Mod10: Orthopedic surgery - Surgery to the Upper Extremities

Question 1

_{Upper Extremities Surgery - Surgery to the Shoulder and Upper Arm}

Although benefits of regional anesthesia are well established for upper extremity procedures, there are concerns:

Answer 1

Presence of preexisting deficits

^{Ulnar nerve transposition, carpal tunnel syndrome - You could be blamed for soemthing that was not your fault - Numbed for prolonged period of time => could lead to further damage to those areas.}

Operative site adjacent to neural structures

^{Total shoulders/proximal humerus fractures}

Significant occurrence of pre-operative neurologic deficits

^{May not be able to protect the limb after the block wares off}

Question 2

_{Upper Extremities Surgery - Surgery to the Shoulder and Upper Arm}

Total Shoulder Arthroplasty (TSA)

^{associated with which injury?}

Answer 2

Brachial plexus injury

^{<strong>(</strong>at level of nerve trunks; level where interscalene is performed - 3% of pts)}

Unknown if injury is from block or surgery

_{90% resolve in 3-4 months}

_{Demonstrates importance of clinical examination before regional technique}

_{Decision to do regional technique = individual basis}

Question 3

_{Upper Extremities Surgery - Surgery to the Shoulder and Upper Arm}

Nerve injury related to Humeral Shaft fractures:

Answer 3

Radial nerve injury (18%)

_{90% resolve in 3-4 months}

_{Demonstrates importance of clinical examination before regional technique}

_{Decision to do regional technique = individual basis}

Question 4

_{Upper Extremities Surgery - Surgery to the Shoulder and Upper Arm}

Nerve injury related to Proximal Humeral fractures:

Answer 4

Axillary and/or Brachial plexus injury

_{90% resolve in 3-4 months}

_{Demonstrates importance of clinical examination before regional technique}

_{Decision to do regional technique = individual basis}

Question 5

_{Upper Extremities Surgery - Surgery to the Shoulder and Upper Arm}

Indications:

Answer 5

Total shoulder arthroplasty (TSA)

Arthroscopic

Rotator cuff repair

Question 6

_{Upper Extremities Surgery - Surgery to the Shoulder and Upper Arm}

Surgical approach/positioning:

Answer 6

Beach Chair

Flexion at hips and knees

Placed in 10 - 20º reverse T-burg

Head/neck firmly supported in neutral position

^{Avoid stretch brachial plexus}

Protect eyes/ears from pressure

Remember BP concern from positioning lecture

^{Blood pressure decreases 2 mmHg for every 2.5 cm height above the point of measurement. So blood pressure within the brain reclining or sitting patient under anesthesia is about 12-16 mmHg lower than that measured at the upper arm}

Risk of Venous air embolism may occur (rare)

Question 7

_{Upper Extremities Surgery - Surgery to the Shoulder and Upper Arm}

Airway access limited

^Precautions:

Answer 7

Secured/connections tightened

Minimize Hypotension

^{(Gradual assumption of position- Adequate hydration)}

Question 8

_{Upper Extremities Surgery - Surgery to the Shoulder and Upper Arm}

Anesthetic Management:

Answer 8

Combination of regional with general most often used

_{Limited access to pt airway during procedure}

_{Requires careful positioning and appropriate sedation}

Question 9

_{Surgery to the <strong>Shoulder and Upper Arm</strong> - Anesthetic Management}

What regional techniques are commonly used?

Answer 9

Interscalene

Supraclavicular

Question 10

_{Surgery to the Shoulder and Upper Arm - Anesthetic Management}

Which nerve is frequently left unanesthetized in an interscalene approach to the brachial plexus?

Answer 10

ULNAR nerve

For this reason the lower part of upper extremity (forearm, elbow, wrist) needs to be anesthetized under axillary or bier block

Question 11

_{Surgery to the Shoulder and Upper Arm - Anesthetic Management}

What is a major complication of an interscalene or supraclavicular approach to the brachial plexus?

Answer 11

Pneumothorax

Because the lung sits right next to needle insertion site; usually diagnozed 12-24 hrs after block, so need to monitor after block

Question 12

_{Surgery to the Shoulder and Upper Arm - Anesthetic Management}

What patient population should interscalene block be performed on with caution and why?

Answer 12

Outpt surgery – b/c need to eval for pneumo after block; loss of pulmonary function and paresis of ipsilateral hemidiaphragm – inability to take adequate vT (b/c block phrenic nerve) – then if pneumo – even more of a problem.

Careful with COPD pt’s – lose 25% of pulm function from block alone

Question 13

_{Surgery to the Shoulder and Upper Arm - Anesthetic Management}

Indications for interscalene nerve block include the following:

Answer 13

Shoulder surgery, such as rotator cuff repair, acromioplasty, hemiarthroplasty, and total shoulder replacement

Humerus fracture

Other arm surgery that does not involve the medial aspect of the forearm or hand

Question 14

_{Surgery to the Shoulder and Upper Arm - Anesthetic Management}

When should the interscalene block be performed?

Answer 14

Preoperatively

^{Pre-emptive analgesia}

^{Reduces anesthetic requirements}

Postoperatively

^{Most common (Shifted more to pre-op now!!)}

Question 15

_{Surgery to the Shoulder and Upper Arm - Anesthetic Management}

Tourniquet cannot be used for these surgeries

^concerns:

Answer 15

Significant blood loss

Surgeon may ask for a hypotensive technique

^{Maintain ongoing communcation with the surgeon}

Question 16

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm}

Regional anesthesia common (brachial plexus)

^{Two approaches:}

Answer 16

Infraclavicular or Supraclavicular approach

Axillary approach

Question 17

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm - Regional anesthesia}

Infraclavicular or Supraclavicular approach:

Answer 17

Provides most consistent and reliable anesthesia to all four major nerves of brachial plexus

^{Median, Ulnar, Radial, & Musculocutaneous nerves}

^{(how about the axillary nerve?)}

Question 18

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm - Regional anesthesia}

Infraclavicular or Supraclavicular approach

^{Associated with what risk?}

Answer 18

Pneumothorax

Question 19

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm - Regional anesthesia}

Infraclavicular or Supraclavicular approach

^{When does this risk typically occur?}

Answer 19

6-12 hrs after discharge

So you want to monitor for 24 hrs after block

Question 20

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm - Regional anesthesia}

Infraclavicular or Supraclavicular approach

^{Is it therefore suitable for outpatient surgery?}

Answer 20

Ok for outpatient surgery if perfomered under ultrasound

Question 21

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm - Regional anesthesia}

Axillary approach

Answer 21

Eliminates risk of pneumothorax

Reliably provides adequate anesthesia for surgery near elbow

Question 22

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm - Regional anesthesia}

Axillary approach

^{Which nerve is least likely blocked with the axillary approach and why?}

Answer 22

Axillary spares Musculocutaneous nerve

because this nerve goes through coracobrachialis muscle

_{To check if the Musculocutaneous nerve is spared, do a cold swab on the face and a cold swab on the portion of the arm to see if it feels the same. If it does, you probably need to supplement the Musculocutaneous nerve with a second block.}

Question 23

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm - Regional anesthesia}

Axillary approach spares Musculocutaneous

^{What can be done to correct this problem?}

Answer 23

Supplement with “circle” or “ring” block at coracobrachialis muscle to anesthetize musculocutaneous nerve

_{To chect if the Musculocutaneous nerve is spared, do a cold swab on the face and a cold swab on the portion of the arm to see if it feels the same. If it does, you probably need to supplement the Musculocutaneous nerve with a second block.}

Question 24

_{Surgery to the Elbow, Distal Humerus & Proximal Forearm - Regional anesthesia}

Innervation of Brachial Plexus nerves within the Arm

^{(See picture)}

Answer 24

(See picture)

Question 25

Surgery to Wrist, Distal Forearm, & Hand

Anesthesia technique:

Answer 25

Regional is well suited

Question 26

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Most commonly used approach:

Answer 26

Axillary approach to brachial plexus

Question 27

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Interscalene is not effective - why not?

Answer 27

Incomplete ulnar nerve anesthesia

Question 28

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Supraclavicular

^{should it be considered?}

Answer 28

Reliably blocks all four major nerves

However, risk of pneumothorax reduces suitability for outpatient surgery

Question 29

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Local infiltration/peripheral blockade

^{Excellent for which type of procedure?}

Answer 29

minor procedures not requiring TQ

Question 30

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Bier block

^{considerations:}

Answer 30

Permits more extensive surgery

Longer TQ time

_{In a Bier block, low dose lidocaine is injected IV with TQ up. TQ is left up long enough to prevent floading the systemic circulation with LA.}

Question 31

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Process of leaving continuous catheter in place to infuse lower dose of LA right at the nerve:

Answer 31

Continuous Brachial Plexus Anesthesia

Question 32

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Continuous Brachial Plexus Anesthesia

^Approaches:

Answer 32

Interscalene

Infraclavicular

Axillary (most common)

Question 33

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Continuous Brachial Plexus Anesthesia

^Technique:

Answer 33

Advance medium gauge needle

Elicit paresthesia or motor response with nerve stimulation

20 ga catheter advanced 5-10 cm

Inject 45-50 ml local anesthetic

^{May leave catheter in place}

^{<u>Good for post-op analgesia</u> - <u>Not as good for surgical analgesia</u>}

^{If supplementing GA, may reduce oipoids requirements}

Produces analgesia to all nerve distributions but does not provide satisfactory surgical anesthesia (supplement with general)

Question 34

_{Surgery to Wrist, Distal Forearm, & Hand - Regional anesthesia}

Continuous Brachial Plexus Anesthesia

^Management:

Answer 34

Can remain indwelling for 4-7 days

Continuous infusion

Lower concentration

Question 35

_{Regional anesthesia}

Motor blockade of Upper extremity vs Lower extremity blockade

^{Which is a contraindication for Hospital discharge?}

Answer 35

Motor blockade of lower extremity is a contraindication to hospital discharge

Motor blockade of upper extremity is Not a contraindication to hospital discharge