Upper extremity blocks Flashcards
What are some considerations of whether to do regional or general anesthesia?
- Patient preference
- Co-existing medical conditions
- Surgical considerations
- Skill of anesthesia provider
- Surgeon preference
What are some advantages of regional anesthesia?
- Can avoid general anesthesia
- Better for patients with cardiac or pulmonary disease
- Avoid use of post-op opiates
- Induced sympathectomy- intraoperative reduction in blood loss and postoperative improvement in perfusion
- Reduced nausea/vomiting
- Preemptive analgesia-reduces postoperative pain and analgesic requirements
What are some contraindications to regional anesthesia?
- Patient refusal
- Patient unable to cooperate
- Coagulopathy
- Existing neurological complications
- Infection near the site of injection
- Septicemia
What is included in the set up for regional anesthesia?
- Monitors
- Suction
- Means of PPV (ambu-bag, mask, oxygen)
- Airway (intubation equipment)
- IV access
- Drugs (emergency medications, anxiolytics, lipids)
What are three ways to verify needle placement during a block?
- Ultrasound
- Nerve stimulator
- Parasthesas (not ideal)
What type of needle do you use for upper extremity nerve blocks?
22 G “B” bevel insulated needle.
How many milliamps do you start at on the nerve stimulator and what do you dial down to?
Start at 1.0 milliamps and dial down to 0.5. Want twitch to still be there at 0.5, but go away by 0.3.
What surgeries can be performed under an interscalene block?
Shoulder or upper arm.
What does an interscalene block provide anesthesia to?
Upper branches of the brachial plexus and the lower cervical plexus.
How much LA do you inject for an interscalene block?
20-30ml
What nerve is often spared during an interscalene block?
Ulnar nerve. Your ring and little finger will not be numb, can pinch and spread fingers.
What is the landmark for the interscalene block?
Lateral border of the sternocleidomastoid muscle at the level of C6.
What are some contraindications to an interscalene block?
Absolute:
-Contralateral recurrent laryngeal nerve palsy
-Phrenic nerve palsy
Relative:
-Preexisting nerve injury
-Brachial plexus pathology
-Significantly impaired pulmonary function
What should you see twitching to verify placement during an interscalene block?
Bicep or distal hand.
How do you evaluate an interscalene block?
- Push (arm extension-radial nerve)
- Pull (arm flexion- musculocutaneous nerve)
- Close (index finger-median nerve)
- Open (little finger-ulnar nerve)
- Sensory loss to shoulder
What are some complications from an interscalene block?
- Intravascular injection
- Subarachnoid/epidural injection
- Pneumothorax
- Recurrent laryngeal nerve block
- Horner’s syndrome
- Phrenic nerve block
What are some indications for a cervical plexus block?
-Unilateral surgical procedures of the neck- carotid endartectomy if combined with a deep cervical plexus block
What is the landmark for a cervical plexus block? How many mls of LA is injected?
Midpoint of the posterior border of the SCM. The needle is tunneled superiorly and then inferiorly along the posterior border and 5ml is injected subcutaneously in both directions.
What is blocked during a supraclavicular block?
- Carried out at the trunks of the brachial plexus
- Effective block for all portions of the upper extremity (hand, forearm, upper arm)
What are some contraindications to a supraclavicular block?
- Contralateral phrenic paralysis
- Recurrent nerve paralysis
- Contralateral pneumothorax
What are the landmarks for insertion of a supraclavicular block?
Lateral border of the clavicular head of the SCM at the level of the insertion into the clavical in the groove between the scalene muscles. Needle only goes 0.5-1cm directed caudally, not very deep.
What are some complications with supraclavicular blocks?
- Increased risk of pneumothorax
- Horner’s syndrome
- Phrenic nerve block
- Recurrent laryngeal nerve paralysis
- Neuropathy
What are indications for an infraclavicular block?
Surgery on the elbow, forearm, hand
What are the landmarks for an infraclavicular block?
Needle is inserted at a 45 degree angle to the skin at the idpoint between the coracoid process and the medial clavicular head
