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Success usually depends on 3 viewpoints:
Yours as the anesthesia provider

The surgeons

The patients
ADVANTAGES [3]
Fewer recovery room admissions

Decreased incidence PONV

Improved postoperative analgesia
DISADVANTAGES [2]
Requires specific skills set from anesthetist

Time
INDICATIONS
Interscalene used most frequently on shoulder procedures
Axillary block used for elbow and hand surgery
Bier block used for hand surgery less than 2 hours
CONTRAINDICATIONS
ABSOLUTE
Patient Refusal
Infection at site
Coagulopathy ****

RELATIVE
Sepsis
Pre-existing neurological condition
COMBINED BLOCK/GENERAL
Good alternative for elderly or “squirmy” patient

Helpful when block is slow to set up or “patchy”

Get benefits of both techniques with less side-effects of individual method.
ANATOMY of BRACHIAL PLEXUS
Knowledge of anatomical landmarks is critical for “minds-eye picture”

Large network of nerves that extend from the neck through the axilla, and upper extremity
Composed of ventral rami (C4-T1 roots), trunks, divisions, cords and branches
BRACHIAL PLEXUS Composed of [5]
ventral rami (C4-T1 roots), trunks, divisions, cords and branches
______ from C4-T1 pass lateral border of scalene muscles to form ______
Roots
trunks
______ pass lateral border 1st rib, posterior to clavicle to form _______
Trunks
divisions
______ enter the axilla become ______
Divisions
cords
_____ are named according to position relative to axillary artery, become ________ at the lateral border of the pectoralis minor muscle.
Cords
branches
LOCAL ANESTHETICS-facts
Success = volume (one exception)

Balance of volume and toxicity

Onset and duration of action
Faster onset = shorter duration
Goals
Rapid Onset
Appropriate duration
Lowest toxicity
Adequate analgesia/anesthesia
Factors influencing plasma levels
Dose concentration
Additives
Rate of injection if intravascular
Site of injection
IV>Intercostals>Caudal>Epidural>Brachial Plexus> Axillary>Peripheral nerve block>local infiltration
LOCAL ANESTHETICS- Max doses/ max with epi

Chloroprocaine
11/14 mg/kg
LOCAL ANESTHETICS- Max doses/ max with epi

Lidocaine
4.5/7 mg/kg
LOCAL ANESTHETICS- Max doses/ max with epi

Mepivicaine
4/7 mg/kg
LOCAL ANESTHETICS- Max doses/ max with epi

Tetracaine
1.5/ 2.5 mg/kg
LOCAL ANESTHETICS- Max doses/ max with epi

Ropivicaine
2/3 mg/kg
LOCAL ANESTHETICS- Max doses/ max with epi

Bupivicaine
2.5/3 mg/kg
Lipid solubility =
POTENCY
Protein binding =
DURATION of ACTION
pK =
ONSET TIME
Addition of vasoconstrictors to decrease absorption (r/t blood flow in the area) [3]
Addition of vasoconstrictors to decrease absorption (r/t blood flow in the area)
Minimizes chance of having a toxic reaction
Increases duration of block
Increased HR if intravascular injection
PRE-OPERATIVE COUNSELING
Patient should be informed of all potential procedures available, potential risk, potential complications, then select technique.

INFORMED CONSENT
Significant risks
Potential benefits
Advantages/Disadvantages
Answer patient questions
PREPERATION FOR BLOCK
Accessibility of nerves of brachial plexus allow 4 primary approaches

Choice of approach is based on:
Patient considerations
Surgical site
Anesthesia practitioner preference

Drugs
Include supplemental O2
Sedatives/narcotics
Supplies
Resuscitation Equipment
Standards for monitoring
Minimal = O2 sat, NIBP, ECG
Standards for monitoring

Minimal =
O2 sat, NIBP, ECG
STIMUPLEX NEEDLE
Insulated needle
22 gauge
B-bevel
Usually 1 _ inches long
Performing Interscalene Blocks
Used for procedures of the shoulder-frequently sparing of ulnar nerve

Bupivicaine/Ropivicaine/Lidocaine/Mepivicaine in combination 30-40cc’s.

Landmarks
Cricoid cartilage (vertebral body of C6)
Lateral border of sternocleidomastoid muscle
Groove between anterior and middle scalene muscles (level of trunks of brachial plexus)

Set up equipment
Nerve stimulator
Syringe with local attached to extension set
Identify landmarks
Cleanse patient skin
Intradermal anesthetic
Stimuplex inserted perpendicularly to skin in caudad direction, advance slowly
After twitch elicited decrease mA from 1.0 to 0.5 or LOWER.
Aspirate, inject 1cc LA, if twitch fades continue injecting after negative aspiration in 5 cc aliquots
Interscalene Blocks Landmarks
Cricoid cartilage (vertebral body of C6)
Lateral border of sternocleidomastoid muscle
Groove between anterior and middle scalene muscles (level of trunks of brachial plexus)
INTERSCALENE – Special Considerations [6]
Recurrent laryngeal nerve block
Horner’s syndrome
Phrenic nerve block
Vertebral artery injection
Subarachnoid or epidural anesthesia
Pneumothorax
Performing Axillary Blocks
Used for procedures distal to the elbow

Lidocaine 1-1.5% 30 cc’s

Landmarks/Position
Upper arm extended slightly less than 90 degrees with forearm flexed
Axillary artery palpated near insertion of pec major on the humerus
Musculocutaneous 9-12 o’clock
Median 12-3 o’clock
Radial 12-3 o’clock
Ulnar inferior to median at 12-3 o’clock
Axillary Blocks Landmarks/Position
Upper arm extended slightly less than 90 degrees with forearm flexed
Axillary artery palpated near insertion of pec major on the humerus
Musculocutaneous 9-12 o’clock
Median 12-3 o’clock
Radial 12-3 o’clock
Ulnar inferior to median at 12-3 o’clock
Axillary Block
Set up equipment
Identify landmarks
Cleanse patient skin
Intradermal anesthetic
Line drawn with index and third finger over artery
Needle inserted above artery, twitch elicited reduce mA to less then 0.5.
Aspirate before injection
Musculocutanous nerve must be injected separately
5cc of local into coracobrachialis
Axillary Block – Special Considerations [2]
Systemic toxicity d/t proximity to axillary artery and vein

Single injection may not be as effective as injections at multiple sites
Performing Bier Blocks (IV Regional)
Used for cases on hand and forearm
Can be used for soft tissue or orthopedic cases
Duration only 90-120 minutes
Assemble equipment
IV cannula in operative arm as distal as possible with small gauge (22 or smaller)
Elevate and exsanguinate with Esmarch
Inflate distal cuff, then proximal, than deflate distal cuff (50-100mmHg above SBP)
Remove Esmarch and check for radial pulse
Inject 50 cc 0.5% MPF lidocaine
Circumferentially occlude the extremity
Bier Block – Special Considerations
Tourniquet should not be released if inflated less than 20-30 minutes

Flooding of local anesthetic manifests as ringing in ears, tingling tongue/lips, bradycardia – can progress to restlessness, dizziness, nausea, convulsions
INNERVATION OF UPPER EXTREMITY


Branches of Posterior Cord
Predominantly supply dorsal portion of upper extremity
INNERVATION OF UPPER EXTREMITY

Branches of Lateral and Medial Cords
Median, Ulnar, and musculocutaneous nerve
Predominantly supply ventral portion of upper extremity
ASSESSING THE BLOCK

Radial (C4-T1)
(PUSH) (PINCH)
Dorsal extension of triceps/upper limb
ASSESSING THE BLOCK

Musculocutaneous (C4-C7)
(PULL)
Motor function of biceps, brachialis & coracobrachialis
ASSESSING THE BLOCK

Median (C6-T1)
(PINCH)
Motor function of flexor and pronator muscles of forearm and hand
Sensory to ventral thumb, 1st/2nd fingers, and lateral 1/3 3rd finger
ASSESSING THE BLOCK

Ulnar (C8-T1)
(PINCH)
Motor to hand, no sensory to forearm, sensory to medial part 3rd finger and entire 4th finger
ULNAR NERVE BLOCKADE

At the elbow
Located in the ulnar groove between medial epicondyle of humerus and olecranon process
3-5cc anesthetic solution injected
ULNAR NERVE BLOCKADE

At the wrist
Runs down flexor compartment of the forearm
Divides into sensory and motor branches 5 cm proximal to wrist
Inject 3-5 cc immediately proximal to ulnar styloid process, lateral to ulnar artery
MEDIAN NERVE BLOCKADE

At the elbow
Lies medial to brachial artery and follows it through antecubital fossa
Through imaginary line of medial and lateral epicondyles of humerus inject 3-5 cc medial to brachial artery
MEDIAN NERVE BLOCKADE

At the wrist
Located very superficially at proximal level of the wrist laterally to tendon of palmaris longus
After patient makes fist palpate tendon of palmaris longus and flexor carpi radialis, insert needle lateral to tendon and inject 3-5cc local
RADIAL NERVE BLOCK

At the elbow
Identify groove between brachioradialis muscle and biceps tendon at distal 1/3 of humerus
Needle directed proximally and laterally to reach lateral epicondyle, inject 2-4cc while withdrawing needle about 0.5cm, continue injecting addit. 5cc until at subcutaneous tiss.
RADIAL NERVE BLOCK

At the wrist
Subcutaneous at this point and purely sensory
Easiest method is raise subQ ring(5-7cc’s) beginning at level of tendon of the flexor carpi radialis and running around the radial border of wrist, dorsal to styloid process
Side Effects/Complications of Single Shot Nerve Blocks
Potential Nerve Injury
COMPLICATIONS [5]
Local anesthetic toxicity/ intravascular injection
Peak at about 20 minute
ALWAYS aspirate before injection!!!!!

Nerve injury/intraneural injection
Use of nerve stimulator decreases
Pain (bad) vs. pressure (ok)

Hematoma/bleeding

Infection

Failure of Block
Assessment of Nerve Injury

Radial
Inability to extend wrist, abduct thumb, wrist drop, decreased sensation over dorsal surface of the lateral three and _ fingers
Assessment of Nerve Injury

Ulnar
Sensory loss in 5th digit, “claw hand”
Assessment of Nerve Injury

Median
Loss of sensation of finger tips from thumb to mid-point ring finger, inability to oppose 1 and 5th digit, “ape hand”
Assessment of Nerve Injury

Musculocutaneous
Inability to flex forearm
brachial plexus

3 trunks
top to bottom

superior c5-6 (4)
middle c7
inferior c8-t1
brachial plexus

divisions

3 what
3 what
3 ventral
3 dorsal
brachial plexus

3 cords
lateral

posterior

medial
brachial plexus

5 terminal brnches
top to bottom

musculocutaneous
axillary
radial
median
ulnar
the brachial plexus is formed by the ____________ of the 5th to 8th cranial nerves and by the greater portion of the ramus of the 1st thoracic nerve
ventral rami
the roots reorganize into ______ after they pass between the _________.
trunks
scalene muscles
At the _______ border of the 1st rib, and ______ to the clavicle, the 3 trunks divide into ______.
lateral
posterior

ventral and dorsal divisions
the posterior divisions of all three trunks unite to form the ___________
posterior cord
the anterior divisions of the superior and middle trunks form the ______
lateral cord
what is the non-united, anterior division of the inferior trunk?
medial cord
the cords are named for their relation to the ________ artery.
axillary
At the lateral border of the pec minor (which inserts in to the _____), each of the 3 cords divide into 2 ________, which reorganize to form the _______.
coracoid process

branches

peripheral nerves of the arm
All branches of the lateral and medial cords are all _______ nerves
ventral
The posterior cord provides all _______ innervation
dorsal
The ______ nerve supplies all of the dorsal innervation of the upper extremity below the shoulder.
radial
The _______ nerve supplies muscular innervation in the arm while providing cutaneous innervation to the forearm
musculocutanous
The _____ and _____ are nerves of passage in the arm. but in the forearm and hand, they provide the ventral musculature with motor innervation
median and ulnar
The ____ nerve innervates more heavily in the forearm

the ______ nerve innervates more heavily in the hand
median

ulnar
The brachial plexus nerve roots leave the spine at the _____ between the______
transverse process

preverterbral fascia (makes up the sheath)
what is push, pull, pinch, pinch?
push-biceps innervation (musculocutaneous)

pull-triceps-[radial]

pinch-2nd finger [pointy] median

pinch-5th finger[pinky]
ulnar
when checking function PPPP after a block, motor weakness is eveident [before/after] a sensory block.
before
As the cervial roots leave the transverse process on thier way to the brachial plexus, they exit in the gutter of the transverse process immediately _____ to the vertebral artery
posterior
The vertebral artery lies ______ to the roots of the brachial plexus as they leave the cervical vertebrae.
anterior
The phrenic nerve is formed by the branches of the ______ nerves and passes through the neck on the ventral surface of the ___________ muscle.
3rd, 4th and 5th cervical nerves

anterior scalene
The phrenic nerve is almost always blocked during _____ block and less frequently with ________ block.
interscalene

supraclavicular
the nerves are more _______ in relation to the first rib.
cephlad
_________ block should be avoided in patient's with impaired pulmonary function
interscalene
there is frequent sparing of the ____ nerve with an interscalene block
ulnar
Interscalene bolck is performned at the level of the _____ vertebral body, which is at the level of the ______.

project a line laterally from the above point and roll you fingers off of the ______ on to the belly of the ____ muscle and then into the _______.

the ______ often overlies the interscalene groove at the level of C6.

volume of LA?
C6
cricoid cartildge
sternocleidomastoid
anterior scalene
intersclene groove

external jugular vein

30-40ml
the interscalene block is very superficial, generally no more than ________ cm needle depth.
1-1.5cm
the ulnar nerve is easier/harder to block after blloking more cephalad nerves?
harder
supraclavicular block is performed at the _____ level.

for shoulders, supplement with ______ block
division

superficial cervical plexus
prime consideration for drug selection is _______ and ______.
length of procedure and degree of motor blockade required.
axillary block best for procedures ______
distal to the elbow

consider suprclavicular for more proximal procedures
The musculocutaneous nerve is found at the ______ position in the substance of the ______ muscle
9 to 12 o'clock

coracobrachialis
the median nerve is most found in the ________ quadrant
12 to 3 o'clock
the radial nerve is most found in the ________ quadrant
6 to 9 o'clock
the ulnar nereve is _______ to the median nerve in the ______ quadrant
inferior

3 to 6 o'clock
anesthesia of the musculocutaneous nerve is best acheived...
by infiltraing the coacobracialis muscle.
for an effective axillary block LA must be deposited....
in each of the 4 quadrants
for an axillary block _______ injections must be made because the sheath is _________
multiple

discontinuous
the _____ and _____ _nerves are more superficial when the arm is in the axillary block position.
median and ulnar
at the elbow, the ulnar nerve passes between the ____&_____
olecranon process

medial epicondyle of humerus
Bier block agent & dose?

onset?
duration?

limiting factor?

_____ can prolong case...
PF lidocaine 0.5% 50cc

5min

90-120

can add 15-30mg ketorolac

tourniquet pain (60 min)

dual tourniquet. (100mm > SBP)
The 4 primary approaches to block the brachial plxus are...

most frequently used?

upper arm sholder? (best)
axillary
interscalene
supraclavicular
infraclavicular

axillary

interscalene
choice of approach based on...[3]
patient considerations
surgery location (site)
skill of practitioner
The infraclavicular portion of the plexus, incudng the 3 cords and thier 4 terminal branches lie in the ____-
axilla
c5-c6 rami?
superior trunk
c7 rami?
middle trunk
c8-t1 rami?
inferior trunk

ON THE FIRST RIB, POSTERIOR TO THE SUBCLAVIAN ARTERY
INTERscalene space? aka
sheath
for success, a ______ must be allowed
adequate set-up time
the ventral divisions generally supple the _______ portion of the upper extremity.
ventral (flexor)
the dorsal divisions generally supple the _______ portion of the upper extremity.
dorsal (extensor)
the ventral divisions generally supple the _______ portion of the upper extremity.
ventral (flexor)
the dorsal divisions generally supple the _______ portion of the upper extremity.
dorsal (extensor)
the lateral cord divides and generates the _____ nerve and the lateral root of the ______ nerve.
musculocutaneous

median
the medial cord divides and generates the ____ nerve and the median root of the ____ nerve.
ulnar

median
the posterior cord divides to generate the _____ and _____ nerves
axillary

radial
the radial nerve arrises from the ____ cord.
the axillary nerve arrises from the ____ cord.
the musculocutaneous nerve arrises from the ____ cord.
the ulnar nerve arrises from the ____ cord.
the lateral root of the median nerve arrises from the ____ cord.
the medial root of the median nerve arrises from the ____ cord.
radial-posterior cord
axillary-posterior cord
musculocutaneous-lateral cord
ulnar-medial cord
lateral root of the median-lateral cord
medial root of the median-medial cord
The branches of the _____ & _____ cords predominately supple the ventral portions off the upper extremity.
lateral and median cords
The branches of the _____ cord predominately supple the dorsal portions off the upper extremity.
posterior
radial nerve trunk origin.

supplies _____ muscles
sensory to _____
C5-C8, T1
dorsal extensor (triceps)
extensor region of the arm, forearm and hand.
musculocutaneous nerve tunk origin.

supplies _____ muscles
sensory to ______
C5-C7

flexor (biceps, brachialis, coracobrachialis)

lateral aspect of forearm between wrist and elbow (lateral antebrachial utaneous nerve)
The _______ and _____ pass through the arm and provide sensory and motor innervation to the forearm and hand.
median and ulnar
median nerve trunk origin.

motor to...
sensory to....
C6-T1

motor-forearm
sensory-palm, 1-2 fingers, ventral thumb, lateral 3rd
ulnar nerve root origin.

motor to...
sensory to....
C8 & T1

motor-hand
sensory-none in forearm, nedial 3rd, 4th and pinky
interscalene landmarks

level of?

needle?

angle?

volume?
C6-cricoid (coorelates to vertebral body of C6 and the corresponding area of the transverse process called Chassaignac's tubercle)

TRUNKS

22G B-bebel 1.5 inches

perpendicular, the slightly caudad

30-35ml
Subclavian approach

apporoach?

complication?
prep/positioned per interscalene (HOB may be 30-45)
palpate for SC artery pulsations behind and below the clavicle, just above the superior surface of the first rib and between the scalene muscles; the artery is palpated at the midpoint of the clavicle. approach is lateral, needle perpendicular, inward and caudad.

horner's syndrome is a positive sign of a succesful block

pneumothorax
Inter-sternocleidomastoid Block

level?

nerves reached?
supraclavicular-between the heads of the SCM muscle, 2 FB's above sternal notch, medial to the clavicular head.

needle advanced laterally, posteriorlty and caudally (45 to table, 15 to clavicle)

TRUNK level

suprscapular, superior trunk, middle trunk, divisions and cord.
stimulation of the suprascapular nerve evokes contraction of the _________
glenohumeral coaptation
supraspinatus, infraspinatus
stimulation of the superior trunk evokes contraction of the _________
biceps brachi, deltiod

elbow flexion and abduction of the arm
stimulation of the middle trunk evokes contraction of the _________
triceps brachi

elbow extension
stimulation of the divisions and cord evokes contraction of the _________
pronation of the hand and digit flexion in conjunction with pectoral contration
stimulatin of the phrenic nerve evokes...
diaphramic contraction

movements of abdome
Axillary approach _loss of resistance technique-first step...needle?

use what fingers?

volume

endpoints to determine if the needle is within the sheath. [3]
22g 1.5 b-bevel

1st and 3rd fingers

50ml (40 in sheath, then field block the last (musculocutaneous, medial brachial cutaneous both exit high),(intercostobrachail-outside of sheath)

loss pf resistance

in the artery

elicitation of paresthesias
2nd step of loss of resistance axillary technique

the coracobrachialis is located immediately _______ to the axillary artery and _____ to the bipeps brachi.

volume?
superior

inferior

3-5cc
last step of axillary block?

what nerves?

why?
3-5cc inferior and perpendicular to artery as the needle is advanced to the hub.


medial brachial cutaneous
intercostobrachial

reduces tourniquet discomfort
transarterial axillary block?
needle?
21g 1.5

each 5 ml is a test dose

risk for intra-arterial injection

the field block can be perfroned afterwards if desired.
Ulnar nerve elbow block

volume?

approach?
less than 3ml

1-2cm proximal to sulcus

insertion between medial condyle of humerus and elecranon process of ulna
median nerve block at elbow

avoid with...

volume
carpal tunnel syndrome, neruitis, artery perforataion

3-5cc
radial block at elbow

nerve located...

volume
in the groove formed by th fascial border of the brachioradial muscle on the lateral edge and the bicpes tendon medially.

3-5ml
wrist blocks
ulnar/medial/radial

2-5cc

medial in carpal tunnel

radial block least tolerated of all the supplemental blocks.
________ can lead to the highest plasma concentrations of LA
multiple intercostal blocks

ICEBABL

can add dextran to extend duration (as can EPI)

use short b-bevel 22g

risk of pneumothorax