This document provides information on a senior professor in the department of anaesthesia at JNMC. It lists his qualifications including an MD in anaesthesiology, fellowship in critical care, and MPhil in health professions education. It also outlines his special interests and major achievements such as being head of the anaesthesia department and involvement in transplant anaesthesia. The document includes over 40 publications and roles in various conferences and professional organizations. A photo of the professor is also included.

1. NAME
PRESENT
DESIGNATION:
• SENIOR PROFESSOR . DEPT OF ANAESTH JNMC
QUALIFICATIO
N
• MD ANAESTHESIOLOGY ,
• FELLOWSHIP IN CRITICAL CARE (DMIMS),
• MPHIL IN HEALTH PROFESSIONS EDU.
SPECIAL
INTEREST
• OBSTETRICS AND PEDIATRICS ANAESTHESIA .
• TRANSPLANT ANAESTHESIA.
• REGIONAL ANAESTHESIA .
PUBLICATIONS • >40 PUBLICATIONS IN VARIOUS JOURNALS
MAJOR
ACHIEVEMENT
S:
(HONOURS)
(AWARDS)
• EX HOD DEPT OF ANAESTH JNMC .
• ANAESTHETIST FOR SMILE TRAIN PROJECT.
• TRANSPLANT ANAESTHETIST -LIVER AND RENAL
• FACULTY IN CITY BRANCHES ,STATE AND NATIONAL
CONFERENCES .
• GOVERNING COUNCIL MEMBER OF ISA WARDHA CITY
BRANCH TO M S STATE CHAPTER
• EX PRESIDENT OF ISA CITY BRANCH WARDHA
• EX VICE PRESIDENT OF ISA CITY BRANCH WARDHA
• EX SECRETARY OF ISA CITY BRANCH
• ORGANISED ANAESTHESIA CME AT JNMC
PHOT
O
Dr Sanjot Ninave

2. 18 Aug 2022 BSC Interdep CME -SOP for RA

3. Anatomy
• A bundle of nerves that
begins in the back of the
base of the neck and
extends through the
armpit, that sends
signals from the spinal
cord to the shoulder,
arm and hand
• The brachial plexus is
formed by the ventral rami
of C5-C6-C7-C8-T1,
• occasionally with small
contributions by C4 and T2.

4. Brachial plexus block
• Regional anesthesia technique for surgery of the upper
extremity.
• Alternative or as an adjunct to general anesthesia.
• The injection of local anesthetic agents in close proximity to
the brachial plexus, temporarily blocking the sensation
and ability to move the upper extremity.
• The subject can remain awake , or they can be sedated or
even fully anesthetized if necessary.
4
Dr Sanjot NInave

5. Indications
• General anesthesia - low blood pressure, undesirable
decreases in cardiac output, central nervous system depression,
respiratory depression, loss of protective airway reflexes (such
as coughing), need for tracheal intubation and mechanical
ventilation, and residual anesthetic effects.
• Important advantage of brachial plexus block - allows for
the avoidance of general anesthesia and therefore its
attendant complications and side effects.
• Brachial plexus block is not without risk, it usually affects
fewer organ systems than general anesthesia.

6. Selection Criteries
• Reasonable option when all of the following criteria are met:
• Surgery - limited to a region between the midpoint of the
shoulder and the fingers
• No contraindications to a block -infection at the intended
injection site, significant bleeding disorder, anxiety, allergy or
hypersensitivity to local anesthetics
• There will not be a need to perform an examination of the
function of the blocked nerves immediately following the
surgical procedure
• Patient prefers this technique over other available and
reasonable approaches

7. Approaches to blockade
• Multiple Approaches
• Classified by the level at which the needle or catheter is
inserted for injecting the local anesthetic —
• 1.Interscalene block on the neck for example is considered
the second most complete postoperative analgesia,
• 2.Supraclavicular block immediately above the clavicle,
• 3.Infraclavicular block below the clavicle and
• 4.Axillary block in the axilla (armpit).
• The concept behind all of these approaches - existence of a
sheath encompassing the neurovascular bundle extending
from the deep cervical fascia to slightly beyond the borders
of the axilla.

8. EQUIPMENT
• Gloves
• Antiseptic solution for skin
disinfection
• Marking pen
• Sterile gauze
• Two 20-mL syringes for local
anesthetic solution
• One 1-mL syringe with a 25-
gauge needle for skin wheal
• One 5-cm, short-beveled, 22-
gauge insulated needle
• Surface electrode
• Nerve stimulator
• Injection pressure monitor

9. Techniques
• Brachial plexus block is typically performed by an
Anesthesiologist.
• To achieve an optimal block - tip of the needle should be
close to the nerves of the plexus during the injection of local
anesthetic solution.
• Commonly employed techniques for obtaining such a needle
position include
• 1.Transarterial,
• 2. Elicitation of a paresthesia, and
• 3. Use of a peripheral nerve stimulator or a
• 4. Portable ultrasound scanning device.

10. • Peripheral nerve stimulator connected to an appropriate needle allows
emission of electric current from the needle tip.
• Needle is close to or contacts a nerve -the subject experience a
paresthesia (a sudden tingling sensation, often described as feeling like
"pins and needles" or like an electric shock) in the arm, hand, or fingers.
• When the needle tip is close to or contacts a motor nerve, characteristic
contraction of the innervated muscle may be elicited.
• Injection close to the point of elicitation of such a paresthesia - result in
a good block
• Modern portable ultrasound devices - visualize internal anatomy,
including the nerves to be blocked, neighboring anatomic structures and the
needle as it approaches the nerves.
• Observation of local anesthetic surrounding the nerves during
ultrasound-guided injection is predictive of a successful block.

11. Peripheral nerve stimulation
Our practice is to set the nerve
stimulator at a starting current intensity
of 0.5-1.0 mA, with a pulse width of 0.1
msec, and advance the needle under
ultrasound guidance towards the
target (Fig. 1)

12. Appropriate block per site-specific procedure are
listed in the following table
Procedure
Site
Interscalene Supraclavicu
lar
Infraclavicula
r
Axillary1
Shoulder ++ +3
Arm + ++ +
Elbow ++ ++ +
forearm + ++ ++
Hand + + ++
1. Include musculocutaneous nerve 2. Include T1-T2 if block is
anesthetic 3. Include C3-C4 if block is anesthetic

13. Positioning
FIGURE 2 A: Patient positioning. The patient lies in a semisitting or
supine position with the head turned away from the side to be blocked.
B: The shoulder is down, the elbow is flexed, and the palm of the hand
rests on the patient’s lap while it is turned toward his face.

14. Providing anesthesia and postoperative analgesia for surgery to the
clavicle, shoulder, and arm.
• Advantages - rapid blockade of the shoulder region,
• and relatively easily palpable anatomical landmarks.
• Disadvantages - inadequate anesthesia in the distribution of
the ulnar nerve, which makes unreliable block for operations
involving the forearm and hand.

15. Side effects of Interscalene block
• Diaphragmatic hemiparesis - Temporary paresis (impairment of
the function) of the thoracic diaphragm occurs in virtually all people who
have undergone interscalene or supraclavicular brachial plexus block.
• Significant respiratory impairment can be demonstrated in these people
by pulmonary function testing.
• Horner's syndrome -if the local anesthetic solution tracks cephalad
and blocks the stellate ganglion. Accompanied by difficulty swallowing
and vocal cord paresis.
• These signs and symptoms are transient however, and do not commonly
result in any long-term problems, although they may be significantly
distressing to patients until the effects subside.

16. • Contraindications
• 1.Severe chronic obstructive pulmonary disease,
• 2.Paresis of the phrenic nerve on the opposite side
as the block.
• Those with severe chronic obstructive pulmonary disease — this can result
in respiratory failure requiring tracheal intubation and mechanical
ventilation until the block dissipates.

17. Interscalene block
Left: the red line corresponds to the course of the subclavian artery, while the
yellow line represents the brachial plexus and the "X" represents the site of
entry of the needle when performing an interscalene block. Right: diagram of the
course of the brachial plexus in relation to other important anatomic structures in
the right side of the neck.

18. Interscalene block

19. • Operations involving the arm and forearm, from the lower humerus
down to the hand. Excluding the shoulder.
• Rapid onset times and, ultimately, high success rates
• Surface landmarks - lateral to (outside) the lateral border of the
sternocleidomastoid muscle and above the clavicle,
• Palpation or ultrasound visualization of the subclavian artery just above
the clavicle provides a useful anatomic landmark for locating the brachial
plexus, which is lateral to the artery at this level.
• Proximity determined using by elicitation of a paresthesia, use of a
peripheral nerve stimulator, or ultrasound guidance.

20. Supraclavicular block
Disadvantages -
• the risk of pneumothorax, which is estimated to be between 1%–4% when
using paresthesia or peripheral nerve stimulator guided techniques.
• Ultrasound guidance -allows to visualize the first rib and the pleura,
thereby needle does not puncture the pleura; this reduces the risk of
pneumothorax.

21. Supraclavicular block

22. Supraclavicular block
The right brachial plexus with its short branches,
viewed from in front. The Sternomastoid and
Trapezius muscles have been completely removed,
the Omohyoid and Subclavius have been partially
removed; a piece has been sawed out of the
clavicle; the Pectoralis muscles have been incised
and reflected. (Spalteholz.)
The suprascapular, axillary, and
radial nerves. (Suprascapular
labeled at upper left.)

23. COMPLICATIONS Supraclavicular block
1.Phrenic nerve block with diaphragmatic paralysis and
2.sympathetic nerve block with development of Horner
syndrome.
• Self-limiting and do not require intervention.
• Reduced by the use of ultrasound guidance.
3.Intravascular injection with systemic local anesthetic toxicity
and hematoma formation .
• High level of vigilance -due to the rich vascularity of the
supraclavicular region.
4.Puncture of the subclavian, transverse cervical or dorsal
scapular arteries, all of which are located near the plexus at this
level.
5.Pneumothorax - delayed onset. diagnosed within a few hours
of the procedure and before the patient’s discharge.

24. Supraclavicular block
• Nerve Stimulator Settings
• The nerve stimulator is initially set to a current intensity of around
0.8 mA and a pulse width of 100 μs.
• Once the desired response is obtained (i.e., a muscle twitch of the
fingers) injection is initiated without reducing the nerve stimulator
current. This is a unique characteristic of the supraclavicular block.
recommended.
• CONTINUOUS TECHNIQUE
• not been considered to be an optimal choice for placement of
catheters. great mobility of the neck at this location carries a risk
for catheter dislodgement.
• Tunneling the catheter to the infraclavicular level could help to make
the catheter more stable; little data are currently available on this
topic.

25. LOCAL ANESTHETIC CHOICES FOR SINGLE-SHOT AND
CATHETER TECHNIQUES
• Upper extremity surgeries - last 1–3 hours.
• 30 mL of 1.5% mepivacaine with 1:200,000 epinephrine, which
provides about 3–4 hours of anesthesia.
• Solution without epinephrine provides about 2–3 hours of anesthesia.
• To speed block onset, 2 mL of 8.4% sodium bicarbonate may be added to
every 20 mL of mepivacaine solution.
• Solutions of levobupivacaine, ropivacaine, or bupivacaine provide
longer acting anesthesia (5–7 hours) when required.
• Use of ultrasound guidance may reduce the volume needed
• For continuous techniques, a bolus dose- 10–15 mL of local anesthetic
solution followed by an infusion rate of 8–10 mL/h. 0.2% ropivacaine
• patient-controlled bolus of 3–5 ml every 30–60 minutes , with the basal
infusion decreased to around 5 mL/h.
• Breakthrough pain must be treated with a bolus of local anesthetic

26. Ultrasound Guided Supraclavicular block
• EQUIPMENT
• Ultrasound machine with linear transducer (8–18 MHz),
sterile sleeve, and gel (or other acoustic coupling agent;
eg, saline)
• Standard nerve block tray
• 20–25 mL local anesthetic
• 5-cm, 22-gauge, short-bevel, insulated stimulating
needle
• Peripheral nerve stimulator
• Opening injection pressure monitoring system
• Sterile gloves

29. Ultrasound-Guided
•A motor response to nerve stimulation is not necessary if the
plexus, needle, and local anesthetic spread are well visualized.
•Color Doppler before needle placement and injection is highly
recommended- as Neck is a highly vascular area.-
Complications-
Pneumothorax (The presence of air or gas in the cavity between the
lungs and the chest wall, causing collapse of the lung) is rare but
typically delayed , therefore, it is important to keep the needle tip
visible at all times.
•Never inject against high resistance to injection - signal an
intrafascicular injection.
•Multiple injections
•May increase the speed of onset and the success rate.
•May allow for a reduction in the required volume of local anesthetic.
•May carry a higher risk of nerve injury.

30. • Double-stimulation technique is better than a single-stimulation
technique.
• When compared to a multiple - stimulation axillary block,
infraclavicular block provides similar efficacy.
• shorter performance time and less procedure-related pain for the
patient.

31. Infraclavicular block
Left: the red line corresponds to the course of the subclavian artery,
while the yellow line represents the brachial plexus and the "X"
represents the site of entry of the needle when performing an
infraclavicular block. Right: diagram of the course of the brachial
plexus in relation to other important anatomic structures in the right
infraclavicular fossa.

33. • For surgery to the elbow, forearm, wrist, and hand.
• Safest approaches to the brachial plexus, ( does not risk
paresis of the phrenic nerve, nor have the potential to cause
pneumothorax.
• Easily palpated axillary artery thus serves as a reliable
anatomical landmark , and
• Injection of local anesthetic close to this artery frequently
leads to a good block of the brachial plexus.
• Commonly performed -Ease of performance and relatively
high success rate

34. Axillary block(contd)
• Disadvantages -inadequate anesthesia in the distribution of the
musculocutaneous nerve.
• and intercostobrachial nerves
• a tourniquet on the arm may be poorly tolerated in such cases.
• Single-injection techniques -unreliable blockade in the areas
supplied by the musculocutaneous and radial nerves.
• Triple-stimulation technique — with injections on the
musculocutaneous, median and radial nerves — is the best
technique for the axillary block.

35. Axillary block
Left: the red line corresponds to the course of the axillary artery, while the "X"
represents the site of entry of the needle when performing an axillary block.
Right: diagram of the course of the axillary artery in relation to the brachial
plexus in the right axilla.

36. Axillary block

37. • Yet no clear evidence to support - that one method of
nerve localization is better than another.
• Numerous case reports- use of a portable ultrasound
scanning device has detected abnormal anatomy that
would otherwise not have been evident using a
"blind" approach.
• Use of ultrasound may create a false sense of security
in the operator, which may lead to errors, especially if
the needle tip is not adequately visualized at all times.

38. Methods of nerve localization (contd
• Using ultrasound - to follow the spread of local anesthetic demonstrated
an improved success rate of the block (relative to blocks done with nerve
stimulator alone) even at the inferior roots of the plexus.
• For supraclavicular block, nerve stimulation with a minimal threshold of
0.9 mA can offer a dependable block.
• Use of ultrasound guidance in combination with nerve stimulation .
- can shorten the performance time of supraclavicular block.
• For axillary block, success rates are greatly improved with multiple
injection techniques whether using nerve stimulation or ultrasound
guidance.

39. Special situations
• Duration
• “Single-shot"- lasting from 45 minutes to 24 hours.
• Extended by placing an indwelling catheter, which may be
connected to a mechanical or electronic infusion pump for
continuous administration of local anesthetic solution.
• A catheter may be inserted at the interscalene, supraclavicular,
infraclavicular or axillary location, depending on the desired
location of nerve block.
• Infusion of local anesthetic can be programmed to be a
continuous flow or patient-controlled analgesia.

40. Complications
•Infection
•Bleeding - using anticoagulant agents,
•Intra-arterial or intravenous injection,- local anesthetic
toxicity.
•serious central nervous system problems such as epileptic
seizure, central nervous system depression, and coma.
•Cardiovascular effects - include slowing of the heart rate and
which may lead to circulatory collapse. In severe cases, cardiac
dysrhythmia, cardiac arrest and death may occur.
•Other rare but serious complications -include pneumothorax
and persistent paresis of the phrenic nerve.

41. Complications (contd)
• Inadvertent subarachnoid or epidural injection of local
anesthetic- result in respiratory failure.(associated with
interscalene and supraclavicular blocks)
• Pneumothorax-Because of the close proximity of the lung to
the brachial plexus at the level of the clavicle- with a risk as
high as 6.1%.
• Other complications of supraclavicular block include
subclavian artery puncture, and spread of local anesthetic
to cause paresis of the stellate ganglion, the phrenic nerve
and recurrent laryngeal nerve.

42. Alternatives
• Depending on the circumstances-
• may include general anesthesia,
• monitored anesthesia care,
• Bier block,
• or local anesthesia.

43. Nerve Stimulator Settings
•Initially - current intensity of around 0.8 mA and a pulse width
of 100 μs.
•Once the desired response is obtained (i.e., a muscle twitch of
the fingers) injection is initiated without reducing the nerve
stimulator current. (This is a unique characteristic of the
supraclavicular block).
• Using Dual guidance compared with ultrasound or
nerve stimulation alone
• overall low incidence of block-related neural injury

44. Continuous Peripheral Nerve Blocks: Local Anesthetic Solutions
and Infusion Strategies
• INFUSATES AND LOCAL ANESTHETIC CONCENTRATION-
Commonly used-
• ropivacaine 0.1%–0.4%,
• bupivacaine 0.125%–0.15%, and
• levobupivacaine 0.1%–0.125%.
• mepivacaine.
• often combined with adjuvants
• Infusates are typically delivered using an infusion pump with a basal
infusion, bolus dose, or combination of the two modalities.
• Regimens are often reported as basal rate (mL/hour)/bolus volume
(mL)/bolus lockout time (minutes).

45. Additives to local anesthetics to prolong the duration of
analgesia for peripheral nerve blocks
• Epinephrine,
• Clonidine,
• Dexmedetomidine,
• Buprenorphine,
• Dexamethasone,
• Tramadol,
• Sodium bicarbonate, and
• Midazolam.
• increasing the duration of the analgesia or shortening
time of onset. To improve analgesia quality, Spare local
anesthetic consumption, and Minimize motor block

46. INFUSATE ADDITIVES AND ADJUVANTS-
• INFUSION PUMPS- should be accurate, reliable, portable,
and programmable,quiet, inexpensive, and easy to refill.
• For ambulatory setting, the local anesthetic reservoir should
accommodate enough infusate for 2 to 3 days.
• Pumps can be arbitrarily categorized as nonelectronic and
electronic (Figure 1). Examples of nonelectronic mechanisms
include spring- and vacuum-powered devices, as well as
elastomeric pumps.

48. Local anesthetics-Adverse Effects
• 1.Systemic toxicity when administered intravascularly or
orally in excessive dosages.
• 2.Hypersensitivity
• Allergic or hypersensitivity reactions - are rare.
• due to Preservative solution. higher with the ester group
• Para-aminobenzoic acid,(breakdown product generated by
the actions of the pseudocholinesterase enzyme.) extremely
antigenic and rapidly sensitizes lymphocytes.
• More commonly, reactions to a local anesthetic arise from
apprehension, anxiety, and phobia about needles. These
feelings may result in a vasovagal response, a panic attack, or
a syncopal episode.

49. Contraindications
• 1.Allergies -
• Ester local anesthetics -metabolized to a para-aminobenzoic
acid-like compound, and anaphylaxis
• Amide local anesthetics sometimes contain the preservative
methylparaben, severe allergic reactions.
• 2.Depressed hepatic function - prolonged duration of action
or a higher risk of toxicity with amides.
• 3.Cholinesterase deficiency may have prolonged effects of
esters

50. Monitoring

51. Toxicity
• Toxicity result from supratherapeutic drug levels.(large
quantities - enter the systemic circulation,)
• Suspected local anesthetic overdose - treated immediately
with
• Intravenous lipid emulsion 20% at 1.5 mL/kg (lean body
mass) given over 1 minute, followed by a 0.25 mL/kg/minute
infusion.
• maximum recommended dose is 10 mL/kg over the first 30
minutes (per the American Society of Regional Anesthesia
and Pain Medicine 2011 Consensus Statement).

52. Take home message
• A bundle of nerves that begins in the back of the base of the neck and
extends through the armpit, that sends signals from the spinal cord to
the shoulder, arm and hand
• The brachial plexus is formed by the ventral rami of C5-C6-C7-C8-T1,
• Regional anesthesia technique for surgery of the upper extremity.
• Alternative or as an adjunct to general anesthesia
• Techniques – Blind paraesthesis tech, PNS tech, Usg guided
• Approaches to blockade - Classified by the level at which the needle or catheter is
inserted for injecting the local anesthetic — 1.Interscalene block
2.Supraclavicular block 3.Infraclavicular block. 4.Axillary block .
• Local Anaesthesic agents and Adjuvents

53. BIBLIOGRAPHY
• 1.MILLER’S ANAESTHESIA 7TH EDITION
• 2.https://www.nysora.com/