interscalene and supraclavicular brachial plexus block.pptx

Brachial plexus block above clavicle

1. INTERSCALENE & SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK DR PRITAM HIRA SPECIALTY DOCTOR ANAESTHETIC, ACUTE PAIN & ICU

2. INDICATIONS Interscalene Block Lateral 2/3 rd of clavicle Shoulder Sx Proximal humerus Supraclavicular Block Distal humerus Elbow Forearm Hand Sx ICBN

3. ANATOMY The brachial plexus is formed by the union of the anterior primary divisions (ventral rami) of the fifth through eighth cervical nerves (C5, C6, C7, C8) and first thoracic (TI) nerve, with variable contributions from C4 and T2. It consists of Roots, Trunks, Divisions, Cords and terminal branches.

4. ANATOMY The roots of the plexus (anterior primary rami of C5-TI nerves) are between the scalene muscles, the trunks in the posterior triangle, the divisions behind the clavicle, and the cords arranged around the second part of axillary artery. About 10% of plexuses are prefixed (from C4-C8) and 10% postfixed (from C6-T2)

5. APPROACHES OF ISB Classic technique (Winnie, 1970) Modified lateral approach (Borgeat 2003, for continuous catheter technique) Modified lateral technique (Meier 2007, for suprascapular nerve) Posterior / Cervical technique (2010) APPROACHES OF SCB Classic technique (Kulencampff, 1911: landmark-based approach, targeting first rib) Modified Plumb-Bob technique (1993: Lateral to SCM)

6. SONOANATOMY 1 (ISB) ASM MSM C5 C6 C7

7. SONOANATOMY 2 (ISB)

8. SONOANATOMY 3 (ISB)

9. REVERSE SONOANATOMY (ISB)

10. Ergonomics & Landmarks Supine or semi-sitting position, head turned to contralateral side Performer, probe & US machine in a straight line Landmarks: Clavicle, Sternocleidomastoid, EJV, Cricoid cartilage. Probe position: transverse (apply caudal angle if necessary), 2-3cm proximal to clavicle, over EJV if visible. “Traffic Light Sign” C5, C6 (often divided) or C5-C7 between Ant. & middle Scalene muscle (Interscalene groove) In-plane approach, Lat-to-medial. Avoid Medial to lateral (risk of phrenic nv . Injury) Use colour doppler Start from the clavicle

11. SONOANATOMY 1 (SCB) omohyoid SCM SA 1 st Rib

12. SONOANATOMY 2 (SCB)

13. SONOANATOMY 3 (SCB)

14. Reverse Sonoanatomy (SCB)

15. Dynamic scanning

16. Distribution of innervation

17. Ergonomics & Landmarks Similar as ISB, identify “Bunch of grapes” structure, lateral to SA Use doppler (avoid injury to DScA , TCA, SScA ) Start at the middle of clavicle, use rotation & anisotropy Shallowest: 1cm needle depth usually sufficient Practical tips: Pneumothorax is a rare but potentially serious complication 1 st inject at “corner pocket” → lower trunk Extra caution for patients on anticoagulant therapy Need separate ICBN injection for medial aspect of arm

18. Complications Interscalene Block Dyspnea (phrenic nv block) Hoarse voice (RLN) Horner Syndrome ( Symp . Block) Muscle weakness Haematoma Nerve root or adj. Nv. Injury IV / IT / Epi injection LAST Supraclavicular Block Pneumothorax Dyspnea (phrenic nv spread) Horner Syndrome ( Symp . Block) Muscle weakness Haematoma Brach. plexus Injury IV injection LAST