BRACHIAL PLEXUS BLOCK

1. BRACHIAL PLEXUS BLOCK
Eniyew. A

2. OUTLINE
 General description
 Indications
 Anatomic consideration
 Preparation
Needle
Depth
Directions
Volume of Las
 Technique
 Caution

3. OUTLINE
 Clarification of dosing of Las
 Side effects
 Complications
 Clinical tips

8. 8

9. Interscalene approach
Anatomy:
 Cervical nerves (C5-T1) course antero-laterally and
inferiorly to lie b/n the anterior scalene and the
middle scalene muscles.
 The prevertebral fascia covers both the scalene
muscles fusing laterally to enclose the brachial plexus
in a fascia sheath.

10. Interscalene nerve block
 B/n the scalene muscles, these nerve roots unite to
form three trunks, which emerge from the
interscalene grove
 To lie cephaloposterior to the subclavian artery as
it courses along the upper surface of the first rib.

12. Interscalene nerve block
 Indications:
 Shoulder and humeral surgery
 Landmarks
Posterior boarder of SCM
Thyroid cartilage prominence (C4)
Subclavian artery - above the clavicle

13. Interscalene nerve block :Equipments
 All resuscitation materials (GA)
 Syringes: two 10mls or 20mls
 Antiseptic solution
 Nerve stimulator
 50mm -insulated needle (depth=35-50mm)

14. Interscalene nerve block : Drugs
 1% lidocaine,1% prilocaine
 0.25-0.5% bupivacaine

15. Interscalene nerve block : Techniques
 Patient supine with head turned away from the side
to be blocked.
 Mark the lateral boarder of SCM
 Head up and palpate SCM grove
 The intersection of the groove with a transverse plane
at the level of the cricoid cartilage is the point at
which the needle should enter the skin and this is
about the level of C6.

16. 16

17. 17

18.  Mark cricoid cartilage level
 Skin prepared
 Needle direction -perpendicularly to the skin with a
45 degree caudad angle (towards the feet) and slightly
posterior angle.

19. 19
1. Cricoid cartilage 4. Puncture site for anterior access
2. Superior thyroid notch 5. Vertical, infraclavicular puncture site
3. SCM
Meier’s approach

20.  Advance needle until:
Paraesthesia is elicited in the shoulder or there is a
motor response in the forearm at <0.5 mA.
If tubercle is contacted, withdraw and re -direct
needle caudad until the motor response or
parasthesia is obtained.
Click may be detected as the needle passes
through the prevertebral fascia.

21. Stimulation and dose
 Deltoid (shoulder surgery): 10-20ml.
 Elbow flexion ( humerus): 20-40ml.

22. Ultrasound guided

24. Interscalene nerve block
 Side effects:
Phrenic nerve block -100%
RLN block -15%
Stellate ganglion block -20%
 Complications:
Inadvertent intravascular injection
Pneumothorax –very low incidence

25. Supraclavicular approach: Anatomy
 The subclavian perivascular block is a supraclavicular
approach to the brachial plexus.
 Aiming to anaesthetise the 3 trunks of the brachial plexus as
they cross the first rib rather than the nerve roots as they
emerge between the scalene muscles.
 This is the point at which the brachial plexus is more
compact.
 As a result it is possible to block the majority of the brachial
plexus with one injection and with the lowest volume of
local anaesthetic.

26.  The first rib runs approximately antero -posteriorly at
the point where the trunks of the brachial plexus cross
it.
 The plexus crosses the first rib between the insertions
of the anterior scalene muscle (in front) and the
middle scalene muscle (behind).
 The brachial plexus lies posterior to the subclavian
artery.

27.  The lower trunk may lie under the subclavian artery.
 The subclavian vein is anterior to the anterior scalene
muscle, and so should be well separated from the
scene of action!

28. Indications:
 Humeral, elbow, fore-arm and hand surgery: areas
supplied by the median and radial nerves, and the lateral
and posterior cutaneous nerves of fore-arm.
 Possibly not the logical choice for surgery confined to the
medial side of the elbow, wrist and hand, or the little
finger (5% failure to block the lower trunk of the plexus).

29. 29
 Landmarks:
 -Interscalene groove
 -Subclavian artery
 Equipments:
 - All resuscitation materials
 -50mm insulated needle ( depth=1.5-4mm)
 -Two -20ml syringes
 -Nerve stimulator
 Drugs:
 -0.1% lidocaine ,1% prilocaine
 -0.25-0.5% bupivacaine

30. Techniques
 Patient lying flat, and the head turned 30o to the opposite side.
 Identify the interscalene groove and follow the groove down to
the root of the neck.
 Palpate the subclavian artery and insert the needle at the
lowest point of the interscalene groove in the posterior part of
the groove, and posterior to the subclavian artery if palpable.

31. 31
Position for needle insertion for subclavian perivascular
block
Best method

32.  Direct the needle parallel to the floor and directly
caudad: straight down towards the patient’s feet.
 Absolutely no medial intent (penetrate pleura ).
 If no paraesthesiae or twitch are elicited, withdraw
the needle almost to skin and redirect gently more
anteriorly or posteriorly.

33.  Direct the needle parallel to the floor and directly
caudad: straight down towards the patient’s feet.
 Absolutely no medial intent (penetrate pleura )
 If no paraesthesiae or twitch are elicited, withdraw
the needle almost to skin and redirect gently more
anteriorly or posteriorly.

34.  If accidental arterial puncture -move needle
posteriorly
 If you contact 1st rib -walk anterio-posteriorly along
rib

35. 35
 Stimulation:
Flexion or extension of wrist and fingers
 Dose: 0.5ml/kg to 40mls

38. Supraclavicular nerve block
Side effects:
Horner’s syndrome
RLN block
Complications:
Vascular puncture
Inadvertent intravascular injection
Pneumothorax

39. Infraclavicular approach
 It is most useful for patients undergoing procedures
on the elbow, forearm, or hand
 Plain bupivacaine produce surgical anesthesia lasting
4 to 6 hours
the addition of epinephrine may prolong this period to 8
to 12 hours
 Thus the technique can substitute for an axillary
block in patients who cannot abduct their arms

40.  Like the axillary block, this technique is carried out distant
from both the neuraxial structures and the lung

41. Infraclavicular approach: Anatomy
 Boundaries of the infraclavicular fossa are:
Pectoralis major and minor muscles anteriorly
Ribs medially
Clavicle and coracoid process superiorly &
Humerus laterally.
 The plexus is approached in close proximity to the
coracoid process

43. Landmarks:
 Anterior process of the acromion
 Jugular/ sternal notch
 Subclavian artery

44.  Equipments
- All resuscitation materials
-50mm insulated needle ( depth= 2-5cm)
syringes
-Nerve stimulator
 Drugs: 1% lidocaine, 0.25-0.5% bupivacaine

45. Techniques:
 Patient is supine, the
ipsilateral arm is abducted
{not necessary} and the
head is turned to the
opposite side.
 Acromion process -the most
prominent structure of the
head of the shoulder.

46. Techniques:
 Mark the midpoint of the
clavicle between the acromion
and the sternal head of the
clavicle.
 Insert needle vertically -2.5 -
3cm below the midpoint of the
clavicle along the axillary artery.

47. Stimulation
 Wrist/finger extension- accept, posterior cord.
 Dose: 0.5mg/kg to 50ml

48. Stimulation
 Pectoral muscle twitch- don’t, needle too medial or
superficial

49. Stimulation
 Elbow flexion- don’t , lateral cord, needle too lateral
or superficial

50. Advantages of the infraclavicular
vertical brachial plexus block
 Clearly defined guide points - clearly defined puncture
direction
 Simple to learn - high success rate
 No anaesthetic gaps resulting from the procedure
 No problems with the Esmarch tourniquet
 Comfortable positioning of the patient

51. Ultrasound for infraclavicular
• Ultrasound is an imaging tool for localization of
the cords of the brachial plexus in the
infraclavicular region.
• Placement of the ultrasound probe at any position
inferior to the clavicle allows visualization
– the axillary artery and vein
– the surrounding brachial plexus cords
– the pleura and pulmonary tissue

52. • A single injection of local anesthetic posterior
to the axillary artery was found to have to be
superior to a triple injection adjacent to each of
the cords.
• local anesthetic is deposited posterior to the
axillary artery alone , one study found a 82.5%
‘anatomical success rate.

53. Technique
• With the patient lying supine, and the ipsilateral arm
in any position, performing the procedure stands at
the head of the bed, behind the shoulder
• The prob is placed on parasagittal plain

55. • Administering local anesthetics at posterior of
axilary artery at site of six O'clock is satisfactory
successful anesthesia analgesia
• It forms U shape bathing of local anesthetics with
axillary artery
• vascular structures, such as pectoral vein and
arterial branches can be present in between the
pectoral muscles, and are easily identified with
color Doppler

57. Vertical Infraclavicular Approach
• A vertical infraclavicular in-plane or out-of-plane
approach has also been described under US
guidance.
• this approach the ultrasound probe is positioned
under and parallel to the clavicle and the needle
insertion point is the middle of clavicle.
• The brachial plexus is more superficial in this
location and is visualized lateral to the subclavian
artery

58. • . An in-plane approach is recommended for
continuous direct visualization of the needle
under ultrasound.

60. Continuous Infraclavicular Block
• When prolonged postoperative analgesia is
desired, placement of a perineural infraclavicular
catheter is appropriate
• The infraclavicular location prefferable due to
– lower risk of dislodgement
– easy to inspect and maintain the catheter site and easy
to secure the catheter to the anterior chest.
– Infraclavicular continuous catheters provided superior
analgesia when compared to supraclavicular
continuous

61. Technical consideration
• After standard monitors are applied, the patient is sedated as needed and
positioned
• the skin is prepared as usual with 2% chlorhexidine in 70% alcohol or
betadine solution.
• A sterile drape is placed around the location where the catheter will be
placed and anchored.
• An ultrasound transducer is placed into a sterile sheath with acoustic gel
and secured with rubber band around the transducer head.
• A 17G or 18 G insulated Tuohy needle is used to contact the neural
structures.

62. Procedure
• The coracoid approach has been described for placement of
continuous infraclavicular block.
• US-guided technique is used, with an in an in plane
approach
• the needle is inserted and advanced to reach the posterior
aspect of the axillary artery
• Injection of a small amount of local anesthetic or D5W may
be used to distend the perineural space and facilitate
threading of the catheter.

63. Side effects/complications
 Horner syndrome
 Vessel puncture (cephalic vein, subclavian artery and
vein and their branches)
 Pneumothorax
 Inadvertent intravascular injection

64. Axillary nerve block
 First described by Herschel in 1911.
 Easy to perform and has few complications.
 Axillary brachial plexus block is most effective for
surgical procedures distal to the elbow
 Some patients can undergo procedures on the elbow
or lower humerus with an axillary technique

65.  The plexus runs from the neck to the axilla passing between
the clavicle and the first rib
 The cords form the nerves to the arm - the median, ulnar,
radial and the musculocutaneous nerve
 Alongside the axillary artery runs the axillary vein & vessels
and nerves are contained in a connective tissue sheath

66.  Indications
 Elbow, forearm and hand surgery
 Musculocutaneous nerve can not be blocked b/c it
always lies outside the sheath ( b/n biceps and
coracobrachialis muscle), because it leaves the lateral
cord before the cords enter the axilla.

67. Methods to block musculocutaneous
nerve
 Isolate the motor response for i.e. elbow flexion
 Extended volume of Las
 Wait for 20 – 25 min

68. Landmark
 Axillary artery: most
important landmark.
 Median nerve superior,
ulnar nerve inferior, and
the radial nerve is
posterior and lateral.
 Insertion of major
pectoralis muscle

69.  Equipments:
Resuscitation materials ( GA)
Anti-septic solution and infiltrate needle insertion
site.
25-50mm insulated needle
Nerve stimulator
 Dose: single injection:0.5ml/kg up to 50mls.

70. Techniques:
 Pt supine, arm abducted to 90° and the elbow
flexed to 90°,& head rotated away from the side
to be blocked
 The axillary artery should be marked as high in its
course in the axilla as is practical

72.  Over the proximal portion of the artery. The index
and middle fingers of the non-dominant hand straddle
the artery just below this point

74. Axillary nerve block: Different
approaches
 Nerve stimulator
 Ultrasound guided
 With out NS
 Trans-arterial
 Slow needle placement until a parasthesia is elicited
 Click with short bevelled needle -piercing sheath

75. Stimulations:
Index or middle finger flexion -median nerve
Thumb abduction or little finger flexion –ulnar
Thumb extension –radial
Elbow flexion –musculocutaneous nerve

76. Multiple injections:
 Around each individual nerve is most reliable
 It may require less volume
 But the minimum required dose/volume per nerve is
not well known .
 Nerve & vascular injury?

77. Ultrasound guided axillary block
• It needs multiple injection through ultrasound
visualization
• Correct identification of biceps, coracobracialis and
conjoint tendon are necessary for musculocutanous
nerve
• High frequency linear probe is necessary
• Parasagittal to axillary artery gives good visualization

80. Complications:
 Block failure
 Bleeding and haematoma
 Inadvertent vascular injection
 Infection
 Nerve damage

81. Elbow block
 In general, distal upper extremity blocks—those at the
elbow or wrist—are not frequently required if facility
with more proximal blocks is gained
 These more distal peripheral blocks are perceived to be
associated with a slightly higher likelihood of nerve
injury
Nerve is contained within bony and ligamentous
surroundings
 Augmentation of higher brachial plexus nerve block

82. Anatomy
 The ulnar nerve is located in the ulnar groove, which
is a bony fascial canal between the medial
epicondyle of the humerus and the olecranon
process
 The median nerve at the elbow lies medial to the
brachial artery, which lies just medial to the biceps
muscle

83. • The radial nerve pierces the lateral intramuscular
septum on its way to the forearm, and lies between
the brachialis muscle and the brachioradialis
muscle in the distal aspect of the upper arm

84. Position
 All three of these nerves are blocked with the patient
in the supine position and the arm supinated and
abducted at the shoulder at a 90-degree angle
 For ulnar nerve block, the forearm is flexed on the
upper arm to more easily identify the ulnar groove

85. Ulnar nerve block position

86. Needle Puncture: Median Nerve
Block
 A line should be drawn between the medial and
lateral epicondyles of the humerus
 Immediately medial to the brachial artery, the needle
is inserted
 After the needle is positioned, 3 to 5 mL of solution is
injected medial to the brachial artery.

87. Needle Puncture: Radial Nerve
Block
 The biceps tendon at that level should be identified,
and then a mark is made 1 to 2 cm lateral to the
tendon
 A small-gauge, 3-cm needle is inserted and 3 to 5 mL
of solution is injected at that site

88. Medial and radial nerve block

89. Needle Puncture: Ulnar Nerve Block
 At a point approximately 1 cm proximal to a line
drawn between the olecranon process and the
medial epicondyle, a small-gauge, 2-cm needle is
inserted
 A parasthesia should be easily obtainable, and once
it is, the needle is withdrawn 1 mm, and 3 to 5 mL
of local anesthetic is injected through the needle

90.  A larger volume of solution should not be injected
directly into the ulnar groove
because high pressure in this tightly contained
fascial space may increase the risk of nerve
injury

92. Wrist block

93. Question!!!!!