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Ultrasound Guided Regional Anesthesia Overview of Upper Extremity Nerve Blocks

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Ultrasound Guided Regional Anesthesia Overview of Upper Extremity Nerve Blocks Ultrasound Guided Regional Anesthesia Overview of Upper Extremity Nerve Blocks Milica Markovic, MD Assistant Professor of Anesthesiology Weill Cornell Medical Center New York Presbyterian Hospital UPPER EXTREMITY BLOCKS Brachial Plexus Brachial Plexus Blocks Interscalene Supraclavicular Infraclavicular Axillary Mid-humeral Upper Extremity Surgery • Shoulder Surgery Interscalene Block Supraclavicular Block • Elbow Surgery Infraclavicular Block Supraclaviular Block • Hand Surgery Axillary Block Infraclavicular block INTERSCALENE BLOCK Interscalene block • C6/cricoid cartilage • Between anterior & middle scalene, posterior to SCM • Best block for shoulder • May miss lower trunk = ulnar distribution (50%); not ideal for hand Illustration by Jennifer Gentry. ©American Society of Regional Anesthesia and Pain Medicine. Interscalene Block Interscalene Block SCM ASM MSM IJ Carotid Interscalene Block Med Lat Ultrasound Interscalene Anterior Scalene Middle Scalene SCM Interscalene Groove Great Vessels Subclavian Vessels Side Effects & Complications • 100% incidence phrenic nerve paralysis - SOB/resp failure • Hoarseness - Recurrent laryngeal nerve block • Horner’s syndrome - Ipsilateral sympathetic block (stellate ganglion) • Vertebral artery injection – immediate seizure • Epidural, subarachnoid, subdural injection • Pneumothorax • Hematoma Limitations • 50% spare of the ulnar nerve • Contraindicated in patients with significant pulmonary impairment • Contraindicated in patients with contralateral vocal cord paresis SUPRACLAVICULAR BLOCK Illustration by Jennifer Gentry. ©American Society of Regional Anesthesia and Pain Medicine. Supraclavicular Block • “Spinal” of the arm • Halfway across clavicle • Trunks/Divisions superior & lateral to the subclavian artery in a compact area • Complications – Peumothorax, hemothorax, Horner’s, phrenic paralysis/paresis Supravlavicular Block Supraclavicular Block Lateral Rib Pleura Pleura Ultrasound Supraclavicular Lat Med Supraclavicular Block INFRACLAVICULAR BLOCK Illustration by Jennifer Gentry. ©American Society of Regional Anesthesia and Pain Medicine. Infraclavicular Block • Forearm/hand, doable for upper arm, not for shoulder Infraclavicular • Deeper structures, low frequency probe • Complications – Pneumothorax – Non-compressible vascular puncture – Intravascular injection of local anesthetic • Limitations – Proximity to large vessels – hesitant to place catheters with large bore needles, esp in anticoagulated patients Infraclavicular Block • Delto-pectoral groove, below clavicle and coracoid process • Identify axillary artery/vein • Point needle lateral to avoid aiming at pleura Ultrasound Infraclavicular AXILLARY BLOCK Illustration by Jennifer Gentry. ©American Society of Regional Anesthesia and Pain Medicine. AXILLARY BLOCK • Most common indication is for hand, forearm and elbow surgery Axillary Block Axillary Blok • Easy and simple landmarks (axillary artery) • Arm abducted, elbow flexed 90° • Palpate artery proximal in axilla. Transarterial, stimulating, paresthesia, ultrasound • Supplement Musculocutaneous nerve or lack anesthesia lateral forearm Ultrasound Axillary Axiallary Block • Limitations – Late or incomplete blockade of musculocutaneous nerve – Difficulty abducting the arm in arthritic or frozen shoulder patients – Transarterial technique is contraindicated in coagulopathic patients • Complications – Very low – Hematoma – Nerve injury – LAST Upper Extremity Pearls • Nerves missed in supraclavicular block for shoulder surgery? – Anterior shoulder, superficial cervical plexus (C1-4), field block • What nerve missed by axillary? – Musculocutaneous comes off proximally, in belly of choracobrachialis Tourniquet pain? Must block the medial brachial cutaneous (C8-T1) & intercostobrachial (T2) which innervate medial & proximal upper arm with subcutaneous cuff around axilla THANK YOU! .
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