Professional Documents
Culture Documents
Positioning
Postoperative analgesia
Advantages of Regional
Reduced incidence of PONV
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
(S:Post
arm/forearm/dorsum/thumb)
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
Positioning
Interscalene Approach
Provides Anaesthesia to
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
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)
Intrathecal/E.
D. injection
Complications
CNS toxicity. Avoid forceful/fast
inj.(L.A)
Pneumothorax
Failed block
Supraclavicular approach
First performed by Kulenkampp in
1911
Haemorrhagic diathesis
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
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 !!