Randomized prospective study of three different techniques for ultrasound-guided axillary brachial plexus block / Estudo prospectivo randomizado de três diferentes técnicas para o bloqueio do plexo braquial via axilar guiado por ultrassom

Abstract Introduction Randomized prospective study comparing two perivascular techniques with the perineural technique for ultrasound-guided axillary brachial plexus block (US-ABPB). The primary objective was to verify if these perivascular techniques are noninferior to the perineural technique. Method 240 patients were randomized to receive the techniques: below the artery (BA), around the artery (AA) or perineural (PN). The anesthetic volume used was 40 mL of 0.375% bupivacaine. All patients received a musculocutaneous nerve blockade with 10 mL. In BA technique, 30 mL were injected below the axillary artery. In AA technique, 7.5 mL were injected at 4 points around the artery. In PN technique, the median, ulnar, and radial nerves were anesthetized with 10 mL per nerve. Results Confidence interval analysis showed that the perivascular techniques studied were not inferior to the perineural technique. The time to perform the blockade was shorter for the BA technique (300.4 ± 78.4 s, 396.5 ± 117.1 s, 487.6 ± 172.6 s, respectively). The PN technique showed a lower latency time (PN - 655.3 ± 348.9 s; BA - 1044 ± 389.5 s; AA - 932.9 ± 314.5 s), and less total time for the procedure (PN - 1132 ± 395.8 s; BA - 1346.2 ± 413.4 s; AA - 1329.5 ± 344.4 s). BA technique had a higher incidence of vascular puncture (BA - 22.5%; AA - 16.3%; PN - 5%). Conclusion The perivascular techniques are viable alternatives to perineural technique for US-ABPB. There is a higher incidence of vascular puncture associated with the BA technique.

Resumo Introdução Estudo prospectivo randomizado, compara duas técnicas perivasculares com a técnica perineural para o bloqueio do plexo braquial via axilar guiado por ultrassom (BPVA-USG). Objetivo primário foi verificar se essas técnicas perivasculares são não inferiores à técnica perineural. Método Foram randomizados 240 pacientes para receber as técnicas: abaixo da artéria (TA), ao redor da artéria (TR) ou perineural (PN). O volume de anestésico usado foi 40 ml de bupivacaína 0,375%. Em todos os pacientes, fez-se o bloqueio do nervo musculocutâneo com 10 ml. Na técnica TA, injetaram-se 30 ml abaixo da artéria axilar. Na técnica TR, injetaram-se 7,5 ml em quatro pontos ao redor da artéria. Na técnica PN, os nervos mediano, ulnar e radial foram anestesiados com 10 ml por nervo. Resultados Análise dos intervalos de confiança mostrou que as técnicas perivasculares estudadas não são inferiores à técnica perineural. A técnica TA apresentou menor tempo para o bloqueio (300,4 ± 78,4 seg; 396,5 ± 117,1 seg; 487,6 ± 172,6 seg; respectivamente). A técnica PN apresentou menor tempo de latência (PN - 655,3 ± 348,9 seg; TA - 1044 ± 389,5 seg; TR - 932,9 ± 314,5 seg) e menor tempo total de procedimento (PN - 1132 ± 395,8 seg; TA -1346,2 ± 413,4 seg; TR 1329,5 ± 344,4 seg). A técnica TA apresentou maior incidência de punção vascular (TA - 22,5%, TR - 16,3%; PN - 5%). Conclusão As técnicas perivasculares são opções viáveis à técnica perineural para o BPVA-USG. Ressalta-se maior incidência de punção vascular associada à técnica TA.

Ultrasound-Guided Axillary Brachial Plexus Block, Performed by Orthopedic Surgeons / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to assess the effectiveness and complications of an ultrasound-guided axillary brachial plexus block performed by orthopedic surgeons. MATERIALS AND METHODS: From March to May 2017, an ultrasound-guided axillary brachial plexus block was performed on a total of 103 cases of surgery. A VF13-5 transducer from Siemens Acuson X300 was used. The surgical site was included in the range of the anatomic sensory distribution of the blocked nerve, except for the case where an operation time of more than 2 hours was expected due to multiple injuries and the operation of the upper arm. The procedure was performed by 2 orthopedic surgeons in the same method using 50 ml of solution (20 ml of lidocaine HCl in 2%, 20 ml of ropivacaine in 0.75%, 10 ml of normal saline in 0.9%). The success rate of anesthesia induction during surgery, anesthetic induction time, anatomical range of operation, duration of postoperative analgesia and complications were investigated. RESULTS: The results from the 2 practices were similar. The anesthesia was successful in 100 out of 103 patients (97.1%). In these patients, the average needling time was 5.5 minutes (2.5–13.2 minutes), the average induction time to complete anesthesia was 18.4 minutes (5–40 minutes), and the average duration of postoperative analgesia was 402.8 minutes (141–540 minutes). The post-anesthesia immediate complications were dizziness in 1 case, nausea and vomiting in 4 cases, and peri-oral numbness in 2 cases, but surgery was performed without problems. All these 7 cases with complications recovered on the same day. A total of 3 cases failed with anesthesia, and they were treated by an injection with local anesthesia in the operation room in 2 cases and switched to general anesthesia in 1 case. CONCLUSION: An ultrasound-guided axillary brachial plexus block, which was performed by orthopedic surgeons allows anesthesia in a brief period and the high success rates of anesthesia for certain surgeries of the elbow and surgeries on forearm, wrist and hand. Therefore, it can reduce the waiting time to the operating room. This technique is a relatively safe procedure and dose selective anesthesia is possible.

Adjunct role of nerve stimulator in ultrasound- guided axillary brachial plexus block / 实用医学杂志

Objective To evaluate the adjunct role of nerve stimulator in ultrasound- guided axillary bra-chial plexus block. Methods 50 patients undergoing lower elbow surgery in our hospital were selected from Sep-tember 2016 to November 2017. They were randomly divided into two groups with 25 cases each,which are guid-ance of ultrasound combined with nerve stimulator group(group US)and ultrasound alone group(group U). 32 mL of 0.4% ropivocaine were administered in both groups. The onset time and duration of sensory blockade in mus-culocutaneous,radial,median and ulnar nerve were recorded. The extent of sensory block of each in nervated re-gion and the anesthetic effect of surgical field(rated as excellent,good and failure)were both assessed. The anes-thetic complications were also observed and recorded. Results There were no significant differences in the onset time and duration of sensory blockade in both groups(P > 0.05). The anesthetic effects of surgical field were 92%in group US and 84% in group U(P > 0.05). No major anesthetic complications occurred in two groups. Conclu-sion Ideal anesthetic effects are achieved in both groups,and the successful rate of anesthesia in group US is not significantly increased. The role of nerve stimulator as an adjunct to ultrasound - guided axillary brachial plexus block may be very limited.

Application of perineural space expansion by normal saline in axillary brachial plexus block / 上海交通大学学报（医学版）

Objective· To compare the clinical effect of ultrasound-guided perineural space expansion by normal saline combined with perivascular technique (PSE-PV) with traditional perivascular technique in axillary brachial plexus block (PV).Methods· A randomized,controlled,and double blind study was performed.Sixty patients arranged for emergency hand surgery were allocated to 2 groups,i.e.PSE-PV group and PV group,with 30 cases in each group receiving ultrasound-guided axillary brachial plexus block.For PSE-PV group,injection was carried out at the 12 o'clock position using 5 mL of normal saline firstly to expand the perineural space followed by 15 mL of 0.5％ ropivacaine at the same position.The patients of PV group got their injections of 20 mL of 0.5％ ropivacaine at the direction of 12 o'clock of axillary artery.The sensory and motor blockade assessment 30 min after drug injection,performance time,success rate,and adverse events were recorded.Results· The sensory and motor blockade scores were 1.7±0.3 and 1.6±0.3 in PSE-PV group,and 1.8±0.4 and 1.6±0.3,respectively in PV group without significant differences (P＞0.05).The performance time of PSE-PV group was (4.0± 1.3) min,a little longer than that of PV group,but the difference was not statistically significant (P＞0.05).The success rates of nerve block reached 100％ in both groups.Only l case in PV group reacted to the local anesthetics.Conclusion · Ultrasound-guided perineural space expansion by normal saline reduces dosage of local anesthetics in axillary brachial plexus block,which has similar anesthetic effect,performance time and adverse effect with traditional perivascular method.

Application of perineural space expansion by normal saline in axillary brachial plexus block / 上海交通大学学报（医学版）

Objective: To compare the clinical effect of ultrasound-guided perineural space expansion by normal saline combined with perivascular technique (PSE-PV) with traditional perivascular technique in axillary brachial plexus block (PV). Methods: A randomized, controlled, and double blind study was performed. Sixty patients arranged for emergency hand surgery were allocated to 2 groups, i.e. PSE-PV group and PV group, with 30 cases in each group receiving ultrasound-guided axillary brachial plexus block. For PSE-PV group, injection was carried out at the 12 o'clock position using 5 mL of normal saline firstly to expand the perineural space followed by 15 mL of 0.5% ropivacaine at the same position. The patients of PV group got their injections of 20 mL of 0.5% ropivacaine at the direction of 12 o'clock of axillary artery. The sensory and motor blockade assessment 30 min after drug injection, performance time, success rate, and adverse events were recorded. Results: The sensory and motor blockade scores were 1.7±0.3 and 1.6±0.3 in PSE-PV group, and 1.8±0.4 and 1.6±0.3, respectively in PV group without significant differences (P>0.05). The performance time of PSE-PV group was (4.0±1.3) min, a little longer than that of PV group, but the difference was not statistically significant (P>0.05). The success rates of nerve block reached 100% in both groups. Only 1 case in PV group reacted to the local anesthetics. Conclusion: Ultrasound-guided perineural space expansion by normal saline reduces dosage of local anesthetics in axillary brachial plexus block, which has similar anesthetic effect, performance time and adverse effect with traditional perivascular method.

Effect of needle approach to the axillary artery on transarterial axillary brachial plexus block quality

BACKGROUND: The authors sought to determine whether a shallow needle approach to the axillary artery would improve complete sensory blocks of median, radial, and ulnar nerves as compared with a perpendicular approach when transarterial axillary block is performed using a scalp vein needle (23G, 3/4'). METHODS: Fifty-four patients were allocated equally to a perpendicular group (the PA group) or a shallow approach group (SA group). Sensory and motor scores were evaluated and compared in the two groups at 5-minute intervals for 20 minutes after block. The main outcome variables were rates of blockage of median, radial, and ulnar nerves. RESULTS: Excellent block rates (defined as completion of surgery using brachial plexus block alone) were obtained in both groups (SA group 77.8% vs. PA group 70.3%, P = 0.755). However, the rate of blockage of all three nerves was significantly higher in the SA group (74% vs. 40.7%, P = 0.013). Furthermore, the rate of complete sensory block of the radial nerve at 20 minutes was significantly greater in the SA group (85.2% vs. 59.3%, P = 0.033). CONCLUSIONS: A shallow needle approach to the axillary artery resulted in a significantly higher median, radial, and ulnar nerve block rate at 20 minutes after LA injection than a perpendicular approach.

Effect of needle approach to the axillary artery on transarterial axillary brachial plexus block quality

BACKGROUND: The authors sought to determine whether a shallow needle approach to the axillary artery would improve complete sensory blocks of median, radial, and ulnar nerves as compared with a perpendicular approach when transarterial axillary block is performed using a scalp vein needle (23G, 3/4'). METHODS: Fifty-four patients were allocated equally to a perpendicular group (the PA group) or a shallow approach group (SA group). Sensory and motor scores were evaluated and compared in the two groups at 5-minute intervals for 20 minutes after block. The main outcome variables were rates of blockage of median, radial, and ulnar nerves. RESULTS: Excellent block rates (defined as completion of surgery using brachial plexus block alone) were obtained in both groups (SA group 77.8% vs. PA group 70.3%, P = 0.755). However, the rate of blockage of all three nerves was significantly higher in the SA group (74% vs. 40.7%, P = 0.013). Furthermore, the rate of complete sensory block of the radial nerve at 20 minutes was significantly greater in the SA group (85.2% vs. 59.3%, P = 0.033). CONCLUSIONS: A shallow needle approach to the axillary artery resulted in a significantly higher median, radial, and ulnar nerve block rate at 20 minutes after LA injection than a perpendicular approach.

Proximal Median Neuropathy Caused by Axillary Brachial Plexus Block

An axillary brachial plexus block (BPB) is commonly used in local anesthesia, especially for hand surgery. Infraclavicular brachial plexopathy is a potential complication of axillary BPB. A 44-year-old man with an injury to his left third fingertip presented with weakness of the left thumb and index finger flexion after orthopedic surgery under axillary BPB. This was a rare case of proximal median neuropathy caused by axillary BPB. The diagnosis was confirmed by a detailed neurological examination and electrodiagnostic studies.

Double-injection perivascular ultrasound-guided axillary brachial plexus block according to needle positioning: 12 versus 6 o'clock position of the axillary artery / 대한마취과학회지

BACKGROUND: We conducted prospective, randomized, observer-blinded trial to compare two double-injection perivascular (PV) ultrasound-guided techniques of axillary brachial plexus block (BPB). METHODS: American Society of Anesthesiologists physical status I-II, 50 patients undergoing surgery of the forearm, wrist or hand were randomly allocated to two groups. For PV12 group, injection was carried out at the 12 o'clock position using 24 ml of 2% lidocaine. Patients of PV6 group got their injection of 24 ml of 2% lidocaine at direction of 6 o'clock of axillary artery. For all 2 groups, the musculocutaneous nerve was identified and 5 ml of 2% lidocaine was deposited around the nerve. The performance time and the onset time were recorded. The induction time (sum of performance and onset time), the success rate of the block, the need rate of rescue block, and incidence of adverse events was compared. RESULTS: The success rate was same (84%) in two groups. The performance time, onset time, and induction time showed no differences between two groups. There were no differences in vessel puncture, paresthesia, and numbness. CONCLUSIONS: Double-injection perivascular ultrasound-guided axillary BPB can be performed at 12 o'clock or 6 o'clock position of axillary artery, and performer may choose needle targeting position by considering surgery site. Thus perivascular double-injection technique may be an alternative method for axillary BPB and useful in case of difficult block.

A comparison of general anesthesia versus axillary brachial plexus block for hand and wrist surgery in the view of patient satisfaction

BACKGROUND: We evaluated whether the analgesic superiority of regional block over general anesthesia improves patient satisfaction. METHODS: Patients were anesthetized with either general anesthesia (GA) (n = 30) or axillary brachial plexus block (BPB) (n = 30). GA was standardized to include induction with propofol and alfentanil and maintenance with desflurane in an oxygen/nitrous oxide mixture. BPB was performed using an axillary perivascular approach, and 1.5% lidocaine 20 ml with epinephrine (1 : 200,000) and 0.5% levobupivacaine 20 ml were injected. Pain scores and numbers of times pushing the patient-controlled analgesia (PCA) button were measured preoperatively and at 2, 6, and 24 hours after the end of surgery. On the first day after the operation, one of our researchers visited the patients to document their opinions of their anesthetic experiences and their satisfaction scores. RESULTS: Group BPB had lower visual analog scale scores at 2 hours and 6 hours postoperatively. Numbers of times pushing the PCA button was also lower in Group BPB within the first 2 hours and between 2-6 hours postoperatively. However, patient satisfaction scores were not statistically different between the two groups (84 +/- 11 vs. 88 +/- 12, P = 0.177). CONCLUSIONS: BPB provided superior analgesia after upper limb surgery compared to GA, but for a complete understanding of patients' satisfaction, detailed consideration of factors such as sedation would be necessary.

Clinical comparisons of 0.5% and 0.375% levobupivacaine for ultrasound-guided axillary brachial plexus block with nerve stimulation / 대한마취과학회지

BACKGROUND: In an axillary brachial plexus block (ABPB), where relatively large doses of local anesthetics are administered, levobupivacaine is preferred due to a greater margin of safety. However, the efficacy of levobupivacaine in ABPB has not been studied much. We performed a prospective, double-blinded study to compare the clinical effect of 0.375% levobupivacaine with 0.5% levobupivacaine for ultrasound (US)-guided ABPB with nerve stimulation. METHODS: Forty patients undergoing elective upper limb surgery were randomized into two groups: Group I (0.375% levobupivacaine) and Group II (0.5% levobupivacaine). All four main terminal nerves of the brachial plexus were blocked separately with 7 ml of levobupivacaine using US guidance with nerve stimulation according to study group. A blinded observer recorded the onset time for sensory and motor block, elapsed time to be ready for surgery, recovery time for sensory and motor block, quality of anesthesia, patient satisfaction and complications. RESULTS: There were no significant differences in the time to find nerve locations, time to perform block and number of skin punctures between groups. Insufficient block was reported in one patient of Group I, but no failed block was reported in either group. There were no differences in the onset time for sensory and motor block, elapsed time to be ready for surgery, patient satisfaction and complications. CONCLUSIONS: 0.375% levobupivacaine produced adequate anesthesia for ABPB using US guidance with nerve stimulation, without any clinically significant differences compared to 0.5% levobupivacaine.

The Effect of Distal Tourniquet in the Axillary Brachial Plexus Block / 대한마취과학회지

BACKGROUND: We investigated the effect of distal tourniquet to the proximal spread of local anesthetics in the axillary brachial plexus block. METHODS: In this prospective, randomized, controlled trial, 60 patients undergoing elective surgery were divided into two equal groups; Group I (2% mepivacaine 20 ml plus 1% lidocaine 20 ml with 250 mmHg of distal tourniquet) and Group II (2% mepivacaine 20 ml plus 1% lidocaine 20 ml alone). Patients were left for 30 minutes after an axillary brachial plexus block with paresthesia and single injection technique. Sensory blockades were evaluated by pin prick test at each nerve dermatome. RESULTS: There was no significant difference of sensory blockade in radial nerve, but there were significant differences of sensory blockade in ulnar, median, musculocutaneous, medial antebrachial cutaneous, and axillary nerves (P < 0.05). CONCLUSIONS: Our findings suggest that the quality and effect of axillary brachial plexus block in group with distal tourniquet is better than the control group.

Persistent Brachial Plexus Injury Associated with Axillary Brachial Plexus Block: A case report / 대한마취과학회지

A 26-year-old male patient presented for stump revision of an amputated right 3rd finger and neurorrhaphy for a lacerated right 2nd finger. An axillary brachial plexus block was performed using the transarterial technique. Postoperatively, the patient demonstrated signs and symptoms of brachial plexus injury. He exhibited paresthesia in the distribution of the ulnar nerve and motor weaknesses the wrist, elbow, and shoulder. On the 18th postoperative day, nerve conduction and electromyographic studies were performed, which revealed possible right radial neuropathy and axillary neuropathy, or right brachial plexopathy with posterior cord involvement. After seven months of medical and physical treatment, the pain subsided but slight paresthesia and muscle weaknesses still remained. We describe a case of postoperative neuropathy, which is believed to be caused by a direct nerve injury after an axillary brachial plexus block with persistent signs and symptoms over a considerable period.