Numb Hands & Our Top Finger-Tips: RA for Upper Limbs
Feb 20, 2024
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Hosts discuss nerve block options for upper limb surgeries, optimizing techniques for precision and safety. They explore ultrasound guidance, tourniquet pain, opioid-free anesthesia, and the decision-making process for selecting nerve block techniques.
Injecting techniques for brachial plexus blocks evolved for safety and efficacy.
Raptor block preferred for quick onset and minimal vessel complications.
Costoclavicular approach offers reliable identification of cords with caution towards pleura.
Addressing nerve coverage is crucial for effective brachial plexus interventions.
Deep dives
Superclavicular Brachial Plexus Block
Injecting the superclavicular fossa for the block led to internal cringe due to potential hazards and vessels present. Technique evolved from injecting within to outside the plexus sheath to enhance safety. Challenges included needle passages and visibility, with caution urged on needle tip placement to avoid neural injury. While two passes were deemed necessary, ensuring correct injection angle and depth was crucial for efficacy.
Raptor Block Technique
The raptor block became favored due to quick onset and fewer vessel interactions compared to the superclavicular approach. Utilizing an under-the-clavicle trajectory, the block provided direct needle path guidance avoiding lateral cord complications and aiming for the six o'clock position for efficient results. Emphasis on needle depth and direction under the clavicle to enhance safety and effectiveness of the block.
Costoclavicular Approach & Nerve Coverage
The costoclavicular approach resembled a mirror image of the superclavicular block with distinct cords for easy identification. Emphasizing infusion close to the artery to spread uniformly and ensure separation of cords effectively. While the technique offered a reliable scenario for identifying cords, caution against directing the needle towards the pleura was advised to prevent complications. Practical considerations highlighted the need to address the intercostobrachial nerve for particular procedures around the medial arm.
Tourniquet & Tourniquet Pain
Addressing concerns around tourniquet discomfort after brachial plexus blocks, the distinction between immediate inflation pain and delayed discomfort was discussed. Practical experiences reflected occasional patient discomfort despite meticulous block administration. To alleviate such discomfort post-tourniquet inflation, a flushing technique with a small volume of the solution was shared as a means to mitigate discomfort effectively.
Considerations of nerve coverage, especially the intercostobrachial and medial cutaneous nerves, were raised for procedures involving the medial arm. Practical concerns regarding tourniquet-related pain highlighted potential discomfort even after successful block administration. The need to address nerve territories efficiently for specific procedures was emphasized, acknowledging the practical implications of nerve targeting during brachial plexus interventions.
Discussion on Regional Anesthesia Techniques
The podcast explores various regional anesthesia techniques focusing on infraclavicular and axillary brachial plexus blocks. The speakers discuss the importance of accurate needle placement and identifying key anatomical structures for successful blocks. They highlight the significance of adapting techniques based on practitioner experience and patient factors, such as anticoagulation status. Techniques like heel toeing and differential pressure application are emphasized for enhancing needle visualization and optimizing block outcomes.
Controversy around Opioid Use in Anesthesia
The episode delves into the controversy surrounding opioid use in anesthesia practice. The speakers share insights on minimizing opioid administration during procedures by incorporating multimodal analgesia techniques. They reflect on the impact of personal patient experiences with opioids on anesthesia preferences and discuss the potential implications of moving towards opioid-free anesthesia practices. The conversation highlights the need for individualized approaches to pain management based on patient profiles and safety considerations.
Amit and Jeff take a tour of the brachial plexus, offering insights, stories, tips and "hold-nothing-back" hot takes regarding best blocks for the upper extremity.
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