Increasing consistency in upper limb UGRA

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Consistency in UGRA: Upper Limb Techniques

Colin J.L. McCartney MBChB PhD FRCA FCARCSI FRCPC

Head of AnaesthesiaThe Ottawa Hospital,

Professor and Chair of AnaesthesiaUniversity of Ottawa, ON, Canada

Conflicts of Interest

• None

Summary: Consistency in UGRA

• 1. Start simple• 2. Stay safe• 3. Get trained• 4. Use volume• 5. Assess carefully and rescue if needed

1. Start Simple

“Everything should be made as simple as possible, but not simpler”

Albert Einstein

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• R, SB 56 patients• Axillary block• US Perivascular or Transarterial technique• 30mL 1.5% Lidocaine with epinephrine• Block Onset time and Success

Diagram demo

Results

Diagram demo

2. Stay safe

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Staying safe

1. Know your block2. Know your ultrasound3. Slow, incremental injection with frequent aspiration4. Use a marker of IV injection5. Use nerve stimulation and injection pressure6. Sedate your patients adequately

Bad stuff happens to us all

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• 1. Start simple• 2. Stay safe• 3. Get trained• 4. Use volume (if needed)• 5. Assess carefully and rescue if needed

3. Get trained

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Kathy Sierra: http://headrush.typepad.com/creating_passionate_users/2006/03/how_to_be_an_ex.html

J Shoulder Elbow Surgery 2007; 16 (Jul/Aug): 379-387

Simulation & Needle guides

• 20 2nd year anesthesia residents• No US experience• 2 groups: Gp1 Standard training; Gp2 1 hour

training on low fidelity model• Both gps started regional rotation• Success/Failure of blocks assessed

RAPM 2012


• Success: Block performed within 15 minutes and suitable for surgery without rescue blocks


• Conventional group 98 successful blocks, and the simulation group had 144 (51.3% vs 64%; P = 0.016).

• CUSUM: Conventional group 40% achieved proficiency, Simulation group, 80% proficiency (P = 0.0849)


• 1. Start simple• 2. Stay safe• 3. Get trained• 4. Use volume (if needed)• 5. Assess carefully and rescue if needed

4. Use volume

• In the hands of experts very low volumes of local anesthetic can be used for successful BPB

• For some techniques (axillary, interscalene)• Not for others (infraclavicular, supraclavicular)• “The proper dose of any drug is enough”

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Axillary Block

Interscalene BlockInterscalene Block

• RDBCT 40 patients USG ISB• Posterior approach• 5 vs 20 ml 0.5% ropivacaine• Standard GA• Primary endpoint: Phrenic block at 30

min• Secondary: Postop pain, Oxygen

saturation, spirometry BJA 2008

Can a low volume US-guided technique reduce common complications of ISB?

Riazi S, Carmichael NM et al BJA 2008

20ml 20ml

5ml

5ml

%=oxygen saturation on air in PACU

Can a low volume US-guided technique reduce common complications of ISB?

Riazi S, Carmichael NM et al BJA 2008

Supraclavicular Block

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Supraclavicular Block

Infraclavicular Block

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Infraclavicular Block


• 1. Start simple• 2. Stay safe• 3. Get trained• 4. Use volume (if needed)• 5. Assess carefully and rescue if required

5. Assess carefully and rescue if needed

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Use a block room if possible

• Reduces anesthesia controlled time• Allows time to perform blocks and allow onset

before moving patient to OR• Benefits for patient• Allows teaching and research• Costs: extra staff, space, equipment

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Assess carefully

• Even experts have slow/failed blocks• Push, pull, pinch, pinch• Use rescue blocks if needed• Don’t be frightened of the dreaded swear

words: Propofol and LMA• Follow up with your patient• Take responsibility for any adverse events

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Rescue blocks: easy with US

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RAPM 2007

Follow up with your patient

Increasing consistency in upper limb UGRA

Health & Medicine

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