Application Value of Sevoflurane Combined with Brachial Plexus Block in Children with Humeral Fracture Surgery and its Effect on Hemodynamics: A Clinical and Anatomical Study

SUMMARY: To observe the effect of sevoflurane combined with brachial plexus block (BPB) in children with humeral fracture surgery and its effect on hemodynamics. 84 children who received surgical treatment of humeral fracture in our hospital from September 2019 to September 2022 were selected. According to different anesthesia methods, the children were divided into control group and study group. The control group only received laryngeal mask sevoflurane; the study group received laryngeal mask sevoflurane combined with BPB. The operation situation, hemodynamic indexes, stress level, pain and adverse reactions of children was observed. The postoperative awakening time in the study group was lower than control group, the postoperative pain onset time in the study group was higher than control group (P0.05). Postoperative 2h, the levels of serum cortisol, b-endorpin, norepinephrine and epinephrine in the study group were lower than control group (P0.05). Sevoflurane combined with BPB is helpful to shorten the postoperative awakening time of children with humeral fracture, reduce the degree of postoperative pain, improve hemodynamics, and reduce stress response, and has good safety.

El objetivo fue observar el efecto del sevoflurano combinado con bloqueo del plexo braquial (BPB) en niños con cirugía de fractura de húmero y su efecto sobre la hemodinámica. Se seleccionaron 84 niños que recibieron tratamiento quirúrgico de fractura de húmero en nuestro hospital desde septiembre de 2019 hasta septiembre de 2022. Según diferentes métodos de anestesia, los niños se dividieron en grupo control y grupo de estudio. El grupo control solo recibió sevoflurano en mascarilla laríngea; el grupo de estudio recibió sevoflurano con mascarilla laríngea combinado con BPB. Se observó la situación operatoria, índices hemodinámicos, nivel de estrés, dolor y reacciones adversas de los niños. El tiempo hasta el despertar postoperatorio en el grupo de estudio fue menor que el del grupo control, el tiempo de aparición del dolor postoperatorio en el grupo de estudio fue mayor que el del grupo control (P0,05). A las 2 horas postoperatorias, los niveles séricos de cortisol, β-endorfina, norepinefrina y epinefrina en el grupo de estudio fueron más bajos que los del grupo control (P 0,05). El sevoflurano combinado con BPB es útil para acortar el tiempo de despertar del posoperatorio de los niños con fractura de húmero, reduce el grado de dolor postoperatorio, mejora la hemodinámica y reduce la respuesta al estrés, además de tener buena seguridad.

Dexmedetomidine versus sufentanil as adjuvants to bupivacaine for brachial plexus block during upper extremity surgery: a randomized clinical trial

Abstract Background: Brachial plexus block (BPB) has been accepted as a reliable alternative for general anesthesia in upper limb surgeries. Adding adjuvant drugs like dexmedetomidine and sufentanil has been shown to have clinical and pharmacologic advantages. In this randomized parallel clinical trial, we aim to compare the effects of these two adjuvants for bupivacaine in BPB. Methods: In this double-blinded study, by using computer-assisted block randomization, 40 patients ranged from 20 to 65 years old and scheduled for elective upper limb surgeries were assigned to two equal study groups (n = 20), receiving 1 mL of 5 μg.mL-1 sufentanil (group S) or 1 mL of 100 μg.mL-1 dexmedetomidine (group D) in adjunction to 30 mL of 0.5% bupivacaine for supraclavicular BPB under the guidance of ultrasonography. Characteristics of local anesthesia and postoperative analgesia were evaluated (n = 40). Results: The duration of blocks significantly improved in group S (sensory: estimated median difference (EMD) [95%CI] = 100.0 [70.0~130.0], p < 0.001; motor: EMD [95%CI] = 120.0 [100.0~130.0], p < 0.001). Group S also had significantly longer postoperative analgesia and lower opioid consumption within 24 hours after the surgery (EMD [95%CI] = 4.0 [3.0~7.0], p < 0.001; EMD [95%CI] = -5.0 [-5.0~-5.0], p < 0.001; respectively). None of the patients showed adverse effects concerning vital signs, nausea, or vomiting. Conclusion: Our study showed that during ultrasound-guided supraclavicular BPB, sufentanil is a fairly better choice than dexmedetomidine as an adjuvant for bupivacaine and can provide preferable sensory and motor blocks. No significant side effects were seen in either of the study groups.

Perineural low dexamethasone dose as adjuvant in supraclavicular brachial plexus block for arteriovenous fistula creation in end stage renal disease: a randomized controlled trial

Abstract Background and aims: Dexamethasone as adjunct to local anesthetic solution improves the quality of brachial plexus block (BPB). However, evidence for its efficacy at low doses (< 4 mg) is lacking. This study was designed to evaluate the duration of analgesia attained with low dose dexamethasone as adjuvant to local anesthetic for creation of arteriovenous fistula (AVF) under BPB. Methods: Sixty-six patients scheduled for AVF creation were randomly allocated to receive either saline (control) or 2 mg dexamethasone, together with 0.5% ropivacaine and 0.2% lignocaine. The primary outcome was duration of analgesia, defined as time from performing the block to the first analgesic request. The secondary outcomes were time from injection to complete sensory block, time from injection to complete motor block, duration of motor block, postoperative analgesic consumption, and fistula patency at three months. Results: All the blocks were effective. In the group that received dexamethasone, the time to first analgesic request was significantly delayed (432 ± 43.8 minutes vs. 386.4 ± 40.2 minutes; p < 0.01). The onset of sensory and motor blockade occurred faster in dexamethasone group and overall analgesic consumption was also reduced. However, dexamethasone addition did not prolong the duration of motor block. There was no statistically significant difference in the patency of fistulas between the two groups at three months. (p = 0.34). Conclusion: Addition of low-dose perineural dexamethasone to local anesthetic solution significantly prolonged the duration of analgesia. Further trials are warranted to compare the adverse effects between dexamethasone doses of 4 mg and lower.

Influencia de posición del brazo en adultos para abordaje de plexo braquial costoclavicular: estudio observacional / Influence of arm position in costoclavicular approach for brachial plexus block in adult patient: observational study

Resumen: Introducción: el bloqueo de plexo braquial con abordaje costoclavicular, ofrece ventajas como sitio de inyección único, sitio adecuado para colocación de catéter de analgesia continua. Objetivo: identificar la visibilidad de los tres cordones del plexo braquial en el espacio costoclavicular según la angulación del brazo. Material y métodos: se realizó un estudio observacional descriptivo y transversal; se incluyeron 99 pacientes entre 18 a 90 años de edad, en un período de dos meses. Se describieron variables continuas, se aplicó la prueba no paramétrica de Friedman para K muestras relacionadas, una regresión lineal para confirmar la correlación entre la distancia de la piel a plexo braquial, peso e índice de masa corporal (IMC). Resultados: se encontró una menor profundidad en relación piel plexo bajo abducción del brazo a una angulación de 90o y 110o, que permite la visualización sonoanatómica del plexo braquial a nivel costoclavicular con significancia estadística. El peso es un factor independiente que determina la distancia entre la profundidad piel plexo. Conclusiones: se determinó que el abordaje del bloqueo costoclavicular ecoguiado es anatómicamente factible con elevada eficacia clínica, el cual concluye ser un sitio anatómico innovador y seguro.

Abstract: Introduction: the brachial plexus block with a costoclavicular approach offers advantages as a single injection site, being a suitable site for continuous analgesia catheter placement. Objective: to identify the visibility of the 3 brachial plexus cords in the costoclavicular space according to the angulation of the arm. Material and methods: a descriptive and cross-sectional observational study was carried out; 99 healthy patients between 18 and 90 years of age were included, in a period of two months. Continuous variables were described, the nonparametric Friedman test was applied for K related samples, a linear regression was performed to confirm the correlation between the distance from the skin to the brachial plexus, weight and body mass index (BMI). Results: a smaller depth was found in relation to the skin plexus under abduction of the arm at an angulation of 90o and 110o, which allows an adequate sonoanatomical visualization of the brachial plexus at the costoclavicular level with statistical significance. Weight is an independent factor that determine the distance between the skin plexus depth. Conclusions: it was determined that the ultrasound-guided costoclavicular block approach is anatomically feasible with greater clinical efficacy, which concludes to be an innovative and safe anatomical site.

Bloqueo de plexo braquial con ultrasonido: estudio descriptivo de práctica clínica habitual en 283 niños / Brachial plexus block with ultrasound: a descriptive study of routine clinical practice in 283 children

Resumen: Introducción: en años recientes con el renacimiento de la anestesia regional a causa de los avances técnicos en equipamiento como el ultrasonido, estos han permitido llevar a cabo bloqueos de plexo braquial con varias técnicas de abordaje, alta eficacia de éxito y disminución de complicaciones. Objetivo: conocer la eficacia y seguridad del bloqueo de plexo braquial con ultrasonido, en anestesiólogos con especialidad en anestesia regional. Material y métodos: se realizó el estudio observacional, descriptivo y retrospectivo de la práctica clínica habitual en 283 pacientes de 0 a 15 años, programados para cirugía electiva de ortopedia y traumatología, de extremidad superior (húmero tercio distal, codo, antebrazo y mano), con manejo anestésico: sedación más bloqueo de plexo braquial con ultrasonido abordaje supraclavicular o infraclavicular. Durante dos años, de enero de 2018 a diciembre de 2019. Resultados: los bloqueos fueron realizados por 11 anestesiólogos con especialidad en anestesia regional. Se evaluó la eficacia con 99.65% de éxito. En cuanto a la seguridad no se registraron complicaciones. Conclusiones: el uso de ultrasonido en bloqueo de plexo braquial con abordaje supraclavicular e infraclavicular es una técnica con éxito alto y sin complicaciones; sin embargo, es necesario tener capacitación y experiencia.

Abstract: Introduction: in recent years with the revival of regional anesthesia due to technical advances in equipment such as ultrasound, have allowed to carry out brachial plexus blocks with several approach techniques with high efficiency of success and reduction of complications. Objective: to know the efficacy and safety of brachial plexus block with ultrasound, in anesthesiologists with a specialty in regional anesthesia. Material and methods: the observational, descriptive, retrospective study of the usual clinical practice was carried out in 283 patients from 0 to 15 years old, scheduled for elective orthopedic surgery and traumatology, of the upper extremity (distal third humerus, elbow, forearm and hand), with anesthetic management: sedation plus brachial plexus block with ultrasound supraclavicular or infraclavicular approach. For two years from January 2018 to December 2019. Results: the blocks were performed by 11 anesthesiologists specializing in regional anesthesia. Efficacy was evaluated with 99.65% success. In terms of safety, there were no complications. Conclusions: the use of ultrasound in brachial plexus block with supraclavicular and infraclavicular approach is a technique with high success and without complications however it is necessary to have training and experience.

Dexmedetomidine versus clonidine as an adjuvant to local anaesthetic in brachial plexus blocks: a metaanalysis of randomised controlled trials

Abstract Objective: This meta-analysis aimed to compare the efficacy and safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. Methods: Two investigators independently searched databases to identify all RCTs comparing the efficacy and/or safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. All outcomes were pooled using the inverse variance method with a random-effect model. An I2 test was used to assess heterogeneity. The source of heterogeneity was explored through meta-regression. The quality of the evidence was assessed using the GRADE approach. Results: Out of 123 full texts assessed, 24 studies (1448 patients) were included in the analysis. As compared to Clonidine, dexmedetomidine groups showed significantly longer sensory block duration (MD = 173.31; 95% CI 138.02-208.59; I2 = 99%; GRADE approach evidence: high); motor block duration (MD = 158.35; 95% CI 131.55-185.16; I2 = 98%; GRADE approach evidence: high), duration of analgesia (MD = 203.92; 95% CI 169.25-238.58; I2 = 99%; GRADE approach evidence-high), and provided higher grade quality of block (RR = 1.97; 95% CI 1.60-2.41 ; I2 = 0%; GRADE approach evidence: moderate). The block positioning technique (regression coefficient: 51.45, p = 0.005) was observed as a significant predictor of the heterogeneity in the case of sensory block duration. No significant difference was observed for the risk of hypotension (RR = 2.59; 95% CI 0.63-10.66; I2 = %). Conclusion: Moderate to high-quality evidence suggests dexmedetomidine is a more efficacious adjuvant to local anesthetic in BPBs than Clonidine.

TO STUDY THE EFFECT OF DEXAMETHASONE AS AN ADJUVANT TO LOCAL ANAESTHETICS IN SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK

BackgroundThere is an increase in use of regional anaesthetic techniques in various surgeries.Steroids have anti inflammatory and analgesic properties. Hence , we decided to study the efficacy ofdexamethasone as an adjuvant to local anaesthetic agents in supraclavicular brachial plexus block vialandmark approach for upper limb orthopaedic surgeries.Materials and MethodsAfter ethical clearance, and informed written consent, this prospective randomised controlled clinical studywas carried out in 50 patients, aged 18-50 years, ASA grade I or II, scheduled for elective or emergencyorthopaedic upper limb surgeries.Patients were randomly divided into two groups,Group A- received Inj. Bupivacaine 0.5% 10 ml, Inj. Lignocaine + Adrenaline (1.5%) 20 ml and Inj..Normal saline (0.9%) 2 mlGroup B- received Inj. Bupivacaine 0.5% 10 ml, Inj. Lignocaine + Adrenaline (1.5%) 20 ml and Inj.Dexamethasone (8 mg) 2 mlAfter confirming complete motor and sensory blockade, surgery was commenced.VAS score was recorded for 18 hours postoperatively where 0 equals no pain and 10 as worst possible pain.Results-● The onset of sensory and motor block was significantly faster in patients who receivedcombination of local anaesthetic and dexamethasone.● The duration of motor and sensory block in dexamethasone group was significantly higher thancontrol group.● There was no significant difference in the hemodynamics found between the two groupsperioperatively.● The duration of post operative analgesia was prolonged in dexamethasone group as compared tocontrol group.● Postoperatively, no complications were observed in any group.ConclusionThe addition of dexamethasone to local anaesthetics in supraclavicular approach of brachial plexus blockproduces adequate anaesthesia with following advantage.• Dexamethasone hastens the time of onset of sensory and motor blockade.• It prolongs the duration of sensory and motor blockade.• It prolongs the duration of postoperative analgesia.• Dexamethasone provides stable haemodynamics without any unwanted side effects in perioperative

Efectividad del bloqueo de plexo braquial con abordaje costoclavicular y factores que modifican la sonoanatomía en pacientes pediátricos / Effectiveness of brachial plexus block with costoclavicular approach and factors modifying sonoanatomy in pediatric patients

Resumen: El bloqueo de plexo braquial en pediatría se ha posicionado como una buena alternativa para procedimientos quirúrgicos de la extremidad superior, en especial a partir del advenimiento de la ultrasonografía. El objetivo del estudio fue evaluar la efectividad del bloqueo con el abordaje costoclavicular en la población pediátrica, comparar la sonoanatomía de la ventana costoclavicular con la coracoidea y determinar si la posición del brazo impacta en la imagen ultrasonográfica. Se evaluaron un total de ocho pacientes con fracturas de miembro superior. De los ocho pacientes, cinco eran de género masculino (62.5%), tres de género femenino (37.5%) con una edad promedio de 8.8 años. Se realizó rastreo ultrasonográfico comparando la sonoanatomía del abordaje costoclavicular y coracoideos, observando mejor los cordones del plexo braquial y estructuras vasculares con el abordaje costoclavicular. Con el brazo en abducción 90 y 110o se optimizó la visualización de las estructuras neurovasculares y mejoría en la calidad del bloqueo. La dosis de ropivacaína fue de 1.5 mg/kg entre el 0.3-0.5%, con un tiempo de bloqueo motor promedio de 6.4 horas, y bloqueo sensitivo promedio de 11 horas. No se presentaron complicaciones. En conclusión, el bloqueo de plexo braquial por vía costoclavicular en la población pediátrica es una técnica segura.

Abstract: Pediatric brachial plexus block has become a good alternative for upper extremity surgical procedures, especially since the advent of ultrasonography. The main aim of the study was to evaluate the effectiveness of the blockade with the costoclavicular approach in the pediatric population, and compare the sonoanatomy of the costoclavicular window with the coracoid one, and determinate if the position of the arm has an impact on the ultrasound image. A total of eight patients with upper limb fractures were evaluated. Of the eight patients, five were male (62.5%), three female (37.5%) with a mean age of 8.8 years. Ultrasonographic screening was performed comparing the sonoanatomy of the costoclavicular and coracoid approaches, better observing the brachial plexus cords and vascular structures with the costoclavicular approach. With the arm abducted 90 and 110o, a better visualization of the neurovascular structures and an improvement in the quality of the block was obtained. The ropivacaine dose was 1.5 mg/kg between 0.3-0.5%, with an average motor block time of 6.7 hours, and an average sensory block of 11.25 hours. There were not complications. In conclusion, the brachial plexus block via the costoclavicular approach in the pediatric population is a safe technique.

Evaluación de la parálisis diafragmática con ultrasonido y espirometría: comparación del bloqueo supraclavicular vs bloqueo interescalénico en cirugía de hombro / Evaluation of diaphragmatic paralysis with ultrasound and spirometry: comparison of supraclavicular vs interscalene block in shoulder surgery

Resumen: Introducción: la cirugía artroscópica de hombro ha ganado popularidad recientemente; sin embargo, el dolor postquirúrgico se reporta de moderado a severo. La anestesia regional es útil para el control del dolor postquirúrgico. El bloqueo interescalénico y supraclavicular produce parálisis diafragmática en diferente proporción. Se busca encontrar cuál es el porcentaje y duración de la parálisis hemidiafragmática mediante mediciones ultrasonográficas, correlacionadas con espirometría comparando el abordaje supraclavicular con interescalénico. Material y métodos: ensayo clínico, controlado y aleatorizado. Se incluyeron 52 pacientes entre 18 y 90 años, programados para cirugía artroscópica de hombro, divididos en dos grupos (bloqueo interescalénico y supraclavicular). Se midió la excursión diafragmática y se realizó una espirometría previo al ingreso al quirófano y a las 24 horas de instalación del bloqueo, el estudio concluyó a las 24 horas del evento anestésico. Resultados: la capacidad vital se redujo en 0.7% en el grupo del bloqueo supraclavicular y 7.7% en el grupo interescalénico, el VEF1 se redujo en 0.2% en el supraclavicular y 9.5% en el interescalénico con una diferencia estadísticamente significativa (p = 0.001). La parálisis diafragmática en ventilación espontánea se presentó en ambos abordajes a los 30 minutos, sin diferencia significativa. A las seis y ocho horas continuó la parálisis en el grupo interescalénico, mientras que en el abordaje supraclavicular se mantuvo en comparación con la basal. Conclusiones: el bloqueo supraclavicular resulta tan efectivo como el bloqueo interescalénico en la cirugía artroscópica de hombro, con menor bloqueo diafragmático (1.5 veces más parálisis diafragmática en el interescalénico).

Abstract: Introduction: arthroscopic shoulder surgery has recently gained popularity, however, postoperative pain is reported as moderate to severe. Regional anesthesia is useful for the control of postoperative pain. Interscalene and supraclavicular blocks produce diaphragmatic paralysis in different proportions. The aim of this study is to find the percentage and duration of hemidiaphragmatic paralysis, by means of ultrasonographic measurements, correlated with spirometry, comparing the supraclavicular approach with interscalene. Material and methods: clinical, controlled and randomized trial. Fifty-two patients, between 18 and 90 years of age, scheduled for arthroscopic shoulder surgery were included, divided into 2 groups (interscalene or supraclavicular block). Diaphragmatic excursion was measured and spirometry was performed prior to admission to the operating room and 24 hours after installation of the block, the study concluded 24 hours after the anesthetic event. Results: vital capacity was reduced by 0.7% in the supraclavicular block and 7.7% for the interscalene, FEV1 was reduced by 0.2% for the supraclavicular and 9.5% in the interscalene with a statistically significant difference (p = 0.001). Diaphragmatic paralysis in spontaneous ventilation appeared in both approaches at 30 minutes, without significant difference. At 6 and 8 hours, paralysis continued in the interscalene group, while in the supraclavicular approach it remained preserved compared to the baseline. Conclusions: supraclavicular block is as effective as interscalene block in arthroscopic shoulder surgery, with less diaphragmatic block (1.5 times more diaphragmatic paralysis in interscalene).

Comparison of interscalene brachial plexus block and superior trunk block with ropivacaine in shoulder arthroscopic surgery / 药学实践杂志

Objective To compare the clinical effects of interscalene brachial plexus block and superior trunk block in arthroscopic shoulder surgery with 0.25% ropivacaine. Methods 46 patients undergoing shoulder arthroscopy surgery were included and randomly divided into group ISB (n=23) and group ST (n=23). Patients in group ISB received 10 ml 0.25% ropivacaine on the lateral side of C5 and C6. Patients in group ST were treated with 5 ml 0.25% ropivacaine on both sides of the superior trunk of brachial plexus. The diaphragmatic excursion, Numerical Rating Scale(NRS), duration of the block, handgrip strength were recorded at different time. Results No statistical difference was detected between the two groups in the reduction of diaphragmatic excursion within 30 min after block (P>0.05). Compared with ISB patients, ST patients had significantly less diaphragmatic excursion at 3 h after block（P<0.05). 30 minutes after block, 8.7% patients in ISB group reached complete HDP and 52.2% patients reached partial HDP. At the same time, no complete HDP and 26.1% partial HDP were detected in ST group. 3 hours after block, patients in ST group had lower complete HDP rate (0.0% vs 17.4%) and lower partial HDP rate (39.1% vs 65.2%) than patients in ISB group. At 30 minutes and 3 h after block, the reduction of grip strength in ST group was significantly lower than that in ISB group (P<0.001). ST group had lower NRS than ISB group (P<0.05). The average block time in ISB group (8.3±1.97 )h was significantly lower than that in ST group (10.9±1.26)h (P<0.01). Conclusion Superior trunk block with 10 ml 0.25% ropivacaine is superior compared to interscalene brachial plexus block in occurrence of HDP, decrease of grip strength, postoperative pain and block duration.

Perineural dexamethasone in ultrasound-guided interscalene brachial plexus block with levobupivacaine for shoulder arthroscopic surgery in the outpatient setting: randomized controlled trial / Dexametasona perineural em bloqueio de plexo braquial interescalênico com levobupivacaína guiado por ultrassonografia para artroscopia de ombro em regime ambulatorial: ensaio clínico controlado e randomizado

Abstract Background and objectives: In shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting. Methods: After approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomized into Group D - blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C - 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS). Results: Seventy-four patients were recruited and 71 completed the study (Group C, n = 37; Group D, n = 34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440 ± 0 min vs. 1267 ± 164 min, p < 0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08 ± 1.72 vs. 0.02 ± 0.17, p < 0.001) and a greater number of patients (68.4% vs. 0%, p < 0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant. Conclusion: Perineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.

Resumo Justificativa e objetivos: Na artroscopia de ombro em regime ambulatorial, o paciente necessita de um bom controle da dor pós-operatória, que pode ser conseguido por meio de bloqueios regionais. A dexametasona perineural pode prolongar o efeito desses bloqueios. O objetivo deste estudo foi avaliar o efeito da dexametasona perineural quanto ao prolongamento do bloqueio sensitivo no período pós-operatório para cirurgia artroscópica de ombro em regime ambulatorial. Métodos: Após aprovação do Comitê de Ética em Pesquisa e consentimento informado, foram incluídos no estudo pacientes submetidos a cirurgia artroscópica de ombro sob anestesia geral e bloqueio de plexo braquial interescalênico guiado por ultrassonografia. Eles foram randomizados nos Grupo D - bloqueio com 30 mL de levobupivacaína 0,5% com vasoconstritor e 6 mg (1,5 mL) de dexametasona, e Grupo C - bloqueio com 30 mL de levobupivacaína 0,5% com vasoconstritor e 1,5 mL solução salina. A duração do bloqueio sensitivo foi avaliada em quatro momentos pós-operatórios (0, 4, 12 e 24 horas), assim como a necessidade de analgesia de resgate, incidência de náuseas e vômitos e Escala Visual Analógica de Dor (EVA). Resultados: Setenta e quatro pacientes foram randomizados e 71 completaram o estudo (Grupo C, n = 37; Grupo D, n = 34). Observou-se um prolongamento do tempo médio de bloqueio sensitivo no Grupo D (1440 ± 0 min vs. 1267 ± 164 min; p< 0,001). Pacientes do Grupo C apresentaram maior média de escore de dor de acordo com a EVA (2,08 ± 1,72vs. 0,02 ± 0,17; p< 0,001) e um maior número de pacientes solicitou analgesia de resgate nas primeiras 24 horas (68,4%vs.0%; p< 0,001). A incidência de náuseas e vômitos não foi estatisticamente significante. Conclusão: A dexametasona perineural prolongou significativamente o bloqueio sensitivo da levobupivacaína no bloqueio de plexo braquial interescalênico, reduziu a intensidade de dor e a necessidade de analgesia de resgate pelo paciente no período pós-operatório.

Comparison between Supraclavicular and Infraclavicular Brachial Plexus Block in Patients Undergoing Forearm Surgeries.

Of the various modalities of achieving surgical anaesthesia of the forearm, brachialplexus block by injecting local anaesthetic is considered highly beneficial andpractical. Supraclavicular and infra-clavicular approaches of brachial plexus blocksprovide comprehensive anaesthesia for surgeries of the forearm. The primaryoutcome measured was the comparison of two blocks with respect to sparing of anydermatome, whereas the secondary outcomes measured were block performancetime, duration of analgesia, and complications associated with each technique.METHODSSixty adult patients of either sex belonging to the American Society ofAnesthesiologists (ASA) physical status I and II in the age range of 20–70 yearsscheduled to undergo surgeries of the forearm were divided into two groups:Supraclavicular (SCB group) and Infraclavicular (ICB group) of 30 each. Both theblocks were given by 30 mL of 0.375% injection Bupivacaine using a 22G, 5 cminsulated needle and nerve locator. Both the groups were compared with respect tosparing of dermatomes, block performance time, duration of analgesia andcomplications like Horner’s syndrome, vascular puncture, and pneumothorax.Statistical analysis was performed with Student unpaired t‑test and Chi‑square testand p < 0.05 was considered to be statistically significant.RESULTSBlock performance time was similar in both the groups. Duration of analgesia wascomparable among the two groups. The incidence of incomplete radial block wassignificantly higher in ICB group as compared to SCB group (p= 0.046, S). Incidenceof Horner’s syndrome in SCB group were higher than in ICB group, but they werestatistically insignificant. (p=0.15, NS). One patient in SCB group had subclavian veinpuncture as compared to none in ICB group and was statistically insignificant.CONCLUSIONSSupraclavicular approach for brachial plexus block provides reliable andcomprehensive anaesthesia for forearm surgeries without any significantdermatomal sparing unlike infraclavicular approach. Both groups had similar blockperformance time and duration of analgesia for forearm surgeries. Even though SCBwas associated with complications like Horner’s syndrome and vascular puncture, itwas transient and statistically insignificant. Hence supraclavicular approach isconsidered to be superior to infraclavicular approach.

Efficacy of Potassium Chloride 0.2 mmol as Adjuvant to 0.5% Ropivacaine versus Plain Ropivacaine 0.5% in Supraclavicular Brachial Plexus Block

Background: Brachial plexus block is one of the most common regional anesthetic techniques used for upper limb surgeries.Various adjuvants have been tried for prolonging the duration of post-operative analgesia and also to enhance the quality ofblock. We aimed to study the effects of the addition of potassium chloride to ropivacaine in supraclavicular brachial plexusblock compared to plain ropivacaine.Materials and Methods: This prospective, randomized, double-blind, and controlled study includes 80 adult patients agedbetween 20 and 60 years with ASA Grade I and II scheduled for upper limb surgeries. These patients were randomly allocatedinto two groups of 40 each. The patients in the group I/non-KCL group received 30 ml of 0.5 % ropivacaine along with 1 mlnormal saline (control group). Group II/KCL group received 30 ml of 0.5% ropivacaine along with 0.2 mmol (0.1 ml) of potassiumchloride (prepared by adding 0.1 ml of potassium chloride diluted with normal saline to make a volume of 1 ml) (study group).The onset, duration of sensory and motor blockade, quality of sensory and motor blockade, and the duration of post-operativeanalgesia were compared between both the groups.Results: The onset of sensory and motor blockade was earlier in Group II/ study group when compared to plain ropivacainegroup/Group I and was statistically significant with a P < 0.05. The mean duration of sensory and motor blockade was prolongedin Group II with enhanced quality of analgesia compared to Group I.Conclusion: In our study, it concludes that the addition of potassium chloride as an adjuvant to ropivacaine had a significantclinical advantage over plain ropivacaine on the onset, duration, quality of sensory and motor blockade, and post-operativeanalgesia in supraclavicular brachial plexus block.

The Effect of Single Point and Two Point Technique for Ultrasound Guided Supraclavicular Brachial Plexus Block in Patients Undergoing Elbow, Forearm and Wrist Surgeries- A Prospective Observational Study

Use of ultrasound for brachial plexus block has improved the precision of drug deposition around the plexus and hence the quality of the block. But there has been debate whether single point technique or double point technique is superior. Our aim was to compare the two techniques for the onset, completeness and quality of the block.METHODSA prospective observational study was designed. 140 patients were equally divided into Group A and Group B containing 70 posted for elbow, forearm and wrist surgery. A drug solution of 30 ml was prepared using Ropivacaine 0.75% 15ml + Lignocaine 2% with adrenaline 10 ml + 5ml of normal saline. Group A received 30ml of drug at the lower end of brachial plexus at 7 O’clock position. Group B received 15 ml of drug at site mentioned above and 15 ml was given at the upper part of brachial plexus at 11 O’clock position. Parameters noted were time taken for giving block, onset and completeness of sensory and motor block, encircle time, total duration of block. Unpaired student t test used for comparing quantitative variables and Chi-square test for qualitative variables. p < 0.05 was considered statistically significant.RESULTSThe time required for giving the block was more in Group B (198.57 ±19.56 sec) compared to Group A (151.53 ± 14.37 sec) but the encircle time in Group B (16 ± 3.32 min) was lesser than Group A (19.01 ± 3.6 min). The time of onset and completion of sensory and motor block for musculocutaneous, radial, ulnar and median nerve was faster in Group B compared to Group A. Duration of block in Group A was 367 ± 50.49 minutes, whereas in group B 388 ± 49.98 minutes.CONCLUSIONSIn ultrasound guided brachial plexus block, even though both techniques have satisfactory results, double point technique is superior to single point technique in terms of onset, completeness and duration of the block but in terms of simplicity in technicality single point technique has the upper hand.

A Study of Supraclavicular Brachial Plexus Block by Paresthesia Technique Success Rate and Complications: An Hospital Based Study

Background: The advantage of regional anaesthesia overgeneral anaesthesia are many and well documented. Brachialplexus can be blocked by various methods includingparesthesia technique, nerve stimulation technique and ultrasound guided. The present study was undertaken forassessing time taken to perform block, Successful blockade,complication of supraclavicular brachial plexus block byparesthesia technique.Methods: The present study was undertaken in thedepartment of Anaesthesia, Government Medical College,Barmer, Rajasthan, India with aim of assessing success rateand Complications of brachial plexus block. A total of 100patients were enrolled in the present study. Ethical approvalwas obtained from institutional ethical committee and writtenconsent was obtained from all the patients after explaining indetail of the entire research process. Complete demographicdetails of all the patients were obtained. All the results wererecorded in Microsoft excel sheet and were analyzed by SPSSsoftware.Results: Mean time to perform block was 5.35 minutes andsuccesfull blockade in 92% patients, in 6% patient’s partialblockade and in 2% patient’s complete failure of block.Incidence of complications were vessels puncture 8 % patientsand pneumothorax 1% patients.Conclusion: Supraclavicular brachial plexus block byparesthesia technique is an easy and relatively safe procedurefor the upper limb surgeries below mid shaft of humerus withfew complications and provide good post-operative analgesia.

Hemidiaphragmatic paralysis with continuous interscalene block and diluted solutions of levobupivacaine / Bloqueo interescalénico y parálisis diafragmática con dosis diluidas de levobupivacaína

The continuous interscalene block represents the analgesic standard for shoulder surgery. However, the incidence of hemidiaphragmatic paralysis can reach up to 100% of cases. We hypothesized that more dilute local anesthetics would decrease the phrenic palsy at 24 hours. METHODS: Prospective series of patients undergoing arthroscopic shoulder surgery with continuous interscalene block. A 15-ml bolus of lidocaine 1%-levobupivacaine 0.25% plus an infusion of levobupivacaine 0.04% at an 8 mL/h rate plus 5 mL boluses on-demand with a 20-minutes lockout was used until discharge. Hemidiaphragmatic excursion was evaluated with M-mode ultrasound in the subcostal region before blocks, in the post-anesthetic unit, and at 24 h. The primary outcome was the presence of hemidiaphragmatic paralysis at 24 hours. Secondary outcomes included postoperative pain, amount of rescue boluses, postoperative opioids consumption, and side effects. RESULTS: Thirty patients were recruited and analyzed. The incidence of diaphragm paralysis at 24 h was 96.7%. The median [IQR] of pain at rest (patients with shoulder immobilizer) in a NRS from 0 to 10 at 0.5; 1; 3; 6; 12; 24; 48; 72 hours were 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2], respectively. The median [IQR] consumption of LA boluses was 1.5 [0-7]. There were no postoperative morphine requirements. The most frequent side effect was Horner´s syndrome. CONCLUSIONS: Continuous interscalene block with 0.04% levobupivacaine provides adequate analgesia for arthroscopic shoulder surgery but does not prevent hemidiaphragmatic paralysis at 24 hours under the conditions of this study.

El bloqueo interescalénico representa el estándar analgésico para cirugía de hombro. No obstante, la incidencia de parálisis hemidiafragmática puede alcanzar 100% de los casos. Nuestra hipótesis es que infusiones con anestésicos locales más diluidos disminuirían la PHD 24 horas postbloqueo. MÉTODOS: Serie prospectiva de pacientes sometidos a cirugía artroscópica electiva de hombro con bloqueo interescalénico continuo. Un bolo de 15 mL de lidocaína 1%-levobupivacaína 0,5% más infusión postoperatoria de levobupivacaína al 0,04% a 8 ml/h más bolos a demanda de 5 mL con intervalo de 20 minutos hasta el alta. La excursión hemidiafragmática se evaluó con ultrasonido con transductor curvo 2-5 MHz en modo M en la región infracostal antes del bloqueo, en la unidad postanestésica y a las 24 h, antes del alta. El outcome primario fue la presencia de parálisis hemidiafragmática 24 horas postbloqueo. Los resultados secundarios incluyeron dolor postoperatorio, total de bolos de rescate, requerimiento de opioides postoperatorios y efectos secundarios. RESULTADOS: Treinta pacientes fueron reclutados y analizados. La incidencia de PHD a las 24 h fue 96,7%. La mediana [RIC] de dolor en reposo (pacientes con inmovilizador de hombro) medido en escala numérica de 0 a 10, a las 0,5; 1; 3; 6; 12; 24; 48; 72 horas fueron 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2] respectivamente. La mediana [RIC] de consumo de bolos de rescate fue 1,5 [0-7]. No hubo pacientes con requerimientos de morfina postoperatoria. El efecto colateral más frecuente fue el síndrome de Horner. CONCLUSIONES: El bloqueo interescalénico continuo con levobupivacaína 0,04% proporciona analgesia postoperatoria adecuada, pero no evita la PHD a las 24 h en las condiciones de esta serie.

Continuous suprascapular nerve block compared with single-shot interscalene brachial plexus block for pain control after arthroscopic rotator cuff repair

OBJECTIVES: We compared the analgesic efficacy of a continuous suprascapular nerve block (C-SSNB) and a single-shot interscalene brachial plexus block (S-ISNB) for postoperative pain management in patients undergoing arthroscopic rotator cuff repair. METHODS: A total of 118 patients undergoing arthroscopic rotator cuff repair were randomly allocated to the S-ISNB or C-SSNB groups. Postoperative pain was assessed using the visual analog scale (VAS) at 1, 2, 6, 12, and 24 h postoperatively. Supplemental analgesic use was recorded as total equianalgesic fentanyl consumption. RESULTS: The C-SSNB group showed significantly higher VAS scores at 0−1 h and 1−2 h after the surgery than the S-ISNB group (4.9±2.2 versus 2.3±2.2; p<0.0001 and 4.8±2.1 versus 2.4±2.3; p<0.0001, respectively). The C-SSNB group showed significantly lower VAS scores at 6−12 h after the surgery than the S-ISNB group (4.1±1.8 versus. 5.0±2.5; p=0.031). The C-SSNB group required significantly higher doses of total equianalgesic fentanyl in the post-anesthesia care unit than the S-ISNB group (53.66±44.95 versus 5.93±18.25; p<0.0001). Total equianalgesic fentanyl in the ward and total equianalgesic fentanyl throughout the hospital period were similar between the groups (145.99±152.60 versus 206.13±178.79; p=0.052 and 199.72±165.50 versus 212.15±180.09; p=0.697, respectively) CONCLUSION: C-SSNB was more effective than S-ISNB at 6−12 h after the surgery for postoperative analgesia after arthroscopic rotator cuff repair.

The best route and dose of dexamethasone for brachial plexus block: A systematic review and meta-analysis / 中国组织工程研究

BACKGROUND: Dexamethasone has been widely used in brachial plexus block to enhance the block effect but the best way (perineural or intravenous) and dose are still inconclusive. OBJECTIVE: To systematically evaluate the optimal approach and dose of dexamethasone for brachial plexus block. METHODS: Studies on dexamethasone and brachial plexus block were searched in PubMed, Embase, Cochrane Library, CNKI, WanFang and VIP. Two evaluators analyzed the literatures, evaluated the quality, extracted relevant research indicators according to the screening criteria, and completed the meta-analysis. RESULTS AND CONCLUSION: A total of 16 articles were finally included in the meta-analysis (1 260 patients). As suggested by the Meta-analysis, regardless of 1-4 mg or 5-10 mg of dexamethasone, the perineural group significantly prolonged the duration of analgesia compared with the intravenous group [weighted mean difference (WMD)=201.38, 95% confidence interval (CI) (68.22, 334.54), P=0.003; WMD=302.96, 95%CI (142.41, 463.50), P=0.000 2]. There were no significant differences in the duration of motor block between the perineural and intravenous groups [WMD=121.06, 95%CI(-62.31, 304.42), P=0.20, I 2 =95%]. Compared with the intravenous group, the perineural group significantly prolonged the duration of analgesia. However, similar duration of analgesia was found in 1-4 mg and 5-10 mg of dexamethasone and the analgesia effect did not increase with the increase of dose. There were no significant differences in the duration of motor block between the perineural and intravenous groups.

Modified braclial plexus block anesthesia / 解剖学报

Objective To analyze the influence of topographic anatomy on brachial plexus block anesthesia, and to provide reference for clinical research and application. Methods Total of 20 cadavers were selected and located through the modified method of inferior brachial plexus block of the coracoid process. The nerve blocking points were marked with blue dye, and the nerve concentration sites and marking points were dissected and exposed at the same time. The anatomical relationship between nerve concentration points and body surface markers were explored. Results The distances from the upper margin of the left centralization to the midpoint of the subclavian border, the inferior margin of the sternoclavicular joint, the shoulder peak and the inferior edge of the coracoid process were (3. 62±0. 24) cm, ( 10. 39± 0.25) cm, (6. 67 ±0.18) cm and (2. 80±0.19) cm, respectively. The distances from the upper edge of the right centralization to the midpoint of the subclavian border, the inferior margin of the sternoclavicular joint, the shoulder peak and the inferior edge of the coracoid process were (4. 24±0. 27) cm, (11. 10±0. 28) cm, (6. 35±0. 19) cm and (3. 03± 0. 15) cm, respectively. Conclusion The application of anatomy improves the accuracy of brachial plexus block, thus improves the effect of brachial plexus block anesthesia, and provides a powerful reference for clinical research and application.

Lateral Vs Classical Approach of Supraclavicular Brachial Plexus Block for Orthopedic Surgeries below Mid-Humerus: A Comparative Study.

Introduction: Supraclavicular brachial plexus blockwith classical approach is used to provide anaesthesia fororthopaedic upper limb surgeries. This approach is safe but notdevoid of complication, therefore we compared a alternativelateral approach with classical approach in terms of sensoryand motor blockade, tourniquet tolerance and complication.Material and Methods: After obtaining the ethics committeeapproval 64 patients posted for orthopaedic surgeries belowmid humerus under supraclavicular block were enrolled. Theywere divided into two groups (32 each), Group C receivedclassical approach and Group L received lateral approachwith the help of nerve stimulator. A mixture of adrenalized2% lignocaine (5-7mg/kg) and plain 0.5% bupivacaine (2mg/kg)(total volume 30 ml) was used. Onset time of sensory andmotor block, duration of sensory and motor block, durationof analgesia, tourniquet tolerance and complications (if any)were noted and compared in both the groups. Quantitative datawere compared by using unpaired T test and qualitative databy using Chi-Square test and Fisher’s Exact test (2X2 tables).Results: The mean times to onset of sensory and motorblockade and the mean duration of sensory and motorblockade did not differ between the two groups. Mean durationof analgesia with lateral approach is found to be longer butstatistically not significant. Tourniquet tolerance was goodand no pneumothorax observed in lateral approach.Conclusion: Lateral approach has shown to be a safealternative to classical approach for supraclavicular brachialplexus block in terms of adequacy of block, tourniquettolerance and complications.