Axillary block technique

[txdoc2b]

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How do yall do your ax blocks? Do you find each nerve individually, or just get a hand twitch and inject all your LA, like it says on NYSORA? If you do find each nerve, how much do you inject into each site? Also, how do you get the MC nerve? Just inject a "cuff of LA" along a line near the artery, or straight into the corocobrachialis muscle? And how much do you inject there?

I was always taught to find each nerve (although can't say I'm all the good at it) but was reading on NYSORA, and thought I might want to try it "their" way. Just wanted to see if anyone had any thoughts...

Thanks! I'm just starting PP, and unfortunately didn't get a lot of blocks in residency, not very comfortable with them, and now that I'm PP, I'm of course expected to know how to do them, and do them well. Scary!

 

[Narcotized]

Getting each nerve will give you a more definitive result. The best way to get the MC nerve is to trace is back to the plexus (or close to the plexus) with ultrasound and get a huge bicep twitch. Will work everytime.

 

[Gern Blansten]

Ultrasound takes a bit longer, but the success rate will go up quite a bit. I don't stim any more. I used stim + ultrasound while I was learning the ultrasound technique, now it is pretty easy and I no longer stim. You can actually find the musculocutaneous with the US and put the local right around the nerve.
I suggest learning all techniques, but I think ultrasound, if you have access is the way to go. For the record, I was very slow to adopt US and was very against it initially. I thought it took too long and offered no advantage. I have changed my mind.

 

[cchoukal]

u/s for the ax and basically do a peri-arterial injection around the whole circumference. I use 20mL of 0.5% bupiv there. then for the mc, move the problaterally about an inch. in btwn the muscle beds you'll see a confluence of hyperechoic fibes that coalesce into the mc. looks like the stem of a jalapeno. I stim this and inject 5mL. the only thing downside (with the peri-arterial gunshot approach) I've seen is occasional ulnar sparing. you can either supplement at the ulnar groove for wrist surgery, or instead take a little more time and stim the nerves around the artery.

 

[txdoc2b]

Thank for very much for all your responces. However, any tips on finding the MC nerve (and doing the whole ax block for that matter ) WITHOUT US? The surgery center we cover, which is where we do the most blocks, does not currently have an US. Plus, I haven;t been trained on it at all, even though I'd love to learn. But for now, I have to get good at doing these without US, since we don't have one there....

 

[smgilles]

Thank for very much for all your responces. However, any tips on finding the MC nerve (and doing the whole ax block for that matter ) WITHOUT US? The surgery center we cover, which is where we do the most blocks, does not currently have an US. Plus, I haven;t been trained on it at all, even though I'd love to learn. But for now, I have to get good at doing these without US, since we don't have one there....

Why not just do a supraclavicular with U/S if not comfortable with axillaries? Much denser block and tends to set up a lot quicker.

 

[sevoflurane]

Why not just do a supraclavicular with U/S if not comfortable with axillaries? Much denser block and tends to set up a lot quicker.

👍 So much easier and reliable IMHO. That being said... you need to learn all apporaches.

For supraclavicular: put the probe in the clavicular fossa, look down, find axillary artery/dome of lung. Look next to the artery > Big old honeycomb of bachial plexus > hit it with cocktail of choice.

 

[sevoflurane]

Thank for very much for all your responces. However, any tips on finding the MC nerve (and doing the whole ax block for that matter ) WITHOUT US? The surgery center we cover, which is where we do the most blocks, does not currently have an US. Plus, I haven;t been trained on it at all, even though I'd love to learn. But for now, I have to get good at doing these without US, since we don't have one there....

The musculocutaneous nerve lives in the substance of the coracobrachialis. It travels between the biceps and brachiallis. Head toward the coracobrachialis with your stim cath, get twitches, inject about 5ccs'.

 

[sevoflurane]

1 = MC nerve
2 = Coracobrachialis

 

[sevoflurane]

 

[sevoflurane]

I would suggest to find the coracobrachialis on yourself first. Arm abducted. Feel under your biceps brachii.. little muscle underneath it. If you palpate hard enough you will hit the MC and get a little zinger. 🙄

 

[leaverus]

I like trans-arterial for post-op blocks in the pacu - works nicely and i spare the patient additional pain of the nerve stim jerking around an already traumatized limb (don't have enough experience with U/S for this particular block otherwise i'd do 'em that way). I usually deposit half my LA posterior and half anterior.

 

[cchoukal]

If I had to do the MC without ultrasound, I'd just move my needle about an inch anatomically lateral (which, in an abducted and externally rotated arm, is superior) and start fanning around with the stim until you get an arm-flexion twitch.

I really like the u/s SC approach mentioned above. We had a hand surgeon who did some international work and told us about an anesthesiologist he worked with in Honduras who did blind SC blocks by inserting into the supraclavicular fossa and basically doing a trans- peri-arterial using blood as his landmark. No thanks!

 

[Boujee]

If U/S is available, why not just do a single shot INfraclavicular block and aim for the posterior cord and ensure yourself a complete upper extremity block? Im pretty biased though...we almost never do an axillary approach...

 

[Planktonmd]

It's much simpler than that to do a blind SC block:
Enter the supraclavicular fossa just lateral to the sternocleidomastoid an aim straight caudad untill you hit the first rib, pull back 1mm and inject.

I really like the u/s SC approach mentioned above. We had a hand surgeon who did some international work and told us about an anesthesiologist he worked with in Honduras who did blind SC blocks by inserting into the supraclavicular fossa and basically doing a trans- peri-arterial using blood as his landmark. No thanks!

 

[cchoukal]

If U/S is available, why not just do a single shot INfraclavicular block and aim for the posterior cord and ensure yourself a complete upper extremity block? Im pretty biased though...we almost never do an axillary approach...

It's theoretically still possible to get a PTX with an infraclavicular, and for forearm/wrist/hand surgery, the ax+mc is perfectly adequate with zero PTX risk.

 

[nap$ter]

It's theoretically still possible to get a PTX with an infraclavicular, and for forearm/wrist/hand surgery, the ax+mc is perfectly adequate with zero PTX risk.

if you stay lateral the chance of PTX is virtually zero with ultrasound guided infraclavicular. supraclavicular is the PTX block.

my personal preference is for infraclavicular over axillary - you don't have to chase the mc, you're not injecting into someone's armpit, doesn't seem to be quite as tender for skin wheal etc, and i won't place axillary catheters. infraclavicular seems a lot easier to me, but i'm not sure if i would feel the same way without ultrasound.

 

[thegasman]

If U/S is available, why not just do a single shot INfraclavicular block and aim for the posterior cord and ensure yourself a complete upper extremity block? Im pretty biased though...we almost never do an axillary approach...

why do you guys keep talking about ultrasound? That is great and everything - but the op said he does not have access to an ultrasound machine at his surgery center. So he is limited to stimulation. I have somewhat limited experience with axillary blocks, but have had pretty good success with stim for hand twitch with additional mc stim when needed. Most of the older guys I work with all do transarterial approach.

 

[2ndyear]

Infraclavicular with nerve stim only is a pretty easy block, once you find the coracoid process. All about the coracoid.

 

[aredoubleyou]

Why not just do a supraclavicular with U/S if not comfortable with axillaries? Much denser block and tends to set up a lot quicker.

My experience has been the opposite when the operative site is distal (below elbow). Its a much easier block, but if you've got a way to get excellent distal coverage plz share what your doing

 

[txdoc2b]

why do you guys keep talking about ultrasound? That is great and everything - but the op said he does not have access to an ultrasound machine at his surgery center. So he is limited to stimulation. I have somewhat limited experience with axillary blocks, but have had pretty good success with stim for hand twitch with additional mc stim when needed. Most of the older guys I work with all do transarterial approach.

Thank you, Gasman...I was wondering the same thing! I already clarified that we don't have the U/S...but still kept getting responses all about U/S! I do appreciate everyone's input, but still am looking for tips/techniques with the nerve stim ONLY....NOT the U/S! I can't help it that our surgery center doesn't have one!!

 

[Planktonmd]

Thank you, Gasman...I was wondering the same thing! I already clarified that we don't have the U/S...but still kept getting responses all about U/S! I do appreciate everyone's input, but still am looking for tips/techniques with the nerve stim ONLY....NOT the U/S! I can't help it that our surgery center doesn't have one!!

A transarterial technique is more reliable than Nerve stim for this block and requires only one injection.

 

[RAToronto]

If ultrasound is not available then I would suggest using stim.
I would suggest investing in an ultrasound machine therefore you wouldn't really need to stim... at least not for an axillary block.

I don't think using an ultrasound is slower since you can see what you're doing and in most cases wouldn't need to suppliment.

 

[txdoc2b]

BUMP! 🙂


Not really needing tips, so much as just explainations of how yall perfrom ax blocks with nerve stim (NO U/S)- and I'm talking for SURGICAL BLOCKS, not post-op blocks. How many people just do one injection transarterial, how many find each nerve (and if you do, which do you usually find first and how much LA for each nerve), and how many just go "above the artery, and below the artery". I've just seen it so many ways, I'm not good at any of them really, and just not sure how to approach it.

When I do them, I can get good analgesic block, their arm feels heavy and numb, but just not numb ENOUGH for a surgical block. Very frustrating....

 

[sevoflurane]

BUMP! 🙂


Not really needing tips, so much as just explainations of how yall perfrom ax blocks with nerve stim (NO U/S)- and I'm talking for SURGICAL BLOCKS, not post-op blocks. How many people just do one injection transarterial, how many find each nerve (and if you do, which do you usually find first and how much LA for each nerve), and how many just go "above the artery, and below the artery". I've just seen it so many ways, I'm not good at any of them really, and just not sure how to approach it.

When I do them, I can get good analgesic block, their arm feels heavy and numb, but just not numb ENOUGH for a surgical block. Very frustrating....

A couple of thoughts:

Wacha using for LA? and... how many mls? This block sometimes needs volume. How long are you waiting before you bust out the knife? Never been a fan of transarterial. Dirty technique if you ask me. If no USD, then try and elicit termial branches (I like to see radial) and get the musculocutaneous as described above. Intercostobrachial is required, especially if using a tourniquet.

30-40 mls for axillary block (median, ulnar, radial). Look for finger flexion or thumb oposition.
10mls for MC
5mls for intercostobrachial

For USD guided blocks I use much less LA: 20-30cc's total and I hit every nerve individually.

Hope this helps. 🙂

 

[aredoubleyou]

BUMP! 🙂


Not really needing tips, so much as just explainations of how yall perfrom ax blocks with nerve stim (NO U/S)- and I'm talking for SURGICAL BLOCKS, not post-op blocks. How many people just do one injection transarterial, how many find each nerve (and if you do, which do you usually find first and how much LA for each nerve), and how many just go "above the artery, and below the artery". I've just seen it so many ways, I'm not good at any of them really, and just not sure how to approach it.

When I do them, I can get good analgesic block, their arm feels heavy and numb, but just not numb ENOUGH for a surgical block. Very frustrating....

If you are unable to have one of your partners train you, then try either more volume or higher concentration. I often will use a higher concentration for surgical blocks, even though technically, usually you shouldnt have to. The upper limit for both volume and concentration is probably higher than you have been led to believe. Also, small volume lidocaine blocks at the elbow can supplement a poor block to get through a surgery...not ideal, but often better than converting to general. Also you risk an intraneural injection if u the nerve is blocked better than you think.

 

[Idiopathic]

my biggest problem with this block had to do with how slowly it set up, when using long acting local...occasionally it would be +30 minutes and they would still have some ulnar sparing so we had to go to sleep. of course when they wake up they have a dense motor block and complete sensory loss so...for shorter cases you can use mepivacaine or a mixture.

 

[aredoubleyou]

my biggest problem with this block had to do with how slowly it set up, when using long acting local...occasionally it would be +30 minutes and they would still have some ulnar sparing so we had to go to sleep. of course when they wake up they have a dense motor block and complete sensory loss so...for shorter cases you can use mepivacaine or a mixture.

Half carbocaine 1.5%, half 0.5% bupiv - rock solid. Supposedly you loose efficacy with mixing two agents, but this combo is so far overkill its not a problem (if that is a tru phenomenon and not just dogma).

 

[IlDestriero]

👍 So much easier and reliable IMHO. That being said... you need to learn all apporaches.

For supraclavicular: put the probe in the clavicular fossa, look down, find axillary artery/dome of lung. Look next to the artery > Big old honeycomb of bachial plexus > hit it with cocktail of choice.

👍

 

[Dejavu]

I like trans-arterial for post-op blocks in the pacu - works nicely and i spare the patient additional pain of the nerve stim jerking around an already traumatized limb (don't have enough experience with U/S for this particular block otherwise i'd do 'em that way). I usually deposit half my LA posterior and half anterior.

While it is comforting to watch, with U/S, the nerves floating in local anesthetics, I do Trans-art and have done so for 34 yrs. I put my success rate up against any other technique. I use a small 25ga sharp needle and do as the above poster. I put a bit more than half the dose behind and the rest anterior to the vessel. Faster than finding the U/S machine and setting it up. People claim the need for less dosage, and they may be right, but I don't see a problem with a few more cc's of drug. Also, I often see the U/S people, when presented with less than comforting pictures, using the same dosages as I do, with a lot more time spent looking at fuzzy pics.

U/S people point to a couple of studies "proving" that it is faster their way, but if you look, the studies count only needle in/needle out times. They don't count looking for the machine, wheeling it down the hall, setting up the machine and gel and sleeves, finding (hopefully) good pics of anatomy, and then injecting, then cleaning the probes and returning the machine down the hall and recharging it.

I support advances in reg anesth, and I do like the feeling of seeing the nerve floating in drug, but is it necessary? I, at this time, don't think so.

I predict it may become standard of care to use U/S, but I hope to retire before then.

All this makes me sound like an old codger, and perhaps I admit to that. With pride, by the way.

 

[sevoflurane]

but is it necessary

Agreed. Definitely not necessary, especially if you've been doing it for as long as you have. Without a doubt, the person driving the needle has a lot to do with it. 👍 😉

I would say that when confronted with someone who has had axillary surgery such as axillary node dissection, vascular surgery, etc, USD can offer a clear advantage over non-USD techniques.

Then again, this is a strong reason why we all should know different approaches to the brachial plexus, sciatic, femoral etc.

 

[pgg]

While it is comforting to watch, with U/S, the nerves floating in local anesthetics, I do Trans-art and have done so for 34 yrs.

The only time I've done trans-arterial axillary blocks was on a humanitarian trip where we didn't have either u/s or a nerve stim. I was apprehensive about it and it felt kind of barbaric ... but they worked. Surgical anesthesia after 5 minutes of work and $1 in local anesthetic drugs.

I may never do another one, but it's good to have the option.

 

[Gern Blansten]

The only time I've done trans-arterial axillary blocks was on a humanitarian trip where we didn't have either u/s or a nerve stim. I was apprehensive about it and it felt kind of barbaric ... but they worked. Surgical anesthesia after 5 minutes of work and $1 in local anesthetic drugs.

I may never do another one, but it's good to have the option.

It was only a few years back that we were doing probably 60% of our institution's ax blocks with the trans art method. The other 40% were with stim. Trans art is definitely very fast and very easy. I think I can get just a few percentage points higher success rate with US guidance, but it is not a whole lot(prob go from mid 90's to high 90's). My expereince with stim was a little bit(not much) worse than trans art for success rate.

 

[Dejavu]

It was only a few years back that we were doing probably 60% of our institution's ax blocks with the trans art method. The other 40% were with stim. Trans art is definitely very fast and very easy. I think I can get just a few percentage points higher success rate with US guidance, but it is not a whole lot(prob go from mid 90's to high 90's). My expereince with stim was a little bit(not much) worse than trans art for success rate.

Do I remember correctly that there was a paper a few years ago where they took Docs who did TransArt, Stim or parathesia techniques and showed them to all have mid-90s % success, but if they had to do some other of the three techniques, their success rate dipped to the low 80s.

Their conclusion was that if you do what you do, you do it well, but if you do what you don't usually do, you are less successful.

As stated by a previous poster, it is the man/woman behind the needle that makes the difference.

On a different note...If I had said "it is the woman/man behind the needle" would people more often think I was a woman? Are we that pre-conditioned? Just a random thought I had while proof-reading my post.