Brachial plexus block Interscalen – supraclavicular access TNS - transcutan nerve stimulation NS - nerve stimulator US - ultrasound Trygve Kjelstrup, MD, section manager www.kjelstrup.tk Dep. of Anaesthesiology, Diakonhjemmet Hospital The Intervention Centre, Oslo University Hospital Norway

RA experience: Diakonhjemmet Hospital from august 2007

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Oslo University Hospital 2002 – 2005 2008 - 2011 KMI – Sophies Minde 1992 - 1993 1998 – 2002 LDS 2005 – 2007 SKI 1994 - 98 Allg. Kr.haus Celle 1984 – 1992 Medizinische Hochschule Hannover 1988 Herzzentrum Nordrhein – Westfalen 1989

ISB / SCB indication Operation and post-operativ workup : Shoulder, arm and forearm Amputation trauma left arm Chip crusher

how to do the block

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150 ISB / year

Supraclaviculary region

v.jug.ext.

Clinical examination : mark the vein and interscalen groove

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Transcutan nerve mapping

pct. max, Max.Stim.Point

Stimuplex-Pen

0.3 -1.0 ms 2.5 – 5 mA SonoGel on Pen + Electrode ! www.kjelstrup.tk

needle

pct. max, MSP

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Needle insertion point • close to the scalenus groove • behind the ext. jug. vein

MSP

• 2 - 4 cm over clavicula • 1 - 2 cm over MSP (maximal stimulation point)

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Terminal nerves - Cords – Divisions – Trunks - Roots

n. suprasc. (1): superior trunk

TNS of the shoulder : 1. red lateral cord : a sup. & b med. trunk 2. blue posterior cord : post. divisions all trunks 3. green medial cord : inferior trunk c

Mapping – details 1.

First clinical examination :

2.

TNS : find pct. max, MSP : maximal stimulation point with motor respons in arm or forearm. New mark and drawing

3.

Difficult : TNS higher up (IS) : n. suprascapularis from truncus superior : musc. supra- and infraspinatus

4.

Wrong : TNS nerv. accessorius (XI) – outside brach. plex. (musc. trapezius, musc. sternocleid.) Wrong : C5 : n. dorsalis scapulae (m. levator scapulae og mm. rhomboideus)

•

Mark the IS – groove

Video : TNS, interscalen – supraclaviculary region

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needle

pct. max, MSP

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Confirming with ultrasound after transcutan nerve stimulation www.kjelstrup.tk

Video : Confirming with ultrasound after transcutan nerve stimulation

19.1.10. ISBdx.pre.deep. wmv

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Plexus brachialis left side, art. transversa colli Anterior

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Earlier equipment : Vasocan 20 G 33 mm i.v. cannula Exstra cable Easy positioning

Standard now : Contiplex D 20 G Atraumatic 33mm 400 mm catheter

Video 1 : Contiplex 20 G Interscalen – Supraclavicular Brachial plexus block, left side

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Video 2 : Contiplex 20 G Interscalen – supraclavicular Brachial plexus block, left side

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Method : 1. Positioning of Contiplex 20 G with NS •continuous motor respons •Follow the plexus nerves 1 – 1.5 cm

•cannula in parallel position to the nerves •Final position : 0.3 ms and 0.5 – 0.8 mA

0.1 –

•If paresthesia or pain : stop advancement, change direction

2. Ultrasound : adjust cannula position, injection

Supraclavicular block : Control with US after insertion “with nerve stimulator” Alternativ : Ultrasound guided insertion with nerve stimulator as backup

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Video : ISB / SCL : standard access

ISB sin. 20G in situ.07.4.08.wmv www.kjelstrup.tk

Video : ISB / SCL : injection on standard access

ISB sin. 20G inject 20ml.07.4.08.wmv www.kjelstrup.tk

Video : ISB / SCL : injection on standard access

ISB SCL sin 20ml 20G in situ 16.10.08.wmv www.kjelstrup.tk

Video : insertion of the 24 G catheter through the cannula

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Solid fixation of the 24 G catheter

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Total dose: 40 ml mix. 20 ml via the cannula, 20 ml via the catheter

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No harm to the patient : 1. Aggressive ISB : Puncture the outer hyperechoic layer or adherent tissue layer = epineurium ? 2. Conservative ISB : less aggressive injection ”on the outside” Puncture nerve sheat / fascia: ok

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Lecture on www.kjelstrup.tk

ISB / SCB : recommendations

1. Start with a clinical approach : Drawing, TNS 2. Start with NS. Then verifying with US 3. Always catheter

Nordfjella / Skarvheimen 2009 Reindeer hunting

This lecture on www.kjelstrup.tk