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USRA OF THE
UPPER EXTREMITY
Christian R. Falyar, DNAP, CRNA
Department of Nurse Anesthesia
Virginia Commonwealth University
Disclosure Statement of
Unapproved/Investigative Use
I, Christian Falyar,
DO NOT anticipate discussing the
unapproved/investigative use of a
commercial product/device during this
activity or presentation.
Disclosure Statement of
Financial Interest
• I, Christian Falyar,
DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could
be perceived as a real or apparent
conflict of interest in the context of the
subject of this presentation.
Objectives
•  Review the anatomy of the brachial plexus
•  State the indications for each upper extremity block
•  Describe the ultrasound landmarks for each upper
extremity block
•  Review the ultrasound-guided needle insertion plane and
local anesthetic requirements for each upper extremity
block
•  Discuss the side-effects and complications related to
upper extremity blocks
Brachial Plexus
Brachial Plexus
•  Consists of ventral rami of the C5-T1 nerve roots.
Contributions from C4 and T2 are often minor or absent
•  Roots exiting the vertebral foramen converge and diverge
into trunks, divisions, cords, branches, and finally terminal
nerves
•  With a few exceptions, the brachial plexus supplies
sensory and motor innervation to the upper extremity
Brachial Plexus Blocks
•  Interscalene
•  Supraclavicular
•  Infraclavicular
•  Axillary
USRA Technique
•  USRA offers three benefits
over landmark technique
•  Visualization of nerves
•  Real-time needle movements
•  Spread of local anesthetic
•  No large study has shown
USRA to be safer
•  To stim or not to stim?
Local Anesthetics
Local Anesthetics
•  How much is enough?
•  Most references recommend 20-40 mLs per block
•  Some authors have demonstrated successful, complete
interscalene blocks with as little as 5 mL
Max Dose (mg/kg)
Max Dose with Epi (mg/kg)
Lidocaine*+
Lidocaine*
4.5mg/kg
4mg/kg
7mg/kg
Mepivacaine*+
Mepivacaine*
4.5mg/kg
4mg/kg
7mg/kg
Bupivacaine*
Bupivacaine*
2.5mg/kg
2.5mg/kg
•  Amount of local anesthetic depends:
•  Patient factors
Drug
Drug
Ropivacaine*
Ropivacaine*
Max Dose (mg/kg)
3mg/kg
5mg/kg
7mg/kg
7mg/kg
N/A
3.2mg/kg
N/A
3.5mg/kg
•  Timing of the procedure
Procaine+
Procaine+
12mg/kg
•  Procedure
Chloroprocaine*
Prilocaine*
11mg/kg
7mg/kg
14mg/kg
8.5mg/kg
Prilocaine*
Tetracaine+
8mg/kg
3mg/kg
8.5mg/kg
N/A
Tetracaine+
3mg/kg
•  Purpose of the block
Chloroprocaine*
12mg/kg
Max Dose with Epi (mg/kg)
11mg/kg
N/A
N/A
14mg/kg
N/A
* - Nagelhout & Plaus, 5th ed., pg. 137
+ - Morgan & Mikhail, 5th ed., pg. 272
Indications
Contraindications
•  Regional anesthesia has many indications,
•  In certain instances regional anesthesia should
including:
 Primary anesthetic
not be considered. Absolute contraindications
include:
 Pain Management
 Patient refusal
 History of severe PONV or risk of MH
 Local infection at the site of the proposed block
 Patient is too ill for general anesthesia
 Active bleeding an anticoagulated patient
 Physician (surgeon) preference
 Proven allergy to a local anesthetic
Contraindications
Complications
•  Most contraindications to regional anesthesia are
•  Regional anesthesia can result in complications
relative. The provider must determine the risk
vs. benefit
such as:
 Local anesthetic toxicity
 Respiratory compromise
 Intra-arterial injection
 Inability to cooperate/understand procedure
 Respiratory compromise
 An anesthetized patient (adult population)
 Parathesias and nerve damage
 Bleeding diathesis secondary to an anticoogulant or
genetic defect
 Bloodstream infection
 Preexisting peripheral neuropathy
•  Risks and benefits of regional anesthesia should
always be discussed beforehand
Pre-Procedure
Block Evaluation
•  Prior to beginning any procedure:
 Verify the correct patient
 Obtain informed consent
 Verify the correct procedure
 Verify the correct extremity
 Gather all necessary equipment
 Place the patient on oxygen
 Obtain baseline VS and monitor during the procedure
 Administer proper/adequate sedation
•  Baseline Evaluation
•  “Push, Pull, Pinch, Pinch”
•  Post-procedure
•  Differential Blockade
•  Mantel Effect
Differential Blockade
Interscalene Block
•  The interscalene block is a root level block
Classificati
on
Diameter
(μ)
Myelin
Conduction
(m/sec)
Location
Function
Motor and
proprioception
A-alpha
A-beta
6-22
+
30-120
Afferents/efferents for
muscles and joints
A-gamma
A-delta
3-6
1-4
+
+
15-35
5-25
Efferent muscle spindle
Afferent sensory nerve
Muscle Tone
Pain, Touch
Temperature
B
<3
+
3-15
Preganglionic
sympathetic
Autonomic
Function
0.7-1.3
Postganglionic
sympathetic
Afferent sensory nerve
Autonomic
Function
Pain
Temperature
C
0.3-1.3
–
•  It is the primary brachial plexus block for
procedures involving the shoulder and proximal
upper arm
•  Nerve roots C5-7 are found in the interscalene
groove between the anterior and middle scalene
muscles at the level of the cricoid cartilage, C6
Morgan & Mikhail 5th. Ed. Pg. 266
Interscalene Block
USRA Technique
•  Supine position with head
turned to non-operative side
•  High-frequency linear array
transducer placed in the midclavicular fossa and moved
cephalad
•  Hypoechoic roots located
between the ASM and MSM
•  5 cm, B bevel needle
•  Incremental injection of 5 mL
up to 20-30 mL
Pre-Procedure Scan
Interscalene Anatomy
Interscalene Anatomy
Interscalene Injection
“Normal”
“Abnormal”
Interscalene Pearls
Interscalene Anatomy
•  The phrenic nerve is frequently blocked, resulting in
hemiparesis of the diaphragm
•  Avoid injecting local anesthetic immediately adjacent to
the transverse process because of the risk of
unintentional epidural or spinal injection
•  Horner’s syndrome (miosis, ptosis, and anhidrosis) may
occur because of the close proximity of the stellate
ganglion
•  The vertebral artery enters the vertebral column at C6,
increasing risk for intravascular injection
Supraclavicular Block
•  The supraclavicular block is performed at the
trunk and division level
•  It is a reliable upper extremity block for
procedures involving the upper arm and hand
•  The trunks/divisions are found lateral to the
subclavian artery and superior to the first rib
•  The brachial plexus is most compact at this level
No anterior tubercle at C7
Supraclavicular Anatomy
USRA Technique
Supraclavicular Imaging
•  Pt. placed supine with head turned to the non-
operative side
•  High frequency linear array transducer is placed
in the supraclavicular fossa
•  Nerves appear as a group of hypoechoic circles
lateral to subclavian artery, superior to first rib
•  22 gauge, 5cm B-bevel needle is inserted lateral
to medial using an in-plane technique
•  Incremental injection of 5 mL up to 20-30 mL
Pre-Procedure Scan
Supraclavicular Block
Supraclavicular Pearls
Infraclavicular Block
•  The infraclavicular block is a cord level block
•  Increased risk of phrenic nerve paralysis and
•  It is an good alternative to the supraclavicular
stellate ganglion block
•  Pneumothorax is the most important complication
•  Because of the proximity of the subclavian artery,
there is the possibility for inadvertent arterial
puncture
block, especially in patients with severe chronic
obstructive pulmonary disease (COPD) or
respiratory insufficiency
•  The cords (lateral, posterior and medial) are
labeled by their relation to the axillary artery
Infraclavicular Anatomy
USRA Technique
•  Patient placed in supine position with their head turned to
the non-operative side
•  Transducer is placed perpendicular to the clavicle just
medial to the coracoid plexus
•  Short-axis image
•  Cords are arranged around the axillary artery
•  22 gauge, 8 cm needle inserted in-plane, cephalad to
caudal
•  Incremental injection of 20-30 mLs of local anesthetic
around axillary artery
USRA Technique
Infraclavicular Pearls
•  Depending on pt. body habitus, a low-frequency
transducer may be required
•  Additional subcutaneous injection of local anesthetic may
be warranted
•  Sliding the needle medially increases the potential for
pneumothorax and hemothorax
•  The thoraco-acromial artery and pectoral veins pass
between the pectoral muscles. Doppler may be used to
help identify these to prevent inadvertent puncture
Infraclavicular Pearls
Infraclavicular Pearls
Axillary Block
USRA Technique
•  Patient is placed in the
•  The axillary block is directed at the terminal branches of
the brachial plexus
•  It is an excellent block for procedures below the elbow
•  Once a mainstay of regional anesthesia for the upper
extremity, ultrasound has made it less attractive because
other blocks can be done as efficiently with minimal
complications
USRA Technique
M
U
R
MSC
supine position with head
turned to the non-operative
side, arm abducted and
rotated externally
•  High-frequency linear array
transducer is placed in the
crease formed by the biceps
muscle and pectoris major
•  22-gauge, 5 cm B-bevel
needle inserted in-plane
•  Incremental injection of 20-40
mLs
Axillary Pearls
•  Compressing the veins may
•  Complications from an axillary block are not common,
decrease the risk of vascular
puncture
•  Block the radial nerve first
because it tends to lie deeper
than the median and ulnar
•  Slide the transducer distally
to appreciate each of the
nerves, then follow them
proximally to their origin
however there is an increased risk of vascular puncture
because the needle must be re-directed several times to
achieve adequate local anesthetic distribution
•  Paresthesia from multiple needle punctures may result in
neuropathy
•  There are multiple veins located around the artery. Be
cautious
Questions?
References
•  Brown DL. Atlas of Regional Anesthesia. 4th. Ed.; 2010,
Saudners Elsevier.
•  Butterworth JF. Morgan & Mikhail’s Clinical Anesthesiology; 5th.
Ed.; 2013, McGraw-Hill Medical.
•  Chan V., & Pollard B.; An Introductory Curriculum for
Ultrasound-Guided Regional Anesthesia; 2009, University of
Toronto Press.
•  Chan, Vincent; Ultrasound Imaging for Regional Anesthesia: A
Practical Guide; 3rd Edition; 2010, Toronto Printing Company.
•  Gray, Andrew; Atlas of Ultrasound-Guided Regional
Anesthesia; 2007, Saunders/Elsevier.
•  Hadzic, Admir; Textbook of Regional Anesthesia and Acute
Pain Management; 2007, McGraw-Hill Medical.
•  Sites, B., & Spence, B.; Ultrasound Guidance in Regional
Anesthesia: Techniques for Upper-Extremity and LowerExtremity Nerve Blocks; 2008, McMahon Publishing.