Comparison of Outside Versus Inside Brachial Plexus Sheath Injection for Ultrasound-Guided Interscalene Nerve Blocks (original) (raw)
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Anesthesiology, 2014
Background: Needle trauma may cause neuropathy after nerve blockade. Even without injection, nerve injury can result from forceful needle–nerve contact (NNC). High opening injection pressures (OIPs) have been associated with intrafascicular needle tip placement and nerve damage; however, the relationship between OIP and NNC is unclear. The authors conducted a prospective, observational study to define this relationship. Methods: Sixteen patients scheduled for shoulder surgery under interscalene block were enrolled if they had clear ultrasound images of the brachial plexus roots. A 22-gauge stimulating needle was inserted within 1 mm of the root, and 1-ml D5W injected at 10 ml/min by using an automated pump. OIP was monitored using an in-line pressure manometer and injections aborted if 15 psi or greater. The needle was advanced to displace the nerve slightly (NNC), and the procedure repeated. Occurrence of evoked motor response and paresthesia were recorded. Results: Fifteen patient...
The Ochsner journal, 2011
The ability to provide adequate intraoperative anesthesia and postoperative analgesia for orthopedic shoulder surgery continues to be a procedural challenge. Anesthesiology training programs constantly balance the time needed for procedural education versus associated costs. The administration of brachial plexus anesthesia can be facilitated through nerve stimulation or by ultrasound guidance. The benefits of using a nerve stimulator include a high incidence of success and less cost when compared to ultrasonography. Recent studies with ultrasonography suggest high success rates and decreased procedural times, but less is known about the comparison of these procedural times in training programs. We conducted a prospective, randomized, observer-blinded study with inexperienced clinical anesthesia (CA) residents-CA-1 to CA-3-to compare differences in these 2 guidance techniques in patients undergoing interscalene brachial plexus block for orthopedic surgery. In this study, 41 patients ...
IP Innovative Publication Pvt. Ltd., 2017
Introduction and Aims: Peripheral nerve block techniques have evolved over time with the advent of peripheral nerve stimulator and ultrasonography. We intend to compare these two techniques in this study with respect to their efficacy, reliability and safety. Materials and Method: Prospective, randomized, observer-blinded study was conducted on 60 ASA I-II patients posted for surgery of shoulder, clavicle or proximal humerus. They were randomly allocated in to two groups to receive either ultrasound guided (USG group) or peripheral nerve stimulator guided (PNS group) interscalene brachial plexus block with 20 ml of local anaesthetic solution (2% lignocaine with adrenaline 10ml + 0.5% bupivacaine 10 ml). We compared the procedure time, time for adequate sensory and motor block, duration of block, block failure rate, complications and patient satisfaction. Result: Ultrasound significantly reduces the time to conduct the block as compared to PNS. The onset of block was earlier and duration was significantly prolonged (p=0.0001) in USG group. The success rate was 100% and patient satisfaction was significantly better in USG group compared to PNS group. Conclusion: Ultrasound guided technique for interscalene brachial plexus block provides a block which is faster in onset, has prolonged duration, higher success rate and better patient satisfaction compared to PNS guided nerve block.
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...
Anaesthesia and Intensive Care, 2015
This prospective, randomised, observer-blinded study was conducted to compare the ease of performance and surgical effectiveness of interscalene block below the C6 nerve root with supraclavicular and infraclavicular techniques of brachial plexus block for upper arm and forearm surgery. Sixty adult patients of American Society of Anesthesiologists grade 1 to 3, undergoing upper limb surgery, were randomly allocated into three groups. Group SC received supraclavicular blockade, group IC received infraclavicular blockade and Group IS received interscalene blockade. All blocks were guided by ultrasound with nerve stimulator confirmation. The anaesthetic mixture consisted of 0.5 ml/kg of equal volumes of 0.75% ropivacaine and 2% lignocaine-adrenaline. The imaging and block performance time, onset time, success rate, duration of block, and duration of postoperative analgesia were recorded by a blinded observer. The onset time was significantly longer in the interscalene group as compared with supraclavicular and infraclavicular approaches. The imaging time and block performance time were comparable between groups. No significant differences were observed between the three groups in terms of block-related pain scores, success rates, duration of block or of postoperative analgesia. Two patients in the interscalene group developed clinically detectable phrenic nerve palsy. Our findings indicate that, although interscalene block below the C6 nerve root can provide surgical anaesthesia for forearm and hand surgery, it appears to have a longer onset time than supra-and infraclavicular approaches and an unacceptable incidence of phrenic nerve palsy.
The Maximum Effective Needle-to-Nerve Distance for Ultrasound-Guided Interscalene Block
Regional Anesthesia and Pain Medicine, 2014
O ne of the most fundamental, 1 yet controversial, 2,3 tenets of regional anesthesia practice has been the adage "no paresthesia, no anesthesia." Implicit to this concept is the requirement for direct needle-nerve contact to achieve a successful block. The advent of ultrasound (US) guidance for peripheral nerve blockade (PNB) has enabled providers to position the needle tip purposefully as close as possible to, 4,5 and even inside, 6,7 the target nerve. Consequently, much of the contemporary regional anesthesia literature has focused on the question "How close is too close?" while investigators challenge the safety limits of US-guided PNB. Regrettably, the risk of nerve injury persists despite US guidance 8 and is underscored by reports of new functional deficits after interscalene brachial plexus block (ISB) performed under US guidance by experienced providers. 9-12 Given that mechanical needle-nerve trauma is an important mechanism of peripheral nerve injury, providers are cautioned to avoid intentional intraneural injection 13 or needle-nerve contact during US-guided PNB. 8,14,15 Potentially hazardous needleto-nerve proximity may be especially relevant during US-guided ISB, where inadvertent injection beneath the epineurium may be as high as 50%. 16 Subepineural, and particularly intrafascicular, injection of local anesthetic may increase the risk of nerve injury. 17 Neural elements of the interscalene brachial plexus are predominantly comprised of axonal tissue 18 and may be especially susceptible to traumatic injury. The optimal needle-tip position relative to the target nerve that balances success and safety during US-guided PNB is elusive and has recently been described as the Holy Grail of regional anesthesia. 14 Therefore, in this upand-down study, we sought to explore the question "How close is close enough?" by determining the maximum distance that the needle tip can be placed from the nerve roots to achieve a successful ISB for analgesia after shoulder surgery. METHODS Recruitment The study protocol was approved by the University Health Network Research Ethics Board, and the trial was prospectively registered on clinicaltrials.gov (NCT01568463). Between January 22 and June 7, 2012, this prospective sequential allocation trial was proposed to all patients of American Society of Anesthesiologists physical status I-II, aged between 18 and 85 years and undergoing ambulatory shoulder surgery. Exclusion criteria included existing neurological deficit in the distribution to be blocked, history of neck surgery or radiotherapy, chronic obstructive pulmonary disease, contraindications to peripheral nerve block (eg, allergy to local anesthetics, coagulopathy, infection in the area, and refusal), and pregnancy. All patients provided written informed consent and were fully informed of the risks and benefits of participating, including the risk of block failure and potential need to repeat the block procedure.
Journal of Clinical Medicine, 2021
Nerve injury is a feared complication of peripheral nerve blockade. The aim of this study was to test the effectiveness of a triple monitoring (TM), i.e., a combination of ultrasound (US), nerve stimulation (NS) and opening injection pressure (OIP) during interscalene brachial plexus block (IBPB) for surgery of the shoulder. Sixty patients undergoing IBPB for shoulder arthroscopy received TM. BSmart®, an inline injection device connected to a 10 mL syringe, was used to detect OIP during IBPB. Nerve stimulation was set to 0.5 mA to rule out any motor response, and if OIP was below 15 PSI, 10 mL of local anaesthetic was injected under US guidance between the C5 and C6 roots. The main outcome was the ability of TM to detect a needle–nerve contact. Other outcomes including the duration of IBPB; pain during injection; postoperative neurologic dysfunction. Triple monitoring revealed needle–nerve contact in 33 patients (55%). In 18 patients, NS evoked motor responses despite first control ...
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 ...
Acta Medica Marisiensis
There are several approaches for brachial plexus anesthesia: supraclavicular, infraclavicular, interscalenic and axillary. Out of these, the axillary approach is considered to be the safest because of the low risk of lesioning the adjacent structures, low risk of phrenic nerve blockade or of producing an iatrogenic pneumothorax. The block can be performed by one single injection at the site, by two injections or by several injection, among each nerve of the plexus. Ultrasound was introduced in regional anesthesia since 1978, being used initially as an auxiliary method to peripheral neurostimulator.: The evaluation of ultrasound efficiency as an auxiliary method for brachial plexus block performance, in terms of success rate, vascular punctures. The influence of obesity on performing time, total duration of the block, and success rate of brachial plexus block.: Prospective, randomized study which enrolled adult patients, scheduled for surgical emergency or elective surgical intervent...