Comparison between Steroid Injection and Stretching Exercise on the Scalene of Patients with Upper Extremity Paresthesia: Randomized Cross-Over Study

PURPOSE: To compare the therapeutic effects on upper extremity paresthesia of intra-muscular steroid injections into the scalene muscle with those of stretching exercise only. MATERIALS AND METHODS: Twenty patients with upper extremity paresthesia who met the criteria were recruited to participate in this single-blind, crossover study. Fourteen of 20 patients were female. The average age was 45.0+/-10.5 years and duration of symptom was 12.2+/-8.7 months. Each participant completed one injection and daily exercise program for 2 weeks. After randomization, half of all patients received ultrasound-guided injection of scalene muscles before exercise, while the other was invested for the other patients. RESULTS: After two weeks, there was a significant decrease of the visual analog scale score of treatment effect compared with baseline in both groups (6.90 to 2.85 after injection and 5.65 to 4.05 after stretching exercise, p50% reduction in post-treatment visual analog scale, was 18 of 20 (90.0%) after injection, compared to 5 of 20 (25.0%) after stretching exercise. There were no cases of unintended brachial plexus block after injection. CONCLUSION: Ultrasound-guided steroid injection or stretching exercise of scalene muscles led to reduced upper extremity paresthesia in patients who present with localized tenderness in the scalene muscle without electrodiagnostic test abnormalities, although injection treatment resulted in more improvements. The results suggest that symptoms relief might result from injection into the muscle alone not related to blockade of the brachial plexus.

Comparison of Ultrasound-Guided Axillary Brachial Plexus Block Techniques: Perineural Injection versus Single or Double Perivascular Infiltration

PURPOSE: We compared three methods of ultrasound-guided axillary brachial plexus block, which were single, and double perivascular (PV) infiltration techniques, and a perineural (PN) injection technique. MATERIALS AND METHODS: 78 patients of American Society of Anesthesiologists physical status I-II undergoing surgery of the forearm, wrist, or hand were randomly allocated to three groups. 2% lidocaine with epinephrine 5 microg/mL was used. The PN group (n=26) received injections at the median, ulnar, and radial nerve with 8 mL for each nerve. The PV1 group (n=26) received a single injection of 24 mL at 12-o'clock position of the axillary artery. The PV2 group (n=26) received two injections of 12 mL each at 12-o'clock and 6-o'clock position. For all groups, musculocutaneous nerve was blocked separately. RESULTS: The PN group (391.2+/-171.6 sec) had the longest anesthetic procedure duration than PV1 (192.8+/-59.0 sec) and PV2 (211.4+/-58.6 sec). There were no differences in onset time. The average induction time was longer in PN group (673.4+/-149.6 sec) than PV1 (557.6+/-194.9 sec) and PV2 (561.5+/-129.8 sec). There were no differences in the success rate (89.7% vs. 86.2% vs. 89.7%). CONCLUSION: The PV injection technique consisting of a single injection in 12-o'clock position above the axillary artery in addition to a musculocutaneous nerve block is equally effective and less time consuming than the PN technique. Therefore, the PV technique is an alternative method that may be used in busy clinics or for difficult cases.

A cadaveric study to determine the minimum volume of methylene blue to completely color the nerves of brachial plexus in cats. An update in forelimb and shoulder surgeries

PURPOSE: To determine the minimum volume of methylene blue (MB) to completely color the brachial plexus (BP) nerves, simulating an effective anesthetic block in cats. METHODS: Fifteen adult male cat cadavers were injected through subscapular approach with volumes of 2, 3, 4, 5 and 6 ml in both forelimbs, for a total of 30 brachial plexus blocks (BPB). After infusions, the specimens were carefully dissected preserving each nervous branch. The measurement of the effective area was indicated by the impregnation of MB. Nerves were divided into four segments from the origin at the spinal level until the insertion into the thoracic limb muscles. The blocks were considered effective only when all the nerves were strongly or totally colored. RESULTS: Volumes of 2, 3 and 4 ml were considered insufficient suggesting a failed block, however, volumes of 5 and 6 ml were associated with a successful block. CONCLUSIONS: The injection of methylene blue, in a volume of 6 ml, completely colored the brachial plexus. At volumes of 5 and 6 ml the brachial plexus blocks were considered a successful regional block, however, volumes of 2, 3 and 4 ml were considered a failed regional block. .

Low-dose ropivacaine for supraclavicular brachial plexus block combined with general anesthesia for successful postoperative analgesia: a case series

Ropivacaine, a long-acting local anesthetic agent, has been used for postoperative analgesia in brachial plexus block [BPB] at high doses. However, use of lower doses would reduce the occurrence of adverse effects. We applied BPB with low-dose ropivacaine [10 mL of 0.375% ropivacaine] after induction of general anesthesia for surgery of the upper extremities in 62 patients at our hospital. Ropivacaine was administered via a fluoroscopy-guided supraclavicular method. Analgesic effects during surgery, visual analog scale pain scores, skin sensation, muscle strength, and postoperative patient satisfaction indices were evaluated. Fifty-six patients [90.3%] did not require supplemental analgesics during surgery. The remaining six patients were administered fentanyl due to the insufficient analgesic effects of the nerve block. Some adverse effects, including numbness and delayed motor and sensory recovery of the upper extremities, were observed. The mean postoperative patient-evaluated visual satisfaction scale was 94.1. Our results suggest that low-dose ropivacaine is clinically acceptable for BPB under general anesthesia

Evaluation of two regional anesthetic methods on the front limb of dogs using hyperbaric bupivacaine / Avaliação de dois métodos de bloqueios anestésicos regionais no membro anterior em cães usando bupivacaína hiperbárica

PURPOSE: To evaluate the effects of bupivacaine 0.5 and 0.25 percent in intravenous regional anesthesia (IVRA) and brachial plexus block (BPB), respectively, on anesthesia, motor block and cardiovascular parameters in dogs. METHODS: Fourteen healthy adult dogs averaging 10 kilograms (kg) of body weight. Animals were randomly assigned to receive one of the two treatments IVRA (n=7) or BPB (n=7). All the animals were sedated with acepromazine (0.1 mg/kg intramuscular). To execute the BPB was used an electrical nerve stimulation. Anesthesia, motor block, sedation, cardiovascular and respiratory effects were measured as effect of the treatment. RESULTS: BPA showed superior efficiency and duration of anesthesia (BPB - 456 ± 94 minutes vs IVRA - 138 ± 44) as well as motor block. There only physiologic parameter which change were the systolic pressure in BPB and respiratory rate for both treatments. CONCLUSION: In dogs the 0.25 percent hyperbaric bupivacaine in BPB produces a front limb anesthesia about three times more than the 0.5 percent in IVRA, with ptosis of the limb blocked and little interference in the cardiovascular system but with decrease in respiratory rate.

OBJETIVO: Avaliar os efeitos da bupivacaína 0,5 e 0,25 por cento na anestesia regional endovenosa (IVRA) e no bloqueio do plexo braquial (BPB) respectivamente, na anestesia, bloqueio motor e parâmetros cardiovasculares em cães. MÉTODOS: Foram utilizados 14 cães sadios adultos pesando em média 10 kilos. Animais foram aleatoriamente designados a um de dois tratamentos IVRA (n = 7) ou BPB (n = 7). Todos os animais foram sedados com acepromazina (0,1 mg/kg intramuscular). Para realizar o BPB foi usado um estimulador elétrico nervoso. Anestesia, bloqueio motor, sedação, efeitos cardiovascular e respiratório foram mensurados como efeitos dos respectivos bloqueios. RESULTADOS: O bloqueio BPB demonstrou eficiência superior e maior duração da anestesia (BPB - 456 ± 94 minutos vs IVRA - 138 ± 44 minutos) bem como maior envolvimento motor. Somente a pressão arterial sistólica foi alterada no grupo BPB e a freqüência respiratória em ambos os tratamentos. CONCLUSÃO: Em cães, a bupivacaína 0,25 por cento hiperbárica no grupo BPB produziu uma anestesia do membro anterior três vezes mais longa que a 0,5 por cento no grupo IVRA, com ptose do membro bloqueado e pequena interferência no sistema cardiovascular e com diminuição da freqüência respiratória.

Midazolam with bupivacaine for improving analgesia quality in brachial plexus block for upper limb surgeries

To compare the onset, duration and postoperative pain scores of supraclavicular block with bupivacaine alone and bupivacaine-midazolam combination. Randomized controlled clinical trial. The Postgraduate Medical Institute, Hayatabad Medical Complex, Peshawar, from April 2005 to June 2007. A randomized controlled clinical trial was conducted on 50 ASA-I or II adult patients undergoing upper limb surgeries under supraclavicular brachial plexus block. Patients were randomly allocated into two groups of 25 each. Patients in group A were administered 30 ml of 0.5% bupivacaine and those in group B were given 30 ml of 0.5% bupivacaine with midazolam 50 micro g.kg-1. Hemodynamic variables [heart rate, noninvasive blood pressure, oxygen saturation], pain scores, rescue analgesic requirements and sedation score were recorded for 24 hours postoperatively, and compared using ANOVA with significance at p <0.05. The onset and duration of sensory and motor block was significantly faster and longer in group B compared to group A [p < 0.001]. Pain scores were significantly lower in group B for 24 hours postoperatively [p < 0.001]. Demand for rescue analgesic were significantly less in group B. Hemodynamics and sedation scores did not differ between the groups in the studied period. Bupivacaine [0.5%] in combination with Midazolam [50 micro gúkg-1] quickened the onset as well as prolonged the duration of sensory and motor blockade of the brachial plexus for upper limb surgery. It improved postoperative analgesia without producing any adverse events compared to plain bupivacaine [0.5%] in equal volume

Recent Advances in Brachial Plexus Anesthesia: a Review

Avances recientes en la anestesia del Plexo Braquial. La anestesia del plexo braquial a estado en boga por más de 80 años. De todas las técnicas regionales que se han realizado, la anestesia del plexo braquial (APB) es la que representa mayores retos al anestesiólogo alrededor del mundo. Parece ser que el riesgo y la incidencia de complicaciones es mayor con abordaje supraclavicular. El pneumotórax casi ha desaparecido como complicación y se ha puesto mayor atención a la alteración respiratoria secundaria a la paresia unilateral del frénico. La incidencia de toxicidad por anestésicos locales es mayor con APB que con otros bloqueos y cuando se compara la incidencia de toxicidad sistémica comparando varios abordajes al plexo braquial, esta es cuatro veces mayor con el método supraclavicular, es por eso que se continua buscando nuevos métodos que sean más satisfactorios. La presente revisión describe los diferentes métodos y técnicas así como los beneficios y/o complicaciones derivadas de la APB

Nova técnica de bloqueio do plexo braquial em cäes / New technique of brachial plexus block in dogs

O objetivo do presente estudo foi analisar a viabilidade e a eficácia de uma nova técnica para o bloqueio do plexo braquial em cäes. Para tanto, foram utilizados 11 cäes, machos e fêmeas, idade e peso variáveis e mestiços. Os animais foram pré-tratados com acepromazina e a induçäo da anestesia foi realizada com propofol. Posteriormente, os animais foram submetidos ao bloqueio do plexo braquial que constou da associaçäo da técnica de múltiplas injeçöes com o emprego do estimulador de nervos e a técnica da palpaçäo arterial como ponto de referência para a localizaçäo dos nervos. Utilizou-se como anestésico local, a bupivacaína com vasoconstritor administrado na dose total de 4mg/kg a 0,375 porcento. O volume total foi dividido em 4 partes iguais, administradas na velocidade de 30 segundos cada, com o objetivo de se atingir a maior quantidade de nervos. O tempo necessário para realizaçäo da técnica foi de 11,30 ñ 4,54 minutos; o período de latência para o bloqueio motor foi de 9,70 ñ 5,52 minutos e para o bloqueio sensitivo foi de 26,20 ñ 8,86 min., sendo a duraçäo da analgesia de 11:00 ñ 0:45 horas. Em 90 porcento dos animais, o bloqueio foi efetivo, constatado através da anestesia de todo o membro torácico distal à articulaçäo escápulo-umeral. A única complicaçäo observada foi a hipotensäo arterial desenvolvida em um animal. Mediante os resultados obtidos, pode-se pressupor que as cirurgias envolvendo o membro torácico distal à articulaçäo escápulo-umeral poderäo ser utilizadas com auxílio desta nova técnica do bloqueio do plexo braquial, bem como na analgesia pós-operatória de longa duraçäo.

Analgesia post-operatoria con lidocaína y tramadol en el bloqueo del plexo branquial / Post-operative analgesia with lidocaine and tramadol in the braquial plexus block

Realizamos un estudio prospectivo en el Hospital Docente Universitario Dr. Darío Contreras en su Departamento de Anestesiología en Santo Domingo, Rep. Dom., en 20 pacientes, los cuales fueron sometido a cirugía de miembros superiores, bajo bloqueo de Plexo braquial con Lidocaína 1// 40Mls (400 mg) mas 100 mg de Tramadol, en el período junio-julio 1996. De los pacientes estudiados el grupo etáreo más frecuente fue de 15 a 25 años con un 45//, en relación con el diagnóstico el 35// fueron fractura de cúbito y radio, de acuerdo a los efectos secundarios fueron náuseas y sedación con 25// y una analgesia post-quirúrgica mayor de 70// correspondiente a 3-4 horas

Bloqueo del plexo braquial con lidocaína más opioides para disminuir el tiempo de latencia / Block of the brachial plexus with lidocaine and fentanyl or bupreorphine to decrease the time of latency

Se estudió el efecto analgésico de la buprenorfina y fentanyl mezclados con lidocaína al 1.5 por ciento en el bloqueo del plexo braquial, en 26 pacientes divididos en tres grupos. El grupo I formado por 5 pacientes, recibió lidocaína al 1.5 por ciento 350 mg; en el grupo II se incluyeron 7 pacientes a quienes se les inyectó lidocaína al 1.5 por ciento 350 mg más 300 µg de buprenorfina; y el grupo III, formado por 14 pacientes recibió lidocaína al 1.5 por ciento 350 mg más 50 µg de fentanyl. El objetivo de agregar un opioide al anestésico local fue disminuir el tiempo de latencia y aumentar la duración del bloqueo sensitivo y motor. La latencia promedio del bloqueo sensitivo total del grupo I fue mayor a la del grupo II (p< 0.001) y III (p< 0.05). El tiempo de latencia promedio del bloqueo motor total del grupo I fue mayor al del grupo II (p< 0.05) y grupo III (p< 0.001). La duración del bloqueo motor total del grupo I fue menor a la del grupo II (p< 0.001) y grupo III (p< 0,05). Por lo tanto se concluye que los opiodes si disminuyen la latencia y aumentan la duración del bloqueo sensitivo y motor cuando se aplican en el plexo braquial

effect of addition of verapamil or dextran singly or in combination in brachial plexus block

Brachial plexus blockade is one of the most satisfactory method of analgesia in the upper limb surgery. It has some limitations as its short duration of action. Addition of verapamil to Lignocaine reduced the time for the onset of analgesia but it reduced its duration of action. Addition of dextran to Lignocaine prolonged the duration of the blockade. Combining Verapamil and Dextran with Lignocaine in brachial plexus blockade leads to a rapid onset of analgesia and a long duration of blockade

Efecto de la alcalinización y el calentamiento de las soluciones anestésicas sobre el periodo de latencia en el bloqueo de plexo axilar vía axilar / Effects of anesthetic Warming and alcalinization upon the latency period in axilary blockade through axilary approach

Se estudiaron tres grupos de 10 pacientes cada uno, de ambos sexos, edad promedio de 34.8 ñ 8.8 años, peso promedio de 68.8 ñ 2.3 zkg. talla promedio de 156 ñ cm. y estados físicos 1 y 2, programados para cirugía electiva ortopédica o reconstructiva del miembro toráxico. A todos ellos se les administró lidocaína al 2 por ciento con epinefrina para bloqueo de plexo braquial vía axilar a dosis de 7 mg/kg. al grupo I sin modificaciones , al grupo II se adicionó bicarbonato de sodio y al grupo III se aumentó la temperatura a 37ºC, para reducir el tiempo de latencia. El tiempo promedio de latencia observado para el grupo I fue de 15.2 ñ 7.3 minutos y para el grupo II fue de 9.1 ñ 1.9 minutos, existiendo diferencias significativas estadísticamente p<0.01. El tiempo promedio de latencia para el grupo III fue de 2.4 ñ 1.3 minutos y en comparación con los dos grupos previos se aprecia una diferencia significativa estadísticamente (P<0.005). En suma, tanto la alcalinización como el calentamiento de las soluciones anestésicas con eficaces para disminuir el tiempo de la latencia