ANAESTHESIA OF THE BRACHIAL PLEXUS AFTER KULENKAMPFF

It is used during operations on the upper limb. With the patient supine and the head turned to the opposite direction the hand is may hang freely. In the supraclavicular depression pulsation of the sub-clavial artery is identified. Following the infiltration of the skin with novocain a long needle without a syringe is pushed laterally from the site of the arterial pulsation and sliding along the upper end of the rib towards the spines of the Th1-2 reaches the plexus (fig. 9). An unpleasant sensation in the hand, numbness or sharp «shooting» pain suggests that the needle has met with some of the branches of the plexus. Appearance of blood in the needle implies that the needle has entered a blood vessel. Following this the needle is withdrawn a little and its direction is changed. Unless blood is not flowing out of the needle, 30-50 ml of 1% novocain or 30-35 ml of 1 % lidocain are given. Anaesthesia is achieved after 10-15 minutes and is maintained for 2-4 hours or even for 6 hours if lidocain is used.

Fig. 9. Humeral plexal anaesthesia (Kulenkampff's method).

INTRA-ABDOMINAL COELIAC NERVE BLOCK AFTER BROWN

This is used in addition to general anaesthesia during gastric resections. Following laparotomy the left lobe of the liver is lifted up and to the right using a retractor, and the stomach to the left and downwards. In the region of the lesser omentum, the left index finger is used to feel for the pulsation of the aorta above the level of the coeliac trunk and press the vertebra on the right side of the aorta. The finger is thus placed between the aorta and the inferior vena cava. A long needle is used for anaesthesia with a syringe containing 0, 5% novocain. The needle is pushed along the finger of the left hand till it hits vertebra Th12, then it is withdrawn a little. Unless there is no blood in the needle, 50-70 ml of 0, 5% novocain are injected into the layer fat. The solution spreads into the retroperitoneal space and covers the coeliac plexus. Anaesthesia is achieved after 5-10 minutes and is maintained for 1¹/₂-2 hours.

NOVOCAIN BLOCKING

The blocking is used for the prevention and treatment of traumatic shock and as the base for subsequent infiltration anaesthesia.

Blocking of the upper arm

With the arm flexed in the elbow joint and on the anterior surface of the middle third of the upper arm, a thin needle is used to inject novocain intradermally to anaesthetise the skin. Then, using a long needle with 0, 25% novocain the skin is pierced followed by the fascia of the arm and the biceps brachii muscle. Pushing the solution of novocain in the needle path, advance the needle to the humerus; slightly drawing back the needle 50-60 ml of 0, 25% novocain fill the fascial pouch of the biceps. Similarly, at the same level with the arm extended 50-60 ml of the drug are injected into the fascial pouch of the triceps.

Blocking of the forearm

This is done in the middle third of the forearm. 60-80 ml of 0, 25% novocain are injected into the fascial pouches of the flexors and extensors of the forearm.

Blocking of the thigh

On the anterior aspect of the thigh in the middle third, a needle is injected preceded by a stream of novocain; the needle is pushed up to the bone and after withdrawing it slightly 150-180 ml of 0, 25% of novocain are given (fig. 10).

Fig. 10. Circular novocain limb blocks.

Blocking of the leg

Similarly to the previous techniques, novocain is injected into the fascia pouches of the extensor and flexor muscles in the middle third. The injection is placed at the lateral and medial sides of the tibia. 80-100 ml of novocain are injected into each muscular pouch (see fig. 10).

Retromammary block

This method is used to treat the initial stages of mastitis or as a part of local anaesthesia during operations on the breast: sectoral resection, incision and drainage. At the base of the breast in three points (upper, lower and the lateral aspects) 0, 5% of novocain is injected intradermally (fig. 11). Then, with a long needle preceded by novocain in the pathway, the drug is injected into the retromammary space. 50 ml of 0, 25% novocain are injected through each of the three points. No resistance should be felt during the injection, and after removing the syringe from the needle novocain should not flow out through the open needle. If the block is achieved, the breast looks raised and lying as if on a pillow.

Fig. 11. Retromammary novocain block.

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