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Regional Anaesthesia for

the Upper limb

Dr. Manish Singhal


Dept. of Anaesthetics
Objectives
 Brief anatomy of brachial plexus
 Gadgets/monitoring
 Indications
 Contraindications
 Techniques
Advantages of Regional
 Minimal changes in metabolism /acid
base balance

 Relatively stable hemodynamics

 Positioning

 Postoperative analgesia
Advantages of Regional
 Reduced incidence of PONV

 Reduced blood loss

 Reduced chances of Atelectasis

 Avoidance of opioids
Contraindications to
Regional
 Patient refusal
 Hysteria…severe anxiety
 Coagulopathy
 Neurological complications
 Skin infection near puncture site
 Septicaemia…abscess seeding
Brachial Plexus
 Upper extremity nerves.
Nerves in close proximity
Identifiable bony and vascular
landmarks.
 Approachable at several levels.
 Multiple techniques.
 Supplies motor function to entire
upper extremity.
 Supplies almost entire sensory
innervation to upper extremity….
caudad branches of cervical plexus
Brachial Plexus
 Robert: R-
5
 Taylor: T-3
 Drinks: D-6
 Cold: C-3
 Beer: B-
5
Terminal Nerves

 Musculocutaneous: (M: Biceps/Flex


forearm)

(S: Lateral mid


forearm)

 Median: (M: flexors/pronators


,forearm)
Terminal Nerves
 Radial:
(M:Triceps/supinator/extensors,f.arm)

(S:Post
arm/forearm/dorsum/thumb)

 Ulnar: (M:Flexor carpi


ulnaris,abduction,fing.)
Regional Anaesthesia
Preparation
 SOAP
Suction

Oxygen

Airway

Pharmacology
Monitoring
 Monitors ( ASA Standards)
EKG

NIBP

Pulse oximetry

Verbal
Equipment
 Sterile gloves
 Marking pen
 PNS/Electrodes
 Sterile gauze packs
 Short/Insulated needle.
 22 G /5 CMS
 Syringes with L.A
Equipment
PNS
*Hi-Low
adjustment
*Digital display
*Alligator clips
Neg.electrode to
needle
Current: 0.3 to 1.0
M.amp.
Equipment
Needles
22G
#Insulated
#Non-insulated
Needle length: 5
cms

Immobile needle
Tech.!
Adjuncts
 Block placement and intraop.
sedation
Midazolam
Fentanyl/Alfentanil
Propofol
 Intraoperative position
Avoid laying flat
“Lawn Chair” position
 Music, headphones, verbal
conversation
TECHNIQUES

Brachial plexus Blocks of I


blocks terminal
1 Interscalene nerves VRA
1. Wrist block
2. Supraclavicular
2. Digital nerve block
3. Axillary
4. Infraclavicular
5.Intersternocleido
mastoid
Choice of Anaesthetic
Onset Anesthesia Analgesia
(min) (hrs) (hrs)
3% 2- 5—10 1.5 2
Chloroprocaine
(+HCO3
1.5% + epin) 10—20 2—3 2—4
Mepivacaine
(+HCO3)
1.5% 5—15 2.5—4 3—6
Mepivacaine
(+HCO3 +epin)
2% Lidocaine 10—20 2.5—3 2—5
+(HCO3)
2%lidocaine+(H 5—15 3—6 5—8
CO3)+(epi)
0.5% 15—20 6—8 8—12
Ropivacaine
0.75% 5—15 8—10 12—18
Ropivacaine
0.5% 20—30 8—10 16--18
Bupivacaine
Local Anesthetics
 Continous: (loading dose: 10-15 mls
of L.A)
Bupivacaine: 0.15 – 0.125% @ 8 -10
mls/hr infusion
Ropivacaine: 0.2% @ 8-10 mls/hr infusion
Continuous or Low basal inf.+ PCA

 Single shot: 35 -40 mls of L.A


Borgeat et al:
Basal infusion of.125%bupivacaine (5ml/hr)
with PCA bolus(2.5ml/30 min) reduces the
Adjuvants to local
Anesthetics
 Epinephrine: 1 in 200,000
Reduces absorbtion/Increases
concentration
Risk of ischemic nerve injury !!

 Alkalinisation: 1 Meq of (8.4%)soda


bicarb.in each 10 mls of L.A reduces
onset time for lidocaine and
mepivacaine but not bupivacaine and
ropivacaine. Milner et al (EJA
Adjuvants to local
Anesthetics
 Clonidine: It reduces onset time,
prolongs postop.analgesia(2-3 hrs)
when used as low as 1 mic/kg with
L.A. Ilfield (Anesth.Analg.2003)

 Clonidine(1 mic/kg) and


ketamine(0.1 mg/kg)
Reduces onset time(5 to 7 min.)and
extends analgesia to upto 2 hrs when
used with bupivacaine/ropivacaine.
Adjuvants to local
Anesthetics
 Peripheral opioids: addition of small
doses of Fentanyl(1mic/kg) or
sufentanyl(0.1 mic/kg) or
Morphine(0.03 mg/kg),results in
improvement in onset time(5 -7 min)
and duration of nerve block (2 -3
hrs). Murphy et al
(Anest.Analg.2000)


Positioning
Interscalene Approach
 Provides Anaesthesia to

Upper branches of brachial plexus

Lower cervical plexus

First performed by Winnie in 1970


Interscalene indications
 Shoulder and clavicle procedures

 Procedures proximal to the elbow

 Inferior fibers frequently not


anaesthetised
T 1 root
Ulnar nerve distribution
Interscalene
Contraindications
 Absolute
Contralateral recurrent nerve
palsy
Phrenic nerve palsy

 Relative
Pre-existing nerve injury
Brachial plexus pathology
Interscalene Anatomy

Carotid
artery

Middle Scalene
Muscle
Sternocleidomastoid
muscle

Phrenic nerve
EJV
Anterior Scalene
Interscalene landmarks
 1. Clavicle

 2.post. Border ,SCM

 3.Ext.Jug.Vein
Interscalene Approach
 Supine,head
turned to
opposite side
 Palpate
posterior border
of SCM
 Cricoid
cartilageC6
 Roll fingers to
palpate groove
between
anterior and
middle scalene
Needle Direction
 Directed
towards
transverse
process of C6
 Medial ,caudal
and slightly
dorsal
 Needle angle-
45 deg caudad
45 deg
Interscalene Approach
 Nerve stimulus
Set@0.5.mA
 Twitch of biceps
muscle or distal
hand (radial or
musculocut. nerve)

 Aspirate for blood,


CSF
 Inject 40 mls of LA
Evaluation
 Ability to abduct arm----Axillary nerve

 Ability to flex arm---


Musculocutaneous nerve

 Ability to extend forearm---Radial


nerve

 Sensory loss to entire shoulder


Side effects
 Ipsilateral diaphragmatic
paralysis(100%)

 Recurrent Laryngeal .N. block


(Hoarseness)
 Horner’s Syndrome
LA spillage onto sympathetic chain
Ptosis
Myosis
Enopthalmos
Complications
 Vertebral
artery
injection
 Steady
pressure:
5 min.
Complications

 Intrathecal/E.
D. injection
Complications
 CNS toxicity. Avoid forceful/fast
inj.(L.A)

 Nerve injury. Never inj…Abnormal


press./resist

 Pneumothorax

 Failed block
Supraclavicular approach
 First performed by Kulenkampp in
1911

 Produces reliable blockade of all


terminal branches of the brachial
plexus

 Significant potential complications


Highest incidence of pneumothorax
Indications
 Theoretical technique of choice for
procedures of
Upper arm
Forearm
Hand
 Increased success of blocking inferior
trunk
Ulnar nerve
Radial nerve
Contraindications
 Contralateral pneumothorax

 Haemorrhagic diathesis

 Contralateral phrenic nerve palsy

 Recurrent nerve palsy


Anatomy
 The three trunks emerge from
between the two scalene muscles
-----lie just posterior to artery

 After crossing first rib the plexus


branches
Posteriorly—Suprascapular nerve
Anteriorly—Long thoracic nerve
Supraclavicular Anatomy

Omohyoid Muscle

Sternohyoid muscle
ANTERIOR SCALENE
MUSCLE
SUPRASCAPULAR
NERVE

BRACHIAL Int.
CLAVICLE PLEXUS Jugular
TRUNKS Vein
Supraclavicular anatomy
 Beware !!

Pleural dome

Subclavian. A
Landmarks
 Lateral insertion of SCM

 Margin of safety: 2.5 cms from


Lateral insert of SCM(Away from
Pleural dome)
Nysora Technique
Supraclavicular approach
 Needle entrance: Cephalad to
Palp.finger,1 inch above clavicle
Parallel to midline

 Needle 1st perpendicular to skin


Then turned and advanced in
Direction of arrows parallel to
Midline.
Needle inserted 0.5 to 1 cm
above clavicular mid point(
Feel for Subclavian. Pulse)

Directed parallel to spinal


column and perpendicular
to first rib,lateral and
cauded.

Walked along rib till plexus


is identified either by PNS
or parasthesia

Plexus usually encountered


at a depth of 2-2.5 cm
(KULAMKAMPFF)
Complications
 Increased risk of pneumothorax
Initial data by papper (1961) : 6.1 %
Recent data by Nysora: Minimal
incidence
Onset : >3 to 4 hrs and <12 hrs.

 Horner’s syndrome : Reassurance!

 Phrenic nerve block: Reassurance!


Complications
 Recurrent laryngeal nerve palsy

 Intravascular injection: subclavian


artery!

 Hematomas

 Neuropraxia
Infraclavicular block
Wrist Block
Digital nerve block
IVRA( Bier’s Block)
Remember to…
 Confirm proper cuff inflation. Check
for air leaks.
 Maintain verbal contact with patient.
Titrate sedation.
 Confirm absence of radial pulse.
 Inflate cuffs 100mmHg above
Systolic pressure.
 Meticulously exsanguinate.
 Always label cuffs.
Drugs used.
 Literature describes the use of
varying volumes and concentrations
of drugs.
 Lignocaine– 0.25-2.0%.
 Prilocaine.
 Ropivacaine 0.2%
 Volume 20-50 mls.
Cuff deflation
 Important to deflate the cuffs slowly .
 Deflate for 10 sec followed by
inflation for 1 min. before final
deflation.
 Watch for signs of local anaesthetic
toxicity.
 Give adequate analgesia before the
analgesic effect of the block wears
off.
Anaesthesia Axioms
 Always give Oxygen !!
 Trust but verify !!
 The record is your friend !!
 Read the label !!

“You should really enjoy


anaesthesia, if you don’t, do
something else !!”