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Brachial plexus block
Dr.Indubala Maurya MD,DNBAssistant Professor
Dept of Aanesthesia & Critical Care, MGMCRI
Indication of peripheral nerve blocks
• Surgical procedure• Postoperative pain relief • Chronic pain management
Advantages /Disadvanges for Nerve blocks
Advantages :• Can be formed in all age group• Avoid poly pharmacy• Early recovery /ambulation• Excellent analgesia Disadvantages:• Difficult in obese • Need expertise • Specific complication associated with particular block• Nerve injury( needle ?)• Local anesthetic toxicity
Contraindications• Uncooperative patient• Bleeding diathesis( on anticoagulant, DIC,hemophilia)
• A hematoma --->risk of ischemic nerve damage (limb or digit ischemia)
• Infection• placement of a catheter a nidus for infection.
• Peripheral neuropathy
Techniques for Localizing Neural Structures
AIM : Correct positioning of the needle tip in the perineural sheath, prior to injection of local anesthetic
• Fascial “pops”• Elicitation of paresthesias, • Perivascular or Transarterial injection, • Electrical stimulation• Direct imaging
– Ultra Sonography – Computed tomography
What is Electrical Nerve Stimulation?
• Low-intensity (up to 5 mA) , short-duration (0.05-1 ms) electrical stimulus (at 1-2 Hz repetition rate) to obtain a defined response (muscle twitch or sensation) to locate a peripheral nerve or nerve plexus with an (insulated) needle.
• The goal is to inject a certain amount of local anesthetic in close proximity to the nerve
Patient’s Preparation• Pre Operative Assessment ( Document
any neurological deficit, consent)• Pre op fasting• Aspiration prophylaxis• Anxiolysis & sedation • Emergency drugs & Resuscitation
equipments
CHOICE OF ANESTHETIC Local anesthetic drugs :
• Toxicity of the agent – Cardiac toxicity – CNS toxicity
• Characteristics of individual local anesthetics such – Time to onset – Duration of action
• Degree of sensory versus motor block
Additives:• Morphine, Fentanyl, Clonidine, Epinephrine,Dexa
Brachial plexus Blocks
Brachial plexus Anatomy
RELATION WITH SCALENE MUSCLES
Relation with bone
Relation with Blood vessels
Various Approach
1. Interscalene2. Supraclavicular 3. Infraclavicular 4. Axillary
Interscalene BP Block
Interscalene--Indication
• Surgery on or manipulation of the shoulder• Proximal Arm
Interscalene – Paresthesia/ NS Technique
Interscalene- USG Technique
Interscalene-Complications• Diaphragmatic paralysis : 100%• Horner syndrome: Ptosis, chemosis, anhydrosis
– need reassurance
• Total spinal Anaesthesia: avoid injection in Dural sleeves, consequent epidural/spinal spread
• Nerve injury: Don’t inject if complain of pain / resistance during injection
• Local anaesthetic toxicity: calculate toxic dose for each pt• Vascular puncture ,Hematoma
Supraclavicular Block
Supraclavicular -Indications
• operations on the distal arm, elbow, forearm, and hand.
Supraclavicular –paresthesia/ NS Technique
Supraclavicular –USG Technique
Supraclavicular -Complications
• Pneumothorax after a supraclavicular block is 0.5% to 6%
• Phrenic nerve block (40% to 60%), • Horner's syndrome• Nerve injury: Don’t inject if complain of pain /
resistance during injection• Local anaesthetic toxicity: calculate toxic dose for each
pt• Vascular puncture /hematoma
Infraclavicular Block
Infraclavicular-Indications
Surgery to the arm and hand..
Infraclavicular-Paresthesia / NS Technique
Infraclavicular-USG Technique
Infraclavicular-Complications• Pneumothorax ---Exaggerated medial needle direction • Nerve injury: Don’t inject if complain of pain / resistance
during injection• Local anaesthetic toxicity: calculate toxic dose for each
pt• Vascular puncture ,Hematoma
Axillary Block
Axillary Block-indications
surgery on the forearm and hand
Axillary Block-Technique
• Transarterial • Perivascular infiltration• Paresthesia • Nerve stimulator • Ultrasound
Axillary Block-Paresthesia/ NS Technique
Axillary Block- USGTechnique
Assessment of blocks
Sensory :Pin prick/ temp in all dermatomes / Nerve
Motor: Muscle strength
Thank you