Upper extremity nerve block: how can benefit, duration, and safety be improved? An update (original) (raw)
Related papers
Medical Ultrasonography, 2021
Aims: Ultrasound guidance has led to marked improvement in the success rate and characteristics of peripheral nerve blocks. However, effects of varying the volume or concentration of a fixed local anaesthetic dose on nerve block remains unclear. The purpose of our study was to evaluate whether at a fixed dose of lidocaine, altering the volume and concentration will have any effect on the onset time of ultrasound-guided axillary brachial plexus block.Material and methods: Twenty patients were randomised to receive an ultrasound-guided axillary brachial plexus block with either lidocaine 2% with epinephrine (20 ml, Group 2%) or lidocaine 1% with epinephrine (40 ml, Group 1%). The primary endpoint was block onset time. Secondary outcomes included duration of the block, performance time, number of needle passes, incidence of paraesthesia and vascular puncture.Results: The median [IQR] onset time of surgical anaesthesia was shorter in Group 1% when compared to Group 2% (6.25 [5-7.5] min ...
Anesthesiology and Pain Medicine
Peripheral nerve blocks (PNB) have become standard of care for enhanced recovery pathways after surgery. For brachial plexus delivery of anesthesia, both supraclavicular (SC) and infraclavicular (IC) approaches have been shown to require less supplemental anesthesia, are performed more rapidly, have quicker onset time, and have lower rates of complications than other approaches (axillary, interscalene, etc.). Ultrasound-guidance is commonly utilized to improve outcomes, limit the need for deep sedation or general anesthesia, and reduce procedural complications. Given the SC and IC approaches are the most common approaches for brachial plexus blocks, the differences between the two have been critically evaluated in the present manuscript. Various studies have demonstrated slight favorability towards the IC approach from the standpoint of complications and safety. Two prospective RCTs found a higher incidence of complications in the SC approach-particularly Horner syndrome. The IC method appears to support a greater block distribution as well. Overall, both SC and IC brachial plexus nerve block approaches are the most effective and safe approaches, particularly under ultrasound-guidance. Given the success of the supraclavicular and infraclavicular blocks, these techniques are an important skill set for the anesthesiologist for intraoperative anesthesia and postoperative analgesia.
Brazilian Journal of Anesthesiology, 2013
Background and objective: Shoulder arthroscopic surgeries evolve with intense postoperative pain. Several analgesic techniques have been advocated. The aim of this study was to compare suprascapular and axillary nerve blocks in shoulder arthroscopy using the interscalene approach to brachial plexus blockade. Methods: According to the technique used, sixty-eight patients were allocated into two groups: interscalene group (IG, n = 34) and selective group (SG, n = 34), with neurostimulation approach used for both techniques. After appropriate motor response, IG received 30 mL of 0.33% levobupivacaine in 50% enantiomeric excess with adrenalin 1:200,000. After motor response of suprascapular and axillary nerves, SG received 15 mL of the same substance on each nerve. General anesthesia was then administered. Variables assessed were time to perform the blocks, analgesia, opioid consumption, motor block, cardiovascular stability, patient satisfaction and acceptability. Results: Time for interscalene blockade was signifi cantly shorter than for selective blockade. Analgesia was signifi cantly higher in the immediate postoperative period in IG and in the late postoperative period in SG. Morphine consumption was signifi cantly higher in the fi rst hour in SG. Motor block was signifi cantly lower in SG. There was no difference between groups regarding cardiocirculatory stability and patient satisfaction and acceptability. Failure occurred in IG (1) and SG (2). Conclusions: Both techniques are safe, effective, and with the same degree of satisfaction and acceptability. The selective blockade of both nerves showed satisfactory analgesia, with the advantage of providing motor block restricted to the shoulder.
Cureus
The interscalene brachial plexus block (ISBB) constitutes the gold standard for analgesia after shoulder procedures. Ipsilateral phrenic nerve block remains the most common adverse effect after ISBB. Alternative nerve blocks are performed in shoulder surgery in order to prevent hemi-diaphragmatic paralysis (HDP). The purpose of the present study was to investigate the minimum effective local anesthetic volume of 0.5% bupivacaine for postoperative analgesia with an anterior suprascapular nerve block (ASSB). The secondary aim was to investigate diaphragm functions with the local anesthetic doses used while conducting effective volume research. Method This prospective observational study was conducted at the American Hospital of Istanbul, Turkey, from March to July 2022. The initial injected volume of 0.5% bupivacaine was 10 ml. Our clinical experience indicates that this yields a complete sensory block of the anterior suprascapular nerve. In accordance with the up-and-down method, the volume of 0.5% bupivacaine used for a particular patient was determined by the outcome of the preceding block, which represented block success. In case of effective ASSB being achieved, the volume of 0.5% bupivacaine to be administered to the next patient was lowered by 1 ml. In case of block failure, however, the volume of 0.5% bupivacaine to be applied in the subsequent case was increased by 1 ml. Ipsilateral hemi-diaphragmatic movement measurements were taken before (baseline) and 30 minutes after the block. General anesthesia was induced 60 minutes after the completion of the block performance by means of a standardized protocol. Results Sixty-seven patients were included in the study. The ED50 and ED95 calculated for anterior suprascapular nerve block using probit transformation and logistic regression analysis were 2.646 (95% CI, 0.877-2.890) and 3.043 ml (95% CI, 2.771-4.065), respectively. When complete paralysis was defined as 75% or above, partial paralysis as 25-50%, and no paralysis as 25% or less, volumes of 6 ml or lower appeared to cause no paralysis for the anterior suprascapular nerve block. Conclusion We, therefore, recommend using a volume of 6 ml or less in order to achieve diaphragm-sparing features for anterior suprascapular nerve blocks.
The Medical Journal of Cairo University, 2018
Background: The use of supraclavicular brachial plexus block is one of the most effective anesthetic techniques in operations for the upper extremity. The use of ultrasound guidance for regional anesthesia became popular owing to detection of anatomical variants, painless performance and correct needle placement. Aim of the study is to evaluate the value of adding ketamine or midazolam to bupivacaine when used for ultrasound guided supraclavicular brachial plexus block in upper extremity surgical procedures as regard the quality of surgical anesthesia and post-operative analgesia. Patients and Methods: Seventy adult patients of both sexes aged (18-60) years with ASA physical status I/II scheduled for elective surgical procedure of the elbow, forearm, wrist and hand. Patients divided into two groups thirty-five patients were given 30ml total volume of 0.5% bupivacaine with midazolam 50µ g/kg injected around brachial plexus cluster (Group A) and thirty-five patients were given 30ml general volume contained 0.5% bupivacaine with ketamine 2mg/kg injected around brachial plexus cluster (Group B). Results: There was no significant difference among both groups according to demographic data, hemodynamic changes, onset of motor and sensory block, sedation score, total doses of rescue analgesia and incidence of complications. There was significant prolongation in duration of sensory and motor block, significant decrease in VAS and significant delay in first request of rescue analgesia in Group A. Conclusion: The addition of midazolam (50 µg/kg) when used as adjuvants to bupivacaine in ultrasound guided brachial plexus block produced prolongation of sensory and motor block, providing desirable sedation, improved quality of postoperative analgesia and decreased necessities of rescue analgesics in post-operative period.
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 2015
Ultrasound-guided interscalene brachial plexus blocks are commonly used to provide anesthesia for the shoulder and proximal upper extremity. Some reviews identify a sheath that envelops the brachial plexus as a potential tissue plane target, and current editorials in the literature highlight the need to establish precise and reproducible injection targets under ultrasound guidance. We hypothesize that an injection of a local anesthetic inside the brachial plexus sheath during ultrasound-guided interscalene nerve blocks will result in enhanced procedure success and provide a consistent tissue plane target for this approach with a reproducible and characteristic local anesthetic spread pattern. Sixty patients scheduled for shoulder surgery with a preoperative interscalene block for postoperative pain management were enrolled in this prospective randomized observer-blinded study. Each patient was randomly assigned to receive a single-shot interscalene block either inside or outside the...
International Journal of Research in Medical Sciences, 2018
Background: To provide adequate intraoperative anaesthesia and postoperative analgesia for orthopaedic surgery continues to be a procedural challenge. The administration of brachial plexus anaesthesia can be facilitated through nerve stimulation or by ultrasound guidance. Hence study was conducted to compare differences in these techniques in patients undergoing interscalene brachial plexus block (ISSB).Methods: In this prospective, randomized, observer-blinded study, 60 patients (Male=41, Female=19) were scheduled for orthopaedic shoulder and upper arm surgeries matching inclusion and exclusion criteria. Patients were randomly allocated to either Ultrasound (US, n=30) group or Nerve Stimulator (NS, n=30) group through a computer-generated randomization.Results: There was significant difference between US and NS group with respect to average number of attempts taken, block performance time (BPT), onset of sensory and motor block, duration of motor block and patient satisfaction scor...
IP innovative publication pvt. ltd, 2019
Introduction: Ultrasound is gaining popularity in routine anesthetic practice both in operating room as well as in intensive care units. Brachial plexus block and peripheral nerve block in various combinations have been used successfully for upper limb surgeries. But the disadvantage of brachial plexus block is the inability to use the affected limb in the post operative period due to motor block. The present study was undertaken to assess the degree of motor sparring under USG guided peripheral nerve block as compared to USG guided brachial plexus block. Materials and Methods: The study was a randomized open label study conducted in two groups viz. group A and group B. Patients in group A received treatment A i.e peripheral nerve block (PNB) and patients in group B received treatment B i.e brachial plexus block. Results: In peripheral nerve block group the median strength loss was 23% whereas the same was 100% in brachial plexus block group. This difference was found to be statistically significant (𝑃=0.001). The anesthetic onset time was found to be significantly shorter in peripheral nerve block group as compared to brachial plexus group (7.71+1.3 Vs 9.58 +1.91 min). Subject’s satisfaction score was reported higher with peripheral nerve block than those who underwent brachial plexus block: 5 Vs 4 respectively (p = 0.012). Likewise these satisfaction scores were found to have inverse correlation with loss of strength in the operative limb (Spearman’s rho −0.62 [p = 0.016] and Kendall’s tau −0.55 [p = 0.025]). Conclusion: Therefore we conclude that ultrasound guided peripheral nerve block can be an effective alternative to brachial plexus block as a primary mode of anesthesia in hand surgeries of short duration.