Tourniquet Issues #2

STYLE POINTS for Intercostobrachial Nerve Block

     I have mentioned elsewhere the need to cover the tourniquet site for an optimum effect. One of those sites is the inner upper arm for a tourniquet used for elbow, wrist and hand cases. This single shot block is usually used in combination with a supraclavicular or infraclavicular block. It is helpful for general anesthetic cases, but it is mandatory for awake/sedation anesthetic techniques. It is an extra security measure when trying to skip the PACU. I would like to introduce you to a few tricks that will guarantee success with a minimum of effort and minimal discomfort to your patient.

     I will typically arrive in the O.R. as the patient monitors are being placed and the first titrations of sedation are drifting in the IV. The brachial plexus block has been in for place for more than enough time to have set up fully at this point. Certainly, this can be done at the conclusion of the first block in the holding or block room, but it takes only seconds, and I am using time to my advantage here as I let the brachial plexus block extend maximally. While the patient is awake enough to communicate with me, I use [nonmember]…

 

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an alcohol pad to confirm that they can recognize the cold sensation of the alcohol evaporating from their chest (anywhere away from the brachial plexus block). Next, I wipe it in an area that is clearly covered by the brachial plexus nerve block. I make sure they can distinguish the difference that I am asking them to report to me. I don’t want to know if they feel the touch. I want them to know that I mean ‘cold’ versus ‘not cold’. 

     Once this is established, I wipe the alcohol pad across the anterior aspect of the biceps toward the axilla and around toward the triceps. I ask them to tell me when it becomes cold. That will establish the anterior border of the intercostobrachial sensory distribution. I continue across this area until the cold sensation is lost. This is the posterior border of this zone. With this area in mind, I enter the skin just anterior to this zone with my 25 gauge needle. It is numb from the brachial plexus block, so it isn’t painful on skin entry. I inject bupivacaine subcutaneously to the point where the sensory zone that I just demarcated ends and stop there. I will ask the patient will tell me when the burning ends to confirm that my injection is complete.

     Wow, that sounds…..underwhelming. Let me continue. Sure, if you are interested in doing this block, you can just guess where the area is going to be and pick a spot more than adequately anterior and inject to a point that is probably more than far enough, and that is that. Do it when they are well sedated or under a general anesthetic, so they don’t feel the injection. You could even use ‘a bunch extra’ local to be sure you got everything covered. The difference is that when I leave the room, I am 100% sure that that tourniquet site is covered, and I did it in the shortest amount of time that I possibly could have done it. 

     I am certain that I will not have missed a quarter inch on either end of the site, and I optimized the local anesthetic right where it needed to be instead of in an area that is already covered (leaving more volume possibly for the brachial plexus block).  I caused the least discomfort possible, and I was most accurate in drug placement. I can also leave the room knowing that my next order of business has my full attention since I have no worries about whether my block is solid or not. If I get called back to the room for ‘something’, I know that I can mark off ‘failure to cover the tourniquet site, so now we’re going to go to sleep’ as a cause for any problems before I enter the room. That’s one less thing for me to do today which I could definitely use on a busy day. Maybe I can more confidently avoid a general anesthetic in a difficult situation. If that’s not enough, I can say that my technique was not sloppy, and I did it with style!

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