Name:
ACA- Hadzic- Peripheral Nerve Block 3e- Ultrasound-Guided Axillary Brachial Plexus Block 1
Description:
ACA- Hadzic- Peripheral Nerve Block 3e- Ultrasound-Guided Axillary Brachial Plexus Block 1
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/637d158b-6747-4783-b8da-f4cefedc7fdb/thumbnails/637d158b-6747-4783-b8da-f4cefedc7fdb.jpg?sv=2019-02-02&sr=c&sig=2BCKp%2Fhp5a1sZ7XvzuAHtkPkQpIN9jfquFIvLs6zpGM%3D&st=2023-03-23T23%3A09%3A51Z&se=2023-03-24T03%3A14%3A51Z&sp=r
Duration:
T00H10M00S
Embed URL:
https://stream.cadmore.media/player/637d158b-6747-4783-b8da-f4cefedc7fdb
Content URL:
https://asa1cadmoremedia.blob.core.windows.net/asset-abc92bcf-95b8-4269-aecd-cc2abee5e83e/ACA- Hadzic- Peripheral Nerve Block 3e- Ultrasound-Guided Ax.mov
Upload Date:
2022-02-23T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DIGITAL INTRO TUNE:
DR. HADZIC: So the procedure starts with the positioning of the patient. As you can see, we use very special positioning that includes actually an ability to see the motor response to the stimulation as we do this. Okay, antiseptic is being applied, and routinely, we use a combination of midazolam and a small amount of ketamine S for sedation. As you can see, we applied a generous amount of antiseptic.
DR. HADZIC: For every procedure, we will use customized nerve block sets and always standardized local anesthetic mixtures. For this particular purpose, we're using a combination of ropivacaine and lidocaine. So we mix 1% of ropivacaine with 2% lidocaine for 20 mL. No nerve block procedure would receive more than 20 mL of local anesthetic.
DR. HADZIC: So what we're seeing here is now, this is the medial fascia up here, subcutaneous tissue, and there's the skin. And what we want to do with the scanning technique is see the brachial plexus sheath. So we can see the medial side of the sheath right there. We can see the conjoint tendon in here. We can see the axillary artery and we can see also the anterior sheath over here.
DR. HADZIC: That's the biceps muscle and that is the coracobrachialis muscle, and in between the two fascia of the biceps and the coracobrachialis, there is the musculocutaneous nerve which obviously in this situation, we will need to block separately. So--
AUDIO CUT OFF: -the ulnar nerve that is, and that is the radial nerve most likely in here. So, now when we have this image we need to do some decision-making, down here's the humerus. We need to inject 20 mL into that sheath, 8 mL that is anterior to the artery, 8 mL posterior to the artery, and 4 mL for the musculocutaneous nerve.
AUDIO CUT OFF: So let's get started. I think we're going to go first injection posterior to the artery of 8 mL, and we'll then make decisions based on what we get there. So that's the needle entering the fascia, subcutaneous tissue and fascia, now we are in the biceps. The needle is aimed right now, and you can sometimes also-- AUDIO DISTORTED: -aimed at the axillary artery and we want to position the needle behind the axillary artery.
AUDIO CUT OFF: So here, there oftentimes is the profunda so we need to make sure we're not going through that vessel. As you enter the sheath, there is usually a distinct pop, which happened just now. Okay, next thing we want to do is check we don't have a nerve stimulation at 0.5 mA that means we are not on the nerve or in the nerve. We always look at the tip of the tubing at the hub of the needle, we don't see any blood.
AUDIO CUT OFF: We aspirate, the blood is absent. And now we measure injection pressure, wanting to make sure that the opening injection pressure is always low, it has to be less than 15 psi. As we inject, we would like to see the distribution of the local anesthetic around the axillary artery. So here we go. That's a pretty good distribution. But now, since we created a little bit of that local anesthetic there, a lot of it seems to be escaping from the brachial plexus sheath and inner, so we need to lift the needle tip up and advance the needle on UNINTELLIGIBLE:.
AUDIO CUT OFF: You're likely going to get another pop as you pop through one of the tissue layers or fascia that's inside, that's good. Okay. Aspiration again, pull back a tiny bit. Aspiration negative, okay. Twitch continues to be absent. Injection pressure is normal. Now we continue with the injection of local anesthetic. That looks a lot better.
AUDIO CUT OFF: Okay. So we're going to now complete the injection with 8 mL of local anesthetic, so here we go. We have 5 mL, we got 6 mL, we got 7 mL, every 3 mL, we aspirate. Aspiration negative, very gentle aspiration. We continue. One, two, so that's a total of 8 mL. One, two, so that's a total of 8 mL.
AUDIO CUT OFF: That comprises the injection posterior to the artery. Now we're going to withdraw the needle back, and we're going to the anterior aspect of the artery, and we're going to the anterior aspect of the artery, and lift the needle tip up to pass between the adventitia of the artery and the median nerve. Okay. Stay there, okay. Aspiration is negative. We look at the hub of the needle, twitch is absent, and injection pressure is normal, and we're looking at the distribution of the local anesthetic but we're not really happy with what we see.
AUDIO CUT OFF: Okay. We need to clearly see the distribution, come back a little bit and aim up a little bit above the artery. If that proves difficult, you also can go out of the sheath one more time and just go above the median nerve altogether into the sheath, yes. So as you could see, there's always elements of decision-making as you perform any nerve block or surgery.
AUDIO CUT OFF: So we're going to go above the median nerve. We're going to enter through the fascia. Push and now lift the needle up to avoid the median nerve Push and now lift the needle up to avoid the median nerve and enter the brachial plexus sheath, you will feel a pop as you do. Push a bit more, in between the two nerves. Yes. Good. Aspiration negative.
AUDIO CUT OFF: Blood is absent. No twitch. It is the injection and now we can see how the local anesthetic pushes down the ulnar nerve and pushes down the median nerve. She did not advance the needle or change the needle position but she simply lowered the needle tip without advancing or withdrawing into the plexus to favor the local anesthetic spread inside the plexus. Okay. Now, in this particular situation I do feel that we do need one injection here.
AUDIO CUT OFF: Okay. So she's going to advance between the artery and the ulnar nerve, just to make sure that we got even spread in the plexus. One more time, push. That's it. Okay. Aspiration, negative. We don't have blood in the syringe or the tubing. Twitch is absent. We're going to inject the last 2 mL of local anesthetic.
AUDIO CUT OFF: And now we can see how this particular injection fills the sheath around the radial nerve, as well as compliments the block of the ulnar and the median nerve. So we have injected 8 mL posterior to the artery, combined 8 mL anterior to the artery, and now we're going to go back to look for the musculocutaneous nerve, which is now located here for one last injection of the local anesthetic.
AUDIO CUT OFF: So all we have remaining now is 4 mL. Okay.
INDISTINCT BACKGROUND CONVERSATION: Okay. So we are now back into the biceps muscle. We don't aim for the nerve but we aim for the fascia between the biceps and the coracobrachialis. We pierce through the fascia and pull the needle back into the fascia layer. Twitch is absent. We are in a good position right there. There's no blood, aspiration is negative and it's the injection that now
UNINTELLIGIBLE: off the musculocutaneous nerve, and that is a perfect injection for the musculocutaneous nerve. So that comprises the axillary brachial plexus. One more time, recognize the sheath, conjoint tendon, okay. Axillary artery injection of 8 mL posterior to the artery, 8 mL to the anterior to the artery. And not all peripheral nerve block images are ideal,
LIKE THIS ONE ISN'T,: but if you stick to the standardized techniques you don't have to chase these individual nerves and expose them to the risk of nerve injury. Rather, standardized injections with 8 mL posterior, 8 mL above the artery, and 4 mL for musculocutaneous, comprises 20 mL total for the axillary brachial plexus, for this procedure. The procedure is a revision of the amputation of the middle finger which will require about an hour of operating room time.
DIGITAL OUTRO TUNE:
