lateral pectoral nerve axiiery upper subscapular nerve torecodorsel nerve Rerve medial cutaneous nerve of the forearm The apove Image snows brachial plexus block at the trunk level, which is the landmark ‘or interzeatene: Supenor & midatle trunk (inferior trunk Blockage Is incomplete) Imerscatene, Disial trunk & proximal aivision Supraciavicular Intereealene block provides surgical anesthesia tor proceduirse of the shoukier and upper arm. “The block Is performed between the antenor and middie sealene muscles in the interseal lavelor Ge. where ihe brachial plaxus emerges. It provides an adequate lock oF ine Superior and midale trunks oF the brachial plexus. UInar nerve (GB, T1) Most common complication of interscalene block seen in 100% of patients Is diaphragmatic hemiparesis due to ipsilateral phrenic nerve blockade ‘This can result in dyspnea, hypoxia. and hypercapnea, especially if the patient has compromised lung runeton of preexisting contralateral phrenic nerve paralysis. ‘other complications of interscalene block are: + Horners syndrome — ptosis, myasis, anhyarosts. Due to volvement of the sympathetic nerves to the cervicotharacie gan Recurrent laryngeal nerve palsy Vagus nerve invowement Bezold varisen renex Accidental vertebral artery injection (immediate seizure is seen) ‘Accidental spinal or epidural injection Pearl #510: Brachial Plexus Block Interscalene Approach Most intense at C5-C7 dermatomes + Least intense at C8-T1 (Uinar nerve area) + Most optimal for procedures on shoulder. arm ‘The axillary block is the most preferred approach to the brachial plexus in pediatne patients for surgeries of the elbow, forearm, and hand as itis 2 relatively easy and safe procedure ‘Complications include systemic toxicity due to accidental intraarterial injection and permanent nerve injury trom the intraneural injection.Regional anesthesia of choice for cisiocated shoulder Ic interseatene brachial plexus block. Interscaiene Superior ana Shoulder 876 Winar nerve sparing pista uneand SIO ‘Avullary and suprascaputar nerve sparing, Supraciaviowtar forearm ana Gneumotnorae phrenic mere Palsy Axitiary Terminatnenves EOFs Inadvertent intravascular injection 4. Identify the procedure depicted below. ‘The supraciavicular block Is a type of Brachial plexus Block used for procedures on the elbow, forearm, ana Known as ‘spinal of the arm’, supraciavicular Bleck provides an adequate block oF the brachial plexus at tne level of the distal trunk = proximal division. ‘The supraciavicular block dees net adequately block the axillary and suprascapular ner not retiabie for snoulder surgery. 5. and thus is “The most common complication of supraciavicular block Is phrenic nerve palsy win an incidence > SO %. Hemiaiapnragmaue paresis - due to phrenic nerve palsy Pneumoinorax —nighest when compared to other brachial plexus blocks, Hoarseness - due to recurrent laryngeal nerve palsy and/or cervical sympathetle Block Pneumotnorax is the mest dangerous complication of supraciavicular block but It Is not the most common. It has an incidence that ranges trom 0.5. 6%. The symptoms develop slowly, may take upto 24 nours. ‘Supraciavicular block is not reliable for shoulder surgeries like reduction of posterior dislocation of shoulder as axillary and suprascpular nerves are spared. Supraciavicular block Is a type of brachial plexus block used for procedures on the elbow, forearm, ana hand. Provides an adequate block of the brachial plexus at the level of the distal trunk - proximal division,‘The incidence of pneumothorax is maximum with supraciavicular block (0.5- 6%) among all the approacnes to brachial plexus block. This can be averted by performing ultrasound guided block. &. Identify the procedure depicted below. ‘The image shows brachial plexus blockade at the Indicating infraciavicular block. 1 of cords and the approach below the level clavicle The Infractavicular Block Is 2 type of brachial plexus block used for procedures of the forearm and hana. the image shows blockade of terminal nerves of brachial plexus around axillary artery inclesting axillary Supraciavieuiar Distal wank ang Phoumotnoras preemie nenwe patey injection Pearl #517: Brachial Plexus Block: Axillary Approach + Most intense block in C771 (Uinar nerve) distribution, 1 Mont optimal tor procedures rom elbow to hanceIntravenous regional anesthesia (IVRA) or the Bier's block was Mirst discovered by August Bier in 1908. He Is also known for the introduction of spinal anesthesia. IVRA/Bier's block: Used to provide regional anesthesia for short surgical procedures (<80 minutes) on the limbs. Ht involves the intravenous administration of a local anesthetic into a tourniquet-occluded limb. Anesthesia sets in within 6 minutes. Drugs used: Lidocaine (most commonly used), prilocaine (frst local anesthetic used), mepivacaine, chicroprocaine, and etidocaine. Bupivacaine Is no longer used due to cardiotoxicity. John Lundy: coined the term balanced anesthesia win lam Morton: demonstrated ether anesthesia Joseph Priestly: discovered nitrous oxide. Pearl #431: Important Root values Uinar nore: Greet) Nucleus ambigous 9. 10. 11- cranial nerve nucte! common complication of cetlac plexus block Is postural hypotension. Celiac plexus: Largest plexus of the sympathetic nervous system: Contains preganglionic sympathetlc from greater, lesser and least splanchnic nerves (T5 to T12). postganglione sympathetic. preganglionic parasympamnetic and visceral sensory afferent fibres. Bravices sensory innervation and sympathetic outflow ta stomach. liver. spizen. pancreas. kidney and GI tract up to splenic flexure. Inateation: Pain arising from the abdominal viscera, particularly intra-abdominal cancers (Eq. pancreatic cancer), ptications: ontnostatic nypetension (most common. can be minimized with fluid nysration) Diarrhea (secondary to blockade of sympathetic Moors) Paraplegia (from damage to artery of Adamkiewic2) Local anesthetic toxeity, spinal or epidural Injection. retropertoeneal hemorrhage. visceral oraan Injury, ana preumotnorax,