AXB - Axillary brachial plexus Block
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1 AXB - Axillary brachial plexus Block TNS - transcutan nerve stimulation NS - nerve stimulator US ultrasound Transarterial block method Trygve Kjelstrup, MD Dep. of Anaesthesiology, Diakonhjemmet Hospital The Intervention Centre, Oslo University Hospital Norway
2 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
3 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 :
4 Capdevilla X et al. Reg Anesth Pain Med. 2004; 29 (3): 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
5 Transcutaneus Nerve mapping Outcome : Anatomic information Position of the nerve before puncture Less vascular punctures higher safety A must : mark out, draw lines...
6 AXB : 1. Short Catheter A. TNS, mark the median nerve B. Skin infiltration Right arm
7 AXB : Short 55mm catheter 18 G, stylet 30
8 AXB, short catheter 2. Subcutanous horizontally perforation: 1 cm Simultant motorisk utslag Caput Thorax (right arm, another patient) Left arm
9 AXB : 3. Penetration of the fascial sheet perpendicular to the skin / 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
10 AXB : 4. After fascia penetration: needle brought down to the skin skulder hø. arm Right arm
11 Short catheter in almost final position Follow up the median nerve preferably Continuous motor response prevents puncture of artery and vein NS start: ma-0.1 ms. Final position: ma-0,1ms hø. arm
12 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
13 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.
14 Spinal fluid AXB dx 40 ml LA via cath. MRI, Coronal view 3.0 Tesla, T2 High proximal spread. Complete block Catheter
15 AXB : Status before ultrasound Done : Catheter in median nerve position Single injection : Insufficient block
16 Stimuplex 15 needle for the ultrasound guided injection
17 AXB dx. Ultrasound dual guided injection Stimuplex 70 mm needle in plane.
18 Prescan AXB dx. Ultrasound, the radial nerve Injection Positioning of the needle NS : 0,3 ms / 1,5 ma
19 AXB right side : Prescan Ultrasound, the median nerve Injection Needle in position
20 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
21 AXB dx. The musculocutaneus nerve axplexdx mcinj.wmv
22 After US guided injection Extension tube on short catheter Properly fixation Injection ml
23 No US : TAB : Transarterial AXB Transarterial punction with 25 G cannula Shoulder caput Right arm
24 Kjelstrup, T. Acta Anaesthesiol Scand 2006; 50:
25 25 G needle through the brachial artery Video :
26 LA injection behind the artery
27 LA - injection in front of the artery
28 Ultrasound from transarterial blockade (TAB) 25 G transart. inj. behind artery inj. in front of artery (fascial sheet)
29 Total : 40 ml mix. 30 ml via US : the radial median mc nerve 10 ml via the catheter : the median nerve
30 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
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Welcome to the July 2012 edition of Case Studies from the files of the Institute for Nerve Medicine in Santa Monica, California. In this issue, we focus on a 23-year-old female patient referred by her