Patient Position: Supine, with the arm abducted at 90° to 110° at the shoulder and flexed 90° at the elbow.
Indications: Anesthesia and postoperative analgesia for surgery at the elbow and below (hand and forearm) and continuous sympathectomy following finger reimplantation.
Needle Size and Catheter: 18-gauge, 50-mm insulated introducing needle and 20-gauge catheter.
Volume and Infusion Rate: 30 to 40 mL of a mixture of 0.5% ropivacaine and 1.5% mepivacaine v/v, continuous infusion of 6 to 8 mL/hour 0.2% ropivacaine.
Anatomic Landmarks: Axillary artery in the middle portion of the axilla.
Approach and Technique: The axillary artery pulse is palpated and marked in the middle of the axilla. After disinfection, sterile draping, and local infiltration with 1% lidocaine, a 50-mm insulated introducer needle or cannula connected to a nerve stimulator (1.5 mA, 2 Hz, 0.1 ms) is inserted above the artery, pointing in a proximal direction almost parallel to the artery at a 30° to 45° angle to the skin (Fig. 27-1A). After identification of a median, or radial nerve response at a current below 0.5 mA, the volume is injected slowly (10 mL/min) and in 5 mL increments. The catheter is then introduced and threaded approximately 5 cm beyond the needle tip (Fig. 27-1B). The introducing needle is removed and the catheter is secured in place and covered with a transparent dressing (Fig. 27-1C).
1. To facilitate threading of the catheter, it can be helpful to lower the needle to an angle of approximately 15° to the skin. In contrast, if a Tuohy needle is used, elevation of the needle to an angle of approximately 45° may be necessary to allow for easy catheter insertion.
Figure 27-1. A: An insulated introducer needle or cannula connected to a nerve stimulator is inserted above the artery. B: The catheter is introduced and threaded. C: The introducing needle is removed and the catheter is secured in place and covered with a transparent dressing.
2. The catheter should be aspirated with a 2-ml syringe before a continuous infusion is started. Catheter dislocation into a blood vessel is possible, even if no blood could be aspirated after the initial needle placement.
3. Patient-controlled local anesthetic administration via axillary catheters has been associated with reduction of local anesthetic requirements and has resulted in higher patient satisfaction.
4. These catheters can be used for up to several weeks. However, careful local care and daily inspection of the catheter site are recommended to avoid infection.
5. This technique represents an interesting alternative to the stellate ganglion block for the treatment of reflex sympathetic dystrophy.
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