The Ax Axed

[OB1🤙]

To the point: I hate the axillary block.

Pick your technique: I think it sucks. You find all 3 nerves? What do you do when you only injected a third of your local and now you can't get your other twitches? You do a single shot? Well then your block fails sometimes, doesn't it? You go transarterial? Likely effective, but barbaric, I say. (I say it jokingly, but I still say it).

I think the ultrasound-guided supraclavicular block makes the axillary block close to obsolete.

But I'm still learning.

So I wanna hear your thoughts.

---

Members don't see this ad.

 

[2ndyear]

I agree that a blind axillary block is inferior for most things. I always thought transarterial was a little off as well. But with the ultrasound you can get all 3 nerves. You can even clearly see the musculocutaneous, a key nerve in this block. The thing I like about this block is the reliability of the anatomy as well as the safety. Supraclavicular is a great block, no question. But every so often you get someone that just doesn't image that well. That block relies on a clear picture to stay out of the lung and to see the nerves, not to mention a clear view of your needle tip. I'm not abandoning the block, but more adding back the ax block to my bag of tricks.

 

[Planktonmd]

A transarterial axillary block is a block every resident should master because you need to be able to perform a few blocks without any other tools.
I say you should learn how to do transarterial axillary block, fascia iliaca block, intercostal blocks, and ankle block without stimulator or ultrasound.

 

[cchoukal]

I love the u/s guided ax+muscolocutaneous block for hand/ wrist stuff. you can see/get all three nerve (even behind the artery without going through it. I do these w/o stim. then I move the probe lateral to visualize the m.c. and use the stim here to be certain I have the nerve.

 

[cchoukal]

all that said, the supraclavicular with u/s is also great and pretty easy to do.

 

[huktonfonix]

I think the anatomy of the brachial plexus is reliable enough that in most patients you can easily do the supraclavicular block under stim without ultrasound. Theoretically its pretty hard to hit the dome of the lung if you follow the technique outlined in the NYSORA website given the anatomical relation of the lung to the scalenes and SCM.

 

[Noyac]

I like the infraclavicular block better than either the supraclav or the axillary. But I still use the axillary when working on the hand and wrist (infraclav for forearm and elbow). I just did one yesterday. My technique is without US and I look for twitches of the nerve which innervates the area of surgery first. I don't inject until I get that nerve first then I put 1/3 to 1/2 of my dose there. Next I look for the other nerves w/c I can usually find without any difficulty even after the initial injection. So if I can't find the other nerves, at least the surgical area is covered. Next I take care of tourniquet pain.

 

[huktonfonix]

I like the infraclavicular block better than either the supraclav or the axillary. But I still use the axillary when working on the hand and wrist (infraclav for forearm and elbow). I just did one yesterday. My technique is without US and I look for twitches of the nerve which innervates the area of surgery first. I don't inject until I get that nerve first then I put 1/3 to 1/2 of my dose there. Next I look for the other nerves w/c I can usually find without any difficulty even after the initial injection. So if I can't find the other nerves, at least the surgical area is covered. Next I take care of tourniquet pain.

The infraclavicular is a good block. I just prefer the suprclavicular because you have to go through less tissue to do it and it seems more comfortable for the patient. Kinda the same reason I do my sciatics lateral instead of supine.

 

[OB1🤙]

Noy- I remember you've said before that you like the infraclavicular block a lot. How did that come to be? I have the least experience with this (only seen it once), so I'm curious as to how it became your go-to.

 

[Noyac]

Noy- I remember you've said before that you like the infraclavicular block a lot. How did that come to be? I have the least experience with this (only seen it once), so I'm curious as to how it became your go-to.

I did an outside rotation with a PP group in my CA-3 year, it was at fastospintini's current gig. They did a lot of AV fistula's and declots. One of the PP guys came to me with an interesting block he wanted to try for the case. By "try" I mean he wanted me to do it while he observed if it worked and that way if it didn't he could blame it on the resident, w/c was fine with me since I was game for a new block in the arsenal. I did a couple that month and then the next year I was in PP and this sick as **** lady broke her humerus. I didn't want to put her to sleep so I decided to just do the infraclavicular with her arm comfortably positioned on her abdomen. It work great and I just continued doing them from then on.

Just grab your regional attending of choice and tell him you want to do one. Locate the coracoid process and measure 2cm caudad and 2cm midline. Advance perpendicuar to the skin about 2-4 cm depending on the size of the pt. BINGO. If you are having trouble it is my opinion that you are under the nerve bundle and redirect upwards slightly. If you are still not getting it feel the axillary pulse with the arm extended outward and try to imagine its path back to your site. Pretty informal description but you get the jest. Let me know how it goes.

 

[huktonfonix]

Noy- I remember you've said before that you like the infraclavicular block a lot. How did that come to be? I have the least experience with this (only seen it once), so I'm curious as to how it became your go-to.

ask for it at SMH.

 

[IN2B8R]

Excellent technique. I have frequently used it. Easily performed when you have Flouro in the room (which is invariably present in the OR when you are dealing with fractures); I do this bllock for many of my chronic pain patients.

I did an outside rotation with a PP group in my CA-3 year, it was at fastospintini's current gig. They did a lot of AV fistula's and declots. One of the PP guys came to me with an interesting block he wanted to try for the case. By "try" I mean he wanted me to do it while he observed if it worked and that way if it didn't he could blame it on the resident, w/c was fine with me since I was game for a new block in the arsenal. I did a couple that month and then the next year I was in PP and this sick as **** lady broke her humerus. I didn't want to put her to sleep so I decided to just do the infraclavicular with her arm comfortably positioned on her abdomen. It work great and I just continued doing them from then on.

Just grab your regional attending of choice and tell him you want to do one. Locate the coracoid process and measure 2cm caudad and 2cm midline. Advance perpendicuar to the skin about 2-4 cm depending on the size of the pt. BINGO. If you are having trouble it is my opinion that you are under the nerve bundle and redirect upwards slightly. If you are still not getting it feel the axillary pulse with the arm extended outward and try to imagine its path back to your site. Pretty informal description but you get the jest. Let me know how it goes.

 

[Arch Guillotti]

Excellent technique. I have frequently used it. Easily performed when you have Flouro in the room (which is invariably present in the OR when you are dealing with fractures); I do this bllock for many of my chronic pain patients.

Fluoro for an infraclavicular? That is something I have never heard of. We do use u/s pretty frequently though.

From your post I gather you are a pain doc and are more familiar w/fluoro. I have never used it in the OR.

 

[Noyac]

Excellent technique. I have frequently used it. Easily performed when you have Flouro in the room (which is invariably present in the OR when you are dealing with fractures); I do this bllock for many of my chronic pain patients.

Are you using it for CRPS?

 

[OB1🤙]

ask for it at SMH.

I will, but the new regional person there is all about the u/s-guided supraclavicular, which is really how this thread came about. I'll definitely get someone to show it to me at some point when I'm back over there.

 

[IN2B8R]

Worked well for a patient who had Phantom limb pain. It can also be effective from a CRPS point of view, but I have had mixed results to that end. Sympathetically mediated pain seems to moderately improve, but long term efficacy is questionable--based on my experience.

Are you using it for CRPS?

 

[IN2B8R]

I practice both chronic pain and anesthesia. The block is more aptly called an "infra-coracoid" block. There are several chronic pain conditions that can benefit from this block. Do not hesitate to snap a shoulder shot in the OR in order to quickly delineate your point of entry. It is convenient, efficient and in most ortho rooms, the machine is already in the room. Alternatively, if you are effecient with the u/s, then use it.

Fluoro for an infraclavicular? That is something I have never heard of. We do use u/s pretty frequently though.

From your post I gather you are a pain doc and are more familiar w/fluoro. I have never used it in the OR.

 

[dhb]

I'm not a big fan if the ax block either. IMHO an IS block will deal with anything above the elbow and an ifra-clavicular is good for anything underneath.
It's good to have it in your repertoire but i just like the other blocks more.

If you use this entry point:

then it's a true infra-clav block

 

[huktonfonix]

I will, but the new regional person there is all about the u/s-guided supraclavicular, which is really how this thread came about. I'll definitely get someone to show it to me at some point when I'm back over there.

i still see no point to ultrasound for supraclav as you dont have to go too low on the nerve stim to get a good block and the landmarks are reliable. I guess maybe on a patient with bad COPD, in which case I probably wouldnt be doing it anyway. They were doing a bunch of infraclavs when I was there.

 

[huktonfonix]

I'm not a big fan if the ax block either. IMHO an IS block will deal with anything above the elbow and an ifra-clavicular is good for anything underneath.
It's good to have it in your repertoire but i just like the other blocks more.

If you use this entry point:

then it's a true infra-clav block

Again a good block, and Ive done them both ways, but this way seems to run through more tissue which = more discomfort.

 

[OB1🤙]

i still see no point to ultrasound for supraclav as you dont have to go too low on the nerve stim to get a good block and the landmarks are reliable. I guess maybe on a patient with bad COPD, in which case I probably wouldnt be doing it anyway. They were doing a bunch of infraclavs when I was there.

To my mind the main advantage of the u/s is you see the dome of the lung and you don't stick a needle into it. I doubt the incidence of PTX in very trained hands is high, but they tried it up at OV with stim only, got a pneumo on their very first attempt->ICU admission for a healthy guy there for an outpt procedure-> no more supraclavicular blocks at OV, u/s or not.

So I don't think it improves efficacy, but I think it makes performing the block safer.

 

[SleepIsGood]

where I'm at we do infraclavicular blocks for all upper extremity surgeries below the elbow. For surgeries above the elbow, we do interscalenes.

with infraclavicular blocks, it's almost impossible to get a PTX. If you do it how Noy described it, then you should miss the lung since it ends typically between the medial 1/3 and middle 1/3 of the clavicle. we stopped doing supraclaviculars because of the hgher incidence of PTX.

Also, I believe infraclavicular blocks have a 97% success rate compared to the 85% success rate that axillary blocks have...see Benzon: Essentials of Pain Medicine.

 

[Noyac]

Worked well for a patient who had Phantom limb pain. It can also be effective from a CRPS point of view, but I have had mixed results to that end. Sympathetically mediated pain seems to moderately improve, but long term efficacy is questionable--based on my experience.

Thats b/c sympathetically mediated pain is centralized.

 

[IN2B8R]

Couple your statement with the fact that we do not have total understanding of sympathetically mediated pain and you get the multimodal approach that most pain docs follow: both interventional peripheral modalities and centrally acting pharmacologic modalities in order to arrive to a "better quality of life."

Thats b/c sympathetically mediated pain is centralized.

 

[BLADEMDA]

For you newbies out there I have some advice: the more you do the better you get. Also, the more ways you can do something (transarterial, nerve stimulator, U/S, etc.) the better.

For the senior guys they know what works and will keep doing it. But, I must say the classic InfraClavicular block does work and is easy to perform. Try it and use a little propofol for sedation then NO PAIN when going through the deep tissues.

As for transarterial axillary blocks they work well. Success is like 95% in experienced hands. In fact the first hundred are for practice. Then, your success gets much better. I found that doing tons of a-lines makes you very proficient at this block. Finally, I check myself at least twice during the transarterial block (come back into the artery) and this will improve your success to 95%. MC nerve outside the sheath and needs separate stick if required for case.

Just did one today. Three minutes to do and worked well. I have done two hundred SC blocks but got one Pneumo so no more; now I do IS, IC and Axillary blocks.
However, once I get better U/S machine and more echogenic needles will reconsider SC.

www.nysora.com