Upper Extremity Nerve Blocks · tion to detect AV and CV and decrease the risk of intravenous...
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Upper Extremity Nerve Blocks Interscalene Indications: Anesthesia and analgesia for surgery on shoulder, distal clavicle and proximal humerus. Patient position: Supine or semi-sitting, head facing to contralateral side. Transducer: Linear. Needle: 22G, 5 cm short bevel. Common EMR obtained: Deltoid response. LA: 10-15 ml. Brachial Plexus Approach Transducer Placement Ultrasound Image Reverse Ultrasound Anatomy TM Anatomy Initial transducer placement: Over external jugular vein, approximately 3 cm above clavicle. Alternatively, start at supraclavicular fossa and scan proximally toward the plexus. Initial depth setting: 3 cm. Landmarks: ASM and MSM, 2 or 3 round hypo- echoic structures (roots or trunks) between the ASM and MSM. Ideal view: C5 C6 C7 nerve roots. Technique: Needle Insertion in plane (most com- mon), lateral to medial; alternatively out of plane. Ideal spread of LA: Within the interscalene space inside the sheath. Number of injections: Based on spread; typically 1-2. BORe. Tips: Use PD to detect and avoid blood vessels on the needle path. Reconsider in patients with history of significant respiratory disease. Use short acting LA through catheter in such pa- tients; extend block through catheter if initial block tolerated well. Supraclavicular Indications: Anesthesia and analgesia for surgery on humerus, elbow, forearm and hand. Patient position: Supine or semi-sitting, head facing to contralateral side. Transducer: Linear. Needle: 22G, 5 cm short bevel. Common EMR obtained: Forearm, hand response. LA: 20-25 ml. Initial transducer placement: In supraclavicular fossa, lateral to clavicular head of SCM, tilted caudally. Initial depth setting: 3 cm. Landmarks: Subclavian artery, brachial plexus sheath (arrows), first rib and pleura. Ideal view: Brachial plexus and subclavian artery above first rib (pleura should be visualized). Technique: Needle Insertion in plane, lateral to medial. Assess the depth of the BP, insert needle with shallow angle and adjust accordingly. Ideal spread of LA: Within BP fascial sheath lateral to the SA but superficial to the first rib. Number of injections: 2-3. BORe. Tips: Visualize the pleura (if unable, consider other technique). Use PD to detect and avoid TCA, DSA. Consider an alternative technique when large vessels are present within the sheath. Injection of LA should fill BPS. Reduce transducer pressure before injection of LA to facilitate spread. Infraclavicular Indications: Anesthesia and analgesia for surgery on humerus, elbow, forearm and hand. Patient position: Supine with arm abducted and flexed at elbow. Transducer: Linear. Needle: 22G, 8-10 cm short bevel. Common EMR obtained: Forearm, hand. LA: 20-25 ml. Initial transducer placement: Parasagittal, below the clavicle, medial to coracoid process. Initial depth setting: 5 cm. Landmarks: Axillary artery and fascia of pectoralis minor muscle (arrows). Ideal view: Axillary artery and vein below the fascia of pectoralis minor muscle, lateral, medial, posterior cords periarterialy. Technique: Needle insertion in plane, cephalad to caudad. Release transducer pressure before injec- tion to detect AV and CV and decrease the risk of intravenous injection. Use PD to identify vascular structures. Ideal spread of LA: periarterialy (U-shaped). Number of injections: 1-2. BORe. Tips: Ensure sufficient lateral placement of the transducer to avoid chest cavity. A single in- jection of LA is made where all cords are visible lateral to the artery, or posterior to the artery. Axillary Indications: Anesthesia and analgesia for surgery on forearm and hand. Patient position: Supine with arm abducted and flexed at elbow. Transducer: Linear. Needle: 22G, 5 cm short bevel. Common EMR obtained: Hand or fingers. LA: 15-20 ml. Initial transducer placement: Perpendicular to humerus in the axillary fossa, at intersection between pectoralis and biceps muscles. Initial depth setting: 3 cm. Landmarks: Axillary artery and Brachial Plexus fascial sheath (arrows). Ideal view: MN, UN, RN scattered around AA, McN between the biceps and coracobrachialis muscles. Technique: Needle Insertion in plane or out of plane. Injections: one above the artery, one between artery and conjoint tendon. McN is blocked separately. LA deposit: 8 ml posterior and 8 ml anterior to the artery, 4 ml for McN. Ideal spread of LA: around AA. Number of injections: 2+McN. BORe. Tips: For extensive elbow surgery consider more proximal technique. Variations of McN are common. McN may be attached to the MN. Pre-scan to look for common anatomical variations. Reduce transducer pressure before injection of LA to facilitate spread and to de- crease the risk of intravascular injection. Osteotomes Dermatomes Suggested Standard Monitoring For Nerve Blocks Ultrasound + Nerve Stimulation + Opening Injection Pressure (OIP) Needle adequately placed as seen on US No twitch 1-2 mL injection of LA results in adequate spread in the desired tissue plane OIP normal <15 psi + Not necessary to look for twitch Complete injection Twitch present No twitch Increase current to 1.5 mA Adjust needle placement by US Needle placement by US uncertain Poor images of Anatomy/needle 1-2 mL injection of LA results in adequate spread in the desired tissue plane OIP normal <15 psi + Reposition the needle to assure NO twitch present at <0.5 mA* Needle adequately placed as seen on US Twitch present Connect Needle to Nerve stimulator (0.5 mA, 0.1 msec, 2 Hz) Legend: US – Ultrasound; NS – Nerve Stimulator *OIP normal (<15 psi) – Based on data both in animal models and clinical trials where opening injection pressure required to inject into fascicles or at needle-nerve contact exceeded 15 psi (Acta Anaesthesiol Scand, 2007; 51(101-7), RAPM 2012; 37:525-9, Anesthesiology 2014; 120:1246-53). + 0.5 mA – Data from several studies suggest that twitch (EMR; evoked motor response) at <0.2 mA (0.1 msec) may indicate intraneural needle placement or needle/nerve contact (Anesth Analg 2005; 101;1844-6, Anesthesiology 2009; 110;1235-43) Anterior Posterior Anterior Posterior CREATED BY NYSORA COLLABORATIVE INTERNATIONAL GROUP. A listing of contributing institutions and electronic copy of the poster are available at www.NYSORA.com Contributors: Admir Hadzic (USA), Ana Lopez (SPA), Daquan Xu (USA), Xavier Capdevilla (FRA), John Laur USA), Alwin Chuen (AUS), Catherine Vandepitte (BE), Pablo Helayel (BRA), Carlos Bollini (ARG), Roman Zuercher (SWI), Dimitri Dylst (BE), Ali Nima Shariat (USA), Emily Linn (USA), Thomas Clark (USA), Philippe Gautier (BE), Malikah Latmore (USA), Manoj Karmakar (HK), Jeff Gadsden (USA), Jason Choi (USA), Xavier Sala-Blanch (SPA), Javier Cubillos (COL), Maria Fernanda Rojas Gomez (COL), Kwesi Kwofie (CAN), Uma Shastri (CAN), Imran Ahmad (UK), Thomas Halaszynski (USA), Yasuyuki Shibata (JPN), Anahi Perlas (CAN), André van Zundert (AU), Luc Van Keer (BE), Jeroen Van Melkebeek (BE) C3-C5 C5-C6 C5-C6 C5-C7 Primary nerve branches Axillary C5-C6 C5-C6 Intercostobrachial T2 Radial C6-T1 Median C5-C6 Ulnar C8-T1 Cutaneus brachii medialis C8-T1 Intercostal T3-T12 Musculocutaneus C5-C6 C2 Supraclavicular Suprascapular Subclavius Long thoracic Subscapular Occipital Cutaneus antebrachii medialis C8-T1 Advance needle towards the nerve or plexus Abbreviations ASM Anterior Scalene Muscle LA Local Anesthetic BP Brachial Plexus MSM Middle Scalene Muscle BPS Brachial Plexus Sheath PhrN Phrenic nerve BORe Bolus Observe Reposition RLN Recurrent Laryngeal Nerve CA Carotid Artery SCM Sternocleidomastoid Muscle EMR Evoked Motor Response SCP Superficial Cervical Plexus EJV External Jugular Vein TPC7 Transverse Process C7 IJV Internal Jugular Vein VA Vertebral Artery LCM Longus Coli Muscle VN Vagus nerve Abbreviations BP Brachial Plexus MSM Middle Scalene Muscle BPS Brachial Plexus Sheath OHM Omohyoid Muscle BORe Bolus Observe Reposition PD Power Doppler CL Clavicle SA Subclavian Artery DSA Dorsal Scapular Artery SSA Suprascapular Artery EMR Evoked Motor Response SV Subclavian Vein LA Local Anesthetic TCA Transverse Cervical Artery Abbreviations AA Axillary Artery IcbN Intercostobrachial N AV Axillary Vein LA Local Anesthetic BORe Bolus Observe Reposition McN Musculocutaneous Nerve CBM Coracobrachialis Muscle MN Median Nerve CfxA Circumflex Artery RN Radial Nerve CNA Cutaneous Nerve of Arm UN Ulnar Nerve EMR Evoked Motor Response Abbreviations AA Axillary Artery MC Medial Cord AV Axillary Vein PD Power Doppler BORe Bolus Observe Reposition PC Posterior Cord CV Cephalic Vein PMaM Pectoralis Major Muscle EMR Evoked Motor Response PMiM Pectoralis Minor Muscle LA Local Anesthetic PN Pectoral Nerve LC Lateral Cord SAM Serratus Anterior Muscle LPA Lateral Pectoral Artery SsM Subcaspular Muscle Nr. 606 1202 International Standardized Techniques, 2nd Edition 2015©
Transcript of Upper Extremity Nerve Blocks · tion to detect AV and CV and decrease the risk of intravenous...
Upper Extremity Nerve Blocks
Interscalene
Indications: Anesthesia and analgesia for surgery on shoulder, distal clavicle and proximal humerus.Patient position: Supine or semi-sitting, head facing to contralateral side.Transducer: Linear.Needle: 22G, 5 cm short bevel.Common EMR obtained: Deltoid response.LA: 10-15 ml.
Brachial Plexus Approach Transducer Placement Ultrasound Image Reverse Ultrasound AnatomyTM Anatomy
Initial transducer placement: Over external jugular vein, approximately 3 cm above clavicle. Alternatively, start at supraclavicular fossa and scan proximally toward the plexus.Initial depth setting: 3 cm.
Landmarks: ASM and MSM, 2 or 3 round hypo-echoic structures (roots or trunks) between the ASM and MSM.Ideal view: C5 C6 C7 nerve roots.
Technique: Needle Insertion in plane (most com-mon), lateral to medial; alternatively out of plane.Ideal spread of LA: Within the interscalene space inside the sheath. Number of injections: Based on spread; typically 1-2. BORe.
Tips: Use PD to detect and avoid blood vessels on the needle path. Reconsider in patients with history of signi� cant respiratory disease. Use short acting LA through catheter in such pa-tients; extend block through catheter if initial block tolerated well.
Supraclavicular
Indications: Anesthesia and analgesia for surgery on humerus, elbow, forearm and hand.Patient position: Supine or semi-sitting, head facing to contralateral side.Transducer: Linear.Needle: 22G, 5 cm short bevel.Common EMR obtained: Forearm, hand response.LA: 20-25 ml.
Initial transducer placement: In supraclavicular fossa, lateral to clavicular head of SCM, tilted caudally.Initial depth setting: 3 cm.
Landmarks: Subclavian artery, brachial plexus sheath (arrows), � rst rib and pleura. Ideal view: Brachial plexus and subclavian artery above � rst rib (pleura should be visualized).
Technique: Needle Insertion in plane, lateral to medial. Assess the depth of the BP, insert needle with shallow angle and adjust accordingly.Ideal spread of LA: Within BP fascial sheath lateral to the SA but super� cial to the � rst rib. Number of injections: 2-3. BORe.
Tips: Visualize the pleura (if unable, consider other technique). Use PD to detect and avoid TCA, DSA. Consider an alternative technique when large vessels are present within the sheath. Injection of LA should � ll BPS. Reduce transducer pressure before injection of LA to facilitate spread.
Infraclavicular
Indications: Anesthesia and analgesia for surgery on humerus, elbow, forearm and hand.Patient position: Supine with arm abducted and � exed at elbow.Transducer: Linear.Needle: 22G, 8-10 cm short bevel.Common EMR obtained: Forearm, hand.LA: 20-25 ml.
Initial transducer placement: Parasagittal, below the clavicle, medial to coracoid process.Initial depth setting: 5 cm.
Landmarks: Axillary artery and fascia of pectoralis minor muscle (arrows).Ideal view: Axillary artery and vein below the fascia of pectoralis minor muscle, lateral, medial, posterior cords periarterialy.
Technique: Needle insertion in plane, cephalad to caudad. Release transducer pressure before injec-tion to detect AV and CV and decrease the risk of intravenous injection. Use PD to identify vascular structures. Ideal spread of LA: periarterialy (U-shaped). Number of injections: 1-2. BORe.
Tips: Ensure su� cient lateral placement of the transducer to avoid chest cavity. A single in-jection of LA is made where all cords are visible lateral to the artery, or posterior to the artery.
Axillary
Indications: Anesthesia and analgesia for surgery on forearm and hand.Patient position: Supine with arm abducted and � exed at elbow.Transducer: Linear.Needle: 22G, 5 cm short bevel.Common EMR obtained: Hand or � ngers.LA: 15-20 ml.
Initial transducer placement: Perpendicular tohumerus in the axillary fossa, at intersection between pectoralis and biceps muscles.Initial depth setting: 3 cm.
Landmarks: Axillary artery and Brachial Plexus fascial sheath (arrows).Ideal view: MN, UN, RN scattered around AA, McN between the biceps and coracobrachialis muscles.
Technique: Needle Insertion in plane or out of plane. Injections: one above the artery, one between artery and conjoint tendon. McN is blocked separately.LA deposit: 8 ml posterior and 8 ml anterior to the artery, 4 ml for McN. Ideal spread of LA: around AA.Number of injections: 2+McN. BORe.
Tips: For extensive elbow surgery consider more proximal technique. Variations of McN are common. McN may be attached to the MN. Pre-scan to look for common anatomical variations. Reduce transducer pressure before injection of LA to facilitate spread and to de-crease the risk of intravascular injection.
OsteotomesDermatomesSuggested Standard Monitoring For Nerve BlocksUltrasound + Nerve Stimulation + Opening Injection Pressure (OIP)
Needle adequately placed as seen on US
No twitch
1-2 mL injection of LA results in adequate spreadin the desired tissue plane
OIP normal <15 psi+
Not necessary to look for twitch
Completeinjection
Twitchpresent
Notwitch
Increase current to 1.5 mA
Adjust needle placement by US
Needle placement by US uncertainPoor images of Anatomy/needle
1-2 mL injection of LA results in adequate spreadin the desired tissue plane
OIP normal <15 psi+
Reposition the needle to assure NO twitch
present at <0.5 mA*
Needle adequately placed as seen on US
Twitch present
Connect Needle to Nerve stimulator (0.5 mA, 0.1 msec, 2 Hz)
Legend:US – Ultrasound; NS – Nerve Stimulator*OIP normal (<15 psi) – Based on data both in animal models and clinical trials where opening injection pressure required to inject into fascicles or at needle-nerve contact exceeded 15 psi (Acta Anaesthesiol Scand, 2007; 51(101-7), RAPM 2012; 37:525-9, Anesthesiology 2014; 120:1246-53). +0.5 mA – Data from several studies suggest that twitch (EMR; evoked motor response) at <0.2 mA (0.1 msec) may indicate intraneural needle placement or needle/nerve contact (Anesth Analg 2005; 101;1844-6, Anesthesiology 2009; 110;1235-43)
Anterior Posterior Anterior Posterior
CREATED BY NYSORA COLLABORATIVE INTERNATIONAL GROUP. A listing of contributing institutions and electronic copy of the poster are available at www.NYSORA.com Contributors: Admir Hadzic (USA), Ana Lopez (SPA), Daquan Xu (USA), Xavier Capdevilla (FRA), John Laur USA), Alwin Chuen (AUS), Catherine Vandepitte (BE), Pablo Helayel (BRA), Carlos Bollini (ARG), Roman Zuercher (SWI), Dimitri Dylst (BE), Ali Nima Shariat (USA), Emily Linn (USA), Thomas Clark (USA), Philippe Gautier (BE), Malikah Latmore (USA), Manoj Karmakar (HK), Je§ Gadsden (USA), Jason Choi (USA), Xavier Sala-Blanch (SPA), Javier Cubillos (COL), Maria Fernanda Rojas Gomez (COL), Kwesi Kwo¨e (CAN), Uma Shastri (CAN), Imran Ahmad (UK), Thomas Halaszynski (USA), Yasuyuki Shibata (JPN), Anahi Perlas (CAN), André van Zundert (AU), Luc Van Keer (BE), Jeroen Van Melkebeek (BE)
C3-C5
C5-C6
C5-C6
C5-C7
Primary nerve branches
Axillary C5-C6
C5-C6
Intercostobrachial T2
Radial C6-T1
Median C5-C6
Ulnar C8-T1
Cutaneus brachii medialis C8-T1
Intercostal T3-T12
Musculocutaneus C5-C6
C2
Supraclavicular
Suprascapular
Subclavius
Long thoracic
Subscapular
Occipital
Cutaneus antebrachii medialis C8-T1
Advance needle towards the nerve or plexus
AbbreviationsASM Anterior Scalene Muscle LA Local AnestheticBP Brachial Plexus MSM Middle Scalene MuscleBPS Brachial Plexus Sheath PhrN Phrenic nerveBORe Bolus Observe Reposition RLN Recurrent Laryngeal NerveCA Carotid Artery SCM Sternocleidomastoid MuscleEMR Evoked Motor Response SCP Super� cial Cervical PlexusEJV External Jugular Vein TPC7 Transverse Process C7IJV Internal Jugular Vein VA Vertebral ArteryLCM Longus Coli Muscle VN Vagus nerve
AbbreviationsBP Brachial Plexus MSM Middle Scalene MuscleBPS Brachial Plexus Sheath OHM Omohyoid MuscleBORe Bolus Observe Reposition PD Power DopplerCL Clavicle SA Subclavian ArteryDSA Dorsal Scapular Artery SSA Suprascapular ArteryEMR Evoked Motor Response SV Subclavian VeinLA Local Anesthetic TCA Transverse Cervical Artery
AbbreviationsAA Axillary Artery IcbN Intercostobrachial NAV Axillary Vein LA Local AnestheticBORe Bolus Observe Reposition McN Musculocutaneous NerveCBM Coracobrachialis Muscle MN Median NerveCfxA Circum� ex Artery RN Radial NerveCNA Cutaneous Nerve of Arm UN Ulnar NerveEMR Evoked Motor Response
AbbreviationsAA Axillary Artery MC Medial CordAV Axillary Vein PD Power DopplerBORe Bolus Observe Reposition PC Posterior CordCV Cephalic Vein PMaM Pectoralis Major MuscleEMR Evoked Motor Response PMiM Pectoralis Minor MuscleLA Local Anesthetic PN Pectoral NerveLC Lateral Cord SAM Serratus Anterior MuscleLPA Lateral Pectoral Artery SsM Subcaspular Muscle
Nr. 606 1202
International Standardized Techniques, 2nd Edition 2015©
