upper extremity blocks Flashcards
regional anesthesia advantages
avoid general
prevent N/V
cardiac disease
pulmonary disease
avoid opiates (resp depression, itching, constipation)
induced sympathectomy - less blood loss, improved perfusion
preemptive analgesia (chronic pain maladies)
regional contraindications
patient refusal patient cooperation coagulopathy neurological comp infection near site septicemia
regional prep
1) monitors
2) suction
3) means of PPV (amby, mask, o2)
4) airway (intubation)
5) IV access
6) drugs (emergency, anxiolytics, libidos)
why the prep stuff?
toxicity need to switch to GA allergic rxn oversedation vagal response (fear) intrathecal (CSF) - total spinal - resp/cardiac depression
3 ways to identify nerve
1) nerve stimulator
2) parasthesias (not ideal)
3) ultrasound
brachial plexus
C5-T1
all motor fx to upper extremity
almost all sensory (exception is caudad branches of cervical plexus - post shoulder sensory)
Musculocutaneous
C5, 6, 7
flex forearm
exits sheath high in axilla
corocobrachialis muscle
motor - biceps, brachialis, coracobrachialis
sensory - lateral mid-forearm, up into wrist
Axillary
C5, 6
leaves plexus at lower border pec muscle
motor - deltoid, teres minor
sensory - inferior shoulder, upper arm
Radial
C6, 7, 8, T1
extend forearm
motor - triceps, supinator, extensors
sensory - posterior arm and forearm, lateral border of elbow, thumb and dorsal surface of hand
Median
C7, 8, T1
flexion of wrist
motor - flexors and pronator muscles of forearm,
sensory - palmar surface of hand, index and middle fingers
Ulnar
C8, T1
ABduct fingers
motor - flexor carpi ulnaris
sensory - little finger and medial ring finger
needles
A bevel - longer with smaller angle
B bevel - shorter with bigger angle
adjuncts to regional
propofol midaz fentanyl positioning verbal conversation
approaches to brachial plexus
interscalene supraclavicular infraclavicular axillary terminal nerves
interscalene approach
roots/trunks
highest, surgery for upper arm, may spare back of arm
anesthesia - upper branches of plexus and lower cervical plexus
indications- shoulder clavicle procedures, procedures prox to elbow
often ulnar nerve sparing (sensory ring, little finger, motor pinch and spread)
interscalene procedure
supine
head toward opposite side
palpate posterior border sternocliedomastoid (clavicular head) at C6 level
roll fingers off and palpate groove between anterior and middle scalene muscles
nere stim at 1mAmp, twitch of bicep or distal hand, drop to .5
aspirate (heme, air, CSF)
inject 20-30ml LA
interscalene contraindications
absolute - contralateral recurrent laryngel nerve palsy, phrenic nerve palsy (contralateral side)
relative - preexisting nerve injury, brachial plex pathology, on same side, significantly impaired pulm function
evaluation of block
push, arm extension - radial
pull, arm flexion - MC
Close, index finger - median
open, little finger - ulnar nerve
alcohol pad, temp and pain go together
interscalene complications
intravascular inj
subarachnoid/epidural inj
pneumothorax (not as much of risk)
recurrent laryngel nerve block
horners syndrome (ptosis, myosis, lack sweating)
phrenic nerve block (80% - feel like can ttake full breath)
cervical block indications
unilateral surgical procedures of neck
combine with deep cervical plexus block for carotid endarterectomy
cervical plexus block procedure
posterior border SCM
needle into midpoint, tunneled both superiorly and then inferiorly along posterior border of SM
5ml LA inj subcutaneous in both directions
supraclavicular approach
trunks/divisions
less chance to spare ulnar and radial
all portions of upper extrem (hand, forearm, upper arm)
supraclavicular contrindications
contralateral phrenic paralysis
recurrent nerve paralysis
contralateral pneumothorax (much higher risk)
vascular complication
aupraclavicular appraoch
lateral border of clavicular head SCM at level of its insertion into clavicle
groove between scalenes
needle inserted .5-1cm cephalad to mid point clavicle
needle direceted caudally, do not aim medially!!!
motor response - more distal response = beter block
see motor at 2-3cm
aspirate prior to injecting and every 5ml after
supraclavicular complications
increased risk pneumothorax 1-6% horners phrenic recurreny laryngeal nerve paralysis neuropathy (nerve pinned against clavical?)
infra clavicular
brach plex coming out from under clavicle
elbow, forearm, hand
medial clavicular head, coracoid process
insert needle at 45 degree angle at midpoint between coracoid process andmedial clavicular head, advance needle in parallel fasion
infraclavicular motor response
initially look for pecoralis twitch = still too shallow
want meadian, radial, ulnar twitch = 5-8cm depth
as long as needle directly laterally, neuroaxial or pulm complications are unlikely
good for continuous techniques
axillary block indications
procedures below elbow
safest and easiest approach
patient musc be able to Abduct arm and place at 90 degree angle (large muscles could occulde artery - landmark)
inject 10ml above and below artery, seperate inj for MC
axillary contraindications
absolute - lymphagitis
relative - preexsting nerve inj
brach plexus pathology
axillary approach
median nerve - superior (anterior) to artery
ulnar nerve - inferior to artery
radial - posterior to axillary artery
MC outside of sheath
axillary procedure
supine
extend arm 100 and flex forearm 90
palpate axillary artery as prox as possible
nerve stim technique for axillary approach
insert needle immediately superior or inferior to palpation of axillary artery
start nerve stim at 1mamp
twitch in distal hand, drop to .5mamp or below
aspirate for heme first and inj 30ml LA, aspirating every 5mls
transarterial technique axillary approach
22 B bevel
palpate axillary artery and aspirate bright red blood
advance until no further blood obtained
entire vol LA inj
paresthesia technique
elicit parasthesia in term nerves
may take undue time and increase discomfort
axillary evaluation
push - radial nerve
pull - MC (usually spared without seperate inj at belly of coracobrachialis)
close - medial
open - ulnar
axillary complications
hematoma
intravascular inj
infection
radial touch up
brachioradialis and tendon of biceps
needle introduced 1-2cm lateral to biceps tendon
ranlike inj 4-6ml LA
median nerve touch up
needle introduced 1cm medial to brachial artery
inj 3-5ml LA
ulnar nerve touch up
forearm flexed
needle introduced 1cm proximal to ulnar groove (between olecranon process and medial epicondyle of humerus)
inj 3-5ml LA - not directly into ulnar groove
MC nerve touch up
deep into body of coracobrachialis
bier block
not for chronic or post op pain, only intraop
distal vein cannulated, arm exsanguinated, tourniquet (lower cuff - then upper cuff)
40ml 5% lidocaine into IV
onset 5 min
forearm and hand 60min - 120min
worry about loceal anesthtetic fox
nearby - ambu, O2, barb, benzo, intubating stuff
