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.

Congenital elbow luxation grade I treated by radial head ostectomy in an English Bulldog / Luxação congênita de cotovelo grau I tratada por ostectomia da cabeça do rádio em um Bulldog Inglês

The aim of this study is to report a long term follow up of a congenital luxation of the radial head (CLRH) case of a young Bulldog treated by radio head ostectomy (RHO). CLRH is an uncommon condition in dogs, but it is the most commom form of elbow dislocation (grade I). An English Bulldog, male, 6 months, 14 kilograms, was suspected of elbow dislocation. Physical examination revealed a lateral proeminence on the lateral surface of the right elbow, as well as grade I lameness and mild pain. Range of motion was normal. Previous radiographs and tomography confirmed CLHR. RHO was chosen instead of corrective techniques, due to the age of the animal at the time of the procedure and the difficulty in repositioning the radial head in the joint. Three and a half years after surgery, new clinical and radiographic examaminations were performed. The patient had no pain, good limb support and good range of motion, allowing good elbow movement. There was a partial regrowth of the proximal segment of the radial head causing better readjustment of it in the joint. Mild signs of joint degeneration were present. RHO proved to be effective in this case, proving to be a good technique to be used in cases of CLRH when conservative treatment or reduction techniques can no longer be used.

O objetivo deste relato foi o de apresentar o acompanhamento tardio de um caso de luxação congênita de cabeça de rádio (LCCR) em um Buldog Inglês jovem, tratada por ostectomia da cabeça radial (OCR). A LCCR é uma condição incomum nos cães, mas é a forma mais comum de luxação de cotovelo nos mesmos (grau I). Um Bulldog Inglês, macho, 6 meses, 14 quilos, foi atendido com suspeita de luxação do cotovelo. Exame físico revelou uma proeminência na superfície lateral do cotovelo direito, além de claudicação grau I e dor leve. Amplitude de movimento apresentava-se normal. Radiografias e tomografia prévias confirmaram LCCR. Optou-se pela OCR ao invés de técnicas corretivas, devido à idade do animal à época do procedimento e à dificuldade no reposicionamento do rádio na articulação. Após 3 anos e meio de pós-operatório, foram realizados novos exames clínicos e radiográficos. O paciente não apresentava dor, apresentava bom apoio do membro e boa amplitude de movimento, permitindo bom movimento do cotovelo. Houve um novo crescimento parcial do segmento proximal da cabeça do rádio ocasionando melhor readequamento do mesmo na articulação. Sinais leves de degeneração articular estavam presentes. A OCR se mostrou efetiva neste caso, provando ser uma boa técnica a ser utilizada nos casos de LCCR quando tratamento conservativo ou técnicas de redução já não podem ser mais utilizados.

Trauma vascular de extremidad superior: presentación de un caso y revisión de la literatura / Upper extremity vascular trauma: a case report and literature review

INTRODUCTION: Vascular trauma is a low frequency event and is related to a high burden of morbidity and mortality. Vascular trauma of the upper limb is of different etiology. More frequent, secondary to closed trauma. It is usually associated with other lesions, soft tissue and nerves. OBJECTIVES: To present a case of complex vascular trauma of the upper limb and its multidisciplinary management. METHOD: Description of the clinical case and literature review. The information was obtained from the patient's clinical record, review and analysis of the published literature was performed using search engines. CASE REPORT: Young man, fall with upper limb in extension, results in elbow dislocation associated with acute ischemia. AngioTAC confirms stop in brachial. Emergency surgery: brachio-radial saphenous bridge. It evolves with absence of pulses. It is reexplored finding incomplete fasciotomy, brachial artery bridge to cephalic vein with inverted saphenous. Elbow dislocated, unstable. Arterial bridge, external fixation and fasciotomy is completed. Coming out with radial pulse. He undergoes multiple surgeries and surgical toilets, achieving skin closure at 45 days. Then traumatology removes external tutors. Electromyography confirms incomplete lesion of median, radial and ulnar. Currently in the process of rehabilitation. DISCUSSION AND CONCLUSION: Vascular trauma of the upper limb is of low incidence. However, they are associated with a high burden of morbidity and mortality, generally occurring in young men. The diagnostic pillar is through the medical history and physical examination. its surgical management.

Minimum effective volume of bupivacaine 0. 5% for ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block / Volume mínimo efetivo de bupivacaína a 0, 5% para abordagem retroclavicular guiada por ultrassom no bloqueio do plexo braquial por via infraclavicular

Abstract Background and objectives: The current study aimed to determine the minimum effective volume (MEV) of bupivacaine 0.5% in 50% of patients for an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block. Methods: A total of 25 adult patients who were scheduled for upper limb surgery received an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block with bupivacaine 0.5%. The needle insertion point was posterior to the clavicle and the needle was advanced from cephalad to caudal. Block success was defined as a composite score of 14 at 30 min after local anesthetic (LA) injection. The minimum effective volume in 50% of patients was determined using the Dixon-Massey up-and-down staircase method. Minimum effective volume for a successful block in 95% of the patients was also calculated using logistic regression and probit transformation. Results: The minimum effective volume of bupivacaine 0.5% resulting in successful block in 50% of patients (MEV50) according to the up-and-down staircase method was found to be 9.6 mL (95% confidence interval (CI), 5.7-13.4). The calculated minimum effective volume required for a successful block in 95% of patients (MEV95) using the probit transformation and logistic regression analysis was 23.2 mL (95% CI, 18.8-36.7). Conclusions: The MEV50 of bupivacaine 0.5% for US-guided retroclavicular approach to infraclavicular brachial plexus block was 9.6 mL and the calculated MEV95 was 23.2 mL. Future studies are required for infraclavicular brachial plexus block with different approaches, other LA agents and different concentrations of bupivacaine.

Resumo Justificativa e objetivos: Determinar o volume mínimo efetivo (VE) de bupivacaína a 0,5% em 50% dos pacientes para uma abordagem retroclavicular guiada por ultrassom no bloqueio do plexo braquial por via infraclavicular. Métodos: Um total de 25 pacientes adultos agendados para cirurgia do membro superior receberam abordagem retroclavicular guiada por ultrassom para o bloqueio do plexo braquial por via infraclavicular com bupivacaína a 0,5%. O ponto de inserção da agulha foi posterior à clavícula e a agulha foi avançada de cefálica para caudal. O sucesso do bloqueio foi definido como um escore composto de 14 aos 30 min após a injeção do anestésico local. O VE em 50% dos pacientes foi determinado com o método de escalonamento progressivo-regressivo de Dixon-Massey. O VE para um bloqueio bem-sucedido em 95% dos pacientes também foi calculado com regressão logística e transformação probit. Resultados: O volume mínimo efetivo (VE50) de bupivacaína a 0,5% que resultou em bloqueio bem-sucedido em 50% dos pacientes, de acordo com o método de escalonamento progressivo-regressivo, foi de 9,6 ml (intervalo de confiança de 95%, IC 5,7-13,4). O cálculo do volume mínimo efetivo necessário para um bloqueio bem-sucedido em 95% dos pacientes (VE95) com a análise de transformação probit e regressão logística foi de 23,2 ml (IC 95%, 18,8-36,7). Conclusões: O VE50 de bupivacaína a 0,5% para abordagem retroclavicular guiada por US para o bloqueio do plexo braquial por via infraclavicular foi de 9,6 ml e o VE95 calculado foi de 23,2 ml. Estudos futuros são necessários para o bloqueio do plexo braquial por via infraclavicular com diferentes abordagens, outros anestésicos locais e diferentes concentrações de bupivacaína.

Upper Body Lift: serie de casos en un hospital clínico universitario entre los años 2013-2016: descripción de la técnica quirúrgica / Upper Body Lift: cases series from a clinical hospital between years 2013-2016, and description of the surgical technique

Introducción: En pacientes obesos la pérdida masiva de peso presenta efectos beneficiosos para la salud, sin embargo, suelen cursar con un excedente cutáneo que genera problemas físicos, afectando la calidad de vida. En casos severos las técnicas convencionales de contorno corporal, no permiten dar solución a grandes alteraciones, siendo necesario utilizar procedimientos más extensos. El Upper Body Lift es una técnica que ofrece un manejo integral del tronco superior. Objetivos: Describir una serie de casos de pacientes sometidos a Upper Body Lift y presentar la técnica quirúrgica. Material y Método: Serie de casos prospectiva entre enero del 2013 y junio de 2016, en un hospital clínico universitario. Se excluyó a pacientes con información incompleta u operados en otro centro. Se utilizó estadística descriptiva. Resultados: 8 pacientes manejados mediante Upper Body Lift, con edad 39,75 ± 9,37 años, 6 (75%) mujeres. Con pérdida de peso de 36,75 ± 9,11 Kg, alcanzando un IMC de 25,97 ± 2,35 Kg/m2. En hombres la región pectoral se manejó con liposucción y posterior injerto de pezón, en mujeres se realizó mastopexia sin implantes en 5 (83,33%). No se observó complicación mayor y en 4 casos (50%) se presentó complicación menor durante posoperatorio. Discusión: Esta serie presenta resultados similares a lo descrito por otros autores. Conclusiones: El Upper Body Lift es un procedimiento que ofrece un manejo integral y con buenos resultados, en pacientes con gran excedente cutáneo en tronco superior.

Introduction: Obese patients gets beneficial health effects with the massive weight loss, however they develop excessive redundant skin and become physical problems affecting their quality of life. In severe cases, the conventional body contouring techniques are not able to solve this large alterations, being necessary to use more extensive procedures. The Upper Body Lift is a technique that offers integral management of the upper trunk. Objectives: To describe a case series of patients submitted to Upper Body Lift and present the surgical technique. Materials and Methods: Prospective case series of patients with Upper Body Lift between January 2013 and June 2016 in a clinical hospital. Patients with incomplete information or operated in another center were excluded. Descriptive statistics was used. Results: 8 patients were included, age 39.75 ± 9.37 years, 6 (75%) women. Prior to the contouring surgery they lose 36.75 ± 9.11 kg, reaching a BMI of 25.97 ± 2.35 kg/m2. In men the chest region was managed with liposuction and subsequent nipple graft, in women mastopexy without implants was performed in 5. No major complications was observed, 4 had minor complications during the postoperative period. Discussion: This series presents similar results to those described by other authors. Conclusions: The Upper Body Lift offers comprehensive and successful management in patients with large upper body disturbance.

Ketorolac versus magnesium sulphate as an adjuvant to lidocaine in intravenous regional anesthesia for upper limb surgeries

Background: intravenous regional anesthesia [IVRA] was first described almost a century ago by August Bier and has been used for the past 50 years. It is a safe anesthetic technique for upper or lower distal limb surgery

Purpose: to compare the onset time of sensory blockade when adding ketorolac versus adding magnesium to the IVRA solution, and to compare the duration of postoperative analgesia

Material and Methods: this is a randomized controlled trial in two groups. The study was performed in Ain Shams University Hospitals. Study period range was 1-2 years

Results: there are 146 patients participated in our study, patients were allocated to two groups 73 patients in each group, a group of which received magnesium sulphate solution and the other received ketorolac solution

Conclusion: we evaluated the effects of adding ketorolac and compared it to the effects of adding magnesium sulphate to the anesthetic solution used in IVRA and we found that magnesium sulphate addition can be of benefit in faster onset of sensory block in the operative limb. However, magnesium sulphate in the used concentration [10 ml MgSo4 10% in 40 ml solution] appeared to cause burning pain varying in intensity while injecting the anesthetic solution

Comparison of two different doses of dexmedetomidine added to ropivacaine in patients posted for upper limb surgery under supraclavicular brachial plexus block

Objective: To compare the effect of adding two different doses of dexmedetomidine to ropivacaine, on onset and duration of analgesia for supraclavicular brachial plexus block in patients scheduled for upper limb orthopedic surgery

Methodology: This prospective randomized double blind comparative study was conducted at our institution. After ethical committee approval and informed patient consents, 50 patients of ASA I, II and aged 21-60 years, who were scheduled for elective upper limb surgery and were enrolled in the study and randomly divided into two equal groups. They received either 30 ml of 0.75% ropivacaine plus dexmedetomidine [1 micro g/kg] diluted with normal saline up to 5 ml [total volume = 35 ml] in Group 1 or 30 ml of 0.75% ropivacaine plus dexmedetomidine [2 micro g/kg] diluted with normal saline up to 5 ml [total volume = 35 ml] in Group 2. The onset and duration of sensory and motor block, duration of analgesia, hemodynamic parameters, sedation score, VAS and side effects were recorded

Results: Onset time of sensory and motor block were earlier in Group 2 than in Group 1 [p < 0.001]. Duration of sensory and motor block and duration of analgesia were longer in Group 2 than in Group 1 [p < 0.001]. There was no significant difference in the incidence of hypotension and bradycardia between both the groups [p > 0.05]. There was a statistically significant reduction in number of rescue analgesic doses and total dose consumption in 24 hours in Group 2 than in Group 1. Quantitative data are represented as arithmetic mean and standard deviation and analyzed using Student's t test or ANOVA as per need. Qualitative data are represented as number [proportion or percentage] and analyzed using Chi square test. The levels of significance and alpha-error were kept 95% and 5% respectively for all statistical analyses. P values < 0.05 were considered significant

Reconstruções complexas de membros superiores e inferiores com retalhos de fluxo reverso: uma série de 32 casos / Complex reconstruction of the upper and lower limbs by using reverse-flow flaps: a series of 32 cases

Introdução: A reconstrução de partes moles após perdas de substância do terço distal dos membros superiores e inferiores, principalmente quando associada à exposição de estruturas nobres (osso, tendão, nervos ou vasos sanguíneos), continua a desafiar a cirurgia plástica. Os retalhos fasciocutâneos de fluxo reverso são uma eficiente opção cirúrgica na cobertura de lesões pequenas e médias nesta localização. Método: Foi realizado um estudo clínico retrospectivo, no período de janeiro de 2013 a dezembro de 2014, de uma série de 32 casos de traumas complexos em membros superiores e inferiores. Resultados: Foram realizados 24 retalhos de fluxo reverso nos membros inferiores e 8 nos membros superiores, observando-se uma cobertura eficaz dos defeitos. Conclusão: Os retalhos de fluxo reverso são confiáveis e apresentam arcos de rotação que permitem a cobertura de lesões diversas no terço distal de membros superiores e inferiores.

Introduction: Reconstruction of the soft tissues after loss of substance in the distal third of the upper and lower limbs, in particular when associated with the exposure of noble structures (bone, tendon, nerves, or blood vessels), remains a challenge in plastic surgery. Fasciocutaneous reverse flow flaps are an efficient surgical option for covering small and medium lesions in this location. Method: A retrospective clinical study was performed on a series of 32 cases of complex trauma of the upper and lower limbs treated between January 2013 and December 2014. Results: A total of 24 reverse-flow flaps were performed in the lower limbs and eight in the upper limbs, resulting in efficient coverage of the defects. Conclusion: Reverse-flow flaps are reliable and present rotation arcs that allow coverage of a variety of lesions in the distal third of the upper and lower limbs.

Braquiotoracoplastia em Z no tratamento do contorno corporal após perda ponderal maciça / Z brachiothoracoplasty for body contouring after massive weight loss

INTRODUÇÃO: A braquioplastia trata as deformidades dos membros superiores. A toracoplastia lateral visa o tratamento do torso superior. As braquioplastias, toracoplastias e também as braquiotoracoplastias em Z têm sido utilizadas no Hospital Estadual de Sapopemba no tratamento das deformidades dos membros superiores e terço superior do tórax. Objetivo: Propõe-se descrever as modificações na técnica cirúrgica resultando na braquiotoracoplastia em Z e analisar a casuística e os resultados obtidos, no tratamento das deformidades da região lateral do tórax. MÉTODO: Foram submetidos à braquiotoracoplastia e toracoplastia lateral 31 pacientes. A demarcação foi feita em posição ortostática, e os membros superiores abduzidos em 90o. Iniciou-se pela demarcação da braquioplastia, em duplo fuso, prolongando-se de maneira modificada a demarcação, seguindo pela linha axilar anterior em direção ao sulco inframamário em forma de Z. RESULTADOS: Todos os pacientes referiram melhora do contorno da região e não houve queixas quanto ao posicionamento da cicatriz. DISCUSSÃO: O procedimento da braquiotoracoplastia em Z atual consiste em estender a linha de incisão da face medial do braço, passando proximalmente à axila e continuando pela linha axilar média até o sulco mamário. Ocorreu a melhora do contorno da região dorsal e das dobras cutâneas da região torácica lateral. CONCLUSÃO: A braquiotoracoplastia em Z e a toracoplastia lateral têm a grande vantagem de eliminar a cicatriz circunferencial no torso superior, promovendo a melhoria do contorno dessa região por meio da ressecção cutânea tanto no sentido craniocaudal, como anteroposterior.

INTRODUCTION: Brachioplasty treats deformities of the upper limbs. Lateral thoracoplasty treats the upper torso. Brachioplasties, thoracoplasties, and brachiothoracoplasties have been performed with Z-plasty for deformities of the upper limbs and upper third of the chest, in the Sapopemba State Hospital. Objective: We describe modifications of surgical technique for the performance of Z brachiothoracoplasty, and evaluate the results of treatment of deformities of the lateral chest. METHOD: Thirty-one Patients underwent brachiothoracoplasty and lateral thoracoplasty. The demarcation was made with the patient upright, and the upper limbs abducted at 90º. Marking for brachioplasty was performed using a double-ellipse, to lengthen the modified demarcation along the anterior axillary line toward the inframammary crease in a Z shape. RESULTS: All patients reported an improvement in the contour of the region, and there were no complaints regarding the positioning of the scar. DISCUSSION: Z brachiothoracoplasty consists of extending the incision line on the medial aspect of the arm, passing proximally to the axilla, and continuing through the midaxillary line to the inframammary crease. There was an improvement in the contour of the dorsal region and the skin folds of the lateral thoracic region. CONCLUSION: Z brachiothoracoplasty and lateral thoracoplasty have the great advantage of eliminating a circumferential scar on the upper torso, thereby improving the contour of the region through skin resection in both the craniocaudal and anteroposterior directions.

Braquioplastia pós-gastroplastia: avaliação da satisfação dos pacientes / Brachioplasty after bariatric surgery: evaluation of patient satisfaction

Introdução: A deformidade dos membros superiores, causada pela perda ponderal maciça, pode ser corrigida por meio da braquioplastia. Essa cirurgia plástica visa melhorar o contorno dos membros, facilitar a higiene e possibilitar o uso de determinadas vestimentas. Objetivo: Demonstrar casuística, relatar intercorrências e complicações e avaliar a satisfação de pacientes submetidos à braquioplastia após gastroplastia. Método: Trinta e quatro pacientes (97% mulheres, idade 46,6 ± 12 anos) submetidos à braquioplastia após cirurgia bariátrica foram recrutados para o estudo. Descrevemos a ocorrência de intercorrências e complicações associadas ao procedimento cirúrgico e avaliamos a satisfação de 33 pacientes por meio de entrevista qualitativa e questionário específico. Resultados: Como complicações menores, observou-se pequena deiscência em cinco pacientes (14,7%); não foram observadas complicações cirúrgicas maiores. O grau de satisfação foi obtido em 81,8% dos pacientes e o resultado alcançado ficou próximo das expectativas de 69,7% deles. Conclusões: As técnicas utilizadas de braquioplastia pós-bariátrica restabeleceram o adequado contorno braquial, com baixo índice de complicações menores e alto grau de satisfação dos pacientes avaliados.

Introduction: Upper limb deformity caused by massive weight loss can be corrected by brachioplasty. This plastic surgery improves limb contour, facilitates hygiene, and enables use of certain clothing. Objective: To present the cases, describe interventions and complications, and evaluate the satisfaction of patients who underwent brachioplasty after bariatric surgery. Method: Herein, 34 patients (including 33 females) aged 46.6 ± 12 years, who underwent brachioplasty after bariatric surgery, were recruited for the study. Interventions and complications associated with the surgical procedure were described, and the satisfaction of 33 patients was evaluated by a qualitative interview and specific questionnaire. Results: As a minor complication, slight dehiscence was observed in five patients (14.7%), but no major surgical complications were seen. Some degree of satisfaction was reported by 81.8% of the patients, and the outcome achieved in 69.7% was close to that expected. Conclusions: The brachioplasty techniques that were used restored proper arm contour with a low rate of minor complications, and a high degree of satisfaction among the patients evaluated.

Short term outcome of brachial plexus block in vascular access surgery

To present short term outcome of brachial plexus block for upper limb vascular access procedures performed for renal dialysis. This is a retrospective review of all cases that had a brachial plexus block for a renal dialysis vascular access procedure at the vascular surgery unit in King Hussein Medical Center, Amman, Jordan, between January 2009 and September 2011. Two hundred eighty- eight patients [172 males, 116 females] with a mean age of 41 [19-68] years had the block. In 183 [63.5%] patients the procedure was primary and in 75 [26.0%] patients it was native access. Procedures performed included: 27 [9.4%] brachio-cephalic arteriovenous fistula, 48 [16.7%] basilic vein transposition, 96 [33.3%] forearm prosthetic loop graft, 67 [23.3%] upper arm prosthetic loop graft, 25 [8.7%] salvage procedures with interposition prosthetic grafts, 14 [4.9%] removal of infected prosthetic grafts, and 11 [3.8%] repairs of false aneurysms and disrupted anastomoses. All blocks were guided by a nerve stimulator at strength of 0.2-0.5MHZ and Bupivacaine 0.375 [25-35 ml] used for the block. Supraclavicular block was used in 132 [45.8%] patients while combined supraclavicular and axillary blocks were used in 156 [54.2%] patients. When local anesthetic infiltration was needed for supplementation of the block, Lignocaine 1% [10-15 ml] was used. Data regarding the procedure, adequacy of the block, time of onset, duration of block, and immediate complications was retrospectively collected from anesthetic charts and operative records. All patients had an adequate block with no conversions to general anesthesia or cancellation of the procedure. A successful block was achieved in 232 [80.6%] patients while a partially successful block was achieved in 56 [19.4%] patients. The median time for onset of the block was 10 [5-20] minutes for motor block and 15 [10-35] minutes for sensory block. The mean duration of the block was 5.6 [2.2-48.0] hours. Prolonged blocks beyond 24 hours occurred in 5 patients [48 hours in 1 patient, 36 hours in 1 patient, and 24 hours in 3 patients]. Injection related complications included discomfort during injection in 100 [34.7%] patients and local hematomas relieved by compression in 8 [2.8%] patients]. Transient nerve paralysis complicated 82 [28.5%] cases [phrenic nerve in 57 [19.8%] patients, sympathetic chain resulting in Horner's syndrome in 20 [6.9%] patients and vagus nerve resulting in hoarseness of voice in 5 [1.7%] patients]. No clinically detectable pneumothorax or drug toxicity occurred. No peri-operative mortality was reported during the study period. Brachial plexus block is an effective and safe mode of anesthesia for upper limb renal dialysis vascular access procedures. It offers major advantages over general anesthesia and enjoys low rate of failure and complications. Its use as a main mode of anesthesia for such procedures is advisable

Primer simulacro de amputación traumática de miembro superior de necesidad y rescate en un escenario inhóspito. Base Marambio, Antártida Argentina. 9 de diciembre de 2011 / First simulacrum of traumatic upper limb amputation of necessity and rescue a bleak scenario. Bse Marambio, Antarctica Argentina. December 9, 2011

Se efectuó un simulacro de amputación de necesidad y rescate en dependencias de la Base Marambio (Antártida Argentina). La amputación de una extremidad constituye un dilema al cual está sujeto un médico en determinadas situaciones críticas. Además, los intentos infructuosos para salvar una extremidad irrecuperable están asociados a una alta morbilidad y muchas veces son letales para el paciente. Existen innumerables discusiones en relación con los criterios de predicción para conservar un miembro lesionado, por lo que se han propuesto varios índices de valoración para determinar qué extremidad puede ser conservada o cuál amputada. Por ello en el presente trabajo se efectúa una revisión bibliográfica sobre el uso de tablas y/o criterios para la toma de tal decisión. Se efectuó un ejercicio simulado en el cual se consideró la escena (situación de aislamiento geográfico, características inhóspitas y recursos limitados en la Antártida) y el estado de atrapamiento de la víctima, más la irrecuperabilidad de la porción distal del miembro superior, en donde debía priorizarse la vida del paciente, respecto a la pérdida de la extremidad que ya se encontraba mutilada en forma irreversible, con el fin de ser estabilizado y extricado del lugar para ser trasladado a otro espacio para completar con mejores medios su tratamiento definitivo. Dicho ejercicio se realizó como parte de la capacitación continua del personal que se desempeña en las Bases Antárticas, que dadas las características del escenario antártico, hacen necesaria tal preparación para afrontar situaciones de extrema gravedad en un lugar inhóspito y alejado del continente.

We conducted a mock amputation and rescue agencies need the Marambio Base (Antarctica Argentina). The amputation of a limb is a dilemma which is subject to a doctor in certain critical situations. In addition, unsuccessful attempts to save a limb unrecoverable are associated with high morbidity and are often lethal to the patient. There are countIess discussions regarding prediction criteria to retain an injured limb, so that several indices have been proposed assessment to determine what can be preserved limb amputated or what, why in the present study the authors reviewed the literature on use of tables and/or criteria for making such a decision. We conducted a simulation exercise, which was considered the scene (geographical isolation, limited resources and inhospitable features in Antarctica) and the state of entrapment of the victim, plus the irrecoverable from the distal upper limb, where needed to prioritize the patient's life, about the loss of the limb that was already irreversibly mutilated, in order to be stabilized and extricated the place to be moved to a place with better ways to complete definitive treatment. This exercise was conducted as part of the continuous training of personnel working in the Antarctic Bases, that given the characteristics of the Antarctic scenario necessitates such a preparation to deal with situations of extreme gravity in an inhospitable place and away from the continent.

Ultrasound-guided single injection infraclavicular brachial plexus block using bupivacaine alone or combined with dexmedetomidine for pain control in upper limb surgery: a prospective randomized controlled trial

Dexmedetomidine, is a selective alpha2-adrenoceptor agonist that is used as an adjuvant mixed with local anesthetics during regional anesthesia. This study was designed to test the efficacy of adding dexmedetomidine to bupivacaine during placement of infraclavicular brachial plexus blockade [ICB]. Sixty adult patients were divided into 2 equal groups of 30 subjects each. Patients in Group I received an ICB using 30 mL of 0.33% bupivacaine and Group II patients received 30 mL of 0.33% bupivacaine mixed with 0.75 micro g/kg of dexmedetomidine. The following brachial plexus nerve block parameters were assessed: block success rate, sensory onset time and duration, motor block onset time and duration, analgesic pain scores using the verbal rating scale [VRS] for pain, duration of analgesia, and amount of supplemental intravenous [IV] morphine required. There was a statistically significant shorter time to onset of sensory blockade [13.2 vs 19.4 min, P=0.003], longer duration of sensory block [179.4 vs 122.7 min, P=0.002], shorter onset time to achieve motor block [15.3 vs 22.2 min, P=0.003], longer duration of motor block [155.5 vs 105.7 min, P=0.002], lower VRS pain scores, prolonged analgesia [403 vs 233 min, P=0.002], and lower morphine rescue requirements for 48 h after surgery [4.9 [0-8.0] vs 13.6 mg [4.0-16.0] mg, P=0.005]. All patients recovered without evidence of sensory or motor deficit.: Adding dexmedetomidine to bupivacaine during the placement of an ICB provides: [1] enhancement of onset of sensory and motor blockade, [2] prolonged duration of analgesia, [3] increases duration of sensory and motor block, [4] yields lower VRS pain scores, and [5] reduces supplemental opioid requirements

Abordaje infraclavicular del plexo braquial para cirugía de miembro superior / Infraclavicular approach of the brachial plexus for superior limb surgery

El objetivo del estudio fue mostrar la eficacia y seguridad del bloqueo braquial para analgesia y anestesia del miembro superior por un abordaje a nivel de la fosa infraclavicular, fácil y reproducible, en un medio hospitalario donde no hay ecografía. Se realizó en 63 pacientes que se iban a someter a osteosíntesis de húmero, codo, muñeca y mano sin contraindicaciones. Se abordó a nivel de la fosa infraclavicular, por punción vertical, buscando respuesta de dedos por neurolocalización a 0,5 mA. Se utilizó lidocaína al 1% y bupivacaína al 0,375 % y al 0,25%, según se buscara anestesia o analgesia, en un volumen de 30-40 ml. Se logró respuesta muscular en 59 pacientes, 58 con respuesta distal, uno con respuesta de flexión de antebrazo, en dos se obtuvieron parestesia sin neurolocalización y en dos no se logró ninguna respuesta. De 61 pacientes a los que se realizó el bloqueo, se buscó anestesia en 24, lográndose en 21, en los tres restantes el bloqueo fue analgésico. En todos los casos se buscó analgesia, y se usó la escala visual análoga de 0-1 en la primera evaluación en recuperación. No hubo neumotórax ni elementos clínicos de intoxicación por anestésicos locales. Hubo tres punciones venosas que no impidieron la realización del bloqueo. Este abordaje es eficaz tanto para la realización de anestesia como analgesia de miembro superior, y seguro, por lo que creemos que debería ser una herramienta de más extendida utilización.

Plexiform neurofibroma of the upper limb / Neurofibroma plexiforme de membro superior

The authors present an unusual case of plexiform neurofibroma affecting the upper limb in a patient diagnosed with type 1 neurofibromatosis. Tumor resection was performed on the median nerve. The patient showed maintenance of limb function and remission of symptoms of pain after four years of follow-up.

Os autores apresentam um caso incomum de neurofibroma plexiforme acometendo o membro superior, com diagnóstico de neurofibromatose do tipo 1. Realizou-se a ressecção do tumor no nervo mediano. A paciente evoluiu com manutenção da função do membro e remissão dos sintomas de dor após seguimento de quatro anos.

Use of neostigmine to augment intravenous regional anesthesia using lignocaine in upper limb surgery

To evaluate the effects of neostigmine on onset and duration of Intravenous regional anesthesia [IVRA] when added to lignocaine. Randomized control trial. Combined Military Hospital Rawalpindi from 21 September 2006 to 23 April 2008. One hundred patients undergoing hand surgery were randomly assigned to two groups to receive IVRA. The control group received 1 mililiter [mL] of saline plus 3 miligram per kilogram [mg/kg] of lignocaine diluted with saline to a total dose of 40 mL, the study group received 0.5 mg [1ml] of neostigmine plus 3 mg/kg of lignocaine diluted with saline to a total dose of 40 mL. Sensory block and motor block onset and recovery were noted. Heart rate, mean arterial blood pressure, and oxygen saturation values were noted before surgery Imin, 5 min, 10 min, 20 min, and 40 min and after tourniquet release. Time to first analgesic requirement was also noted. The mean sensory block onset was 4.14 min as compared to 10.1 min in control group. Mean value of motor block onset was 6.3 min as compared to 13.8 min in control group.similarly mean for sensory recovery was 6.9 min as compared to 3.1 min for control group. Mean value for motor recovery was 5.17 min as compared to 2.17 min in control group. Experiment group had their demand for analgesics after a mean of 35.3 min and control group had their analgesia after 16.5 min. There was highly significant difference in all the variables. We concluded that neostigmine as an adjunct to lignocaine improves quality of anesthesia and is beneficial in IVRA

Isquemia artrial crónica de miembro superior con resolución quirúrgica: relato de un caso poco frecuente / Chronic arterial ischemia of the upper extremity with surgical resolution: report of an uncommon patient

The arterial reconstruction as a treatment for chronic ischemia of the upper extremities is common during the current surgical practice. It represents only the 4% of the total vascular surgical operations, by which only few reports have been published in the worldwide literature. Ischemic pathology of the upper extremities differs from the lower extremities, because it is more frequent the observation of a history of embolia, trauma, collagen vascular disease and thromboanguiitis obliterans. The surgical resolution is not frequent and the loss of the extremity even less, due to the abundantly colateral circulation of the vascular tree. A patient with this pathology is reported and the surgical management is discussed.

Anestesia para miembro superior con la utilización del estimulador de nervio periférico: Hospital Vicente Corral Moscoso – 2007 / Anesthesia for upper limb with the use of peripheral nerve stimulator: Vicente Corral Moscoso Hospital - 2007

Con un diseño descriptivo longitudinal se incluyeron 105 pacientes de ambos sexos, ASA I - III, a quienes se realizó bloqueo de plexo braquial con bupivacaína, lidocaína o la mezcla de ambas con la ayuda de un neuroestimulador (Stimuplex Dig-RC™ de Braun™) para ser sometidos a cirugía de miembro superior en el Hospital Vicente Corral de Cuenca, Ecuador, en un período de dos años, se alcanzó un 97,2% de bloqueos exitosos y de éstos el 86.7% fueron completos y el 10,5% parciales. La edad promedio de la muestra fue de 29,4 ± 19,8 años con un rango entre 5 y 75 años. Los varones fueron el 71,4%. Artesanos y pacientes sin ocupación (estudiantes y preescolares) fueron el 76,1% del grupo, el 62.9% (n = 66) de las intervenciones fueron electivas. El acceso supraclavicular se utilizó en el 42,9% (n = 45), el interescalénico en el 41.% (n = 43) y el axilar en el 16.2% (n = 17),el tiempo quirúrgico tuvo una mediana de 90 min (rango 10 a 240), el tiempo anestésico de 120 min (rango 30 a 420) y el tiempo de analgesia de 250 min (rango 30 a 640), dos pacientes (1.9%) presentaron desorientación, ansiedad y diaforesis transitorias que se normalizaron en 20 – 30 min.

With a longitudinal descriptive design 105 patients of both sexes included themselves, ASA I - III, to those who blockade of brachial plexus with bupivacaine, lidocaine or mixture of both with aid of a neuroestimulator was made (Stimuplex Dig-RC™ Braun™) to be undergoing surgery of superior member in Vicente Corral Hospital of Cuenca, Ecuador, in a period of two years, a 97.2% of successful blockades were reached and of these the 86,7% were complete and 10.5% partisans. The age average of the sample was of 29.4 ± 19.8 years with a rank between 5 and 75 years. The men were 71.4%. Craftsmen and patients without occupation (students and prestudents) were 76.1% of the group, the 62,9% (n = 66) of the interventions were elective. The access to supraclavicular was used in 42.9% (n = 45), the interescalénico in (the 41,% n = 43) and the axillary one in the 16,2% (n = 17), the surgical time min had a medium one of 90 (rank 10 to 240), anesthetic time of 120 min (rank 30 to 420) and time of analgesia of 250 min (rank 30 to 640).Two patients (1,9%) showed transitory disorientation, anxiety and diaphoresis that were normalized in 20 - 30 min.