HAND

ANESTHESI
A
Roll 60 Yassine NSANZABAGANWA
 Table Of Contents

01 02 03
Introduction TECHNIQUE Complication
Overview on performing Important regional blocks Allergic responses to
procedures anesthetics
01 Introduction
 INTRODUCTION
Anesthesia is way to control pain during surgery or procedures using medication .the type of
medication used for this purpose are called anesthetics .Anesthesia can help control
breathing ,blood pressure and heart rate .
They are several types of anesthesia for patients undergoing hand surgery .these
include ,local ,regional and general anesthesia .the type used depends on different
factors .surgical factors , includes the types and the length of the surgery are assessed .the
patients health and other medical condition are assessed. Also considered are the preferences
of the patient, surgeon and anesthesiologist .
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● Local Anesthesia

Local anesthesia means anesthesia for a small area ,and may include injection of numbing
drugs in the finger or at the site of surgery .Local anesthetics produce a transient block of
nerve conduction by interfering with sodium channels .local anesthesia are classified into
2 groups ,esters and amides, based on their organic structure. Local anesthesia
Of the ester class include cocaine ,procaine ,tetracaine ,chloroprocaine ,and
benzocaine .the amide class of local anesthetics includes lidocaine ,mepivacaine,
bupivacaine and ropivacaine.
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● General anesthesia

With general anesthesia , the patient is unconscious and does not feel anything during
surgery .with this type of anesthesia , the patient requires airway and breathing support
from ventilator .this due to the anesthetic agent( gas) they are inhaling or medication in
their iv that sedate them .
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● Regional anesthesia

Regional anesthesia refers to focused delivery of anesthetic agent(s) to a given part of the
body .Regional anesthesia is used extensively for various purposes ,including as a primary
anesthetic technique for hand surgery , as analgesic modality to manage pain in the
preoperative period .
 2
Techniqu
e
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The important regional block that can be applied for procedure of the upper extremity and
hand include axillary ,elbow ,wrist and digital blocks . These important blocks are briefly
described below .

● Axillary block

The axillary block is useful form of anesthesia foe upper extremity procedures because of
the ease of the technique, low prevalence of complications ,reliability of analgesia in the
C7 ,C8 ,T 1 distribution .many techniques of axillary block have been described .the adult
patient is positioned with the arm abducted 90 degrees and flexed at the elbow the axillary
artery is located at its proximal part in the axilla.
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● Axillary block

After skin preparation ,a short beveled needle is carefully inserted seeking ulnar or
median nerve paresthesia is felt in the fingers ,the needle is fixed in the position .the
anesthetics agent is infiltrated after the aspiration confirms that the needle isn’t
intravascular .digital pressure distal to the needle tip and the use of large volume ( 40
ml)of a local anesthetic ensure blockage of the musculocutaneous nerve for the tourniquet
area
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● Elbow blocks

Elbow block are rarely used for upper extremity procedures. Elbow block proved more
muscle paralysis but no more anesthesia than wrist block for procedures on the
hand .Occasionally ,upper extremity nerve are blocked in this region .

The medial nerve located on the medial side of the branchial artery and the biceps
tendons .The medial nerve can be blocked 0.6 cm medial to the pulse of the brachial artery
at the level between the epicondyles.
The radial nerve emerges from the lateral intramuscular septum ,it can be blocked using
anterior approach ,injecting 1cm lateral to the biceps tendon and medial to the
brachioradialis muscle.
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● WRIST BLOCK

The radial nerve block at the wrist is a field block of multiple peripheral branches
descending along the dorsum and radial side of the wrist . The extensor pollicis longus
tendon can be identified when the patient extends the thumb. The needle insertion is over
this tendon at the base of the first metacarpal, the injection is superficial to the tendon .2
ml of local anesthetics is injected proximally along the tendon , and any additional 1ml is
injected as the the needle passes at the right angle across’’ the anatomic snuffbox ‘’
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● WRIST BLOCK

At the wrist ,the ulnar nerve lies beneath the flexor carpi ulnaris tendons
Between the ulnar artery and the pisiform bone .at this point ,it has already given off its
palmar cutaneous and dorsal branches . The nerve can be approached by directing the
needle medially from the radial side of the tendon or ,alternatively ,by directing the needle
radially from the ulnar side of the tendon .after eliciting a paresthesia ,3 -5 ml of solution
is injected or spread in a fanwise fashion .
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● DIGITAL BLOCK

Perhaps the most frequent used block for hand procedures is the digital
block .each digit is innervated by 4 nerve branches , 2 dorsal and 2 volar . The volar
approach involves one injection over the flexor sheath with 2-3 ml of local anesthetic
directed to each digit nerve radial and ulnar to the flexor .using the dorsal approach . The
dorsal branches can be blocked .the dorsal approach is performed by injecting the dorsal
skin first ,creating small wheal ,then directing the needle to ulnar and radial in the volar
direction toward , but not into the proper digital nerves , placing 2 ml on each side .
in performing the digital block ,a small needle 27 gauge should be used to avoid
irreversible injury to both digital arteries which could result in finger gangrene.
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● THE TRANSTHECAL DIGITAL BLOCK TECHNIQUE

The Transthecal technique was first introduced by Chiu in 1990 .this technique involves a
single palmar percutaneous injection of lidocaine into the space of the flexor tendon sheath
.this result in complete anesthesia of the digital nerves of the finger via centrifugal
anesthesia diffusion .in addition to requiring only one injection , this technique is also
beneficial because it reduces the risk of trauma to the neurovascular bundle relative to the
tradition technique.
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COMPLICA
TIONS
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● Complication

1. ALLERGIES : in general patients are more likely to have an allergy with and airway
obstruction.
2. The risk of nerve injury is theorized to be higher when more distal peripheral blocks
are performed .
3. Tourniquet discomfort , rapidity of recovery leading to preoperative pain , difficulty in
providing a bloodless field .
4. Toxicity and death in case of use of bupivacaine for intravenous regional anesthesia .
5. Phlebitis ( 2 –chloroprocaine) , development of compartement syndrome ,and loss of
limb .
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