upper limb blocks- interscalene,superficial cervical plexus block,nerve injury protocol,perineural catheters

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2. Interscalene block
Superficial cervical plexus block
Perineural catheters
Nerve injury protocol
By
Dr Nalluru Likhitha (MD Anaesthesia)
Moderator:Dr Suryanarayana
MD Anaesthesia
NRIIMS
Sanghivalasa

3. Interscalene Block
3
• The interscalene block
provides analgesia or surgical
anesthesia to the upper limb
from the distal end of the
clavicle to the shoulder joint
and proximal humerus

4. Interscalene Block
Landmarks of Interscalene Space
• Sternal head of the sternocleidomastoid muscle
• Clavicular head of the sternocleidomastoid muscle
• Upper border of the cricoid cartilage
• Clavicle
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5. INDICATIONS OF INTERSCALENE BLOCK
• Surgery or manipulation on clavicle , shoulder or upper arm except medial side.
• Therapeutic frozen shoulder
• Post herpetic neuralgia
• Tumour related pain
• Sympathicolysis
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6. CONTRAINDICATIONS OF INTERSCALENE BLOCK
SPECIFIC:
• Infection or malignant disease in the neck.
• Infection of the skin in the puncture area.
• Contralateral paresis of the phrenic or recurrent laryngeal nerves.
• Anticoagulation treatment.
• Distorted anatomy - e.g. due to prior surgical
• interventions or trauma to the neck
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7. CONTRAINDICATIONS OF INTERSCALENE BLOCK
RELATIVE:
• Hemorrhagic diathesis.
• Local nerve injury
• Severe chronic obstructive pulmonary disease
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8. INTERSCALENE BLOCK GOAL
• Local anaesthetic injection around the superior and middle trunks of brachial plexus in interscalene space
between anterior and middle scalene muscles,
• It is reliable anaesthesia of shoulder and upperarm.
• The supraclavicular brances of cervical plexus supplying skin over acromian and clavicle also blocked due to
superficial spread.
• The inferior trunk (C8-T1) is usually spared .
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9. Interscalene plexus block
Single injection technique :(Winnie’s Anterior Route )
• Patient position : supine with head roatated away from the side to be blocked .
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10. Interscalene plexus block
Single injection technique :
Landmarks :
• Sternocleidomastoid muscle (lateral border)
• Scalenus muscle
• Interscalene groove
• Cricoid cartilage
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11. Interscalene plexus block
Technique :
• With patient head elevated slightly , palpate the lateral border of SCM , and place index and middle fingers of
non injecting hand immediately behind the muscle.
• Ask patient to relax so palplating fingers move medially behing this muscle and come to rest on anterior belly
of scalenus anterior musvle .
• Roll fingers across laterally across thius muscle until interscalene groove is palpated.
• Insert needle in interscalene grove 2cm cephalad to cricoid cartilage .
• Direct needle toward middle third of opposite clavicle at 30 degrees
to skin.
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12. Interscalene plexus block
Technique :
• The traditional technique first described by Winnie is classic paraesthesia technique .
• When needle is positioned superficially paresthesia usually occur in area of elbow index and thumb finger.
• Paresthesias in shoulder region also occur frequently.
• These result due to stimulation of suprascapular nerve .
• Electrical nerve stimulation can also be used.
• Twitching of deltoid or biceps brachii muscles at stimulating current of 0.3mA/0.1ms indicate correct
placement.
• After negative aspiration 10-40ml of solution injected incrementally depending on desired extent of blockade.
• After successful injection the entire area is massaged to ensure even distribution of local anesthestic and
also provides as hematoma prophylaxis .
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13. Interscalene plexus block
Complexity :
• as the plexus is superficial (usually no deeper than 2cm) most complications caused by advancing the
needle tip too deeply.
• Contraction of levator scapulae muscle with stimulation indicates the needle is directed too posteriorly.
• Contraction of phrenic nerve(diaphragm) indicates needle has been directed too anteriorly.
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14. INTERSCALENE BLOCK TECHNIQUES
• ANTERIOR APPROACH (WINNIE’S)
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15. Interscalene plexus block
Continous catheter technique :
• Hold the needle steady , remove nerve stimulator lead from needle and attach to proximal end of catheter.
• Remove stylet from needle and insert distal end of catheter into needle .
• Keep the nerve stimulator output constant between 0.5 and 1.5mA , advance the catheter beyond tip of
needle and observe unchanged muscle twitchingduring advancement.
• If muscle twitches stop during movement ….. It means the catheter tip moved away from nerve .
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16. Interscalene plexus block
Continous catheter technique :
• Withdrwaw the catheter carefully so distal end is again inside shaft of needle.
• Adjust the needle slightly and advance the catheter again.
• Repeat until correct muscles twitch briskly during advancement.
• Do not advance the catheter further beyond 5cm to needle tip since it may curl around nerve and injure
them.
• Remove the needle while advancing the catheter slowly as epidural.
• Apply the SNAPLOCK.
• Apply nerve stimulator to SNAPLOCK and perform final stimulation test..
• Muscle twitches should be brisk at a setting of 0.3-0.8mA and 200-300ms .
• Cover and secure the catheter.
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17. Interscalene plexus block
Continous catheter technique :
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18. Interscalene plexus block
Posterior technique “
First described by Kappis in 1912and was republished by Pippa in 1990 as a “Loss Of Resistance Technique”
Position :
Sitting with neck flexed (to relax cervical muscles) and supported by assistant .
Landmarks :
Midpoint between spinous process of C6 and C7 .
Puncture site located 3cm lateral to this point .
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19. INTERSCALENE BLOCK TECHNIQUES
Procedure :
The needle is introduced at saggital level and perpendicular to the skin aiaming approximately for the level of
cricoid cartilage.
At adepth of 5-6cm contact is made with transverse process of C7 .
The needle is then withdrawn slightly , at directed cranially and advances past the transverse process a further
1.5-2cm deeper.
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20. INTERSCALENE BLOCK TECHNIQUES
Ultrasound guided :
Anatomy :
• The brachial plexus at interscalene level is seen lateral to carotid artery and IJV
between anterior and missle scalene msucles.
• The prevertebral fascia,superficial cervical plexus and
SCM seen superficial to plexus.
• The brachial plexus is usually visalised at a depth of 1-3cm.
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21. INTERSCALENE BLOCK TECHNIQUES
Technique :
• With patient in position,skin is disinfected and linear transducer is positioned in transverse plane to identify
carotid artery .
• Once artert identified transducer is moved slightly laterally across the neck..
• The goal is to identify anterior and middle scalenus muscles and brachial plexus between them.
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Signal lights appearence

22. INTERSCALENE BLOCK TECHNIQUES
Technique :
• The needle is the inserted in plane towards brachial plexus typically in lateral to medial in direction .
• The needle should be aimed in between the roots instead of directly at them to avoid nerve injery.
• As needle passes through prevertrbral fascia a certain pop is often appreciated.
• When stimulator used entrance of needle in interscalene groove is assosciated with motor response of
shoulder,arm ,forearm.
• After careful aspiration ,1-2ml local anesthetic injected to verify proper placement.
• After initial injection plexus are displaced from needle , additional advancement of 1-2mm towards plexus
may be beneficial.
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23. INTERSCALENE BLOCK TECHNIQUES
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24. INTERSCALENE BLOCK COMPLICATIONS
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• Ipsilateral phrenic nerve block -→ diaphragmatic paresis-→ altered pulmonary function:
• Use of low volume and performing block more caudad in neck can avoid phrenic nerve blockade.
• Severe hypotension and bradycardia (i.e BEZOLD JARSICH REFLEX) have been reported in awake sitting
patient sundergoing shoulder surgery under ISB due to stimulation of intracardiac meachnoreceptors by
decreased venous return which produces abrupt withdrawl of sympathetic tone and enhanced
parasympathetic output.
• Nerve damage and neuritis.
• Local anesthetic toxicity.
• Horner syndrome.
• Rarely pneumothorax.

25. TROUBLESHOOTING
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https://aneskey.com/interscalene-brachial-plexus-block-3/

26. SUPERFICIAL CERVICAL PLEXUS BLOCK
Anatomy :
• The cervical plexus originates from anterior branches of C1-C4 that combine into 3 loops from which
superficial and deep branches arise.
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27. SUPERFICIAL CERVICAL PLEXUS BLOCK
Anatomy :
• Deep branches :
• Phrenic nerve inervates diqapgragm.
• Nerve to geniohyoid and thyrohyoid (c1) innervate muscles and soft tissue of airway.
• Ansa cervicalis (c1-c3) supplies muscles for swallowing and speech.
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28. SUPERFICIAL CERVICAL PLEXUS BLOCK
Anatomy :
• Superficial branches:
• Emerge from prevertebral fascia between longus capitis
and middle scaleni muscles to run deep to SCM.
• SCM froms roof over these branches.
• This occurs approximately at the the intersection of EJV.
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29. SUPERFICIAL CERVICAL PLEXUS BLOCK
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30. SUPERFICIAL CERVICAL PLEXUS BLOCK
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• Cranial to C4, the branches of the cervical plexus are located within the prevertebral fascia in a groove
between the longus capitis and the middle scalene muscle
• At the C4-C5 level, the branches of the cervical plexus are located between the prevertebral fascia,
overlying the interscalene groove, and the investing layer of the deep cervical fascia.
• At the C6-C7 level, the branches of the cervical plexus are located superficially to the investing layer of the
deep cervical fascia

31. SUPERFICIAL CERVICAL PLEXUS BLOCK
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32. SUPERFICIAL CERVICAL PLEXUS BLOCK
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Indications :
• Superficial neck surgeries.
• Thyroid surgery.
• Carotid endarterectomy .
• Lymph node dissections
• Excision of thyroglossal or brachial cleft cysts.
• Vascular access surgery .
• Postoperative anaelgesia for head and neck surgeries.

33. SUPERFICIAL CERVICAL PLEXUS BLOCK
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Contraindications :
• Patient refusal
• Local infection
• Previous surgery
• Radiation therapy to neck
• Phrenic nerve palasies
• Pulmonary compromise.

34. SUPERFICIAL CERVICAL PLEXUS BLOCK
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Anatomical landmarks .
The following three landmarks for deep cervical plexus block identified and marked.
1.Mastoid process.
2.Transverse process of C6
3.Posterior border of SCM.

35. SUPERFICIAL CERVICAL PLEXUS BLOCK
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• For a deep injection: Local anesthetic is injected at the C2-C4 level. This technique blocks the entire plexus
and is generally not recommended due to the high risk of complications.
• For an intermediate injection: Local anesthetic is injected at the C4-C5 level, between the prevertebral
fascia and the investing layer of the deep cervical fascia, under the sternocleidomastoid muscle (SCM). This
is the most common technique used in clinical practice.
• For a superficial injection: Local anesthetic is injected at the level of C6, subcutaneously, superficial to the
investing layer of the deep cervical fascia.

36. SUPERFICIAL CERVICAL PLEXUS BLOCK
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Procedure:
• The block needle is connected to a syringe with local anesthetic via flexible tubing.
• The site of needle insertion is marked at midpoint of this line.
• This is where the branches of superficial cervical plexus emerge behind posterior border of SCM.

37. SUPERFICIAL CERVICAL PLEXUS BLOCK
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Procedure:
• a skin wheal is raised at the site of needle insertion using a 25-gauge needle.
• Using a “fan” technique with superior-inferior needle redirections, the local anesthetic is injected alongside
the posterior border of the sternocleidomastoid muscle 2–3 cm below and then above the needle insertion
site.
• The goal is to achieve block of all four major branches of the
superficial cervical plexus.
• The goal of the injection is to infiltrate the local anesthetic subcutaneously
and behind the sternocleidomastoid muscle.
• Deep needle insertion should be avoided (e.g., >1–2 cm).

38. SUPERFICIAL CERVICAL PLEXUS BLOCK
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Ultrasound guided
Position :
• Supine or semisitiing with head turned away from site to be blocked.
• This facilitates access to the anterolateral aspedct of the neck.
• Landmarks :
• Posterior border of SCM at the midpoint between mastoid
Process and clavicle.

39. SUPERFICIAL CERVICAL PLEXUS BLOCK
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• Place the transducer transverse over the lateral aspect of the neck, overlying the SCM at the midpoint
between the mastoid process and clavicle.

40. SUPERFICIAL CERVICAL PLEXUS BLOCK
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• Identify SCM and place the posterior edge in middle of screen.

41. SUPERFICIAL CERVICAL PLEXUS BLOCK
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• Slide the transducer cranial and caudally to identify the superficial branches of the cervical plexus as a small
collection of hypoechoic nodules (yellow arrows) located under the SCM.

42. SUPERFICIAL CERVICAL PLEXUS BLOCK
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• Insert the needle inplane through skin , inject the local anesthetic subcutaneously at the level of C6 posterior
to SCm.

43. SUPERFICIAL CERVICAL PLEXUS BLOCK
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Complications :
• Infection
• Hematoma
• Phrenic nerve block rare with superficial cervical plexus block.
• Local anesthetic toxicity.
• Nerve injury.
• Spinal anesthesia : avoid high volume and excessive pressure during injection are best measures to avoid.

44. PERINEURAL CATHETERS
• A perineural catheter is a long,thin,floppy tube that has been positioned to lie next to the nerve that is
connected to specialised pump that delivers local anesthestic through the catheter to numb the nerve
continusoly.
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45. PERINEURAL CATHETERS
Disadvantages :
• Better analgesia with fewer side effects than systemic opiods.
• Peripheral techniques offer more targeted sensory and motor block.
• Minimal sympathetic block and hemodynamic disturbances.
• Less risk of castotrophic complications.
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46. PERINEURAL CATHETERS
Contraindications :
Absolute :
• Patient refusal
• Skin infection at or near puncture site
• Local anesthetic allergy
Relative
• Systemic allergy
• Pyrexia
• Risk of compartment syndrome
• Bleeding diasthesis or anticoagulation
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47. PERINEURAL CATHETERS TYPES
• Stimulating vs Non stimulating
• Catheter through needle
• Catheter over needle
• Stiff vs flexible
• Single vs multioriface catheters
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48. PERINEURAL CATHETERS TYPES
Types :
Catheter through needle
• more commonly used.
• The catheter is easier to feed after a small volume (5 mL) of local anaesthetic has been injected to distend
the potential space. However, the needles are 18 to 19 gauge (large-bore needles),which makes the
placement of the catheter slightly more uncomfortable in the awake patient, but the needle is much easier
tovisualise on ultrasound.
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49. PERINEURAL CATHETERS TYPES
Types :
Catheter through needle
• familiar like epidural.
• Can vary target depth.
• Can vary amount of catheter threaded.
• Can tunnel them.
• No gurantee of tip location.
• Leakage common.
• More complex insertion.
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50. PERINEURAL CATHETERS TYPES
Catheter over needle
• Catheter over needle (similar to an intravenous cannula). The catheter over needle system should be quicker
to place and generally involves a smaller-gauge needle.
• In the past, catheters were more difficult to feed, but more recently with the advent of ultrasound, the needle
can be placed in the correct position and simply withdrawn to leave the catheter in thecorrect position
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51. PERINEURAL CATHETERS TYPES
Catheter over needle
• Familiar like single shot block.
• does not leak at insertion site.
• Known tip position
• Simpler insertion process
• Less flexibility
• Catheter has fixed lengths
• Cathetr protrudes a fixed distance past cannula
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52. STIMULATING VS NONSTIMULATING CATHETERS
• A stimulating catheter can cause electrical stimulation of the nerve at the tip of the catheter and can be used
to verify that the catheter has not dislodged from the original position in the postoperative period.
• When a nonstimulating catheter is used, the set normally comes with an insulated needle through which you
can stimulate; the catheter is then fed through the needle into the correct position.
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53. STIMULATING VS NONSTIMULATING CATHETERS
Advantages of non stimulating (ultrasound guided ) than stimulating …..
• Usg guided catheters have higher success rates.
• Usg guided catheters quicker than PNS
• Usg guided catheters are more comfortable.
• Have less vascular punctures
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54. SINGLE OR MULTIORIFACE
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55. ULTRASOUND GUIDED NON STIMULATING
CATHETER PLACEMENT
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• We use an 18G insulated Tuohy tip needle (a component of the nerve stimulator kit) with a nonstimulating
catheter as part of the ‘catheter through the needle’ technique
• Advance the needle until the desired twitches are obtained or the needle tip is seen on ultrasound in the
desired position(perineural or in the correct fascial plane)
• After aspirating to exclude intravascular placement, we inject 5 to 10 mL of a short-acting local anaesthetic
(1% prilocaine/or1% lignocaine) with adrenaline 1:200 000 via the needle to distend the space and facilitate
catheter insertion.

56. ULTRASOUND GUIDED NON STIMULATING
CATHETER PLACEMENT
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• A short-acting local anaesthetic solution with adrenaline may also be injected down the catheter to exclude
inadvertent intravenous placement. Observe the electrocardiogram; an increase in heart rate may be
suggestive of intravascular placement.
• note the distance from the skin to the needle tip and then feed the catheter in until there is 2 to 3 cm beyond
the needle tip. The position of the catheter tip can be confirmed on the ultrasound by injecting 0.5- to 1-mL of
local anaesthetic.
If resistance to advancing the catheter beyond the needle tip is encountered, 1 or more of the following
techniques may be helpful.
• Advance the catheter 0.5 cm while withdrawing the needle at the same time.
• Rotate the needle by about 458.
• Withdraw the needle half a centimetre and try again.
• Expand the perineural space with local anaesthetic, saline, or 5% dextrose.
• If ultrasound is being used, the needle tip should still be visible and can be repositioned near the nerves
before placing the catheter. It is easier to withdraw the catheter under ultrasound guidance into the correct
position.

57. ULTRASOUND GUIDED NON STIMULATING
CATHETER PLACEMENT
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• Once the placement of the catheter is confirmed, secure it using surgical skin glue and/or tunnelling away
from the surgical field . Tunnelling will help prevent catheter dislodgement and has also been shown to
reduce the incidence ofinfection.The use of surgical glue at the catheter puncture site also reduces leakage
of infused local anaesthetics.

58. THREADING OF CATHETER
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• Far enough close to nerve.
• Not too far to avoid knots/kinks
• More than 1cm and less than 5cm

59. TUNELLING OF CATHETER
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• Subcutaneous tunnelling involves having a few centimetres of the catheter subcutaneously embedded
proximal to insertion site which minimise risk of dislodgement and also bacterial colonisation.
Steps :
1.Once the catheter is injected into needle, after
confirmation we will pull back the needle a cm .
Using the stylet of tuohy needle we enter the
skin at same puncture site.
The stylet is pushed subcutaneously

60. TUNELLING OF CATHETER
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2.Then bevel of a syringe is used to tend the
skin safely and pop through

61. TUNELLING OF CATHETER
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3.Tuohy is inserted via the stylet backwards
where touhy stylet introduced at puncture site

62. TUNELLING OF CATHETER
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3.The block needle is then removed

63. TUNELLING OF CATHETER
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4.The end of catheter is then fed through
needle
Once catheter is got at other end withdraw the
Tuohy .

64. TUNELLING OF CATHETER
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5.Pull the catheter until it disappears under the
skin from insertion site and then fix the catheter

65. How to find catheter tip??
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• Direct ultrasound visualisation can be tricky
• Catheter movement.
• Injection of micorbubbles
• Injection of air
• Injection of fluid

66. ULTRASOUND VIEWS
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• Long axis in plane technique
• Difficult to align and perform .
• Takes time to perform

67. ULTRASOUND VIEWS
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Short axis in plane and out of plane:
• SA-OOP technique is better according to studies in term of post displacement.

68. CATHETER COMPLICATIONS
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• They dislocate and accidentaly extract
• They get struck or kink
• They get infected
• They migrate
• They leak.
• Local anesthetic toxicity

69. CATHETER COMPLICATIONS
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• They dislocate and accidentaly extract
• They get struck or kink
• They get infected
• They migrate
• They leak.
• Local anesthetic toxicity

70. CATHETER COMPLICATIONS
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72. References
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1. Hadzick’s textbook of Regional Anaesthesia 2 edition
2. Brown’s Atlas of Regional Anaesthesia 5 edition
3. A pocket guide of Oxford Regional Anaesthesia
4. https://www.nysora.com/techniques/upper-extremity/intescalene/interscalene-brachial-plexus-block/
5. https://resources.wfsahq.org/wp-content/uploads/412_english.pdf
6. https://www.uhsussex.nhs.uk/resources/regional-anaesthesia-using-peri-neural-catheters/
7. https://aneskey.com/continuous-peripheral-nerve-blocks-4/

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Thank You