Axillary Block using U/S

[BLADEMDA]

Okay, So I'm doing less "blind" blocks these days and more U/S. Anyone doing a volume based U/S guided Axillary block.

I mean use the U/S to locate the artery. First block the MC nerve (up high in the axilla or in the belly of the biceps) then deposit 15 mls of local at the 6:00 position under the artery and 15 mls at the 12:00 position on top of the artery.

This saves times and actually avoids touching the key nerves. I'm curious if anyone is doing this technique. It's sort of my old technique (transarterial) merged with new technology.

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[BLADEMDA]

Reg Anesth Pain Med. 2012 Feb 17. [Epub ahead of print]
A Prospective, Randomized Comparison Between Double-, Triple-, and Quadruple-Injection Ultrasound-Guided Axillary Brachial Plexus Block.

Tran DQ, Pham K, Dugani S, Finlayson RJ.
Source

From the Department of Anesthesia, Montreal General Hospital, McGill University, Montreal, Quebec, Canada.

Abstract

BACKGROUND:

This prospective, randomized, observer-blinded study compared double-, triple-, and quadruple-injection ultrasound (US)-guided axillary brachial plexus block (AXB) for upper-extremity surgery.
METHODS:

One hundred twenty patients were randomly allocated to receive a double- (n = 40), triple- (n = 40), or quadruple-injection (n = 40) US-guided AXB. The local anesthetic agent (lidocaine 1.5% with epinephrine 5 μg/mL) and total volume (35 mL) were identical in all subjects. For all 3 groups, the musculocutaneous nerve was identified and anesthetized first. Subsequently, a perivascular technique was performed. Lidocaine was deposited at the 6-o'clock position of the axillary artery for the 2-injection group. For the 3- and 4-injection groups, injections were carried out at the 12-/6-o'clock and 2-/10-/6-o'clock positions, respectively. During the performance of the block, the performance time, number of needle passes, and complications (vascular puncture, paresthesia) were recorded. Subsequently, a blinded observer assessed the onset time, block-related pain scores, and success rate (surgical anesthesia). The main outcome variable was the total anesthesia-related time (sum of performance and onset times).
RESULTS:

No differences were observed among the 3 groups in terms of total anesthesia-related time (29.2-31.4 mins), success rate (90.0%-97.5%), block-related pain scores, vascular puncture, and paresthesia. Compared with its 3- and 4-injection counterparts, the double-injection technique required fewer needle passes (4.0 ± 1.6 vs 5.2-6.0 ± 1.7-2.8; both P ≤ 0.001).
CONCLUSIONS:

Double-, triple-, and quadruple-injection US-guided perivascular AXB result in comparable success rates and total anesthesia-related times. Because it requires fewer needle passes, the double-injection technique provides a simple alternative for US-guided AXB.

 

[dhb]

I don't really understand the "high" volume echo blocks: if you're going to use volume it's much faster to do it blind. I usually don't see the radial so i put 5cc under the artery, 2cc for the mc 2-3 for the median which is often easily found 3-5 on the ulnar side so max 15cc.

 

[BLADEMDA]

I don't really understand the "high" volume echo blocks: if you're going to use volume it's much faster to do it blind. I usually don't see the radial so i put 5cc under the artery, 2cc for the mc 2-3 for the median which is often easily found 3-5 on the ulnar side so max 15cc.

BLIND. That's the issue. Avoiding all vascular structures is beneficial.

 

[dhb]

BLIND. That's the issue. Avoiding all vascular structures is beneficial.

Show me the data

 

[OffPiste]

If you have the U/S, forget the Axillary block altogether and go with Supraclavicular. Faster, easier, great for same clinical indications. Very little risk of pneumo when using the U/S.

 

[dhb]

I've had failed surgical blocks for hand surgery with a supraclavicular block despite complete motor blockade. I think infraclav and axillary blocks are very good for hand surgery.

 

[Narcotized]

If you have the U/S, forget the Axillary block altogether and go with Supraclavicular. Faster, easier, great for same clinical indications. Very little risk of pneumo when using the U/S.

More ulnar sparring in hand/wrist surgery

 

[Tuohy]

More ulnar sparring in hand/wrist surgery

You need to actively seek out the "corner pocket" with your needle and inject local there.... No ulnar sparing whatsoever if the local is placed in the space between the subclavian artery and first rib.

 

[EdPierce]

BLIND. That's the issue. Avoiding all vascular structures is beneficial.

an interesting point for you to be making after critizing this suggestion when I made it for a post-op nerve complication on another thread ... in fact i think my post was called "the most ridiculous post ever" hmmm...

anyway - forget the exact positioning whether its 12 o clock, 6 o clock, how many injections, just look at what you are doing on the screen and spread the local in a ring aroudn the artery starting back to front - less of a multiple injections at different positions kind of thing and more of a continous fanning above, behind, infront, and below the artery

 

[BLADEMDA]

an interesting point for you to be making after critizing this suggestion when I made it for a post-op nerve complication on another thread ... in fact i think my post was called "the most ridiculous post ever" hmmm...

anyway - forget the exact positioning whether its 12 o clock, 6 o clock, how many injections, just look at what you are doing on the screen and spread the local in a ring aroudn the artery starting back to front - less of a multiple injections at different positions kind of thing and more of a continous fanning above, behind, infront, and below the artery

No. I was criticizing your claim than U/S was superior to NS in terms of efficacy and safety FOR EVERY TYPE OF BLOCK. That is an incorrect statement without factual basis.

An Axillary block is a particular block where avoiding the artery completely has benefits.
The old tried and trued Transarterial block does involve getting some local in the systemic circulation. IMHO, several mls ends up going intravascular even with a good transrterial axillarly block.

 

[BLADEMDA]

You need to actively seek out the "corner pocket" with your needle and inject local there.... No ulnar sparing whatsoever if the local is placed in the space between the subclavian artery and first rib.

Debatable. Success is high but not 100% like actually blocking the Ulnar nerve itself in the Axilla or more distal in the forearm.

Also, the Supraclavicular block's high success is VOLUME dependent unlike the Axillary block where a mere 2 mls per nerve get s the job done.

That said, I'm fast with U/S guided Supraclavicular blocks and like them a great deal.

 

[secoy]

I hardly ever do axillary blocks. It seems much quicker and less patient positioning required to do a supraclavicular or infraclavicular. I do however use much more volume for these blocks

SECOY

 

[Oggg]

Axillary with ultrasound is extremely easy because the structures are so shallow and the artery and musculocutaneous n are easy to identify.

We just started doing ax blocks for AV fistulas.
1. Several articles suggest one injection at the MC nerve and one big injection at six o'clock to the artery. The articles suggest that these two injections are all you need (ie you don't have to inject at 12 o'clock or anywhere else or bother with NS) and a higher volume (40cc total) gives a longer duration.
2. We've only done a few, but it seems like ax block lasts a lot less time than an interscalene or infraclav. A few days ago we had one last maybe six hours (10cc to MC, 15cc at 0600, 15cc at 1200).

 

[BLADEMDA]

Axillary with ultrasound is extremely easy because the structures are so shallow and the artery and musculocutaneous n are easy to identify.

We just started doing ax blocks for AV fistulas.
1. Several articles suggest one injection at the MC nerve and one big injection at six o'clock to the artery. The articles suggest that these two injections are all you need (ie you don't have to inject at 12 o'clock or anywhere else or bother with NS) and a higher volume (40cc total) gives a longer duration.
2. We've only done a few, but it seems like ax block lasts a lot less time than an interscalene or infraclav. A few days ago we had one last maybe six hours (10cc to MC, 15cc at 0600, 15cc at 1200).

I do an u/s guided block just like I used to transarterial:

1. Block the MC nerve first (5 mls)
2. High up in the axilla for the axillary block
3. 25 mls at 600
4. 15 mls at 1200

I believe this works well and gives you a highly successful block. I was 98 percent using a transarterial approach so this u/s version should be just as good.

The axillary block is a short block (6-10 hours) compared to an infraclavicular block (12 hours) or a supraclavicular block (12-24 hours). I prefer a SCB for a single shot post op pain block because I can get 22 or more hours.

The recent study in our regional journal seems to add evidence to this type of approach.

 

[Oggg]

RAPM says MC and six o'clock are all you need, but I enjoy moving the needle to 1200 so that's what I do.

Infraclav is only 12 hrs? If so, I am going to stop doing them and go back to ironing out my supraclav technique.

 

[BLADEMDA]

RAPM says MC and six o'clock are all you need, but I enjoy moving the needle to 1200 so that's what I do.

Infraclav is only 12 hrs? If so, I am going to stop doing them and go back to ironing out my supraclav technique.

I don't think success rates of 90% are all that great. The Axillary block (with or without u/s) is a volume block for high success. Hence, I use my tried and true technique of VOLUME around the artery high up in the axilla. Think of the u/s version of an axillary block as a transarterial approach without going through the vessel. For me this means VOLUME behind and in front of the artery.

I haven't been able to get a ICB to last longer than 16 hours with my average being 12-14 hours with decadron 4mg. In contrast, I'm getting over 20 hours (22 on average with 4 mg decadron) with a SCB.

Of course, you can place a catheter at 600 (posterior cord) with an ICB and run an infusion; but, my patient satisfaction with a single shot SCB (0.5% Rop with decadron) is high and no catheter is required most of the time.

 

[BLADEMDA]

Effect of Local Anesthetic Volume (15 vs 40 mL) on the Duration of Ultrasound-Guided Single Shot Axillary Brachial Plexus Block: A Prospective Randomized, Observer-Blinded Trial

Schoenmakers, Karin P. W. MD*; Wegener, Jessica T. MD*†; Stienstra, Rudolf MD, PhD*









Background and Objectives: One of the advantages of ultrasound-guided peripheral nerve block is that visualization of local anesthetic spread allows for a reduction in dose. However, little is known about the effect of dose reduction on sensory and motor block duration. The purpose of the present study was to compare the duration of sensory and motor axillary brachial plexus block (ABPB) with 15 or 40 mL mepivacaine 1.5%.
Methods: Thirty patients were randomly allocated to receive ultrasound-guided ABPB with either 15 (group 15 mL, n = 15) or 40 mL (group 40 mL, n = 15) mepivacaine 1.5%. Onset, efficacy, and duration of sensory and motor block were compared.
Results: Two patients in group 15 mL needed an additional rescue block before surgery and were excluded from subsequent analysis. The overall median duration of sensory and motor block was significantly shorter in group 15 mL (225 [148–265] mins vs 271 [210–401] mins and 217 [144–250] mins vs 269 [210–401] mins, respectively; P < 0.01). Duration of sensory and motor block of individual nerves was significantly shorter in group 15 mL (20%–40% reduction for sensory and 18%–37% for motor block). Time to first request of postoperative analgesia was also significantly reduced in group 15 mL (163 [SD, 39] vs 235 [SD, 59] mins, respectively, P < 0.05). There were no differences in the other block characteristics.
Conclusions: In ABPB with mepivacaine 1.5%, reducing the dose from 40 mL to 15 mL (62.5%) shortens the overall duration of sensory and motor block by approximately 17% to 19%, reduces sensory and motor block duration of individual nerves by 18% to 40%, and decreases the time to first request of postoperative analgesia by approximately 30%.

 

[BLADEMDA]

A Prospective, Randomized Comparison Between Double-, Triple-, and Quadruple-Injection Ultrasound-Guided Axillary Brachial Plexus Block

Tran, De Q.H. MD, FRCPC; Pham, Kevin; Dugani, Shubada MBBS, FRCA; Finlayson, Roderick J. MD, FRCPC






Abstract



Background: This prospective, randomized, observer-blinded study compared double-, triple-, and quadruple-injection ultrasound (US)&#8211;guided axillary brachial plexus block (AXB) for upper-extremity surgery.
Methods: One hundred twenty patients were randomly allocated to receive a double- (n = 40), triple- (n = 40), or quadruple-injection (n = 40) US-guided AXB. The local anesthetic agent (lidocaine 1.5% with epinephrine 5 &#956;g/mL) and total volume (35 mL) were identical in all subjects. For all 3 groups, the musculocutaneous nerve was identified and anesthetized first. Subsequently, a perivascular technique was performed. Lidocaine was deposited at the 6-o'clock position of the axillary artery for the 2-injection group. For the 3- and 4-injection groups, injections were carried out at the 12-/6-o'clock and 2-/10-/6-o'clock positions, respectively. During the performance of the block, the performance time, number of needle passes, and complications (vascular puncture, paresthesia) were recorded. Subsequently, a blinded observer assessed the onset time, block-related pain scores, and success rate (surgical anesthesia). The main outcome variable was the total anesthesia-related time (sum of performance and onset times).
Results: No differences were observed among the 3 groups in terms of total anesthesia-related time (29.2&#8211;31.4 mins), success rate (90.0%&#8211;97.5%), block-related pain scores, vascular puncture, and paresthesia. Compared with its 3- and 4-injection counterparts, the double-injection technique required fewer needle passes (4.0 ± 1.6 vs 5.2&#8211;6.0 ± 1.7&#8211;2.8; both P &#8804; 0.001).
Conclusions: Double-, triple-, and quadruple-injection US-guided perivascular AXB result in comparable success rates and total anesthesia-related times. Because it requires fewer needle passes, the double-injection technique provides a simple alternative for US-guided AXB.

 

[BLADEMDA]

 

[BLADEMDA]

Figure 1
FIGURE 1. A "silhouette sign" at the 2-o'clock position (4-injection technique). A indicates axillary artery. The image was obtained with a Zonare Z One Ultra sp US machine and an L14-5w linear array probe (ZONARE Medical Systems, Mountain View, California

 

[BLADEMDA]

For an axillary block (u/s or old fashioned transarterial) I use 2 bottles of local (30 ml bottles).

I usually inject 40-45 mls around the artery (25 mls at 600 and 20 mls at 1200) plus 5 mls for the MC nerve. I use the remaining 10 mls for a skin wheal in the axilla/upper arm.

Your success rate will be high if you use sufficient volume and perform the block high up in the axilla. IMHO, you can push the success rate from 90% to over 95% by using high volume and performing an axillary block (u/s or transarterial) high up in the axilla.

 

[BLADEMDA]

Axillary with ultrasound is extremely easy because the structures are so shallow and the artery and musculocutaneous n are easy to identify.

We just started doing ax blocks for AV fistulas.
1. Several articles suggest one injection at the MC nerve and one big injection at six o'clock to the artery. The articles suggest that these two injections are all you need (ie you don't have to inject at 12 o'clock or anywhere else or bother with NS) and a higher volume (40cc total) gives a longer duration.
2. We've only done a few, but it seems like ax block lasts a lot less time than an interscalene or infraclav. A few days ago we had one last maybe six hours (10cc to MC, 15cc at 0600, 15cc at 1200).

1. I have posted that article. I still believe your highest success rates depends lots of local at 6:00 and more local at 12:00. MC nerve only needs to be blocked if there is surgey at that location and the nerve is easily seen on u/s. Be careful about ONE Study for your technique and claims as that article was wrong about TRANSARTERIAL success rates in experienced hands.

2. Axillary blocks don't last long and are the shortest brachial plexus blocks for post-op pain. I usually can't get more than 8-10 hours out of an axillary block. Certainly, you won't get overnight pain relief from an Axillary bock placed at 800 AM regardless of what you inject (unless it is toxic or experimental).

3. I prefer Infraclavicular blocks or SCBs for AV fistulas because my surgeons sometimes change the location of the fistula from the distal forearm to higher up in the forearm/antecubital fossa. That said, an Axillary block is an excellent choice for distal AV fistula surgery.

 

[epidural man]

I've had failed surgical blocks for hand surgery with a supraclavicular block despite complete motor blockade. I think infraclav and axillary blocks are very good for hand surgery.

sometimes you need to block the cutaneous nerves that sometimes leave the the plexus higher than your block location - those can be pesky little buggers!

 

[dhb]

sometimes you need to block the cutaneous nerves that sometimes leave the the plexus higher than your block location - those can be pesky little buggers!

Yes that's what i figured, sometimes you can see small structures over the artery outside of the plexus

 

[Frank Rizzo]

For an axillary block (u/s or old fashioned transarterial) I use 2 bottles of local (30 ml bottles).

I usually inject 40-45 mls around the artery (25 mls at 600 and 20 mls at 1200) plus 5 mls for the MC nerve. I use the remaining 10 mls for a skin wheal in the axilla/upper arm.

Your success rate will be high if you use sufficient volume and perform the block high up in the axilla. IMHO, you can push the success rate from 90% to over 95% by using high volume and performing an axillary block (u/s or transarterial) high up in the axilla.

I do a large number of hand/wrist surgeries under block alone. I agree with still using a decent amount of volume, with or without u/s, in fact, our approach is very similar. It works well.

 

[Oggg]

For shoulder surgery with supraclav block, do you inject all your local at the superior trunk? Or do you aim superior to the artery as well? I would think you could ignore the corner pocket for shoulder surgery.

 

[BLADEMDA]

For shoulder surgery with supraclav block, do you inject all your local at the superior trunk? Or do you aim superior to the artery as well? I would think you could ignore the corner pocket for shoulder surgery.

I inject at the 300 position (12 mls) and 1200 position (10 mls). Follow up u/s shows cepalad spread to the cervical roots

I use 20-22 mls to aim full duration of block for post op pain relief.

Alternatively, you could inject all the local at the 1200/1300 position. The corner pocket isn't necessary