upper limb reginal block using ultrasound

1. ULTRASOUND GUIDED PERIPHERAL
NERVE BLOCK
-UPPER LIMB
RAZIMAN ABDUL RAZAK
JAB. ANESTHESIOLOGI & RAWATAN RAPI
HOSPITAL AMPANG

4. Contents:
1. Advantages/ Disadvantages
2. Indication/ Contraindication
3. Methodology
 Checklist
 Anatomy/ sonoanotomy
 Common upper limb nerve block
4. Questions/ answers/ discussions

5. Avoid GA and
problem with GA
Post-operative pain
Stable
haemodynamic
Not contraindicated
in patient with
coagulopaty/ sepsis/
fixed cardiac output
ADVANTAGES

6. Patchy block/ not
dense
Slow onset
LA toxicity
Others; hematoma,
pneumathorax etc
Difficult (operator
dependant)
DISADVANTAGES

7. Direct
visualisation
Avoid
intravenous/
pleura
Reduce the dose
of LA
Easier to
learn
ULTRASOUND GUIDED PNB

8. INDICATION
• Patient refusal
• Allergic to LA
• Relative:
coagulopathy,
sepsis
CONTRAINDICATION
• Limbs operation
• Limbs physiotherapy
• Arterial spasm
INDICATIONS/ CONTRAINDICATIONS

9. METHODOLOGY
Procedure Checklist
Consent Aseptic technique
Indication L.A. to skin
Contraindication Needle
Emergency Drug Technique
GA machine & US Equipment End point
IV Drip Dosage
Full monitoring Complication
Patient positioning Anaesthesia
Landmark

12. Simplified Diagram

14. Interscalene Approach Brachial Plexus Block

15. Indications
 Shoulder surgery
 Proximal arm surgery
 Lateral clavicle surgery
 Less useful in forearm & hand surgery

16. Complications
Horner’s Syndrome ( 10-25% )
Phrenic nerve paresis ( 100 % )
Recurrent Laryngeal nerve paresis ( 5-10% )
Vertebral artery injection
Epidural & Subarachnoid injection

19. LA injection
Volume : 15 mls for analgesia
Volume : 30-40 mls for surgical anaesthesia

20. • Supraclavicular Approach Brachial plexus
Block

21. Supraclavicular plexus block
Block – Level of Trunk
Anaesthetize entire plexus ( compact nature )
Most complete block
Rapid onset

22. complications
I. Pneumothorax ( 0.5-25 % )
II. Phrenic & Recurrent laryngeal nerve paresis
III. Subclavian artery puncture ( 20 % )

25. Local anaesthetic spread
Pre LA injection Post LA injection
Site : LA volume above the first rib + lateral to subclavian artery
( for lower BP trunk block for distal limb surgery )
Volume : 25 – 40 mls

26. • Infraclavicular Approach Brachial Plexus Block

28. indications
Block – at level of trunk
For elbow, forearm and hand surgery

29. Contraindications
Chest deformity
Dislocated clavicle
Coagulopathy
Complications
Horner’s syndrome
Phrenic paresis
Vessels puncture ( 15% )
Pneumothorax ( < 0.5 % )

30. anatomy
AA – axillary artery
AV - axillary vein
CP - coracoid process
BP – cords of brachial plexus
PMiM – pectoralis minor muscle

31. Probe positioning
• l
Linear 7 MHz US transducer
Medial to coracoid process
Parasagittal plane
Depth of field 3-5 cm
Surface landmark

32. Nerve localization
INTERMEDIATE skill level
From superficial to deep scan
AA & AV deep to pectoralis minor
Look hyper-echoic structures in relation to AA
LC - cephalad 9-12 o’clock
PC - posterior 6-9 o’clock
MC - caudad 3-6 o’clock

33. In plane approach
Recommended for continuous needle visualization &
tip movement Aim to place needle tip &
LA volume posterior to
AA
adjacent to posterior
cord
U shape spread around
AA leads to complete
blockade of arm, forearm
& hand
10-15 mls LA post to AA
at 6 o’clock (post cord )
Withdraw needle to 9
o’clock ( lat cord )

34. ANATOMICAL VARIATIONS IN CORACOID REGION
Picture from Sauter Anesth Analgesia 2006;(103): 1574-1576
Wide anatomical variations
But only 2 cords and not 3 had
this variations
A -- axillary artery
L – lateral cord
M – medial cord
P -- posterior cord
V -- axillary vein

35. • Axillary Approach Brachial Plexus Block

36. INDICATIONS
Block terminal branches of brachial plexus
 Median nerve
 Ulnar nerve
 Radial nerve
 Musculo-cutaneous nerve
Hand, wrist and ulnar side of forearm surgery

37. contraindications
 Coagulopathy
COMPLICATIONS
Intra-arterial injection of LA

38. In plane vs out of plane approach
BASIC skill level block
In plane Out of plane

39. ian
Pre LA injection
Post LA injection

40. Musculocutaneous nerve

41. Anatomical correlation

42. Anatomical variations
Ultrasonographic
findings
of variation in nerve
location around the
Axillary artery
Picture from :
Anesth Analg 2001;
92:1271-5

43. summary

44. BP Blockade Approaches For upper Extremity Surgery
Block
Surgery
Interscalene Supraclavicular Infraclavicular Axillary
Shoulder
√
Arm
√ √
Elbow
√ √ √
Forearm
√ √ √
Hand
√ √ √

45. Questions & Answers, Discussions

46. references
http://www.usra.ca
http://www.nysora.com
Ultrasound Guidance for Nerve Blocks
Principles and Practical Implementation
Peter Marhofer
Oxford University Press, 2008