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