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

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

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

Fluoroscopy-guided subclavian vein catheterization in children with hematologic diseases: methodology study / 介入放射学杂志

Objective To investigate the success rate of fluoroscopy-guided subclavian vein catheter implantation (SVCI) in children with hematologic diseases,to improve the visualization of the position of the catheter head,and to reduce the incidence of procedure-related complications.Methods Fluoroscopyguided SVCI was performed in 183 sick children (aged 1-16 years) with confirmed hematologic disease.The success rate of the catheter implantation,the number of needle puncturing,the operation time,the fluoroscopy time and the occurrence of procedure-related complications were recorded.Results Successful fluoroscopy-guided SVCI was accomplished in all 183 sick children,with a success rate being 100％.Successful SVCI was obtained with ＜3 times of puncturing in 151 sick children (82.5％),with 4-6 times of puncturing in 25 sick children,and with 7-10 times of puncturing in 7 sick children.The catheter tip was successfully positioned at the junction of the superior vena cava with the right atrium in all sick children.The operation time ranged from 5 min to 25 min with a mean of (10.38±4.04) min.The fluoroscopy time varied from 16 seconds to 607 seconds with a mean of (65.46±55.86) seconds.During the procedure,artery was wrongly punctured two times in two sick children.The mean follow-up time was 35 days.Cather-related infection occurred in 2 sick children.No local hematoma at puncture point,nor hemopneumothorax or catheter-related thrombosis occurred.Conclusion Fluoroscopy-guided SVCI has high technical success rate in children with hematologic diseases.For a successful procedure of SVCI,less number of needle puncturing is needed by using this technique.The satisfaction rate for the placement of catheter tip is high and the incidence of complications is low.Therefore,fluoroscopy-guided SVCI is a safe and effective method.

Relaciones anatómicas de la vena subclavia en un grupo de recién nacidos con puntos de orientación óseos para su mejor punción con técnica infraclavicular y supraclavicular

Introducción. Objetivo: corroborar de manera objetiva las diferencias anatómicas existentes en el trayecto de la vena subclavia en un grupo de recién nacidos para describir la mejor técnica de punción subclavia en este grupo de edad. Material y métodos. Estudio quirúrgico-radiológico, descriptivo, prolectivo, midiendo distancias de la vena subclavia con relación a la clavícula y la articulación esterno-clavicular. Resultados. El punto donde cruza la vena a la clavícula es más lateral respecto a lo reportado en la literatura. La profundidad de la vena respecto a la clavícula es de 3.2 mm para el lado izquierdo (2-5) y de 2.0 mm para el lado derecho, el ángulo ascendente que sigue la vena es en promedio de 38° del lado izquierdo y de 34° del lado derecho. El punto más alto de la vena sobre la articulación es de 9 mm del lado izquierdo y 7 mm del lado derecho. Los ángulos en la porción descendente de la vena subclavia son en promedio de 27° del lado izquierdo y de 81° del lado derecho. Conclusiones. Se propone una técnica de punción de la vena subclavia tanto con técnica supra como infraclavicular en recién nacidos, basada en los hallazgos anatómicos.

Introduction. To correlate in an objective manner the anatomical differences of the subclavian vein in newborns for a better approach to it's puncture. Material and methods. A descriptive, surgical and pathological study in cadavers measuring the subclavian vein related to the clavicle and the sterno-clavicular joint. Results. The specific point where the subclavian vein cross the clavicle is lateral than the 1 reported in literature. The deepness of the vein with respect to the clavicle is 3.2 mm for the left side and 2 mm for the right, the ascending angle of the vein is 38° on the left and 34° on the right side. The highest point of the vein over the joint is 9 mm on the left and 7 mm on the right side. The descending angles of the vein are 27° on the left and 81° on the right side in average. Conclusions. We propose, based on our results, a puncture technique for the subclavian vein in newborns either with the supra or infraclavicular technique.