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Anesthesia Concepts-Cassie > Upper Extremity - Peripheral Nerve Blocks > Flashcards

Upper Extremity - Peripheral Nerve Blocks Flashcards

0
Q

Regional Anesthesia Advantages:

*Regional avoids giving ____ in some cases.
Can avoid intubation and instrumentation (teeth damage, sore throat).
Easier to keep patient’s temp warm with regional.

*Avoid use of ____ because they can cause respiratory depression, nausea, vomiting, itching, constipation.

A
  • General Anesthesia

* Opiates

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1
Q

Regional Anesthesia Advantages:

1) ______ - Administer anesthesia in an extremity, that extremity vasodilates and you get better perfusion in that extremity.
* Intraoperative - reduction in?
* Postoperative - improvement in?
2) Reduced nausea and vomiting
3) _____ - Reduces postoperative pain and analgesic requirements

A

1) Induced Sympathectomy
* blood loss
* perfusion
3) Preemptive Analgesia

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2
Q
  • Too much sedation, patient too sleepy (may need to instrument their airway, supplemental oxygen).
  • Patient gets vagal response because you are coming at them with the needle.
  • Can give _____ (injection into CSF, then you would get a total spinal). Patient will not have respiratory effort and have cardiac complications.
  • Patient could get a ____ that could compromise their airway.
A
  • Intrathecal injection

* Huge hematoma

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3
Q

Interwoven network of nerves that innervates the pectoral girdle and upper limb?
* ____ in close proximity to each other
* Easily identifiable bony and vascular landmarks
* Approached at several levels
* Multiple techniques - ultrasound, nerve stimulator, elicit
paresthesia

A

Brachial Plexus

*Nerve roots

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4
Q

Brachial Plexus: Supplies all motor function to the upper extremity

Supplies almost all ____ of the upper extremity.

 * With the exception of the \_\_\_\_ of the cervical plexus
                        - Supplies posterior shoulder
A
  • Sensory function

* Caudad branches

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5
Q

This nerve allows you to flex the forearm?

A

Musculocutaneous nerve

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7
Q

Brachial Plexus: Musculocutaneous Nerve

1) Nerve roots?
2) Exits the sheath high in the axilla. ____?
3) Motor: (3) they allow you to?

A

1) C5, C6, C7
2) Coracobrachialis muscle
3) Biceps brachii, coracobrachialis, brachialis
Flex forearm

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8
Q

Brachial Plexus: Musculocutaneous Nerve

Supplies sensory innervation to the ____ and up into the ____.

A

Lateral mid-forearm, up into the wrist

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9
Q

Brachial Plexus: Axillary Nerve

1) Nerve roots? (Leaves plexus at lower border of the ____)
2) Motor: ____ & ____
3) Sensory: Inferior ____, Upper ____

A 
1) C5-T1
    pectoralis muscle
2) Deltoid
    Teres minor
3) Shoulder
    Upper Lateral arm
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10
Q

This nerve allows you to supinate and extend the forearm?

A

Radial nerve

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11
Q

Increased success of blocking inferior trunk: Ulnar and radial nerves
*Less chance of ulnar nerve sparing

A

Supraclavicular Approach

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13
Q

Brachial Plexus: Radial Nerve

1) Nerve roots?
2) Motor: Triceps, supinator & extensors of the forearm
3) Sensory: (3) ____, ___ border of ____, ____ & ____ of hand

A

1) C5-T1
3) Posterior arm & forearm
Lateral border of elbow
thumb & dorsal surface of hand

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15
Q

This nerve allows you to flex your wrist?

A

Median Nerve

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17
Q

*Stimulation depends on intensity of the current (mAmp) and pulse duration (ms) = high-low adjustment, digital display, alligator clips, long cables

*Needles - __ gauge, ___ (this is shorter and at a bigger angle)
Needles can be insulated or non-insulated

A
  • Nerve stimulator

* 22 G, B-bevel

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18
Q

Needles with Nerve Stimulator:
1) ____: Electric current comes out of the tip of the needle rather than the entire length of the shaft

2) ____: Current would come out the entire length of the shaft of the needle

A

1) insulated

2) non-insulated

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19
Q

Nerve stimulator - use for peripheral nerve blocks:

1) Two wires?
* Current gets picked up by ___ first, goes from?
2) Want red to be ____ and black wire to be ____.

*Stimulators deliver an electric current in mA (1-1.5 when stimulating).
Before giving anesthetic want to dial it down to 0.5 mA.

A

1) Red & Black wires
*black first
goes from black to red
2) Proximal - red
Distal - black

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20
Q

1) This block is carried out at the roots and trunks of the brachial plexus?
2) This block is carried out at the trunks and divisions of the brachial plexus?

A

1) Interscalene block

2) Supraclavicular block

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21
Q

This nerve allows you to abduct your fingers?

A

Ulnar nerve

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22
Q

Block Needles:

1) This needle is longer and less of an angle?
2) This needle is shorter and at a bigger angle?

A

1) A-bevel

2) B-bevel

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23
Q

Adjuncts:

1) Block patient & ____ (propofol, midazolam, fentanyl)
*Like to give a little, still need patient to be awake enough to be
cooperative. So they can let us know if we are eliciting paresthesia,
talk to patient attempt to identify any CNS changes.
2) ____: Place patient in a position they will be able to tolerate, make sure patient can tolerate the position they will need to be in in the OR.
3) Verbal conversation

A

1) Intraoperative sedation

2) Intraoperative positioning

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24
Q

Approaches to the Brachial Plexus: (5)

A

1) Interscalene
2) Supraclavicular
3) Infraclavicular
4) Axillary
5) Terminal nerves

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25
Q

Ideal for surgery of the shoulder, upper arm, clavicle & procedures proximal to the elbow?

*This will be closer to the spinal column, may spare the back of the shoulder a little. But usually will be able to perform most shoulder surgeries with this block.

A

Interscalene

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26
Q

Interscalene Block provides Anesthesia to:

1) ____ of the brachial plexus
2) Lower _____

*Inferior fibers frequently not anesthetized?

A

1) Upper branches of the brachial plexus
2) Lower cervical plexus

*Ulnar nerve sparing

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27
Q

Interscalene:
*Anesthesia provided for upper arm to the elbow procedures

  • Can spare the back of the shoulder and spare the inferior fibers at the trunk level (____ - if you have spared it patient will be able to pinch and spread fingers)
  • If patient can do this may need to do a?
A
  • Ulnar nerve

* Terminal Branch Block

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28
Q

Interscalene Approach:
*Patient supine, head turned toward opposite side

1) Palpate posterior border of _____ at the level of ____.
2) Roll fingers posteriorly and palpate groove btw ____ & ____.

A

1) Sternocleidomastoid
C6 (cricoid cartilage)
2) Anterior & middle scalene muscles

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29
Q

Interscalene Approach continued:

1) Insert needle at the C6 level in a slightly ____, ____ direction
2) Nerve stimulator - start at 1 mAmp
3) Twitch at the ___ or ___ (drop to 0.5 mAmp or below)
4) ____ (heme, air, CSF) and inject ____ of LA.

A 
1) caudad 
    posterior
3) bicep or distal hand 
4) Aspirate
    20-30 mL of LA
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30
Q

If doing pure ____ technique will give a little more volume

With ____, more accurate, do not need to give as much volume 15-20 mL.

A

Nerve stimulator

Ultrasound

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31
Q

Interscalene Contraindications:

  • ABSOLUTE:
    1) Contralateral?
    2) ?

*Relative: Preexisting nerve injury, brachial plexus pathology, significantly impaired pulmonary function

A

1) Contralateral recurrent laryngeal nerve palsy
2) Phrenic nerve palsy

*These are bilateral nerves. If you have palsy on one side and you block the contralateral side, will have pulmonary issues.

32
Q

Interscalene Evaluation: Evaluate block with alcohol pad. May be a able to block temp. but could still possibly have some pain sensation.
Can also use blunt object (tongue depressor) to compare sides.
Evaluate muscle tone.

1) Push (arm extension - ?)
2) Pull (arm flexion - ?)
3) Close (index finger - ?)
4) Open (little finger - ?)
5) Sensory loss to ____. (Posterior shoulder is often spared)

A

1) Radial nerve
2) Musculocutaneous nerve
3) Median nerve
4) Ulnar nerve
5) shoulder

33
Q

*Safest and easiest approach to plexus.

Great for postop pain. Great artery to palpate.

A

Axillary Block

34
Q

Interscalene Complications:

  • Intravascular injection
  • Subarachnoid/Epidural injection
  • This is not as much of a risk as with some of the other blocks?
  • ? Block
A
  • Pneumothorax

- Recurrent laryngeal nerve block

35
Q

Interscalene Complications continued:

1) Will see droopy eyelids (ptosis), pupils constrict (myosis), lack of sweating. Interruption of the nerve pathways around the eye.
*This can be worrisome for patients, but this is benign will go
away once the block dissipates
2) 80-90% of patients will get this, tell patient they may feel like they can’t take a deep breathe etc.

A

1) Horner’s Syndrome

2) Phrenic Nerve Block

36
Q

Brachial Plexus: Ulnar Nerve (abduct fingers)

1) Nerve roots?
2) Motor?
3) Sensory? (2)

A

1) C8, T1
2) Flexor carpi ulnaris
3) Little finger
Medial ring finger

37
Q

Indicated for unilateral surgical procedures of the neck?

*May be combined with a ____ for a carotid endarterectomy.

A

Cervical Plexus Block

*deep cervical plexus block

38
Q

Cervical Plexus Block: Can do superficially. Usually right around?

Or can do a deep cervical plexus block, usually around? Block around muscles on neck, sensory skin block around muscles up there.

A
  • C6

- C2-C4

39
Q

Supraclavicular Contraindications:

1) ____ paralysis
2) ____ paralysis
3) Contralateral?

A

1) Contralateral phrenic paralysis
2) Recurrent nerve paralysis
3) Contralateral pneumothorax

40
Q

Supraclavicular Approach:

1) Lateral border of the ____ of ____, at the level of it’s insertion into the clavicle (insert needle at clavicular level, very shallow do not go deep).
2) Groove btw the scalene muscles is identified.
3) Needle inserted ____ cephalad to the midpoint of the ____.
4) Needle directed ____. DO NOT AIM ____!

A 
1) Clavicular head
    Sternocleidomastoid 
3) 0.5 to 1 cm 
    clavicle
4) caudally 
    medially
41
Q

Supraclavicular Approach:

1) Motor response in the ____ or ____ should be elicited immediately after the needle has entered the interscalene groove.
* The more ____ the response = a more reliable block.

2) Motor response usually elicited at a depth of _____. Motor still maintained at _____ or less. Inject, aspirate prior to injecting and every 5 mL thereafter!!!!

  • If using ultrasound - 2 injections.
  • If using nerve stimulator will only give one injection.
A

1) hand or arm
* distal
2) 2-3 cm
0. 5 mAmp

42
Q

Supraclavicular Complications:

1) Increased risk of this, 1-6%?
2) Horner’s Syndrome
3) Phrenic nerve block
4) _____ paralysis
5) _____ (Nerve may be pinned against the clavicle)

*Much higher risk of ____ and giving a ____

A

1) Pneumothorax
4) Recurrent Laryngeal Nerve Paralysis
5) Neuropathy

  • Pneumothorax
    Vascular injection
43
Q

Indicated for surgery on elbow, forearm, hand?

A

Infraclavicular approach

44
Q

Infraclavicular Approach:

1) Landmarks are the ____, ____
2) Block is performed by inserting the needle at a 45 degree angle to the skin at the midpoint btw the ___ and the ____.
3) The needle is then advanced in a ____ fashion.

A 
1) medial clavicular head
    coracoid process 
2) coracoid process 
    medial clavicular head 
3) Parallel
45
Q

Where clavicular head comes into shoulder, direct needle out toward the shoulder.
*Usually will see pectoral twitch (this is uncomfortable) keep moving or direct your needle. Need terminal branch twitching.

A

Infraclavicular approach

46
Q

Start IV on surgical arm, cap it.
Place double tourniquet on arm to exsanguinate (squeeze venous blood out of arm) inflated to 250 mL on upper extremity, 300-350 on lower extremity. This can be painful. Also worried about blood supply, extremity not getting any blood supply.

Start off inflating lower cuff, inject large anesthetic into IV (large vessel). Once you inject take IV out. The extremity will stay numb as long as tourniquet is inflated. After 30-60 minutes, patient c/o pain. If this happens can deflate lower cuff and increase upper cuff.

A

Bier Block

47
Q

Infraclavicular Approach:

1) Initially look for ____ (still too shallow)
2) Want ____, ____, or ____ twitch (5-8 cm depth of needle)
3) As long as the needle is directed ____, neuraxial or pulmonary complications are unlikely
4) This is a good technique for ____.

*Really no risk of pneumothorax.

A

1) pectoralis twitch
2) median, ulnar, radial twitch
3) laterally
4) continuous catheters

48
Q

Cervical Plexus Block:

1) Posterior border of ____ identified.
2) Needle inserted at the midpoint of the posterior border of SCM
3) Needle tunneled both superiorly and then inferiorly along posterior border of SCM. 5 mL of LA injected subcutaneously in both directions.

A

Sternocleidomastoid

49
Q

Axillary Block Indications:

*Gets less riskier the farther away from the neck you get.
Not for procedures on the elbow, for procedures ____ the elbow.

*Patient must be able to _____ and place at a _____.
This is the position you will have the patient in.
Big muscular patient’s can occlude the axillary artery with their musculature may need to bring their forearm up a little.

A

*Below

*abduct the arm
90 degree angle

50
Q

Axillary Block:

*Must inject ____ separately, this nerve is not in the neurovascular sheath.

A

Musculocutaneous nerve

51
Q

Axillary Contraindications:

1) ABSOLUTE: ____
2) Relative: Preexisting nerve injury, brachial plexus pathology

A

1) Lymphangitis (do not do if lymph nodes are swollen)

52
Q

Axillary Approach:

1) Superior (anterior) to the axillary artery?
2) Inferior to the axillary artery?
3) Posterior to the axillary artery?

A

1) Median nerve
2) Ulnar nerve
3) Radial nerve

53
Q

Axillary Approach:

1) Patient in the ____ position.
2) Extend arm ____, forearm flexed _____.
3) Palpate _____ proximally as possible.

A

1) supine

2) 100 degrees
90 degrees

3) axillary artery

54
Q

Nerve stimulator technique, trans-arterial technique, paresthesia technique - all 3 techniques can be used when performing an?

A

Axillary Block

55
Q

Use the axillary artery as indication that you are in the right place. Feel for the pulse direct needle into artery, aspirate blood and keep advancing until you do not get blood and inject (radial nerve). Now pull back out, get blood again, keep pulling until you do not and now inject on anterior side of artery (median nerve).

Can get hematomas, intravascular seeping. Not a technique that is used as much anymore.

A

Transarterial Technique with Axillary Block

56
Q

Axillary Block: Nerve Stimulator

1) Insert insulated needle immediately superior or inferior to palpation of?
2) Start nerve stimulator at 1.0 mAmp
3) Twitch in the _____. Drop to 0.5 mAmp or below.
4) Aspirate for heme first and inject ____ of LA, aspirating every 5 mLs.

A

1) Axillary artery
3) distal hand
4) 30 mLs

57
Q

Axillary Block: Single vs. Multiple Injections:

____ of one nerve is just as efficacious as identifying 2 nerves or 3 nerves.

____ of one nerve requires slightly less time to perform and is technically easier
*Proficiency & Efficiency

A

Electrolocation

Electrolocation

58
Q

Needle selection: often 22 gauge B-bevel.
Palpate the axillary artery and aspirate bright red blood.
-Advance until no further blood is obtained
-Entire volume of local anesthetic injected
*This technique is known as the?

A

*Transarterial Technique with Axillary Block

59
Q

Elicit paresthesia in the terminal nerves.
May take undue time and increase patient discomfort.

*This is known as?

A

*Paresthesia Technique with Axillary Block

60
Q

Axillary Block Evaluation:

1) “Push” - ____
2) “Pull” - ____
*Usually spared and often requires separate injection into the belly
of the coracobrachialis or fanning approach. Not in the sheath,
easy to miss.
3) “Close” - ____
4) “Open” - ____

A

1) Radial nerve
2) Musculocutaneous nerve
3) Median nerve
4) Ulnar nerve

61
Q

Axillary Block Complications:

1) (if you do get into the artery)
2) Intravascular injection
3) (hair in arm, more prone)

A

1) Hematoma

3) Infection

62
Q

“Touch-up” Nerve Blocks:

1) Brachioradialis muscle and tendon of biceps. Needle introduced 1-2 cm, lateral to the biceps tendon. A fanlike injection of 4-6 mLs of LA?
2) Needle introduced 1 cm medial to brachial artery. Inject 3-5 mLs of LA.

A

1) Radial nerve

2) Median nerve

63
Q

“Touch-up” Nerve Blocks:

1) Forearm is flexed. Needle introduced 1 cm proximal to the ulnar groove (btw the olecranon process and the medial epicondyle of the humerus). Inject 3-5 mL of LA. Do not inject directly into the?
2) Deep in the body of coracobrachialis muscle?

A

1) Ulnar nerve
Ulnar groove

2) Musculocutaneous nerve

64
Q

A distal vein is cannulated and the arm is exsanguinated, while a proximal tourniquet is inflated.

 * 40 mL of 0.5 Lidocaine are injected into the IV  - Onset of block usually within 5 minutes - Ideal for forearm and hand cases that are about 60 minutes, but can be effective for cases up to about 120 minutes
A

Bier Block

65
Q

Bier Block:

1) Disadvantages: ____
* Must be prepared to treat - Oxygen, ambu, barbs/benzos, intubating equipment

A

Local anesthetic toxicity

66
Q

Bier Block:

After you take off cuff, patient may have little rush from anesthetic. The longer it is in the tissue of the extremity you are working on the less of an effect it will have, the anesthetic has had time to ____. If you take cuff off earlier or it fails will get a much bigger ____ from the local anesthetic which is now circulating in the system.

A
  • diffuse

- systemic reaction

67
Q

Advantages: ?

  • Utilizes direct visualization
  • Reduction in complications and side effects (because we can give lower volumes of LA)
  • Useful in patients with difficult anatomy
A

Ultrasonography

68
Q

Disadvantages of Ultrasonography:

-Operator knowledge and skill
-Familiarity with visualized anatomy
-Cost
-Clinical results are just as good using ____ - although it depends on
who you ask

A

-Nerve stimulation

69
Q

Used intraop not used for postop or chronic pain modalities.
Used for anything from the elbow down.

A

Bier Block

70
Q

Indicated for procedures below the elbow?

A

Axillary Block

71
Q

Effective block for all portions of the upper extremity (hand, forearm, upper arm).

*Carried out at the ____ level of the brachial plexus.
*Increased success of blocking inferior trunk - ulnar & radial nerves
(less chance of ulnar nerve sparing)

A

Supraclavicular Block

*Trunks

72
Q

Brachial Plexus: Median Nerve (flex wrist)

1) Nerve roots?
2) Motor: ___ & ___ muscles of ____
3) Sensory: ___ surface of ____, ____ & ____ fingers

A

1) C5-T1
2) Flexors & Pronator muscles of forearm
3) Palmar surface of hand
Index & middle fingers

Anesthesia Concepts-Cassie (4 decks)

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