Axillary Brachial Plexus Block INTRODUCTION Brachial plexus block at the level of axilla is typically chosen for anesthesia

of the distal upper limb. Axillary block is a basic regional anesthesia technique and perhaps the most common approach to brachial plexus blockade. Low risk of serious complication, superficial location, and good analgesia of the upper arm muscle make this block suitable for ambulatory procedures of longer duration that require a tourniquet. HISTORY The surgical technique of this block was first describe by Hall1 in New York (Roosevelt Hospital) in 1884, and the percutaneous technique was described by Hirschel2 in 1911. While dissecting the axilla in a child in 1958, Burnham,3 recognized that filling the neurovascular sheath with local anesthetic could simplify the axillary block. He also described the characteristic fascial click felt on penetration by the needle. In 1961 while using the formula for a cylinder volume, De Jong4 calculated that in an average adult, 42 ml, of local anesthetic (AL) was necessary to fill the fascial compartment to the level of the cords and block all terminal nerves to the arm. A year later, Erikson and Skarby,5 in an effort to promote the proximal spread of AL, advocated wrapping a rubber tourniquet around the arm, distal the needle. In 1979, Winnie and coworkers6 found the tourniquet ineffective and painful and recommended firm distal digital pressure on the neurovascular sheath instead. In addition, they also recommended arm adduction after AL injection, thinking that the head of the abducted humerus compressed the neurovascular sheath. Both maneuver were later proved to be clinically ineffective.7-9 Thompson and Rorie,10 in 1983, studied brachial plexus using computed tomograms and suggested that the median, ulnar, and radial nerves lie in separate fascial compartments within the neurovascular sheath; this finding provided a rational explanation for incomplete blocks. However, anatomic studies by Lassale and Ang11 in 1984 and VesterAndersen and coworkers12 in 1986 did not confirm the existence of a true neurovascular sheath. The interfascial space they found contained the median and the ulnar nerves, infrequently the musculocutaneous, and occasionally the radial nerves. Moreover the space was suggested to communicate proximally only with the medial cord of the plexus. In 1987 Partridge and coworkers 13 described the interneural septa, which were easily broken by injection of dyed latex. In 2002 Klaastad and coworkers 14 were the first to investigate the spread of the AL through the axillary catheter in studies using magnetic resonance imaging (MRI) scanning. They found that in the most patients the spread of AL was uneven and the clinical effect inadequate. Until the 1960s, the prevalent block techniques were double or multiple axillary injection. After the concept of the neurovascular sheath had been established by De Jong4 in 1961, the single injection technique, being the simplest, became standard. However, Vester-Anderson and coworkers15,16 demonstrated in 1983 and 1984, that despite high volume of AL, analgesia was often inconsistent (patchy). In the early 1990s, the double injection, transarterial technique was popularized by Urban and Urquhart17 and Stan and coworkers.18 More recently, however, development of peripheral nerve stimulators and insulated atraumatic needles has allowed electrolocation and separate blockade of the individual terminal nerves (median, musculocutaneous, ulnar, and radial). This is known as the multiplenerve stimulation technique. Baranowski and Pither19 (in 1990), Lavoie and coworkers20 (in 1992), Koscielniak-Nielsen and coworkers23,24 (in 2001 and 2002), independently showed that multiple-nerve stimulation was superior, both to the single- and the double-injection methods by increasing the success rate nad shortening the block onset. A recent Cochrane review by Handoll and coworkers 25 validated these findings. INDICATIONS & CONTRAINDICATIONS The most common indications for axillary block include surgery of the forearm , wrist, or hand of moderate to long duration, with or without arm tourniquet. Relative contraindications to use of this block are skin infection at the block site, axillary lymphadenopathy, and severe coagulopathy. In addition, this

block is best avoided in patients with severe preexisting neurologic disease of the upper extremity because sensory assessment may be difficult. PERTINENT ANATOMY In the apex of axilla, the three plexus cords (lateral, medial, and posterior) form the main terminal nerves of the upper extremity (axillary, musculocutaneous, median, ulnar, and radial). However, only the last three nerves accompany the blood vessels thorough the axilla where the blocks are performed (Figure 281), while the axillary and the musculocutaneous nerves leave the plexus approximately at the level of coracoid process. The axillary nerve departs at a wider angle from the posterior cord, laterally into the coracobrachial muscle and continues downward. The medial antebrachial and brachial cutaneous nerves run subcutaneously parallel to the axillary vessels, although the medial antebrachial cutaneous nerve often follows the median nerve within the neurovascular sheath. In the axilla, the median and musculocutaneous nerve lie superior to the artery, whereas the ulnar and radial nerves lie inferior it. The depths at which the nerve are found vary. Typically the median nerve is more superficial than the musculocutaneous, and the ulnar nerve is more superficial than radial. Occasionally, the radial or the musculocutaneous nerves (or both) are found behind the artery. These two nerves progressively diverge from the neurovascular sheath, continuing down the upper arm, the musculucutaneous above (anterior) and the radial below (posterior) to the humerus, where they can be approached using the midhumeral approach.26 Landmarks Surface landmarks for the axillary brachial plexus block include (Figure 28-2): 1. Pulse of the axillary artery 2. Coracobrachialis muscle 3. Pectoralis major muscle 4. Biceps muscle 5. Triceps muscle EQUIPMENT Sterile towels and 4-in. x 4-in. gauze packs Sterile gloves, marking pen, and a skin electrode 1-in., 25-gauge needle for the skin infiltration 1- to 1,5-in. atraumatic, insulated stimulating needle 20-ml syringes containing AL of choice Peripheral nerve stimulator INJECTION TECHNIQUES Arm Position the Block The arm to be operated on is abducted approximately 90 degrees( see Figure 28-2 ). The albow is flexed and the forearm rests comfortably, supported by a pillow. A skin electrode is typically placed on the patient,s shoulder and connected to the positive electrode ( anode ) of the nerve stimulator. After scrubbing the axilla, the arterial pulse is palpated at the level of the mayor pectoral muscle, and the subcutaneous tissue overlying the artery is infiltrated with 4 to 5 ml of LA (to Blok the intercotobracial and medial cutaneous nerver of the arm ). Numerous techniques and approaches ton the brachial plexus blok at the level about the axilla have been described. Discussion of all the technique variation is beyond the scope of this text; we will describe some of the best studied and clinically useful techniques. Clinical Pearl

Various approaches and techniques described in the following sections all have their advantages and disadvantages. However, a triple- injection axillary blok is probably the fastest and most efficient technique for axillary brachial plexus blockade. NERVE STIMULATION TECHNIQUES Single-Injection (Stimulation) Technique 1. The nerve stimulator is set to deliver 0.5-1.0 mA (2 Hz, 0.1 msec); electrical connections with the needly and the neutral electrode are checked. 2. Depending on the surgical site (palmar and medial or dorsal and lateral aspects of the hand /forearm), the stimulating needle is interted above the arterial pulse (toward the median nerve ) or below the arterial pulse ( toward the radial nerve ), respectively (Figures 28-3 and 28-4 ). 3. As the brachial superficial fascia is penetrated, a characteristic click is often felt, and current amplitude is slowly increased ( eg, at 1-mA increments) until the desired twitch (flexion or extension of the wrist and fingers ) is obtained. The helps avoid painful electrical paresthesia when the elastic fascia suddenly gives in and the needle enters the neurovascular sheath.27 4. After the initial motor response is obtained, the needle is slowly advanced toward the stimulated nerve while reducing the amplitude. 5. Once the stimulation is abtained using a current intensity of 0.3 to 0.5 mA, the entire volume of LA is injected slowly, while intermittently aspirating to reduce the risk of accidental intravascular injection. This results in substantial. Clinical Pearls Arterial pulse palpation may prove challenging in some pations. In these pations, the firs abtained motor response can be used to guide needle redirection to achieve the desired response can be used guide needle redirection to achieve the desired response. Elbow flexion (stimulation of the coracobrachialis muscle or the musculocutaneous nerve) indicates that the needle iss outside the neurovascular sheath; the needle should be redirected downward and more superficially. Extension of the wrist and hand (radial nerve) indicates that the needle is below the artery. The more difficult differentiation is between the median and the ulnar nerves, which both result in wrist/finger flexion. In this scenario, the following method can be used to differentiate between the two nerves: When flexionis accompanied by forearm pronation, the stimulated nerve is the median (the needle is positioned above the artery). Anather way to differentiatiate between these two nerves is by palpation of the flexor tendons at the wrist. Median nerve stimulation produces movements of the Palmaris longus and the flexor carpi radialis tendons, which lie in the middle of the wrist, whereas ulnar nerve stimulation produces movement of the flexor carpi ulnaris tendon, which lies medially. Decreasing the intensity of the output current of the nerve stimulator helps facilitate differentiation between median and ulnar nerve stimulation. Double-Injection Technique 1. The stimulating needle is first inserted above the artery, below the coracobrachialis musde (see Figure 28-3). After penetreating the fasci, the amplitude is increased until synchronous wrist flexion/pronatin and flexion of the first three fingers are obtained (median nerve stimulation). The needle is advanced slowly toward this nerve while reducing the amplitude to 0.3 to 0.5 mA. At this point, half of the planned volume of LA is slowly injected with intermittent aspiration to rule out intravascular injection. 2. The needle is then withdrawn and inserted below the artery and above the triceps muscle (see Figure 28-4). The fascia is again penetrated and the amplitude slowly increased. The firs response

is usually either arm extension (muscular branches to the triceps) or thumb adduction and flexion of the last two fingers (ulnar nerve). Howewer, these responses are ignored, and the needle is advanced deeper, often slightly upward, behind the artery (Figure 28-6) until wrist and finger extension is obtained (radial nerve). After stimulation is obtained using a current intensity lower than 0,5 mA, the remaining volume of LA is slowly injected with intermitten aspiration. Multiple-Injection Thechnique Needle insertion sites are identical to those for the double-injection technique 1. After electrolocation of the median nerve, 5-10 mL of the LA volume is injected (see Figure 283). 2. The needle is withdrawn subcutancously and redirected obliquely, above and into the coracobrachialis musde. After obtaining stimulation-synchronous elbow flexion, the amplitude is reduced to 0,3 to 0,5 mA and another 5-10 mL, of LA is injected. 3. The needle is removed and incerted below the artery (see Figure 28-4). The first stimulated nerve is usually the ulnar, into which 5-10 Ml of LA is injected. 4. The needle is advanced deeper until the radial nerve is found (see under Duoble-Injection Technique). Clinical Pearl Two recent studies by Sia and colleagues23,28 suggest that two separate injections below the artery do not improve success rates, and therefore only one such injection is needed. This injection is made close to the radial nerve and should contain half of the planned LA volume. Electrolocation of multiple nerve may occasionally take some time. Because the first injection of the LA injection in the vicinity of the median nerve may partially block the ulnar nerve, the search for the nerves should be made expeditiously to minimize the risk of nerve injury by advancing needle of intraneural injection into an anesthetized nerve. For these rasons, this technique could be considered an advanced regional anesthesia technique. Careful assessment of resistence to injection by an experienced practitioner or objective monitoring of injection pressure should be used with each injection. Transarterial Technique The transarterial technique is perhaps most commonly used for axillary blockade. This relatively simple technique does not rely on a nerve stimulator; instead, placement of the needle within the neurovascular sheath is encured by relying on the pulse of the axillary artery; The axillary artery is palpated and stabilized using a two finger palpation technique. As the needle is advanced toward the pulse of the axillary artery, bright red arterial blood is aspirated. A thin, long-beveled needle (typically 1.5 in., 25-gauge) is used to minimize the risk of axillary hematoma. The needle is advanced deeper until blood cannot be aspirated (the tip of the needle has exited the artery) and half of the volume of the LA is injected behind the posterior wall. This should block the radial nerve. The needle is slowly withdrawn while aspirating. As the needle enters the axillary artery, bright red blood is again aspirated. The withdrawal of the needle is continued until blood can not be aspirated (the needle exirs the artery and its tip is positioned superficial (medial) to the artery inside the neurovascular sheath). The remaining volume of LA is injected supervicial to the anterior wall to block the median and ulnae nerves. Clinical Pearl A transarterial injection is made as high up in the axilla as possible, and the needle should traverse the artery at an oblique angle. This reduces the risk of making the injection behind the

artery intramuscularly and improves the spread of the LA to the plexus cords to block the musculocutaneous nerve. Continuous Axillary Brachial Plexus Block Technique Continuous axillary brachial plexus block is similar to the single-injection technique; nerve stimulator technique is typically used. The needleof choice is connected to the nerve stimulator , and the desired twitch response is sought.once the stimulation is obtained with a current close to 0.5 mA,a catheter is advanced 5-8 cm cephalad into the neurovascular sheat. When a stimulating catheter is used , a nonconducting solution (eg, 5% dextrose29) can be injected though the catheter to dilate the sheat and facilitate insertion of the catheter. The catheter is secured using either a tunneling technique or application of a sterile clear dressing Clinicial Pearl Strict aseptic precautions should be adhered to, just as with any other indwelling catheter technique. MIDHUMERAL APPROACH(HUMERAL CANAL BLOCK) The difference between the multiinjection axillary and the midhumeral (humeral canal) approaches is that in the latter, the two terminal nerves, the musculocutaneous and the radial,are blocked above and below the humeral bone, respectively(Figure 28-7). With any multistimulation technique, there is always a risk that an intraneural injection may by made into the already anesthetized nerves. For that reason, theoretically, the midhumeral approach may carry a lower risk of neurologic complications the nerves are farther apart. Althought the four-injection midhumeral block has been found to be more effective than the double injection axillary technique,30 either block results in a hight success rate when four injection technique are used.24 An advantage of the axillary approach is that incomplete axillary block can be supplemented with a midhumeral block.31 The opposite is not possible, nor is it recommended because electrotimulation may be precluded by blockade distal to the site of nerve localization. An incomplete midhumeral block, on the other hand, can be supplemented at the elbow or the wrist. Technique The injection technique for the midhumeral block is similar to the four-injection axillary technique , except the injection are made more distally. In addition, the musculocutaneous and the radial nerves are sought at a deeper location than in the axillary approach (see Figure 28-7). Figure 28-8 demonstrates the spread of the injected local anesthetic in the midhumeral technique. The anesthesiologists nondominant hand grips the biceps muscle while searching for the musculocutaneous nerve, and the stimulating needle is inserted below the muscle (to avoid direct stimulation). When the bone is contacted before elicting the twitches , the needle is rederected upward, toward the belly of the biceps muscle.ft on its way downward The triceps muscle is stabilized similarly while attempting stimulation of the radial nerve. Winds around the humeral shaft on its way downward, which makes electrolocation of this nerve challenging with distal approaches. Clinical Pearl The technique,s name, midhumeral , is a misnomer, as the block is typically performed between the upper and middle thirds of the arm. CHOICE OF LOCAL ANESTHETIC

The choice of LA depends on the length of surgery and the desired density and duration of blockade. For single-injection block, short-and medium-acting. LAs (prilocaine, 2-chloroprocaine, lidocaine, or mepicaine) in concentration of 1.5% to 2% ( 3%for 2-chloroprocaine), with or without epinephrine or sodium bicarbonate, will provide reliable sensory and motor block of rapid onset ( 10-20 min) and sufficient duration (3-4 h, 1.5-2 h for 2-chloroprocaine) for most common surgiral procedures (wound debridement; closed fracture repositions; ligament-,tendon-,or nerve sutures; finger amputations; etc). for elective procedures of longer duration (arthrodeses, arthroplasties, osteosyntheses, extensive palmar fasciectomy, etc) ropivacaine 0.5-0.75% or bupivacaine 0.375-0.5%, with or without epinephrine, will provide analgesia of slightly slower onset (15-20 min) and longer duration (6-16 h). for specialized hand surgery that may last several hours-for example, multiple joint replacement or reimplatations of severed extremities-a continous ropivacaine (0.2-0.375%) infusion via an axillary catheter is probably the best technique. Clonidine (0.5 mcg/kg) may be added to intermediate-acting AL to prolong analgesia after single-shot blocks.32 PERIOPERATIVE MANAGEMENT The multiple nerve stimulation technique is uncomfortable to patients27,33 and should be preceded by adequate premedication (eg, midazolam+sufentanil).34 adequate sedation and analgesia not only improve patients acceptance of the block but also help relax the arm muscles. This makes precise needle manipulation as well as eliciting and interpreting the motor response to nerve stimulation significantly easier for the practitioner and more acceptable to patients. Clinical Pearl The first sign of a successful block is weakness of the upper arm muscles, which can be tested immediately after needle withdrawal. This can be done by asking the patient to place the hand on the abdomen or touch the practitioners fingers. Loss of coordination signifies that the mantle fascicles of the musculocutaneous and radial nerves, which supply, which supply flexors and extensors, are being blocked. Patients typically report an early loss of the position sense in the blocked extremity. The onset and distribution of analgesia can be tested every 5 or 10 min after block administration in sensory areas of the terminal nerves (Figure 28-9). Thirty minutes after block insertion, the unblocked nerves can be supplemented distal to the initial block site (eg, elbow blocks). Clinical Pearl Most hand surgery (eg. palmar fasciectomies and nerve or tendon repair) is done on the volar aspect and theoretically can be performed with partial blocks (ie, without the radial or musculocutaneous nerves). Surgery on the thumb can also be performed without blocking the ulnar nerve. However, this is not advisable because patients are often very apprehensive about the preserved sesnsation in the nonanesthetized parts of the hand and demand heavy sedation. In addition, the surgeon may need to extendteh operative site, encroaching on the sensory territory of the unblocked nerves. Hence it is advisable to also ensure forearm, wrist, and hand anesthesia. Alternatively, the surgeon can supplement the block intraoperatively with injection of local anesthetic when necessary. For elbow surgery, an infraclavicular approach is a better choice then the axillary block. Tourniquet analgesia may be more related to the total injected dose of AL rather than to successful block of the medial cutaneous brachial nerves. Most of the injected AL is absorbed into the surrounding muscle, which are the main source of ischemic pain.35 CONTINOUS AXILLARY BLOCK

The indications for continous axillary block include control of acute postoperative pain, management chronic pain, and treatment of vascular disease, (eg, Raynaud syndrome). Technique The axillary fossa is best shaved and disinfected. After subcutaneous AL infiltration, the specific muscle twitch from the nerve of greatest interest is elicited by a needle or stimulation introducer cannula (see section on the Single-Injection Technique) aspiration. The intensity of the stimulating current is progressively reduced to 0.5 mA or less, while making find adjustment to the cannulas position. A catheter is inserted (under sterile condition) 5-8 cm cephalad into the neurovascular sheath and either sutured to the skin or tunneled. This help maintain the catheter in place because the nerves are superficial and the arm sweat makes maintenance of an occlusive dressing difficult. Clinical Pearl Difficult with catheter insertion usually indicated that the inroducer cannula is placed outside the neurovascular sheath. Following negative aspiration, 30-40 mL of AL (eg, ropivacaine 0.5%) is intermittently injected while closely observing patient. Maintenance Diluted solutions of long-ating AL (eg, 0.125% bupivacaine or 0.2 ropivacaine) are most often used for continous infusions. Ropivicaine is preverable because of its relative sparing effect on the motor neurons and its lower cardiotoxicity. Clinical Pearl Either electronic or elastomeric pumps may be used. The former are more expensive but allow for repeated adjustments, and they have alarm and data-storage capability. The latter are less expensive, simpler, and disposable, but may lack versatility and accuracy. Different modes of AL administration may be employed: a continous basal nfusion, repeated boluses, and a combination of both (in which a bolus administration is patient-controlled). The first is limited by the size of pumps reservoir, for example, a 250-mL reservoir at 10 mL/h will last only 1 day. The combination of baseline infusion and boluses offers the advantage of adjusting the level of analgesia to individual needs and puts the patient in charge of pain control (which has an important psychological aspect). A typical infusion regimen for 0.2% ropivacaine is a basal rate of, for example, o.1 mL/kg bodyweight per hour (minimum, 5 mL; maximum, 10 mL) and a 5 mL patient-controlled bolus with a lock-out time of 30 min. such a regimen may be maintained for 2 to 3 days for the treatment of acute postoperative pain and as long as necessary in the chronic conditions. Complications of Axillary Blocks Acute Vascular puncture Vascular puncture is frequent; however, intravascular injection usually can be avoided dy repeatedcarefull needle aspiratin. However, venous puncture may go undetected when vigorous aspiration collapss the venous lumen. Intravascular AL Injection Intravascular AL injection (see earlier discussion) typically presents as lightheadsdness and or tachycardia (ropivacaine-or epinephrine-containing solutions). Intraarterial injection produces hand paresthesia during injection, accompanied by sudden paleness, which may last a couple of minutes. Intravascular injection of a lerge AL dose may lead to loss of consciousness, seizures, and cardiac arrest. Slow injection with repetead needle aspirations is mandatory.

Hematoma Hematoma may occur after arterialpuncture, especially with large-bore blunt needles and in older patients. If the artery is punctured, firm, steady preassure should be apply over the puncture site for 5 to 10 min. for the transarterial technique, needles of smaller gauge should be used to minimize the risk of hematoma. Toxicity Due to Absorption of AL Toxicity due to absorptionof AL (in contrast to the accidental intravascular injection, which becomes symptomatic during or immediately after the injection) usually becomes symptomatic 5-30 min after injection. The symptoms include lightheadness, dizziness, tunnel vision, circumoral paresthesia, brady- or tachycardia, anxiousness (eventually progressing to unconsciousness), seizures. Oxygen, a sedative/hypnotic in repeated, small doses, and airway support if necessary should be immediately administered. Subacute & Chronic Nerve Injury Nerve injury may be caused bay the advancing needle, intraneural injection, application a tourniquet, or a combination of these. Intraneural injections are characterized by pain, extremity withdrawal, and resistance to injection. Needle and injection injuries typically manifest as neurologic deficit in the distribution of the affected nerve. Ischemic damage caused by prolonged application of the tourniquet more commonly results in diffuse injury, affects several nerves, and is usually accompanied by soreness of the upper arm. Symptoms of nerve damage (sensory loss and persistent paresthesia) usually appear within a day or two after recovery from the block. Most nerve injuries are neurapraxia (functional damage), which carry a good prognosis and heal within a few weeks. Clinical Pearls AL should probably not be injected when a motor response to nerve stimulation is seen with a current strength <0.2 mA (0.2 sec) because the tip of the needle may be positioned intraneurally. When the motor response to nerve stimulation is seen with currents <0.2 mA, the tip of the needle should be slightly withdrawn or repositioned to maintain the twitch with 02 to 0.5 mA. AL should never be injected when abnormal resistence (high pressure) to injectionis encountered. When this occurs, the needle should be pulled back slightly and the injection reattempted. If the resistence persists, the needle should be completely withdrawn and cleared; it should never be assumed that the cause of the resistence is related only to the needle obstruction. SUMMARY For axillary brachial plexus block, a triple-injection nerve stimulator technique with electrolocation of median, musculucutaneous, and radial nerves is preferred. This technique is probably the best compromise with regard to block success rate, onset, and simplicity. A double-injection technique is the next best and may be used with or without a nerve stimulator. The mid humeral (a four-injection technique) is probably best suited for supplementing incomplete axillary blocks, although it can be used as a primary technique. For continous blocks, a catheter should be placed closed to the amin nerve innervating the surgical site (eg, the median nerve for surgery of medial and volar surfaces; the radial nerve for surgery of lateral and dorsal surfaces). For more extensive surgery involving the entire circumference of the arm (eg, major trauma/amputation), an approach higher in the axilla or infraclavicular block may be better suited. An optimal perineural infusion technique is the basal rate with the patient-controlled boluses; the suggested AL for this application is ropivacaine 0.2%. an accidental intravascular injection is the most common complication of axillary block. The risk of systemic toxicity of AL can be decreased by avoiding fast, forceful njection and using frequent aspiration to rule out intravascular injection. Pain, parasthesia, extremity withdrawal or high injection

pressure may indicate intraneural needle placement; occurrence of any of these signs and symptoms should prompt immediate cessation of the injection and reevaluation.