- 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:
- 0.25% to 0.5% bupivacaine
- 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.
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Figure 1
:
Basic supplies for axillary block.
Figure 2
:
Nerve stimulator and insulated needle.
Figure 3
:
The brachial plexus as it exits the neck, traverses the first rib, and enters the axilla. From Drake L, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy. Philadelphia, Churchill Livingstone Elsevier, 2008, p. 369.
Figure 4
:
Schematic of the brachial plexus, showing the roots, trunks, divisions, cords, and terminal nerves. From Drake L, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy. Philadelphia, Churchill Livingstone Elsevier, 2008, p. 369.
Figure 5
:
Relationship of the cords of the brachial plexus to the axillary artery. From Drake L, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy. Philadelphia, Churchill Livingstone Elsevier, 2008, p. 370.
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