Axillary Block

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Editor(s): Lee A. Fleisher, MD, FACC, FAHA Lee A. Fleisher, MD, FACC, FAHA

Robert Dunning Dripps
Professor and Chair
Department of Anesthesiology and Critical Care

Professor of Medicine
University of Pennsylvania School of Medicine
| Robert Gaiser, MD Robert Gaiser, MD

Professor of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine

Contributor(s): Moustafa M. Ahmed, MD Moustafa M. Ahmed, MD

Assistant Clinical Professor
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine
Philadelphia Veterans Administration Medical Center
Philadelphia, PA
| Acknowledgements Acknowledgements

Jeremy D. Kukafka, MD
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Infraclavicular Nerve Block: Ultrasound-Guided Technique
Intercostal Nerve Block: Ultrasound-Guided Technique
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Psoas Compartment Block: Ultrasound-Guided Technique
Supraclavicular Nerve Block: Ultrasound-Guided Technique

Gail A. Van Norman, MD
Clinical Associate Professor
Department of Anesthesiology
Univ of Washington
Seattle, WA

Elizabeth J. Watson, MD
Post-Doctoral Fellow
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Liang Xue, BS
Research Assistant
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

  • Anesthesia for surgery of the elbow, forearm, wrist, or hand
  • Anesthesia for closed procedures (such as fracture reduction) of the elbow, forearm, wrist, or hand
  • Analgesia for injuries and for postoperative pain control for surgeries and/or procedures on the elbow, forearm, wrist, or hand
  • Perivascular blockade to produce prolonged postoperative vascular dilation for vascular/reconstruction/reimplantation surgeries of the upper extremity below the elbow

Absolute Contraindications

  • Patient refusal
  • Inability to abduct the arm
  • Drug allergy
  • Bleeding disorders or therapeutic anticoagulation
  • Infection at the site of injection

Relative Contraindications

  • Preexisting neurodeficits in the distribution of the block
  • Traumatic nerve injury
  • Uncooperative patient
  • Previous surgery in the axilla, especially lymph node dissection or vascular surgery
  • Systemic infection and bacteremia

Transarterial Technique

  • Note: You will need an assistant.
  • Appropriate resuscitation equipment, including oxygen, suction, emergency airway equipment, and resuscitation medications
  • Local anesthetic, such as the following:
    • 1% to 1.5% lidocaine
    • 1% to 1.5% mepivacaine
    • 0.25% to 0.5% bupivacaine
    • 2% chloroprocaine
  • Sterile gloves and mask
  • Sterile fenestrated drape or sterile towels for draping
  • Sterile prep solution
  • Two 30-mL syringes
  • 1- to 1.5-inch 25-gauge short bevel needle
  • IV extension tubing
  • 3-way stopcock
  • 4 X 4 inch sterile gauze pack

Additional Equipment for Nerve Stimulator Technique

  • Note: You will need an assistant.
  • Peripheral nerve stimulator
  • 1- or 1.5-inch 25-gauge short bevel insulated nerve stimulating needle
  • ECG patch

The axillary approach to the brachial plexus block targets three of the four major terminal nerves of the brachial plexus: the ulnar, radial, and median nerves. It should be noted that the musculocutaneous nerve leaves the lateral cord early and high in the axilla; it is often incompletely blocked by the axillary approach and frequently requires supplementation to allow patient tolerance of the tourniquet and to supply anesthesia for the cutaneous distribution of the nerve. The nerves supplying sensation and motor innervation to the shoulder and upper arm have also left the plexus above the axilla and are not blocked by the axillary approach.

In the axillary approach to brachial plexus blockade, the close relationship of the axillary artery with the three major nerves of the brachial plexus is used to determine the site of injection. The pulsation of the axillary artery is identified as high as possible in the axilla, and in the case of transarterial technique, a needle is inserted into and through to the posterior side of the artery for injection; and in the case of the nerve stimulator technique, the needle is inserted just to either side of the artery to produce muscle contraction in the distribution of the nerves, where injection is made.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Immediately after placing the block:
    • Instruct the patient to avoid moving the arm; poor motor control of the arm can lead to injury.
    • Assess the distribution of nerve block.
    • Areas not covered by the block can be filled in by supplemental local anesthetic at the surgical site (field block).
    • Full development of the block can take 30 minutes.
  • After surgery
    • In the postanesthesia care unit (PACU) reassess the pain level and score.
    • Look for any evidence of axillary hematoma.
    • Assess the motor and sensory function; let the patient know that an axillary block may not recede for 4 to 6 hours.
    • Provide the patient with an arm sling to use until the block recedes.
    • Follow up with patient after complete resolution of the block by assessing motor and sensory function.

Complications of Vascular Puncture

  • Axillary tenderness
  • Ecchymosis
  • Hematoma
  • Pseudoaneurysm of the axillary artery
  • Transient vasospasm
  • Intravascular injection

Local Anesthetic Toxicity

  • Absorption of local anesthetic from the perivascular compartment
  • Intravascular injection

Nerve Injury

  • Intraneural injection
  • Direct needle injury
  • Neuritis
  • Injury resulting from malpositioning of the anesthetized limb

Complications of Needle Puncture of Soft Tissue

  • Infection
  • Swelling
  • Bruising
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