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

• 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!