5. Avoid GA and
problem with GA
Post-operative pain
Stable
haemodynamic
Not contraindicated
in patient with
coagulopaty/ sepsis/
fixed cardiac output
ADVANTAGES
6. Patchy block/ not
dense
Slow onset
LA toxicity
Others; hematoma,
pneumathorax etc
Difficult (operator
dependant)
DISADVANTAGES
9. METHODOLOGY
Procedure Checklist
Consent Aseptic technique
Indication L.A. to skin
Contraindication Needle
Emergency Drug Technique
GA machine & US Equipment End point
IV Drip Dosage
Full monitoring Complication
Patient positioning Anaesthesia
Landmark
22. complications
I. Pneumothorax ( 0.5-25 % )
II. Phrenic & Recurrent laryngeal nerve paresis
III. Subclavian artery puncture ( 20 % )
23.
24.
25. Local anaesthetic spread
Pre LA injection Post LA injection
Site : LA volume above the first rib + lateral to subclavian artery
( for lower BP trunk block for distal limb surgery )
Volume : 25 – 40 mls
30. anatomy
AA – axillary artery
AV - axillary vein
CP - coracoid process
BP – cords of brachial plexus
PMiM – pectoralis minor muscle
31. Probe positioning
• l
Linear 7 MHz US transducer
Medial to coracoid process
Parasagittal plane
Depth of field 3-5 cm
Surface landmark
32. Nerve localization
INTERMEDIATE skill level
From superficial to deep scan
AA & AV deep to pectoralis minor
Look hyper-echoic structures in relation to AA
LC - cephalad 9-12 o’clock
PC - posterior 6-9 o’clock
MC - caudad 3-6 o’clock
33. In plane approach
Recommended for continuous needle visualization &
tip movement Aim to place needle tip &
LA volume posterior to
AA
adjacent to posterior
cord
U shape spread around
AA leads to complete
blockade of arm, forearm
& hand
10-15 mls LA post to AA
at 6 o’clock (post cord )
Withdraw needle to 9
o’clock ( lat cord )
34. ANATOMICAL VARIATIONS IN CORACOID REGION
Picture from Sauter Anesth Analgesia 2006;(103): 1574-1576
Wide anatomical variations
But only 2 cords and not 3 had
this variations
A -- axillary artery
L – lateral cord
M – medial cord
P -- posterior cord
V -- axillary vein
36. INDICATIONS
Block terminal branches of brachial plexus
Median nerve
Ulnar nerve
Radial nerve
Musculo-cutaneous nerve
Hand, wrist and ulnar side of forearm surgery