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MaverickRegional Anesthesia Education, LLC
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Most proximal block of the brachial plexus
Conducted at the level of the distal roots and trunks
The modern approach was introduced by Dr. AlonWinnie in 1970, needle approach is perpendicular to skin
G. Meier described a more lateral and caudadneedle approach (1997, 2001)
Pippa described the posterior approach (1990)
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Winnie Approach
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Surgical Procedures on shoulder and upper arm
Shoulder arthroplasty
Mobilization and physiotherapy for frozen shoulder
CPNB provides superior postoperative analgesia (our practice 48‐60 hrs)
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Superficial block
Reliable block for shoulder and upper arm procedures
Continuous block with catheter is very reliable
Simple/easy positioning for patients with fractures or limited mobility
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Inferior trunk is often missedUnsuitable for procedures on forearm, wrist and hand.
Complications can be life threatening if not recognized and treated.
Total spinal, pneumothorax, IV injection, hemidiaphramtic block
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Local or systemic infection @ needle insertion site
Severe COPD (home O2 = NO block)
Contralateral pneumothorax or pneumonectomy
Contralateral paresis of recurrent laryngeal or phrenic nerve (can cause acute Respiratory Distress Syndrome)
Patient refusal
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Non‐cooperative patient
Severe respiratory compromise (may consider smaller initial bolus volume and/or weaker concentration of LA)
The need for bilateral upper extremity anesthesia
Preexisting neuro deficits in the distribution of the block (new).
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Brachial Plexus formed by anterior rami of C5‐T1
Roots unite to form three trunks
Trunks are stacked vertically between the anterior and middle scalene muscles
Trunks, the subclavian artery and scalene muscles are enclosed in a fascial sheath
The subclavian artery is anterior and medial to trunks of brachial plexus as they exit the interscalene space.
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5 Roots: C5‐T1
3 Trunks: Upper, Middle, lower
3 Cords: Medial, Lateral, Posterior
Individual Nerves(Musculocutaneous, Radial, Median, Ulnar)
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The Phrenic Nerve (C3‐5) is anterior to the anterior scalene muscle
The Cervical Sympathetic Chain runs medially to anterior scalene muscle
The Recurrent Laryngeal Nerve hooks underneath the subclavian artery on the right side
The Recurrent Laryngeal Nerve hooks underneath the arch of the aorta on the left side.
The Dorsal Scapular and Accessory nerves are lateral and posterior to the middle scalene muscle.
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Supine with the arms by the side
Head turned to the opposite side
Rolled blanket placed behind the shoulder to extend the neck
Take off all wraps and splints
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Assemble appropriate supplies , needle and/or catheter
Intravenous line started
Usual monitors (minimum EKG, Pulse Ox)
Neck, clavicle, shoulder and upper arm prepped and draped
Mild sedation (usually 1‐2mg Versed)Perform time out with nurse prior to sedation
Skin wheal at needle insertion site with 1% lidocaine
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Palpate the cricoid cartilage
Identify and mark posterior border of clavical head of SCM
Mark needle insertion point at posterior border of SCM at level of cricoid cartlage
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Brachial plexus is usually contacted rather superficially (1 to 1.5cm), but due to angle of approach may be up to 3.5cm deep
Initial current on the nerve stimulator should be set at 1.0mA
0.7mA initial current in the presence of fractures or trauma
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Insert needle in a posterior, medial and slightly caudaddirection (~30 degrees) aiming at midpoint of clavicle
Insert needle at point marked in a medial and caudaddirection (“freehanded” without compressing anatomy with other hand)
Should not insert needle >4cm
Orient needle in caudad direction to avoid intrathecal or vertebral artery injection
50mm 18g insulated B bevel or 4 inch 22g insulated B bevel with 18g angiocath slipped over it if continuous catheter to be inserted.
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Musculocutaneous response: Contraction of biceps and brachialis muscles (flexion of elbow).
Radial response: Contraction of triceps muscle (extension of elbow)
Pectoral response: Contraction of pectoral muscles (adduction of shoulder)
Axillary nerve response: Contraction of deltoid muscles (abduction of shoulder) Most desirable for shoulder procedures
Hand/Fingers: Most desirable for Humeral or upper arm procedures
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Diaphragmatic contraction: stimulation of phrenic nerve—needle is positioned too anterior…redirect needle slightly posterior.
Trapezius contraction (shoulder shrug): stimulation of spinal accessory nerve—needle is positioned too posterior redirect needle slightly anterior.
Posterior compartment neck muscles (Rhomboids, levatorscapulae): stimulation of the dorsal scalpular and levatorscapulae nerves—needle is too posterior from plexus.
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The nerves of the brachial plexus most often blocked via ISB are (C5‐C8):
AxillaryMedianRadialMusculocutaneousSuprascapular, Pectorals, and Medial Cutaneous nerve of the arm
Nerves most often missed are (T1): UlnarMedial Cutaneous nerve of the forearm
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Phrenic nerve palsy: 90‐100% incidence of hemidiaphragmatic paralysis on CXR
FVC is decreased and patients will experience dyspnea and inability to breathe deeply
Sympathetic chain blockade:Horner’s syndrome: Myosis (small pupil), ptosis (drooping of upper eye lid) and enophthalmoses (sinking of the eyeball).
Unilateral flushing of conjunctiva and nasal congestion.
Recurrent Laryngeal nerve palsy: presents as hoarseness, usually with right‐sided blocks
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Have patient turn face away from the side to be blocked. This tenses the sternocleidomastoid muscles and makes it much more prominent.
Have patient lift head. This tenses the sternocleidomastoid muscles helping to identify posterior border of clavicular head of sternocleidomastoid muscle.
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The clavicular head of sternocliedomastoid and cricoid cartilage are most important landmarks.
The external jugular vein is not a consistent landmark. It has a highly variable course. However, we find that the brachial plexus is almost always immediately in front of or behind the EJ at the posterior border of SCM.
In patients with difficult anatomy, the clavicle and external jugular vein often prove to be the most reliable landmarks.
The tip of the earlobe to the mid‐clavicular line is another helpful landmark.
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Pneumothorax
Intrathecal injection
CNS toxicity via absorption or IV injection
Phrenic nerve palsy resulting in hemidiaphragmatic paralysis
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Chelly JE, Peripheral Nerve Blocks; A Color Atlas. 3rd ed. HadzicA, Vloka JD. The Practice of Peripheral nerve Blocks in the U.S.; A National Survey. Regional Anesthesia Pain 1998; 23;241‐246Meier, G. Peripheral Regional Anesthesia; An Atlas of Anatomy and Techniques; 2nd ed. Pgs 10‐23. HadzicA; Interscalene Nerve Block. Retrieved on April 2009 from New York School of Regional Anesthesia Web siteBrown David L. Atlas of Regional Anesthesia; 3rd ed. 2006 pg 39‐43.UrmeyW, McDonald M. Hemidiaphragmatic paresis during interscalene brachial plexus block; effects on pulmonary function and chest wall mechanics. Anesthesia & Analgesia 1992; 74;352‐357.Khaladkar B. Course material provided on Peripheral nerve blocks 2008. Yung, E, Bicarbonate plus epinephrine shortens the onset and prolongs the duration of sciatic block using Chloroprocainefollowed by Bupivacaine in Sprague‐Dawley rats. Regional Anesthesia and Pain Management, 34, May‐June 2009, 196‐200.
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