a. OR efficiency b. Pain control c. Decrease chronic pain syndrome d. Decrease morbidity/mortality e. Maintain airway f. Avoid large dose of opioids g. Patients with co-existing: cardiac/pulm disease h. Decrease blood loss i. Decrease PONV

Disadvantages to regional // 6 categories of complications

a. Patient discomfort b. Block failure c. Nerve injury d. LAST i. Mechanical trauma to nerve 1. Needle trauma 2. Intraneuronal (fascicular) injection ii. Neuronal ischemia iii. Inadvertent needle placement at unwanted location iv. LAST v. Drug error vi. Infection

Absolute -3 Relative- 3 Contraindications to regional as a whole

3. Contraindications Absolute a. Patient refusal b. Patient cooperation c. Coagulopathy 4. Contra relative a. Neurological complication: liability b. Infection near injection site c. Septic

Brachial plexus antatomy: RTDCB

roots: c5,6,7,8,T1 3 trunks: superior, middle, inferior 2 divisions: 3 ventral 3 dorsal 3 cords: lateral posterior medial 4 branches: Axillary, radial , median, ulnar

Blockade onset:

b pregang autonomic c- dorsal root and sympathetic, pain, temp, touch, post gang a moter: alpha: motor, propriception beta: touch delta motor gamma: Paine cold touch

Supplies all motor function to upper extremity:

brachial plexus

Supplies most all sensory function to upper extremity

brachial plexus

5 terminal nerves of brachial plexus

a. Musculocutaneous c5,6,7 b. Axillary c5,6 c. Radial c6,7,8 T1 d. Median c6,7,8 T1 e. Ulnar C8 T1

Indications of interscalene block What nerve does it block Does it spare anything?

shoulder or upper arm clavicle anything proximal to elbow **ulnar sparing brachial plexus

Interscalene block contraindication: Absolute Relative

i. Absolute: 1. Contralateral RLN palsy 2. Phrenic nerve palsy ii. Relative: 1. Pre-existing nerve injury 2. Brachial plexus pathology 3. Significantly impaired pulm function

Landmarks of brachial plexus -5

sternal notch clavicle clavicular head SCM sternal head SCM mastoid process