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UPPER LIMB
BLOCKS
BRACHIAL
PLEXUS
BLOCK
Abraham Tarekegn
University of Gondar, Department of Anesthesia
1/4/2018
1
Outlines
 General description of each nerves
 Indications
 Landmarks
 Preparation
 Needle
 Depth
 Directions
 Volume of LAs
 Technique
 Side effects & Complications
1/4/2018
2
The Brachial Plexus
 Supplies all of the motor and almost all of the
sensory function of the upper extremity.
 The plexus is formed from the anterior
primary rami of the fifth cervical to the first
thoracic roots.
 Contributions may also be received from C4
to T2.
 Blockade of the brachial plexus can provide
surgical anesthesia of the hands, upper/lower
arm, and shoulder depending on the
approach.
1/4/2018
3
Major Motor Function of the Individual
Nerves of the Brachial Plexus
Nerve Major Motor Function
Axillary Abduction of the shoulder
Musculocutaneous Flexion of the elbow
Radial Extension of the elbow, wrist, &
finger
Median Flexion of the wrist & finger
Ulnar Flexion of the wrist & finger
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1/4/20185
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These nerves (C5 -
T1) leave
intervertebral foramina
- Root
 Trunk-they unite to
form three trunks
between the anterior
and middle scalene
muscles.
Upper, middle, and
The Brachial Plexus….
8
At the first rib each
trunk will separate
into anterior and
posterior divisions.
 As the brachial
plexus emerges
under the clavicle,
the anterior and
posterior divisions
come together to
The Brachial Plexus….The Brachial Plexus….
9
The lateral cord is lateral
to the axillary artery;
The posterior cord is
located posterior to the
axillary artery; and
The medial cord is located
medial to the axillary artery.
At the lateral border of the
pectoralis minor muscle,
each cord divides into
branches, terminating in
The Brachial Plexus….The Brachial Plexus….
1/4/2018
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Techniques and use of brachial plexus
The brachial plexus is
enveloped by a facial
sheath which allows for
the administration of
brachial plexus
anesthesia.
Injection into the sheath,
at any anatomical point,
will allow for the spread of
local anesthetics and
subsequent blockade.
Choice of a specific
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12
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Interscalene approach: Anatomy:
 Cervical nerves (C5-T1) course antero-
laterally and inferiorly to lie between 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. 1/4/2018
16
Brachial Plexus Anatomy
 Interscalene
block
 At level of
Distal Roots/
Proximal
Trunks
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Anatomy
- Nerves lie in the
Interscalene groove
 Between anterior and
middle scalene
muscles
 Posterior/Lateral to
Sternocleidomastoid
muscle (clavicular
head)
- Posterior to Phrenic
Nerve
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Anatomy…
 Vertebral artery
(VA) is medial to
the anterior
scalene muscle
(AS)
 Phrenic nerve (PN)
overlies the
anterior scalene
muscle.
 C5 and C6 nerve
roots join to form 1/4/2018
19
1/4/2018
20
Interscalene nerve block
 Between 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.
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Indications of interscalene
block
 Surgery of
 Shoulder
 Distal clavicle
 Proximal Humerus
 Elbow
 Open shoulder
surgery
 Arthroscopic surgery
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Interscalene nerve block...
 Landmarks
Posterior boarder of SCM
Upper border of Cricoid cartilage
Subclavian artery - above the clavicle
external jugular vein
 interscalene groove.
1/4/2018
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Interscalene nerve block
:Equipments
 All resuscitation materials (GA)
 Syringes: two 10mls or 20mls
 Antiseptic solution
 Nerve stimulator
 50mm -insulated needle (depth=35-
50mm)
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Interscalene nerve block :
Drugs
 1% lidocaine,1% Prilocaine
 0.25-0.5% Bupivacaine
 Deltoid (shoulder surgery): 10-20ml.
 Elbow ( humerus): 20-40ml.
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Interscalene nerve block :
Techniques
The patient should be supine, with one
small pillow under their head and neck.
The head should be turned comfortably to
the opposite side.
At the level of the cricoid cartilage draw a
line laterally to intersect the posterior
border of the sternocleidomastoid; this
usually corresponds to where the external
jugular vein crosses.
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Palpate the scalene anterior underneath
the lateral border of the sternomastoid.
Moving the fingers laterally, palpate the
interscalene groove, between the
scalenus anterior and medius.
To aid palpation ask the patient to their
lift head gently off the pillow (contracting
the sternomastoid) or sniff (contracting
scalene muscles).
Interscalene nerve block :
Techniques
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Stand to the side of patient or at their
head, raise a weal and insert a 22G 25
mm/50 mm needle of choice
perpendicular to the skin in all directions
with a slight caudad direction.
On entering the prevertebral fascia sheath
a pop may be elicited; advance until
paraesthesia or specific motor stimulation
is achieved (peripheral nerve stimulation).
After careful aspiration inject 10–20 ml for
Interscalene nerve block :
Techniques
1/4/2018
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29 1/4/2018
30 1/4/2018
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1. Cricoid cartilage 4. Puncture site for anterior access
2. Superior thyroid notch 5. Vertical, infraclavicular puncture site
3. SCM
Meier’s approach
Nerve Stimulator
Technique
 Roll fingers
posteriorly off
lateral border of
SCM muscle
 Palpate
Interscalene
Groove between
two fingers
 Beware of
nearby External1/4/2018
32
Nerve Stimulator
Technique
 Insert needle
slightly posterior
and caudad.
 Watch for twitches
of bicep, tricep,
forearm, or hand
 Diaphram twitch=
phrenic nerve=too
anterior.
 nerve block vedio
1/4/2018
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Interscalene nerve block
 Side effects:
 Phrenic nerve block -98%
 RLN block -15%
 Stellate ganglion block -20%
 Horner’s Syndrome
 Complications:
 Inadvertent intravascular injection
 Pneumothorax –very low incidence
1/4/2018
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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.1/4/2018
35
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 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.
 The lower trunk may lie under the subclavian
artery.
 The subclavian vein is anterior to the anterior1/4/2018
37
Supraclavicular approach:
Anatomy
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
1/4/2018
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39
 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
1/4/2018
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.
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41
Position for needle insertion for subclavian perivascular
block
Best method
1/4/2018
 Puncture site:
Immediate dorso-lateral
from the palpated
pulsation of the
subclavian artery and1
cm behind the midpoint of
the clavicle.
 Paresthesia will usually
be immediately elicited.
 If no paresthesia assess
up to the first rib.
Techniques
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 If no paraesthesiae or twitch are elicited,
withdraw the needle almost to skin and redirect
gently more anteriorly or posteriorly.
 If accidental arterial puncture -move needle
posteriorly.
 If you contact 1st rib -walk anterio-posteriorly
along rib.
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Techniques...
44
 Stimulation:
 Flexion or extension of wrist and fingers
 Dose: 0.5ml/kg to 40mls
 Side effects:
 Horner’s syndrome
 RLN block
 Complications:
 Vascular puncture
 Inadvertent intravascular injection
 Pneumothorax 1/4/2018
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
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46 1/4/2018
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
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Landmarks:
 Anterior process of the acromion
 Jugular/ sternal notch
 Subclavian artery
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Equipments and drugs
 Equipments
- All resuscitation materials
-50mm insulated needle ( depth= 2-5cm)
-Three 20ml syringes
-Nerve stimulator
 Drugs: 1% lidocaine, 0.25-0.5%
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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
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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. 1/4/2018
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Stimulation
 Wrist/finger extension- accept, posterior cord
 Dose: 0.5mg/kg to 50ml
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Stimulation
 Pectoral muscle twitch- don’t= needle too
medial or superficial
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Stimulation
 Elbow flexion- don’t = lateral cord, needle too
lateral or superficial
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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
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Side effects/complications
 Horner syndrome
 Vessel puncture (cephalic vein, subclavian
artery and vein and their branches)
 Pneumothorax
 Inadvertent intravascular injection
1/4/2018
57
Axillary nerve block
 The most commonly practiced block.
 For surgical procedures from the elbow to
the hand.
 There is intense blockade of C7-T1 (forearm
and hand surgery).
 Not adequate for the shoulder and upper arm
(C5-6).
 Easy to perform and has few complications.
 Axillary brachial plexus block is most
effective for surgical procedures distal to the1/4/2018
58
1/4/201859
 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
1/4/2018
60
Axillary nerve block...
Anatomic consideration
 Beneath the clavicle, the subclavian artery
becomes the axillary artery.
 Behind the clavicle, at the apex of the
axilla the brachial plexus splits from upper,
middle, and lower trunks into anterior and
posterior divisions.
 The anterior and posterior divisions travel
to the lateral border of the pectoralis minor
and form the lateral, posterior, and medial
cords. 1/4/2018
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 The cords split to form individual nerves
that innervate the arm.
 Other branches of the plexus arise from
the neck and axilla, directly from the roots,
trunks, and cords.
 Knowledge of where each individual nerve
is located within the sheath is important.
 The median nerve is superior to the axillary artery.
 The ulnar nerve is inferior to the axillary artery.
 The radial nerve is inferior and posterior to the axillary artery.
 The musculocutaneous nerve has already separated from the brachial
plexus, traveling within the coracobrachialis muscle.
Anatomic consideration….
Indications
 Elbow, forearm and hand surgery
 Operations in the arm (distal upper arm, lower
arm, hand)
 Continuous analgesia
 Pain syndrome
 Sympathicolysis
 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.
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Landmarks
 Axillary artery pulse :
most important
landmark.
 Median nerve
superior, ulnar nerve
inferior, and the
radial nerve is
posterior and lateral.
 Insertion of major
pectoralis muscle
 Coracobrachialis
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Axillary block
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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. 1/4/2018
66
1. The patient lies supine with the arm
extended 90 degrees from the side &
flexed at the elbow
Extension beyond 90 degrees potentially
compresses the axillary artery because
of the pressure from the head of the
humerus & may make identification of
the landmarks more difficult
Techniques
:
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Techniques....
1/4/2018
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2. Axillary artery is marked as high in its
course in the axilla as is practical.
 Usually felt in the intramuscular groove
between the coracobrachialis & triceps
muscles
 Also passes between the insertions of the
pectoralis major & latissimus dorsi muscles on
the humerus.
1/4/2018
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Techniques....
3. After aseptic preparation, a skin wheal is
raised over the proximal portion of the artery
 Index & middle fingers of the nondominant
hand straddle the artery just below this point,
both localizing the pulsation & compressing
the neurovascular bundle below the intended
site of injection.
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 At this point raise a weal, and fixing the
artery against the humerus with the index
and middle fingers insert a 22G 50 mm
needle angled slightly proximally to pass
either above or below the artery to contact
either median or ulnar nerve respectively.
 A perceptible click or pop is felt on
entering the fascial sheath, and
paraesthesia or specific motor responses
can be elicited.
 nerve block vedio
Techniques....
1/4/2018
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 Needle; 22-25G/25-50mm
insulated/uninsulated.
 Direction; 45° to the skin, proximally
 Depth; 10-15mm
 Volume; single injection: 0.5ml/kg up to
50mls.
 Inject 40-50ml of LA increments.
 LA; 1% Lidocaine, 1% Prilocaine
0.25%-0.5% Levobupivacaine
Techniques....
Axillary nerve block: Different
techniques
Four different techniques can be
employed:
 Transarterial; injecting 20 ml of solution both
anterior and posterior to the artery.
 Multiple injections; finding each of the four
nerves separately, the success of the block
being increased when each successive
nerve is identified.
 Single loss of resistance using a short
bevelled needle; fascial click, injecting after
either through the needle or after insertion of
a cannula.
 Infiltration; fanwise injection of 15 ml of1/4/2018
73
Multiple injections:
 Around each individual nerve is most
reliable.
 It may require less volume(7-10ml each
nerve).
 But the minimum required dose/volume
per nerve is not well known .
 Nerve & vascular injury?
1/4/2018
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Stimulations:
Index or middle finger flexion -median
nerve
Thumb abduction or little finger flexion –
ulnar
Thumb extension –radial
Elbow flexion –musculocutaneous nerve
1/4/2018
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Clinical tips
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 Single injection almost always misses two
nerves from getting blocked.
 The musculo-cutaneous nerve: which
supplies the lateral side of the forearm. It is
important to inject as high as possible in the
axilla in order to block this nerve. If it has not
been blocked, inject 5ml of local anaesthetic
solution at a point 2.5cm distal to the elbow
crease and lateral to the biceps tendon.
 The intercostobrachial nerve: which
supplies the medial half of the upper arm.
This is blocked by injecting the last few ml of
local anaesthetic as the needle is withdrawn.
Complications:
 Block failure
 Bleeding and haematoma
 Inadvertent vascular injection
 Toxicity due to absorption of LA
 Infection
 Nerve damage
1/4/2018
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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 plexus1/4/2018
78
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.
 The radial nerve pierces the lateral
intramuscular septum on its way to the
forearm, and lies between the brachialis
muscle and the brachioradialis muscle1/4/2018
79
1/4/2018
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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.
1/4/2018
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Indication and landmarks
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 Indications
 Elbow blocks are indicated for surgery on
the forearm and hand.
 Landmarks:
 flexion crease of the elbow, brachial
artery, biceps tendon, medial and lateral
epicondyles.
 In all cases the arm should be slightly
abducted with the elbow slightly flexed,
the forearm supinated.
Blockade of median nerve
 At the elbow, the
median nerve is
located medial to the
brachial artery near
the insertion of the
biceps tendon.
1/4/2018
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Blockade of median nerve
 Identify the brachial artery in the
antecubital space.
 It is generally located medially, at
the biceps tendon insertion.
 Insert a 22-27 gauge, 4 cm blunted
needle medial to the brachial
artery. Direct the needle toward the
medial epicondyle.
 A click may be felt as the
needle pierces the deep fascia,
and paraesthesia or a motor
response elicited.
 Continue insertion of the needle
until bone is contacted.
 At this point withdraw the needle 1
cm and inject 3-5 ml of local
anesthetic.
1/4/2018
84
Radial Nerve Dermatomes
Radial nerve block
 Block of the radial nerve
provides anesthesia to the
lateral aspect of the
dorsum of the hand
(thumb side) and the
proximal portion of the
thumb, index, middle, and
lateral half of the ring
fingers.
1/4/2018
86
Blockade of the Radial Nerve
 Identify the lateral aspect of the biceps
tendon at the crease of the elbow.
 Insert a 22-27 gauge, 4 cm blunted needle
parallel to the forearm.
 Direct the needle toward the lateral
epicondyle.
 If a paresthesia is encountered, withdraw
the needle slightly, and inject 5 ml of local
anesthetic. Do not inject if the patient
complains of a paresthesia. If no paresthesia
is encountered, continue to insert the needle
until bone is encountered.
 Withdraw the needle 1 cm and inject 5 ml of
local anesthetic.
1/4/2018
87
Ulnar nerve block
 Used to supplement a patchy
axillary or interscalene block
or for minor surgical
procedures in the distribution
of the ulnar nerve.
 At the elbow, the ulnar nerve
can be palpated proximal to
the medial epicondyle.
1/4/2018
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Ulnar nerve block position
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Blockade of the Ulnar Nerve at the Elbow
To anesthetize the ulnar nerve at
the elbow, have the patient flex
their arm 90 degrees.
Identify the olecranon process
and the medial condyle.
The ulnar nerve can be palpated
between these two structures.
Insert a 22-27 gauge blunted
needle slowly in this space.
The ulnar nerve will be
superficial.
If a paresthesia is obtained,
withdraw the needle slightly and
inject 3-5 ml of local anesthetic.
If no paresthesia, then
superficially infiltrate the area
with local anesthetic.
1/4/2018
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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
1/4/2018
91
Ulnar Nerve Block
 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
1/4/2018
92
Wrist block
1/4/2018
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Wrist block
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 Wrist block is a technique for blocking
branches of the ulnar, medial, and radial
nerves at the level of wrist.
 It is simple to perform and devoid of
systemic complications and highly
effective for variety of procedures on the
hand and fingers.
 Wrist block can be used in outpatient
setting, office setting, emergency setting
for repair of hand injuries in emergency
Indications and landmarks
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 Indications:
 Carpal tunnel and hand surgery
 Finger surgery
 Landmarks:
 Palmaris longus
 Flexor carpi radialis
 Ulnar artery
 Flexor carpi ulnaris
 Radial styloid
1/4/2018
96
Blockade of the Radial Nerve
at the Wrist
 At the wrist, the radial nerve is located
between the radial artery and flexor
carpi radialis tendon.
 The administration of 2-5 ml of local
anesthetic, deep to the flexor carpi
radialis will block the sensory branches
of the radial nerve which innervate the
lateral side of the thumb.
 Proximal to the wrist, dorsal branches
of the radial nerve provide sensation to
the dorsal aspect of the lateral three and
half fingers. This branch can be blocked
by placing a superficial field block at
the wrist.
1/4/2018
97
Blockade of the Median Nerve at
the Wrist
 Identify the Palmaris longus tendon and
flexor carpi radialis by asking the patient
to flex their wrist against resistance.
 It is marked at the proximal flexion
crease.
 Insert a 25G 25 mm needle between the
tendons of the Palmaris longus and
flexor carpi radialis at the level of the
proximal palmar crease and 3–5 mL of
anesthetic is injected.
 If a paresthesia is encountered, withdraw
the needle slightly and inject 3-5 ml of
local anesthetic.
 If no paresthesia is encountered, infiltrate
the area with 3-5 ml of local anesthetic.
98
Blockade of the Ulnar Nerve
at the Wrist
 The ulnar nerve, at the wrist, is located
lateral to the flexor carpi ulnaris tendon
and medial to the ulnar artery.
 Locate the pulsation of the ulnar artery
on the palmar surface of the wrist.
 Insert a 22-27 gauge blunted needle on
the medial side of the arterial pulsation.
 The ulnar nerve is superficial.
 If a paresthesia is obtained, pull back
slightly and inject 3-5 ml of local
anesthetic.
 If there is not a paresthesia, infiltrate
the area with local anesthetic.
1/4/2018
99
Digital nerve block
1/4/2018
100
 Indications:
 Surgery distal to the base of proximal
phalanx.
 Landmarks:
 Base of proximal phalanx
 Technique:
 Dorsal injection
 On the dorsolateral aspect of finger
 At the base of proximal phalanx
Digital nerve block…
1/4/2018
101
Palpate the metacarpophalangeal joint
and insert a 25G 25 mm needle
perpendicular to the skin just distal to
the joint.
 Advance the needle towards the palmar
surface, injecting 3 ml on each side of
the phalanx.
Insert a 25G 25 mm needle into the web
space to a depth of 2 cm, injecting 5 ml
of solution into each space; massage
Digital nerve block….
 These nerve blocks are used for minor
operations on the fingers and to supplement
brachial plexus blocks.
 Each digit has two dorsal and two palmar
branches of the digital nerve.
 A 23- to 25-gauge needle is inserted at the
medial and lateral aspects of the base of the
selected digit.
 A total of 2–3 mL of local anesthetic without
epinephrine is injected on each side near the
periosteum.
 Addition of a vasoconstrictor (epinephrine)
can seriously compromise blood flow to the
digit.
 Never administer more than 4 ml of total
volume per digit. 1/4/2018
102
anesthesia (IVRA)
Bier's
block
1/4/2018
103
 This simple method of providing
anesthesia of the distal arm or leg was
first described by August Bier in 1808.
 Indications
 (IVRA) is indicated for any procedure on
the arm below the elbow or leg below the
knee that will be completed within 40-60
minutes.
 Its use is limited to procedures lasting less
than an hour because of increasing
Indications:
 Closed fractures
 Burn debridement
 Removal of ground-in debris
 Abscess I&D
 Laceration repair
 Foreign body removal
 Limited surgical procedures
Contraindications
 Reynaud’s disease
 Homozygous sickle cell disease(the
tourniquet can precipitate a sickling crisis)
 Crush injuries
 Young Children
 Adrenaline in the LAs can cause gangrene of
the extremities
 Must have a reliable/operative tourniquet! If
this can not be guaranteed then this
technique should not be used due to risk of
toxicity! 1/4/2018
105
Conditions
1.Surgical procedures involving the arm
below the elbow.
2.Surgical procedures involving the leg
below the knee.
 Ensure that the patient has been fasting
for an appropriate period of time.
Equipments
A standard regional anesthesia tray is
prepared with the following equipment:
 22-gauge intravenous catheter
 Esmarch bandage
 Double cuff tourniquet
 20 mL syringes with LA
 Pressure source
 Resuscitation equipment
 Running IV in non-operative arm
Local Anesthetic Choice
1/4/2018
108
 Many local anesthetic agents have been used
for IVRA.
 However, because of side effects (e.g.,
Chloroprocaine: venous thrombosis; Prilocaine:
methemoglobinemia; Bupivacaine:
cardiotoxicity) should use cautiously.
 Lidocaine is currently the local anesthetic of
choice in a usual concentration of 0.5% with
volumes, in adults, of 30 mL (upper extremity
forearm tourniquet) and 50 mL (upper extremity
arm tourniquet or lower extremity leg
Local Anesthetic Choice…
1/4/2018
109
 It is essential that plain and not adrenaline-
containing solutions are used.
 Bupivacaine is not suitable and should never be
employed as it is too toxic, particularly to the
myocardium.
 A suitable dose to use in an arm is 40ml of 0.5%
Prilocaine (or 0.5% lignocaine).
 This can be increased to 50ml in muscular
individuals or decreased to 30ml in small or frail
patients. Larger volumes are necessary in the leg
e.g. 50-60ml.
 Maximum recommended volumes for a 60-70 kg
patient are 400mg Prilocaine (80ml 0.5% solution)
or 250mg lignocaine (50ml 0.5% solution).
1. Premedicate the patient appropriately.
2. A small IV intravenous catheter (e.g, 22-
gauge) is introduced in the dorsum of the
patient's hand of the arm to be
anesthetized. The patient is in the supine
position.
Technique
3. A tourniquet is
placed on the proximal
arm of the extremity to
be blocked. We use a
"double cuff" to increase
the reliability of the
technique and help reduce
the tourniquet pressure pain.
Inflate the cuff to 100 mm/Hg above the systolic
blood pressure. Clamp the cuff to prevent
leakage.
Techniques
Techniques
1/4/2018
112
4. Insert an indwelling cannula on the side
opposite that to be blocked as distally as
possible.
5. Monitor the blood pressure on the side
opposite that to be blocked. Use pulse
oximetry and ECG if available.
5. Insert an indwelling needle (scalp vein
needle or cannula 21G) and secure it with
a piece of strapping.
6. Apply wide
Esmarch rubber
bandage to
complete the
exsanguination
of the extremity.
Techniques
7. Elevate arm to
promote venous
drainage. The
Esmarch is then
unwrapped and the
extremity is checked
for color (pale skin)
and arterial
occlusion
(absence of the radial
Techniques
6.The extremity is then lowered and the
local anesthetic is slowly injected
through the previously inserted IV
catheter.
Techniques
Rules for deflating the cuff:
1/4/2018
116
 It is advisable to wait 20 minutes after the injection
of the lignocaine before the cuff is deflated. Then
the cuff can be deflated in one step, over 2-3
minutes.
 If the cuff has to be deflated before the 20 minutes
are up, the deflation must be done in steps, i.e.
deflate quickly and then inflate again. This must
be done several times before the cuff is finally
deflated.
 Always watch the patient very carefully for the
next 15 minutes after deflation of the cuff for signs
of toxicity of the local anaesthetic solution.
 It is important not to leave the tourniquet on for
 If use double tourniquet on the operative
arm.
Proximal Cuff
Distal Cuff
1/4/2018
117
Technique….
Technique
 Have patient hold arm
up.
 Use Eschmark to
exsanguinate the arm
 Exsanguinate the arm
from distal to
proximal.
 Inflate the proximal
tourniquet to 150
mmHg over the1/4/2018
118
1/4/2018
119
 Confirm the absence of a radial pulse.
 Inject your local (0.5% Lidocaine or
Prilocaine in a dose of 3 mg/kg).
 Remove IV catheter, hold pressure and
have OR staff prep arm. Onset of
anesthesia should occur in 5 minutes.
 When the patient complains of pain you
can inflate the distal tourniquet and then
deflate the proximal tourniquet
Technique….
Minimum time for tourniquet
inflation
 The tourniquet should be up for at least 25
minutes…releasing it before this may
result in toxicity.
 Releasing the tourniquet in cyclic
deflations (10 second intervals) will
decrease peak levels of local anesthetic.
1/4/2018
120
 If the operation is prolonged, the patient may
complain of pain due to pressure from the
tourniquet. This may be reduced either by the
subcutaneous infiltration of a few mls of local
anesthetic above the tourniquet or by the use of a
"double tourniquet technique”.
 At the end of the procedure, the tourniquet is
deflated and normal sensation quickly returns.
 The tourniquet is reinflated again 20-30 seconds.
Post procedure
Advantages of the Bier Block
 Easy to administer
 Low incidence of block failure
 Safe technique when used appropriately
 Rapid onset and recovery
 Patient is awake during procedure.
 Controllable extent of anesthesia.
Disadvantages of the Bier Block
 Should be used for only short procedures
 Patient may experience tourniquet pain
after 20-30 minutes
 Sudden cardiovascular collapse or
seizures may occur if local anesthetic is
released into the circulation too early.
 Lose pulse
 Rapid recovery may lead to postoperative
pain
 Difficulty in providing a bloodless field
Complications
1. Tourniquet discomfort
2. Rapid return of sensation after tourniquet
release and subsequent surgical pain.
3. Toxic reactions from malfunctioning
tourniquets or deflating the tourniquet prior
to the 25 minute limit.
4. Toxicity of local anesthetics
 Signs and symptoms may include nausea,
vomiting, dizziness, tinnitus, funny
sensation around the mouth, loss of
1/4/2018
124
Local Anesthetic Toxicity
Management
 Use the A, B, C’s for the management
of local anesthetic toxicity.
 A= airway. administer 100% oxygen.
 B= breathing. May need to assist the
patient with positive pressure
ventilation or intubation.
 C= circulation. Check for a pulse..
Complications...
Drugs
1.Prilocaine
 It is least toxic
 largest therapeutic index.
 One complication is methemoglobinemia .
Prilocaine is metabolized to o-toluidine
derivatives, which converts hemoglobin to
methemoglobin.
 Onset 2 - 15minute and duration 1 – 4hours.
2.Bupivacaine
 not suitable
 it is too toxic, particularly to the myocardium.
 Slower onset .
3.Lignocaine/Lidocaine
 Acceptable alternative or drug of
choice.
 Onset 1.5 - 5minute and duration 1 –
3hours.
Dosage
 The arm dosage can be: 30-40 ml of
0.5% Prilocaine or 0.5 % Lidocaine.
 In leg, larger volumes 50-60 ml.
Drugs …
Conclusion
 IVRA is a simple and valuable technique
that is easy to learn and perform. It is very
safe provided excessive doses of local
anesthetic are avoided, if the tourniquet
pressure is carefully monitored and if
resuscitation equipment is always
immediately available.
References
1/4/2018
129
1. Miller 7th edition
2. Sobotta: atlas of human anatomy
3. Myoclinical analgesia pathway & PNB
4. The abbott pocket guide to practical peripheral
nerve block
5. Barash,6th edition
6. Peripheral regional anaesthesia: Tutorial in Ulm
rehabilitation hospital.
7. Peripheral Nerve Blocks: A Color Atlas, 3rd ed.
8. Text book of regional Anaesthesia and acute
pain management.
9. Oxford hand book of anaesthesia.
1/4/2018
130

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Upper limb blocks

  • 1. UPPER LIMB BLOCKS BRACHIAL PLEXUS BLOCK Abraham Tarekegn University of Gondar, Department of Anesthesia 1/4/2018 1
  • 2. Outlines  General description of each nerves  Indications  Landmarks  Preparation  Needle  Depth  Directions  Volume of LAs  Technique  Side effects & Complications 1/4/2018 2
  • 3. The Brachial Plexus  Supplies all of the motor and almost all of the sensory function of the upper extremity.  The plexus is formed from the anterior primary rami of the fifth cervical to the first thoracic roots.  Contributions may also be received from C4 to T2.  Blockade of the brachial plexus can provide surgical anesthesia of the hands, upper/lower arm, and shoulder depending on the approach. 1/4/2018 3
  • 4. Major Motor Function of the Individual Nerves of the Brachial Plexus Nerve Major Motor Function Axillary Abduction of the shoulder Musculocutaneous Flexion of the elbow Radial Extension of the elbow, wrist, & finger Median Flexion of the wrist & finger Ulnar Flexion of the wrist & finger 1/4/2018 4
  • 8. These nerves (C5 - T1) leave intervertebral foramina - Root  Trunk-they unite to form three trunks between the anterior and middle scalene muscles. Upper, middle, and The Brachial Plexus…. 8
  • 9. At the first rib each trunk will separate into anterior and posterior divisions.  As the brachial plexus emerges under the clavicle, the anterior and posterior divisions come together to The Brachial Plexus….The Brachial Plexus…. 9
  • 10. The lateral cord is lateral to the axillary artery; The posterior cord is located posterior to the axillary artery; and The medial cord is located medial to the axillary artery. At the lateral border of the pectoralis minor muscle, each cord divides into branches, terminating in The Brachial Plexus….The Brachial Plexus…. 1/4/2018 10
  • 11. Techniques and use of brachial plexus The brachial plexus is enveloped by a facial sheath which allows for the administration of brachial plexus anesthesia. Injection into the sheath, at any anatomical point, will allow for the spread of local anesthetics and subsequent blockade. Choice of a specific 1/4/2018 11
  • 12. 12
  • 15.
  • 16. Interscalene approach: Anatomy:  Cervical nerves (C5-T1) course antero- laterally and inferiorly to lie between 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. 1/4/2018 16
  • 17. Brachial Plexus Anatomy  Interscalene block  At level of Distal Roots/ Proximal Trunks 1/4/2018 17
  • 18. Anatomy - Nerves lie in the Interscalene groove  Between anterior and middle scalene muscles  Posterior/Lateral to Sternocleidomastoid muscle (clavicular head) - Posterior to Phrenic Nerve 1/4/2018 18
  • 19. Anatomy…  Vertebral artery (VA) is medial to the anterior scalene muscle (AS)  Phrenic nerve (PN) overlies the anterior scalene muscle.  C5 and C6 nerve roots join to form 1/4/2018 19
  • 21. Interscalene nerve block  Between 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. 1/4/2018 21
  • 22. Indications of interscalene block  Surgery of  Shoulder  Distal clavicle  Proximal Humerus  Elbow  Open shoulder surgery  Arthroscopic surgery 1/4/2018 22
  • 23. Interscalene nerve block...  Landmarks Posterior boarder of SCM Upper border of Cricoid cartilage Subclavian artery - above the clavicle external jugular vein  interscalene groove. 1/4/2018 23
  • 24. Interscalene nerve block :Equipments  All resuscitation materials (GA)  Syringes: two 10mls or 20mls  Antiseptic solution  Nerve stimulator  50mm -insulated needle (depth=35- 50mm) 1/4/2018 24
  • 25. Interscalene nerve block : Drugs  1% lidocaine,1% Prilocaine  0.25-0.5% Bupivacaine  Deltoid (shoulder surgery): 10-20ml.  Elbow ( humerus): 20-40ml. 1/4/2018 25
  • 26. Interscalene nerve block : Techniques The patient should be supine, with one small pillow under their head and neck. The head should be turned comfortably to the opposite side. At the level of the cricoid cartilage draw a line laterally to intersect the posterior border of the sternocleidomastoid; this usually corresponds to where the external jugular vein crosses. 1/4/2018 26
  • 27. Palpate the scalene anterior underneath the lateral border of the sternomastoid. Moving the fingers laterally, palpate the interscalene groove, between the scalenus anterior and medius. To aid palpation ask the patient to their lift head gently off the pillow (contracting the sternomastoid) or sniff (contracting scalene muscles). Interscalene nerve block : Techniques 1/4/2018 27
  • 28. Stand to the side of patient or at their head, raise a weal and insert a 22G 25 mm/50 mm needle of choice perpendicular to the skin in all directions with a slight caudad direction. On entering the prevertebral fascia sheath a pop may be elicited; advance until paraesthesia or specific motor stimulation is achieved (peripheral nerve stimulation). After careful aspiration inject 10–20 ml for Interscalene nerve block : Techniques 1/4/2018 28
  • 31. 31 1. Cricoid cartilage 4. Puncture site for anterior access 2. Superior thyroid notch 5. Vertical, infraclavicular puncture site 3. SCM Meier’s approach
  • 32. Nerve Stimulator Technique  Roll fingers posteriorly off lateral border of SCM muscle  Palpate Interscalene Groove between two fingers  Beware of nearby External1/4/2018 32
  • 33. Nerve Stimulator Technique  Insert needle slightly posterior and caudad.  Watch for twitches of bicep, tricep, forearm, or hand  Diaphram twitch= phrenic nerve=too anterior.  nerve block vedio 1/4/2018 33
  • 34. Interscalene nerve block  Side effects:  Phrenic nerve block -98%  RLN block -15%  Stellate ganglion block -20%  Horner’s Syndrome  Complications:  Inadvertent intravascular injection  Pneumothorax –very low incidence 1/4/2018 34
  • 35. 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.1/4/2018 35
  • 37.  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.  The lower trunk may lie under the subclavian artery.  The subclavian vein is anterior to the anterior1/4/2018 37 Supraclavicular approach: Anatomy
  • 38. 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 1/4/2018 38
  • 39. 39  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 1/4/2018
  • 40. 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. 1/4/2018 40
  • 41. 41 Position for needle insertion for subclavian perivascular block Best method 1/4/2018
  • 42.  Puncture site: Immediate dorso-lateral from the palpated pulsation of the subclavian artery and1 cm behind the midpoint of the clavicle.  Paresthesia will usually be immediately elicited.  If no paresthesia assess up to the first rib. Techniques 1/4/2018 42
  • 43.  If no paraesthesiae or twitch are elicited, withdraw the needle almost to skin and redirect gently more anteriorly or posteriorly.  If accidental arterial puncture -move needle posteriorly.  If you contact 1st rib -walk anterio-posteriorly along rib. 1/4/2018 43 Techniques...
  • 44. 44  Stimulation:  Flexion or extension of wrist and fingers  Dose: 0.5ml/kg to 40mls  Side effects:  Horner’s syndrome  RLN block  Complications:  Vascular puncture  Inadvertent intravascular injection  Pneumothorax 1/4/2018
  • 45. 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 1/4/2018 45
  • 47. 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 1/4/2018 47
  • 49. Landmarks:  Anterior process of the acromion  Jugular/ sternal notch  Subclavian artery 1/4/2018 49
  • 50. Equipments and drugs  Equipments - All resuscitation materials -50mm insulated needle ( depth= 2-5cm) -Three 20ml syringes -Nerve stimulator  Drugs: 1% lidocaine, 0.25-0.5% 1/4/2018 50
  • 51. 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 1/4/2018 51
  • 52. 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. 1/4/2018 52
  • 53. Stimulation  Wrist/finger extension- accept, posterior cord  Dose: 0.5mg/kg to 50ml 1/4/2018 53
  • 54. Stimulation  Pectoral muscle twitch- don’t= needle too medial or superficial 1/4/2018 54
  • 55. Stimulation  Elbow flexion- don’t = lateral cord, needle too lateral or superficial 1/4/2018 55
  • 56. 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 1/4/2018 56
  • 57. Side effects/complications  Horner syndrome  Vessel puncture (cephalic vein, subclavian artery and vein and their branches)  Pneumothorax  Inadvertent intravascular injection 1/4/2018 57
  • 58. Axillary nerve block  The most commonly practiced block.  For surgical procedures from the elbow to the hand.  There is intense blockade of C7-T1 (forearm and hand surgery).  Not adequate for the shoulder and upper arm (C5-6).  Easy to perform and has few complications.  Axillary brachial plexus block is most effective for surgical procedures distal to the1/4/2018 58
  • 60.  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 1/4/2018 60 Axillary nerve block...
  • 61. Anatomic consideration  Beneath the clavicle, the subclavian artery becomes the axillary artery.  Behind the clavicle, at the apex of the axilla the brachial plexus splits from upper, middle, and lower trunks into anterior and posterior divisions.  The anterior and posterior divisions travel to the lateral border of the pectoralis minor and form the lateral, posterior, and medial cords. 1/4/2018 61
  • 62. 1/4/2018 62  The cords split to form individual nerves that innervate the arm.  Other branches of the plexus arise from the neck and axilla, directly from the roots, trunks, and cords.  Knowledge of where each individual nerve is located within the sheath is important.  The median nerve is superior to the axillary artery.  The ulnar nerve is inferior to the axillary artery.  The radial nerve is inferior and posterior to the axillary artery.  The musculocutaneous nerve has already separated from the brachial plexus, traveling within the coracobrachialis muscle. Anatomic consideration….
  • 63. Indications  Elbow, forearm and hand surgery  Operations in the arm (distal upper arm, lower arm, hand)  Continuous analgesia  Pain syndrome  Sympathicolysis  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. 1/4/2018 63
  • 64. Landmarks  Axillary artery pulse : most important landmark.  Median nerve superior, ulnar nerve inferior, and the radial nerve is posterior and lateral.  Insertion of major pectoralis muscle  Coracobrachialis 1/4/2018 64
  • 66. 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. 1/4/2018 66
  • 67. 1. The patient lies supine with the arm extended 90 degrees from the side & flexed at the elbow Extension beyond 90 degrees potentially compresses the axillary artery because of the pressure from the head of the humerus & may make identification of the landmarks more difficult Techniques : 1/4/2018 67
  • 68. Techniques.... 1/4/2018 68 2. Axillary artery is marked as high in its course in the axilla as is practical.  Usually felt in the intramuscular groove between the coracobrachialis & triceps muscles  Also passes between the insertions of the pectoralis major & latissimus dorsi muscles on the humerus.
  • 70. Techniques.... 3. After aseptic preparation, a skin wheal is raised over the proximal portion of the artery  Index & middle fingers of the nondominant hand straddle the artery just below this point, both localizing the pulsation & compressing the neurovascular bundle below the intended site of injection. 1/4/2018 70
  • 71. 1/4/2018 71  At this point raise a weal, and fixing the artery against the humerus with the index and middle fingers insert a 22G 50 mm needle angled slightly proximally to pass either above or below the artery to contact either median or ulnar nerve respectively.  A perceptible click or pop is felt on entering the fascial sheath, and paraesthesia or specific motor responses can be elicited.  nerve block vedio Techniques....
  • 72. 1/4/2018 72  Needle; 22-25G/25-50mm insulated/uninsulated.  Direction; 45° to the skin, proximally  Depth; 10-15mm  Volume; single injection: 0.5ml/kg up to 50mls.  Inject 40-50ml of LA increments.  LA; 1% Lidocaine, 1% Prilocaine 0.25%-0.5% Levobupivacaine Techniques....
  • 73. Axillary nerve block: Different techniques Four different techniques can be employed:  Transarterial; injecting 20 ml of solution both anterior and posterior to the artery.  Multiple injections; finding each of the four nerves separately, the success of the block being increased when each successive nerve is identified.  Single loss of resistance using a short bevelled needle; fascial click, injecting after either through the needle or after insertion of a cannula.  Infiltration; fanwise injection of 15 ml of1/4/2018 73
  • 74. Multiple injections:  Around each individual nerve is most reliable.  It may require less volume(7-10ml each nerve).  But the minimum required dose/volume per nerve is not well known .  Nerve & vascular injury? 1/4/2018 74
  • 75. Stimulations: Index or middle finger flexion -median nerve Thumb abduction or little finger flexion – ulnar Thumb extension –radial Elbow flexion –musculocutaneous nerve 1/4/2018 75
  • 76. Clinical tips 1/4/2018 76  Single injection almost always misses two nerves from getting blocked.  The musculo-cutaneous nerve: which supplies the lateral side of the forearm. It is important to inject as high as possible in the axilla in order to block this nerve. If it has not been blocked, inject 5ml of local anaesthetic solution at a point 2.5cm distal to the elbow crease and lateral to the biceps tendon.  The intercostobrachial nerve: which supplies the medial half of the upper arm. This is blocked by injecting the last few ml of local anaesthetic as the needle is withdrawn.
  • 77. Complications:  Block failure  Bleeding and haematoma  Inadvertent vascular injection  Toxicity due to absorption of LA  Infection  Nerve damage 1/4/2018 77
  • 78. 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 plexus1/4/2018 78
  • 79. 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.  The radial nerve pierces the lateral intramuscular septum on its way to the forearm, and lies between the brachialis muscle and the brachioradialis muscle1/4/2018 79
  • 81. 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. 1/4/2018 81
  • 82. Indication and landmarks 1/4/2018 82  Indications  Elbow blocks are indicated for surgery on the forearm and hand.  Landmarks:  flexion crease of the elbow, brachial artery, biceps tendon, medial and lateral epicondyles.  In all cases the arm should be slightly abducted with the elbow slightly flexed, the forearm supinated.
  • 83. Blockade of median nerve  At the elbow, the median nerve is located medial to the brachial artery near the insertion of the biceps tendon. 1/4/2018 83
  • 84. Blockade of median nerve  Identify the brachial artery in the antecubital space.  It is generally located medially, at the biceps tendon insertion.  Insert a 22-27 gauge, 4 cm blunted needle medial to the brachial artery. Direct the needle toward the medial epicondyle.  A click may be felt as the needle pierces the deep fascia, and paraesthesia or a motor response elicited.  Continue insertion of the needle until bone is contacted.  At this point withdraw the needle 1 cm and inject 3-5 ml of local anesthetic. 1/4/2018 84
  • 86. Radial nerve block  Block of the radial nerve provides anesthesia to the lateral aspect of the dorsum of the hand (thumb side) and the proximal portion of the thumb, index, middle, and lateral half of the ring fingers. 1/4/2018 86
  • 87. Blockade of the Radial Nerve  Identify the lateral aspect of the biceps tendon at the crease of the elbow.  Insert a 22-27 gauge, 4 cm blunted needle parallel to the forearm.  Direct the needle toward the lateral epicondyle.  If a paresthesia is encountered, withdraw the needle slightly, and inject 5 ml of local anesthetic. Do not inject if the patient complains of a paresthesia. If no paresthesia is encountered, continue to insert the needle until bone is encountered.  Withdraw the needle 1 cm and inject 5 ml of local anesthetic. 1/4/2018 87
  • 88. Ulnar nerve block  Used to supplement a patchy axillary or interscalene block or for minor surgical procedures in the distribution of the ulnar nerve.  At the elbow, the ulnar nerve can be palpated proximal to the medial epicondyle. 1/4/2018 88
  • 89. Ulnar nerve block position 1/4/2018 89
  • 90. Blockade of the Ulnar Nerve at the Elbow To anesthetize the ulnar nerve at the elbow, have the patient flex their arm 90 degrees. Identify the olecranon process and the medial condyle. The ulnar nerve can be palpated between these two structures. Insert a 22-27 gauge blunted needle slowly in this space. The ulnar nerve will be superficial. If a paresthesia is obtained, withdraw the needle slightly and inject 3-5 ml of local anesthetic. If no paresthesia, then superficially infiltrate the area with local anesthetic. 1/4/2018 90
  • 91. 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 1/4/2018 91
  • 92. Ulnar Nerve Block  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 1/4/2018 92
  • 94. Wrist block 1/4/2018 94  Wrist block is a technique for blocking branches of the ulnar, medial, and radial nerves at the level of wrist.  It is simple to perform and devoid of systemic complications and highly effective for variety of procedures on the hand and fingers.  Wrist block can be used in outpatient setting, office setting, emergency setting for repair of hand injuries in emergency
  • 95. Indications and landmarks 1/4/2018 95  Indications:  Carpal tunnel and hand surgery  Finger surgery  Landmarks:  Palmaris longus  Flexor carpi radialis  Ulnar artery  Flexor carpi ulnaris  Radial styloid
  • 97. Blockade of the Radial Nerve at the Wrist  At the wrist, the radial nerve is located between the radial artery and flexor carpi radialis tendon.  The administration of 2-5 ml of local anesthetic, deep to the flexor carpi radialis will block the sensory branches of the radial nerve which innervate the lateral side of the thumb.  Proximal to the wrist, dorsal branches of the radial nerve provide sensation to the dorsal aspect of the lateral three and half fingers. This branch can be blocked by placing a superficial field block at the wrist. 1/4/2018 97
  • 98. Blockade of the Median Nerve at the Wrist  Identify the Palmaris longus tendon and flexor carpi radialis by asking the patient to flex their wrist against resistance.  It is marked at the proximal flexion crease.  Insert a 25G 25 mm needle between the tendons of the Palmaris longus and flexor carpi radialis at the level of the proximal palmar crease and 3–5 mL of anesthetic is injected.  If a paresthesia is encountered, withdraw the needle slightly and inject 3-5 ml of local anesthetic.  If no paresthesia is encountered, infiltrate the area with 3-5 ml of local anesthetic. 98
  • 99. Blockade of the Ulnar Nerve at the Wrist  The ulnar nerve, at the wrist, is located lateral to the flexor carpi ulnaris tendon and medial to the ulnar artery.  Locate the pulsation of the ulnar artery on the palmar surface of the wrist.  Insert a 22-27 gauge blunted needle on the medial side of the arterial pulsation.  The ulnar nerve is superficial.  If a paresthesia is obtained, pull back slightly and inject 3-5 ml of local anesthetic.  If there is not a paresthesia, infiltrate the area with local anesthetic. 1/4/2018 99
  • 100. Digital nerve block 1/4/2018 100  Indications:  Surgery distal to the base of proximal phalanx.  Landmarks:  Base of proximal phalanx  Technique:  Dorsal injection  On the dorsolateral aspect of finger  At the base of proximal phalanx
  • 101. Digital nerve block… 1/4/2018 101 Palpate the metacarpophalangeal joint and insert a 25G 25 mm needle perpendicular to the skin just distal to the joint.  Advance the needle towards the palmar surface, injecting 3 ml on each side of the phalanx. Insert a 25G 25 mm needle into the web space to a depth of 2 cm, injecting 5 ml of solution into each space; massage
  • 102. Digital nerve block….  These nerve blocks are used for minor operations on the fingers and to supplement brachial plexus blocks.  Each digit has two dorsal and two palmar branches of the digital nerve.  A 23- to 25-gauge needle is inserted at the medial and lateral aspects of the base of the selected digit.  A total of 2–3 mL of local anesthetic without epinephrine is injected on each side near the periosteum.  Addition of a vasoconstrictor (epinephrine) can seriously compromise blood flow to the digit.  Never administer more than 4 ml of total volume per digit. 1/4/2018 102
  • 103. anesthesia (IVRA) Bier's block 1/4/2018 103  This simple method of providing anesthesia of the distal arm or leg was first described by August Bier in 1808.  Indications  (IVRA) is indicated for any procedure on the arm below the elbow or leg below the knee that will be completed within 40-60 minutes.  Its use is limited to procedures lasting less than an hour because of increasing
  • 104. Indications:  Closed fractures  Burn debridement  Removal of ground-in debris  Abscess I&D  Laceration repair  Foreign body removal  Limited surgical procedures
  • 105. Contraindications  Reynaud’s disease  Homozygous sickle cell disease(the tourniquet can precipitate a sickling crisis)  Crush injuries  Young Children  Adrenaline in the LAs can cause gangrene of the extremities  Must have a reliable/operative tourniquet! If this can not be guaranteed then this technique should not be used due to risk of toxicity! 1/4/2018 105
  • 106. Conditions 1.Surgical procedures involving the arm below the elbow. 2.Surgical procedures involving the leg below the knee.  Ensure that the patient has been fasting for an appropriate period of time.
  • 107. Equipments A standard regional anesthesia tray is prepared with the following equipment:  22-gauge intravenous catheter  Esmarch bandage  Double cuff tourniquet  20 mL syringes with LA  Pressure source  Resuscitation equipment  Running IV in non-operative arm
  • 108. Local Anesthetic Choice 1/4/2018 108  Many local anesthetic agents have been used for IVRA.  However, because of side effects (e.g., Chloroprocaine: venous thrombosis; Prilocaine: methemoglobinemia; Bupivacaine: cardiotoxicity) should use cautiously.  Lidocaine is currently the local anesthetic of choice in a usual concentration of 0.5% with volumes, in adults, of 30 mL (upper extremity forearm tourniquet) and 50 mL (upper extremity arm tourniquet or lower extremity leg
  • 109. Local Anesthetic Choice… 1/4/2018 109  It is essential that plain and not adrenaline- containing solutions are used.  Bupivacaine is not suitable and should never be employed as it is too toxic, particularly to the myocardium.  A suitable dose to use in an arm is 40ml of 0.5% Prilocaine (or 0.5% lignocaine).  This can be increased to 50ml in muscular individuals or decreased to 30ml in small or frail patients. Larger volumes are necessary in the leg e.g. 50-60ml.  Maximum recommended volumes for a 60-70 kg patient are 400mg Prilocaine (80ml 0.5% solution) or 250mg lignocaine (50ml 0.5% solution).
  • 110. 1. Premedicate the patient appropriately. 2. A small IV intravenous catheter (e.g, 22- gauge) is introduced in the dorsum of the patient's hand of the arm to be anesthetized. The patient is in the supine position. Technique
  • 111. 3. A tourniquet is placed on the proximal arm of the extremity to be blocked. We use a "double cuff" to increase the reliability of the technique and help reduce the tourniquet pressure pain. Inflate the cuff to 100 mm/Hg above the systolic blood pressure. Clamp the cuff to prevent leakage. Techniques
  • 112. Techniques 1/4/2018 112 4. Insert an indwelling cannula on the side opposite that to be blocked as distally as possible. 5. Monitor the blood pressure on the side opposite that to be blocked. Use pulse oximetry and ECG if available. 5. Insert an indwelling needle (scalp vein needle or cannula 21G) and secure it with a piece of strapping.
  • 113. 6. Apply wide Esmarch rubber bandage to complete the exsanguination of the extremity. Techniques
  • 114. 7. Elevate arm to promote venous drainage. The Esmarch is then unwrapped and the extremity is checked for color (pale skin) and arterial occlusion (absence of the radial Techniques
  • 115. 6.The extremity is then lowered and the local anesthetic is slowly injected through the previously inserted IV catheter. Techniques
  • 116. Rules for deflating the cuff: 1/4/2018 116  It is advisable to wait 20 minutes after the injection of the lignocaine before the cuff is deflated. Then the cuff can be deflated in one step, over 2-3 minutes.  If the cuff has to be deflated before the 20 minutes are up, the deflation must be done in steps, i.e. deflate quickly and then inflate again. This must be done several times before the cuff is finally deflated.  Always watch the patient very carefully for the next 15 minutes after deflation of the cuff for signs of toxicity of the local anaesthetic solution.  It is important not to leave the tourniquet on for
  • 117.  If use double tourniquet on the operative arm. Proximal Cuff Distal Cuff 1/4/2018 117 Technique….
  • 118. Technique  Have patient hold arm up.  Use Eschmark to exsanguinate the arm  Exsanguinate the arm from distal to proximal.  Inflate the proximal tourniquet to 150 mmHg over the1/4/2018 118
  • 119. 1/4/2018 119  Confirm the absence of a radial pulse.  Inject your local (0.5% Lidocaine or Prilocaine in a dose of 3 mg/kg).  Remove IV catheter, hold pressure and have OR staff prep arm. Onset of anesthesia should occur in 5 minutes.  When the patient complains of pain you can inflate the distal tourniquet and then deflate the proximal tourniquet Technique….
  • 120. Minimum time for tourniquet inflation  The tourniquet should be up for at least 25 minutes…releasing it before this may result in toxicity.  Releasing the tourniquet in cyclic deflations (10 second intervals) will decrease peak levels of local anesthetic. 1/4/2018 120
  • 121.  If the operation is prolonged, the patient may complain of pain due to pressure from the tourniquet. This may be reduced either by the subcutaneous infiltration of a few mls of local anesthetic above the tourniquet or by the use of a "double tourniquet technique”.  At the end of the procedure, the tourniquet is deflated and normal sensation quickly returns.  The tourniquet is reinflated again 20-30 seconds. Post procedure
  • 122. Advantages of the Bier Block  Easy to administer  Low incidence of block failure  Safe technique when used appropriately  Rapid onset and recovery  Patient is awake during procedure.  Controllable extent of anesthesia.
  • 123. Disadvantages of the Bier Block  Should be used for only short procedures  Patient may experience tourniquet pain after 20-30 minutes  Sudden cardiovascular collapse or seizures may occur if local anesthetic is released into the circulation too early.  Lose pulse  Rapid recovery may lead to postoperative pain  Difficulty in providing a bloodless field
  • 124. Complications 1. Tourniquet discomfort 2. Rapid return of sensation after tourniquet release and subsequent surgical pain. 3. Toxic reactions from malfunctioning tourniquets or deflating the tourniquet prior to the 25 minute limit. 4. Toxicity of local anesthetics  Signs and symptoms may include nausea, vomiting, dizziness, tinnitus, funny sensation around the mouth, loss of 1/4/2018 124
  • 125. Local Anesthetic Toxicity Management  Use the A, B, C’s for the management of local anesthetic toxicity.  A= airway. administer 100% oxygen.  B= breathing. May need to assist the patient with positive pressure ventilation or intubation.  C= circulation. Check for a pulse.. Complications...
  • 126. Drugs 1.Prilocaine  It is least toxic  largest therapeutic index.  One complication is methemoglobinemia . Prilocaine is metabolized to o-toluidine derivatives, which converts hemoglobin to methemoglobin.  Onset 2 - 15minute and duration 1 – 4hours. 2.Bupivacaine  not suitable  it is too toxic, particularly to the myocardium.  Slower onset .
  • 127. 3.Lignocaine/Lidocaine  Acceptable alternative or drug of choice.  Onset 1.5 - 5minute and duration 1 – 3hours. Dosage  The arm dosage can be: 30-40 ml of 0.5% Prilocaine or 0.5 % Lidocaine.  In leg, larger volumes 50-60 ml. Drugs …
  • 128. Conclusion  IVRA is a simple and valuable technique that is easy to learn and perform. It is very safe provided excessive doses of local anesthetic are avoided, if the tourniquet pressure is carefully monitored and if resuscitation equipment is always immediately available.
  • 129. References 1/4/2018 129 1. Miller 7th edition 2. Sobotta: atlas of human anatomy 3. Myoclinical analgesia pathway & PNB 4. The abbott pocket guide to practical peripheral nerve block 5. Barash,6th edition 6. Peripheral regional anaesthesia: Tutorial in Ulm rehabilitation hospital. 7. Peripheral Nerve Blocks: A Color Atlas, 3rd ed. 8. Text book of regional Anaesthesia and acute pain management. 9. Oxford hand book of anaesthesia.

Editor's Notes

  1. - Horner's syndrome - a syndrome marked by sinking in of the eyeball, contraction of the pupil, drooping of the upper eyelid, and vasodilation and anhidrosis of the face, and caused by paralysis of the cervical sympathetic nerve fibers on the affected side. Horner’s Syndrome= Ptosis, Miosis,,, -Phrenic Nerve Block = diaphragm, Dyspnea ,,, Recurrent Laryngeal Nerve Block=Hoarseness,,,, Vascular Puncture(Several nearby vessels): Carotid, Vertebral Artery