AXB - Axillary brachial plexus Block TNS - transcutan nerve stimulation NS - nerve stimulator US – ultrasound Transarterial block method
Trygve Kjelstrup, MD www.kjelstrup.tk
Dep. of Anaesthesiology, Diakonhjemmet Hospital The Intervention Centre, Oslo University Hospital Norway
Axillary Plexus Block (AXB) : actual methods
1. TNS : transcutan nerve stimulation
2. Catheter on the med. nerve / NS
cath
3. Ultrasound and NS guidet block
4. Eventually : TAB : Transarterial blockade
AXB : starting the block 1. Drawing 2. Stimuplex Pen ”R” + Gel 3. Transcutan nerve mapping 0,3 – 1,0 ms / 2,5 – 5 mA
U: n. ulnaris M: n. medianus brachial artery R: n.radialis
video : www.kjelstrup.tk
Capdevilla X et al. Reg Anesth Pain Med. 2004; 29 (3): 206 – 11
Percutaneous electrode guidance using the insulated needle for prelocation of perferal nerves during axillary plexus blocks.
Axillary mapping, localization and depth determination of perifer nerves
Transcutaneus Nerve mapping Outcome : • Anatomic information • Position of the nerve before puncture • Less vascular punctures – higher safety • A must : mark out, draw lines .....
AXB : 1. Short Catheter A. TNS, mark the median nerve B. Skin infiltration
Right arm
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AXB : Short 55mm catheter 18 G, stylet 30 ͦ
AXB , short catheter 2. Subcutanous horizontally perforation: 1 cm
Simultant motorisk utslag
Caput
Thorax (right arm, another patient)
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Left arm
AXB : 3. Penetration of the fascial sheet – perpendicular to the skin / 90° 1. Penetrate close to the artery, cranially
2. Direction : n. medianus 3. NS : 2 mA/0.3ms
4. Thumb on brachial artery distally Artery should be pulsing continuously
Right arm www.kjelstrup.tk
AXB : 4. After fascia penetration: needle brought down to the skin
hø. arm
Right arm
skulder
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Short catheter in almost final position Follow up the median nerve preferably
hø. arm
Continuous motor response prevents puncture of artery and vein NS start: 0.5 - 2.5 mA-0.1 ms. Final position: 0.4–0.8 mA-0,1ms www.kjelstrup.tk
AXB : Advantages with a catheter • Incomplete block – easy additional dose • Delayed start / OP – easy top-up dose • Postoperative pain treatment Continous LA, electrical or elastomeric pump
Why not ultrasound for the short AXB catheter ?
AXB dx, Contiplex 18 G next to the median nerve. Difficult to follow the catheter high up in the axillae. NS better.
AXB dx 40 ml LA via cath.
Spinal fluid
MRI, Coronal view 3.0 Tesla, T2
High proximal spread. Complete block
Catheter
AXB : Status before ultrasound Done : Catheter in median nerve position
Single injection : Insufficient block
Stimuplex 15 ͦneedle for the ultrasound guided injection
AXB dx.
Ultrasound dual guided injection Stimuplex 70 mm needle – in plane.
AXB dx. Ultrasound, the radial nerve Prescan Injection
Positioning of the needle
NS : 0,3 ms / 1,5 mA www.kjelstrup.tk
AXB right side :
Ultrasound, the median nerve
Prescan
Injection
Needle in position www.kjelstrup.tk
Why not US guidet injection on the ulnar nerve ? Multi injection or ultrasound technique : - the ulnar nerve will be blocked
Selective ulnar nerve localization is not essential for brachial plexus block using a multiple nerve stimulation technique. Sia S. Bartoli M. Reg Anesth Pain Med. 2001; 26 (1): 12 – 6
AXB dx. The musculocutaneus nerve
axplexdx7.5.09.mcinj.wmv www.kjelstrup.tk
After US guided injection • • •
Extension tube on short catheter Properly fixation Injection 10 - 20 ml
No US : TAB : Transarterial AXB Transarterial punction with 25 G cannula caput Shoulder
Right arm
Kjelstrup, T. Acta Anaesthesiol Scand 2006; 50: 112 - 116
25 G needle through the brachial artery
Video : www.kjelstrup.tk
LA – injection behind the artery
LA - injection in front of the artery
Ultrasound from transarterial blockade (TAB) 25 G transart.
inj. in front of artery (fascial sheet)
inj. behind artery
Total : 40 ml mix. 30 ml via US : the radial – median – mc nerve 10 ml via the catheter : the median nerve
AXB : Recommendations 1. Start with a clinical approach : Drawing, TNS 2. Always catheter, master various methods 3. Dual guidance – Ultrasound and Nerve Stimulator
This lecture on www.kjelstrup.tk
