SUPRACLAVICULAR

• Pearls:
  • Targets the trunks/divisions
  • Good block for the arm, not shoulder
  • Greatest risk is pneumothorax- pleura is immediately inferior to 1st rib
  • The most serious complication of supraclavicular block is pneumothorax.

INFRACLAVICULAR

• Pearls:
  • Targets the cords
  • Cords are named according to their anatomic relationship with the axillary artery (lateral, posterior, and medial)
  • With nerve stimulation of the cords, the fifth digit will move in these directions: lateral- laterally; medial- flex; posterior- extend
  • The goal is to place the needle posterior to the axillary artery.
  • Phrenic and stellate blockade is greatly reduced
  • The most painful of the brachial plexus blocks is the infraclavicular because the needle must pass through the pectoralis major and minor muscles.

AXILLARY

• Pearls:
  • Targets four terminal branches
  • Provides anesthesia to the arm distal to the elbow
  • Primary nerves are radial, median, and ulnar (located around the axillary artery); musculocutaneous is outside the axillary sheath.
  • Coracobrachialis is the muscle which the musculocutaneous nerve exits.
  • Complications are uncommon
  • While performing an axillary block, the musculocutaneous nerve is unlikely to be blocked.
  • The musculocutaneous nerve lies within the coracobrachialis muscle.
  • The trans-arterial approach to an axillary block most blocks the radial nerve.
  • The axillary artery is intentionally penetrated and confirmed by aspiration of blood. Then the needle is inserted past the artery until blood is no longer aspirated. Posterior to the axillary artery is the radial nerve (and slightly lateral).
  • The axillary block is typically chosen for anesthesia distal to the elbow.

INTERSCALENE BLOCK

• Pearls:
  • Targets the roots
  • Hypoechoic roots stacked between the ASM and MSM are called the snowman or stoplight sign ULTRASOUND.
  • Complications: unilateral phrenic nerve blockade; stellate ganglion blockade leading to Horner’s syndrome; inadvertent arterial injection
  • The ulnar nerve is often missed with interscalene block.
  • The highest risk of unilateral phrenic nerve blockade of the brachial plexus blocks is the interscalene.

HORNER’S SYNDROME

• Horner’s syndrome results in ipsilateral ptosis and miosis.
• Horner’s syndrome is not common with the cervical plexus block.

LUMBAR PLEXUS (COMPARTMENT)

• Pearls:
  • L2-L4 nerve roots form the lumbar plexus within the psoas muscle.
  • AKA 3-in-1 block (femoral, obturator, and lateral femoral cutaneous nerves).

FASCIA ILIACA

• Pearls:
  • The anterior approach to the lumbar plexus block; aims to block the femoral, obturator, and lateral femoral cutaneous nerves.

PERICAPSULAR NERVE GROUP BLOCK (PENG)

• Pearls:
  • Single injection for hip fracture/arthroplasty
  • Targets the articular branches of the femoral nerve, accessory obturator, and obturator nerves while sparing the femoral nerve’s quadriceps innervation.
    • •  

SCIATIC

• Pearls:
  • Does not block the femoral or saphenous.

ADDUCTOR CANAL

• Pearls:
  • This block spares the quadriceps strength (as compared to the femoral nerve block).
  • An adductor canal block is performed for postoperative pain control following an ACL repair.
  • This block is used for surgeries involving the anteromedial knee and spares the quadriceps muscle.
  • The midpoint of the adductor canal is just distal from the midpoint of the anterior superior iliac spine and patellar base.
    • • •  

FEMORAL

• Pearls:
  • When combined with the sciatic nerve block, the femoral nerve block provides complete coverage of the lower extremity.
  • NAVL (nerve, artery, vein, lymphatics) from lateral to medial
  • The femoral nerve block (along with the sciatic nerve block) provides complete anesthesia to the lower extremity.
    • • •  

ILIOHYPOGASTRIC

• The iliohypogastric nerve is blocked for an inguinal hernia repair.

BIER BLOCK

• Lidocaine 0.5% 50 mL is the local anesthetic is used for upper extremity intravenous regional anesthesia.
• Toradol is the only additive agent that has been shown to offer any significant clinical benefit in a bier block.
• The tourniquet needs to stay inflated for 20 minutes for an intravenous regional anesthetic.
• Patients with history of seizures, history of strokes, and malignant hyperthermia may still have a Bier block. These are NOT contraindications.
• The intercostobrachial nerve is blocked for tourniquet pain.

DIGITAL

• Epinephrine should NOT be used in digit blocks because it can cause ischemia and necrosis.

ULNAR

• Pearls:
  • Blocks at the elbow and wrist are primarily sensory (meaning can still move their arm) and are often used as a rescue to a failed upper extremity block.
  • Intercostobrachial and brachial cutaneous nerves can be blocked for tourniquet pain. Musculocutaneous/coracobrachialis is also beneficial.
  • Ulnar nerve block at the ulnar sulcus should be limited to ≤ 3mL
  • Elbow blocks are:
    • Primarily sensory only
    • Used as an adjunct to a failed brachial plexus block
    • The maximum amount of local anesthesia that can be injected for an ulnar nerve block at the ulnar sulcus is 3 mL.

FOOT

• For complete coverage of the foot, the saphenous nerve must be blocked along with the sciatic via popliteal approach.
• The terminal branch of the femoral nerve in the foot is the saphenous nerve.

TRANSVERSUS ABDOMINUS PLANE (TAP)

• A TAP block:
  • Does NOT provide sensory coverage to the abdominal viscera.
  • Requires two injections bilaterally to provide complete coverage.
  • Local anesthesia is injected between the internal oblique and transversus abdominus muscles.
  • Transversus abdominus plane block is a fascial plane block between the internal oblique and transversus abdominus muscles. It does not cover sensory to the viscera.
• The provider has the advantage of using ultrasound, perform fascial plane blocks on patients on anticoagulation, and lack of sympathectomy when compared to paravertebral and thoracic epidural.

PECS 1 BLOCK

•  local anesthesia is injected between the pectoralis major and pectoralis minor muscles and targets the medial and lateral pectoral branches of the brachial plexus.

FASCIAL PLANE BLOCKS

• Pearls:
  • Pecs I- inject between the pectoralis major and pectoralis minor muscles; targets the medial and lateral pectoral branches of the brachial plexus.
  • Pecs II- modification to the Pecs I; adds a second injection between the pectoralis minor and serratus anterior muscles at the 3rd-4th ribs; targets the long thoracic nerve and lateral cutaneous branches of the thoracic intercostal nerves.