p. 115).
32
“At the beginning of the developmental series stands the bare
animal impulse, stripped of all moral motives; at the end we
have the complete interpenetration of organic requirement and
moral idea.”—Wundt, Ethics: the Facts of the Moral Life
(1908), p. 191.
33
See II, The Ethics of Industrialism, Chapter XVIII.
34
Respecting certain Brazilian tribes the naturalist Bates
remarks: “The goodness of these Indians, like that of most
others amongst whom I lived, consisted perhaps more in the
absence of active bad qualities than in the possession of good
ones; in a word, it was negative rather than positive” (The
Naturalist on the River Amazon). Cf. Edward Howard Griggs,
The New Humanism, 6th ed., pp. 103 f.
35
For the relation of motherhood and infancy to the beginnings of
morality, see Fiske, Cosmic Philosophy (1875), vol. ii, pp. 340
ff.
36
“The spring of virtuous action is the social instinct, which is set
to work by the practice of comradeship.”—Clifford, Lectures
and Essays (1901), vol. ii, p. 253. Cf. Peabody, The Approach
to the Social Question (1909), p. 149.
37
“This family worship (long-forgotten precursor of our modern
family prayers) was always offered to the ancestors at the
domestic hearth.”—Helen Bosanquet, The Family (1906), p.
18. Cf. Wundt, Ethics: the Facts of the Moral Life (1908), p.
171.
38
The blessing offered at the daily family meal is presumptively a
survival from the consecrated communal meal of the primitive
kinship group.
39
When such an individual arises he becomes, if circumstances
favor, a lawgiver, and the age of law supersedes the age of
custom. Morality now consists in obedience to the law.
40
(1906), vol. i, chap. ii, and passim.
41
“In early times the solidarity of the kinship is such that it does
not occur to the individual to regard as unjust a suffering which
he endures in behalf of, or along with, his people.”—Edward
Caird, The Evolution of Religion (1894), p. 37.
42
Hobhouse, Morals in Evolution (1906), vol. i, p. 283.
43
The system of collective responsibility arises in part, it is true,
from the belief that sin is contagious and infects all persons
related to the transgressor. Therefore the innocent members of
the family or group of the transgressor may be put out of the
way as a merely preventive measure—not as a measure of
justice or punishment. But the ethical element is seldom or
never absent and it is this which gives the conception its
importance for the student of morals.
44
“Outlawry from the clan is the most effective of all weapons,
because in primitive society the exclusion of a man from his
kinsfolk means he is delivered over to the first comer
absolutely without protection.”—Hobhouse, Morals in
Evolution (1906), vol. i, p. 90.
45
Gen. iv. 13, 14.
46
“Blood atonement ... was one of the very earliest cases we can
find in which there was a notion of duty and social
obligation.”—Sumner, Folkways (1907), p. 506.
47
“It [the feud] is the Southern sense of the solidarity of the
family in opposition to extreme Northern individualism.”—
Wines, Punishment and Reformation (1895), p. 33.
48
On the Lex talionis consult Westermarck, The Origin and
Development of the Moral Ideas (1906), vol. i, pp. 177 ff.;
Hobhouse, Morals in Evolution (1906), vol. i, pp. 84 ff.;
Spencer, Principles of Ethics (1892), vol. i, pp. 369 ff. The
principle embodied in the Lex talionis has played a large part in
the jurisprudence of all peoples.
49
The Religion of the Semites (1894), p. 267.
50
Seeck (Geschichte des Untergangs der antiken Welt (1901),
Bd. i, S. 200) reminds us how the ancient German player when
he had lost in a game where the stake was his own liberty,
honorably gave himself up as the slave of the winner.
51
The Truth about the Congo (1907), p. 29.
52
“Throughout tribal life the stranger is a menace; he is a being
to be plundered because he is a being who plunders.... Native
houses are often left for days or weeks, and it would be easy
for any one to enter and rob them. Yet robbery among
themselves is not common. To steal, however, from a white
employer ... is no sin.”—Starr, The Truth about the Congo
(1907), pp. 28 f.
53
See VI, International Ethics: the New International Conscience,
in Chapter XVIII.
54
On this subject see Westermarck, The Origin and
Development of the Moral Ideas (1906), vol. i, chap. xxiv,
“Hospitality.”
55
Speaking of the duty of hospitality among the early Greeks,
Farnell says, “The sanctity of the stranger guest ... was almost
as great as the sanctity of the kinsman’s life” (The Cults of the
Greek States (1896), vol. i, p. 73).
56
Without doubt other feelings and conceptions than purely
ethical ones are sometimes operative in the case of the guest
right. The stranger may be kindly treated because of
superstitious fears. Thus the primitive man’s notions of magic
and sorcery may cause him to be hospitable to the stranger
through fear of the consequences of a refusal, since untutored
people are apt to attribute magical powers to the stranger. See
(1906), vol. i, chap. xxiv.
57
Among some uncivilized peoples, however, where the
population is thin and there is little competition wars are
unknown. “To the Greenlander ... war is incomprehensible and
repulsive, a thing for which their language has no word”
(Westermarck, The Origin and Development of the Moral Ideas
(1906), vol. i, p. 334).
58
Cannibalism springs from several roots. Sometimes savages
eat the body of the enemy slain in battle because they believe
that thereby they destroy the soul or double and thus secure
themselves against its vengeance. Again the custom grows out
of the belief that the virtues of the victim pass into him who
eats the flesh. But the most common motive is the subsistence
motive. Indeed, many of the incessant wars waged by primitive
tribes are nothing more nor less than man-hunting expeditions
for securing food. Later these expeditions became raids for
securing slaves.
59
Quoted by Letourneau, La guerre dans les diverses races
humaines (1895), p. vi.
60
Often we find vestiges of the abandoned practice in what may
be called celestial cannibalism (see W. Robertson Smith, The
Religion of the Semites (1894), p. 224). Thus the god of war of
the Mexican Aztecs and the gods of many Polynesian tribes
were cannibals, for human sacrifices must be regarded as a
sort of celestial cannibalism, when the offering is made in the
belief that the god actually repasts on the blood and the finer
essences of the sacrificial victim. Where men have thus made
their gods like unto themselves, and the practice of
cannibalism has been consecrated by religion, the gods,
because religion is always conservative, are certain to remain
anthropophagi much longer than their worshipers.
Consequently we find human sacrifices still lingering on as a
kind of survival among peoples, as, for instance, the Mexicans,
who have themselves left far behind the practice of eating
human flesh.
61
Letourneau, La guerre dans les diverses races humaines
(1895), p. 185.
62
Od. i. 260.
63
Spencer, Principles of Ethics (1892), vol. i, p. 350.
64
Ibid. vol. i, pp. 355 f.
65
Ibid. vol. i, pp. 368, 398, 401.
66
Spencer, Principles of Ethics (1892), vol. i, pp. 359 f.
67
Ibid. vol. i, p. 349.
68
For the influence of the war ethics of the modern nations upon
their peace ethics, see VI, International Ethics: the New
International Conscience, in Chapter XVIII.
69
Breasted, A History of Egypt (1905), p. 65.
70
Development of Religion and Thought in Ancient Egypt (1912),
p. 176.
71
Breasted, Development of Religion and Thought in Ancient
Egypt (1912), p. 250.
72
Maspero, The Dawn of Civilization, p. 172.
73
This moralization of pure physical myths marks the advance of
all races in culture and morality. As we shall see, Greek and
Hebrew mythologies underwent just such an ethicalizing
process.
74
Renouf, The Religion of Ancient Egypt (1884), p. 73.
75
“It has long been recognized that the Egyptians had a much
more highly organized conscience than that of most other
nations of early times.”—Petrie, Religion and Conscience in
Ancient Egypt (1898), p. 86.
76
Maspero, The Dawn of Civilization, pp. 193 f.
77
Wiedemann, The Ancient Egyptian Doctrine of the Immortality
of the Soul (1895), pp. 62 f.
78
of the Soul (1895), p. 64.
79
The same evolution is to be traced in China. “Imitations made
of wood, clay, straw, paper, and of other material have been
substituted for the real things.... Slaves and servants, wives
and concubines are also burned, i.e., in paper imitations. They
point back to the time when actual human sacrifices were the
custom” (De Groot, The Religion of the Chinese (1910), p. 71).
80
Primitive Culture (1874), vol. ii, p. 85.
81
Maspero, The Dawn of Civilization, pp. 187 ff.
82
Truthfulness was one of the cardinal virtues of the Egyptian
ideal. The requirements here were very exact: “I have not
altered a story in the telling of it; I have repeated what I have
heard just as it was told to me,” are the words of one in the
judgment hall of Osiris. Cf. Renouf, The Religion of Ancient
Egypt (1884), pp. 76 f.
83
The Egyptian Book of the Dead, tr. Davis, chap. cxxv.
84
The Egyptian Book of the Dead, tr. Davis, chap. cxxv.
85
Annihilation appears to have been the lot of the very wicked;
but the texts are not perfectly clear on this point. Consult
of the Soul (1895), p. 55.
86
Here are six declarations of the confession which correspond
almost exactly with six of the Ten Commandments: (1) I have
not blasphemed; (2) I have not stolen; (3) I have not slain any
one treacherously; (4) I have not slandered any one, or made
false accusations; (5) I have not reviled the face of my father;
(6) I have not eaten my heart through with envy. See
Rawlinson, History of Ancient Egypt, 2d ed., vol. i, p. 142.
87
Petrie, Religion and Conscience in Ancient Egypt (1898), p.
135.
88
Ibid. p. 162.
89
“In this judgment the Egyptian introduced for the first time in
the history of man the fully developed idea that the future
destiny of the dead must be dependent entirely upon the
ethical quality of the earthly life, the idea of future
responsibility,—of which we found the first traces in the Old
Kingdom” (Breasted, A History of Egypt (1905), p. 173).
Professor Breasted suggests a connection between the growth
of the ideal of an ethical ordeal in the hereafter with the
discontinuance of the building of immense pyramids. He says:
“It is impossible to contemplate the colossal tombs of the
Fourth Dynasty, so well known as the pyramids of Gizeh, and
to contrast them with the comparatively diminutive royal tombs
which follow in the next two dynasties, without ... discerning
more than exclusively political causes behind this sudden and
startling change.... The recognition of a judgment and the
requirement of moral worthiness in the hereafter ... marked a
transition from reliance on agencies external to the personality
of the dead to dependence on inner values. Immortality began
to make its appeal as a thing achieved in a man’s own soul”
(Development of Religion and Thought in Ancient Egypt
(1912), pp. 178 f.).
90
Records of the Past, New Series, vol. iii. For extended
comments on the maxims of Ptah-hotep, see Amélineau, Essai
sur l’évolution historique et philosophique des idées morales
dans l’Egypt ancienne (1895), pp. 93 ff.
91
Budge, Egyptian Ideas of the Future Life (1899), p. ii.
92
For other documents of this age which embody the same spirit
of social justice as the precepts of Ptah-hotep, see Breasted,
Development of Religion and Thought in Ancient Egypt (1912),
lect. vii.
93
Amélineau, Essai, pp. 140 f.
94
Alongside slavery proper there existed the system of serfdom,
the nature of which is revealed by the history of the Children of
Israel in Lower Egypt. The status of the Egyptian serf appears
to have been somewhat like that of the Helots of Laconia in
Greece. If we rightly interpret the Biblical account of the
servitude of the Children of Israel, the number of serfs, if their
increase seemed dangerous, was kept down by enforced
infanticide (Ex. i. 7–22).
95
Laurent, Études sur l’histoire de l’humanité, t. i, p. 321.
96
Amélineau, Essai, p. 344. The monotheist Ikhnaton
(Amenhotep IV), the reform Pharaoh of the Eighteenth
Dynasty, it is true, pursued throughout his reign a peace policy,
but this policy manifestly was dictated by temperament, or the
king’s preoccupation with religious affairs, and not by moral
scruples. His reform was essentially a religious and not a
social or moral one. Not one of the historical documents of the
age contains a word in condemnation of war as inherently
wrong (see Breasted, Ancient Records of Egypt (1906), vol. ii,
pp. 382–419), though in these “the customary glorying in war
has almost disappeared” (Petrie, A History of Egypt (1896),
vol. ii, p. 218).
97
This, however, must not be regarded as wholly an act of
wanton savagery. The killing of his prisoners by the king was
probably a sort of sacrifice in honor of the god who had given
him victory over his enemies. See Amélineau, Essai, p. 12.
98
Essai, p. ix; see also p. 252, n. 1.
99
For the influence of the moral ideas of Egypt on Greece, see
Amélineau, Essai, chap. xii, pp. 359–399; Wiedemann, The
Ancient Egyptian Doctrine of the Immortality of the Soul
(1895), p. x; and Toy, Judaism and Christianity (1891), p. 387.
100
Petrie, Egypt and Israel (1911), p. 133.
101
Demonism here was not, as it was and is in China (p. 55), a
moral educator of the people, for the reason that the spirits
were not conceived as the avengers of wrongdoing, but were
thought to molest indifferently the good and the bad.
102
It is not possible, however, to draw a definite chronological line
between the nonethical and the ethical texts. Cf. Jastrow, The
Religion of Babylonia and Assyria (1898), p. 297.
103
King, Babylonian Religion and Mythology (1899), p. 220.
104
The nature myths constituting the epic literature of the
Babylonians, which consisted largely of elaborate tales of the
struggle between the gods of light and the powers of darkness,
were never moralized like the Egyptian myth of Osiris and Set,
or the Iranian myth of Ahura Mazda and Ahriman.
105
Here are a few lines of a penitential prayer or psalm:
O my god who art angry with me, accept my prayer;
* * * * *
May my sins be forgiven, my transgressions be wiped out.

May the ban be loosened, the chain broken,
May the seven winds carry off my sighs.
Let me tear away my iniquity, let the birds carry it to heaven;
* * * * *
May the beasts of the field take it away from me,

The flowing waters of the stream wash me clean.
Let me be pure like the sheen of gold.
Jastrow, The Religion of Babylonia and Assyria (1898), p. 323.
106
Cf. above, p. 35.
107
The stele which bore this code of laws was discovered at Susa
in 1901–1902. The reign of Hammurabi is placed at about the
end of the third millennium b.c. There are translations of the
code by C. H. W. Johns (1903) and Robert Francis Harper
(1904).
108
“If a man owe a debt and Adad [god of storms] inundate his
field and carry away the produce, or, through lack of water,
grain have not grown in the field, in that year he shall not make
any return of grain to the creditor, he shall alter his contract-
tablet and he shall not pay the interest for that year.”—Code,
sec. 48. [We have used throughout Harper’s translation.]
109
Code, secs. 196, 197, 200. Cf. similar provisions of the Mosaic
code: Ex. xxi. 23–25; Deut. xix. 21.
110
Ibid. secs. 209, 210.
111
Ibid. secs. 229, 230.
112
The provisions read: “If a man aid a male or female slave of
the palace, or a male or female slave of a freeman to escape
from the city gate, he shall be put to death.”
“If a man harbor in his home a male or female slave who has
fled from the palace or from a freeman, and do not bring him
[the slave] forth at the call of the commandant, the owner of
that house shall be put to death” (Code, secs. 15, 16).
113
Maspero, The Dawn of Civilization, p. 744.
114
Taylor, Ancient Ideals (1896), vol. i, p. 41.
115
Records of the Past, New Series, vol. ii, pp. 143 ff.
116
“The white man has no doubt committed great barbarities upon
the savage, but he does not like to speak of them, and when
necessity compels a reference he has always something to
say of manifest destiny, the advance of civilization and the duty
of shouldering the white man’s burden in which he pays tribute
to a higher ethical conscience” (Hobhouse, Morals in Evolution
(1906), vol. i, p. 27). King Leopold may have been responsible
for barbarities committed against the natives of the Kongo as
atrocious as those of the Assyrians, but he paid tribute to the
modern conscience by refraining from portraying them in
imperishable marble at The Hague.
117
Cf. Martin, The Lore of Cathay (1901), p. 226.
118
Though the people are shut out from participation in the state
worship, they have set up for themselves a multitude of local
shrines where they worship the spirits of almost every earthly
thing, such as mountains, rivers, trees, and rocks. “Men
debarred from communion with the Great Spirit resorted more
eagerly to inferior spirits, to spirits of the fathers, and to spirits
generally.... The accredited worship of ancestors, with that of
the departed great added to it, was not enough to satisfy the
cravings of men’s minds.” (Legge, The Religions of China
(1881), p. 176).
119
The Lore of Cathay (1901), p. 274.
120
Williams, The Middle Kingdom (1883), vol. ii, p. 239.
121
We do not mention Buddhism in this connection for the reason
that it is not possible to trace any decisive influence, save in
the promotion of toleration, that this system has exercised
upon Chinese morality. Buddhism enjoins celibacy, and this,
like Christian asceticism, is in radical opposition to the genius
of Confucianism. For this reason, in conjunction with others,—
among these its early degeneracy,—Buddhism has remained
practically inert as an ethical force in Chinese society. What
little influence it has exerted has been confined almost wholly
to the monasteries.
122
“The dread of spirits is the nightmare of the Chinaman’s life.”—
Legge, The Religions of China (1881), p. 197.
123
The Religion of the Chinese (1910), p. 34.
124
The Taoist doctrines are contained in the Tao-teh-king,
supposed to have been written by Lao-tsze, a sage who lived
in the fifth century b.c. The religion which grew out of his
philosophy became in time degenerate, absorbed the worst
elements of Buddhism, and is to-day a system of gross
superstitions, magic, and sorcery, which has undeniably a
blighting effect upon morality.
125
De Groot, The Religion of the Chinese (1910), pp. 139 ff.
126
Ibid. 138.
127
Legge, The Religions of China (1881), p. 229.
128
De Groot, The Religion of the Chinese (1910), p. 143.
129
Nietzscheism is in essence at one with Taoism. Nietzsche
insists that man should behave as Nature behaves; for
instance, that the strong should prey upon the weak. The
difference between Lao-tsze and Nietzsche lies in their
different readings of the essential qualities of the universe. See
below, p. 355.
130
Taoism is too lofty a doctrine for the multitude. They are
enjoined to imitate the ancient sages, and as these imitated
the way of heaven and earth, in imitating them they are really
imitating the universe.
131
De Groot, The Religion of the Chinese (1910), p. 143.
132
The imitation of the qualities of nature “have given existence to
important state institutions, considered to be for the nation and
rulers matters of life and death.” (De Groot, The Religion of the
Chinese (1910), p. 139).
133
The Works of Mencius (The Chinese Classics, 2d ed., vol. ii),
bk. vi, pt. i, chap. ii, 2.
134
“This inference [that man is naturally good] comes into
prominence in the classics as a dogma, and therefore has
been the principal basis of all Taoistic and Confucian ethics to
this day” (De Groot, The Religion of the Chinese (1910), p.
137). Every schoolboy is taught this doctrine: “Man
commences life with a virtuous nature” (Martin, The Lore of
Cathay (1901), p. 217).
135
The Works of Mencius, bk. vii, pt. i, chap. ii, 2. And so
Confucius: “An accordance with this nature [man’s] is called
the Path of Duty” (The Doctrine of the Mean, chap. i; The
Chinese Classics, 2d ed., vol. i).
136
The Works of Mencius, bk. vi, pt. i, chap. vii, 2, 3.
137
Confucian Analects (The Chinese Classics, 2d ed., vol. i), bk.
xvii, chap. ii. The student of biology will see in this view an
anticipation of the latest teaching of modern science in respect
to the relative importance of heredity and education in the
determining of character.
138
“There is nothing in this world so dangerous for the national
safety, public health and welfare as heterodoxy, which means
acts, institutions, doctrines not based upon the classics.”—De
Groot, The Religion of the Chinese (1910), p. 48.
139
Confucius thus describes himself: “A transmitter and not a
maker, believing in and loving the ancients” (Confucian
Analects, bk. vii, chap. i).
140
The Religions of China (1881), p. 255.
141
Chinese literature bears unique testimony to the high
consideration in which the virtue of filial devotion and
reverence is held. It abounds in anecdotes exalting this virtue,
holding up great exemplars of it for imitation by the Chinese
youth. See Doolittle, Social Life of the Chinese.
142
The Hsiao King (Sacred Books of the East, vol. iii), chap. xviii.
143
Ibid. chap. xi.
144
Doolittle, Social Life of the Chinese (1868), p. 103.
145
Ibid. p. 103.
146
China in Law and Commerce (1905), p. 34.

First Aid Perioperative Ultrasound Acute Pain Manual For Surgical Procedures Jinlei Li Editor Wei Jiang Editor Nalini Vadivelu Editor

Uploaded by

Copyright:

Available Formats

First Aid Perioperative Ultrasound Acute Pain Manual For Surgical Procedures Jinlei Li Editor Wei Jiang Editor Nalini Vadivelu Editor

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

First Aid Perioperative Ultrasound Acute Pain Manual For Surgical Procedures Jinlei Li Editor Wei Jiang Editor Nalini Vadivelu Editor

Uploaded by

Copyright:

Available Formats

Full download test bank at ebookmeta.

First Aid Perioperative Ultrasound Acute Pain

Download More ebooks from https://ebookmeta.com

Anesthesiologist s Manual of Surgical Procedures 6th

The Acute Management of Surgical Disease Martin D.

Ophthalmology Clerkship A Guide for Senior Medical

Atlas of Interventional Orthopedics Procedures:

Textbook of Dermatologic Ultrasound Ximena Wortsman

Aortic Dissection and Acute Aortic Syndromes Frank W

Micro LEDs (Volume 106) 1st Edition Hongxing Jiang

Absolute Breast Imaging Review Multimodality Cases for

ISBN 978-3-031-21290-1 ISBN 978-3-031-21291-8 (eBook)

This Springer imprint is published by the registered company Springer Nature

Part I Ultrasound Guided High-Yield Perioperative

Safe Practice of Ultrasound Guided Regional

Part II Evidence-Based Utilization of Opioid

Part III Acute Pain Management Protocols

Acute Pain Management Protocol

Acute Pain Management Protocol for Ophthalmic

Jordan Abrams, MD Department of Anesthesiology, Periopera-

Rushil Bose Department of Anesthesiology and Perioperative

Henry R. Govekar Division of Colon and Rectal Surgery,

Jacob A. Lambert Department of Anesthesiology, West Virginia

Shayann Ramedani Penn State College of Medicine, Penn State

Justin Walker Department of Anesthesiology and Perioperative

Tae S. Lee and Yan H. Lai

Case Stem As a regional anesthesiology fellow, you are meeting

T. S. Lee · Y. H. Lai (*)

© The Author(s), under exclusive license to Springer Nature 3

sion. He is interested in regional anesthesia in order to avoid

• Dislodgement (up to 15% of all catheters, 5% with ISB

Table 1 Advantages of continuous peripheral nerve blocks (CPNBs) relative

• Local anesthetic systemic toxicity (LAST), and LA induced

Indications for CPNB tend to vary between different institutions,

Case Stem At the end of your preoperative discussion with the

type of anesthetic, and regional anesthesia (RA) is no exception.

Table 2 Sedatives for regional anesthesia

Onset General IV drug

nated [10]. Therefore, emergency drugs and resuscitation equip-

Case Stem You summarize the patient’s pertinent medical his-

Table 3 Resuscitation equipment and emergency medications for regional

Fig. 1 18-gauge insulated CPNB needle with stimulation wire

tion, sterile drape, skin adhesive (i.e., Dermabond), transparent

Fig. 2 CPNB supplies: (Upper left counterclockwise) PNB tray (sterile

UG is used in conjunction with anatomic landmarks to locate

• Needle and its relation to muscles, bones, blood vessels, and

Ultrasound waves are a type of acoustic energy that are gener-

tals will vibrate again, thereby transforming acoustic energy

• Reflection: Acoustic impedance (resistance to passing of ultra-

Key Question 4: What Is Peripheral Nerve Stimulation

violating essential neural structures (such as intraneural fascicles).

Case Stem As you begin positioning the patient to perform the

Key Question 5: What Factors Are Involved When Choosing

• Onset dependent on proximity to nerve (likely most important

Case Stem With US not functioning, you decided it would be

Table 4 Local anesthetic properties [14]

suddenly complains of shooting pain down his arm. You imme-

Key Question 6: What Are the Complications Associated

• Inadvertent puncture of neighboring vascular structures during

Part I Ultrasound Guided High-Yield Perioperative

Safe Practice of Ultrasound Guided Regional

Part II Evidence-Based Utilization of Opioid

Part III Acute Pain Management Protocols

Acute Pain Management Protocol

Acute Pain Management Protocol for Ophthalmic

1 Ultrasound Image of Superficial Cervical

1.1 High Frequency Probe; Short-Axis

2 Ultrasound Image of Cervical Root

2.1 High Frequency Probe; Short-Axis

Probe position: horizontal plane, transverse on neck, superior to c lavicle

2.2 High Frequency Probe; Short-Axis

2.3 High Frequency Probe; Short-Axis

Probe position: horizontal plane, transverse on neck, superior to c lavicle

2.4 High Frequency Probe; Short-Axis

Probe position: horizontal plane, transverse on neck, superior to c lavicle

3 Ultrasound Image of Great Auricular

3.1 High Frequency Probe; Short-Axis

Probe position: horizontal plane, transverse on neck, superior to c lavicle

4 Ultrasound Image of Lesser Occipital

4.1 High Frequency Probe; Short-Axis

Probe position: horizontal plane, transverse on neck, superior to c lavicle

5 Ultrasound Image of Greater Occipital

5.1 High Frequency Probe; Short-Axis

Probe position: horizontal plane, transverse just inferior to the h airline

6 Ultrasound Image of Superior Laryngeal

6.1 High Frequency Probe; Long-Axis

7 Ultrasound Image of Cricothyroid

7.1 High Frequency Probe; Short-Axis