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.

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.

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.

The need for supplemental blocks in single versus triple injections in infraclavicular brachial plexus blocks with a medial approach: a clinical and anatomic study / Bloqueio complementar de nervos no bloqueio de plexo braquial infraclavicular com técnica medial de injeção única versus tripla: estudo anátomo-clínico

Abstract Background and objectives: To evaluate the single-injection and triple-injection techniques in infraclavicular blocks with an ultrasound-guided medial approach in terms of block success and the need for supplementary blocks. Methods: This study comprised 139 patients who were scheduled for elective or emergency upper-limb surgery. Patients who received an infraclavicular blocks with a triple-injection technique were included in Group T (n = 68). Patients who received an infraclavicular blocks with a single-injection technique were included in Group S (n = 71). The number of patients who required supplementary blocks or had complete failure, the recovery time of sensory blocks and early and late complications were noted. Results: The block success rate was 84.5% in Group S, and 94.1% in Group T without any need for supplementary nerve blocks. The blocks were supplemented with distal peripheral nerve blocks in 8 patients in Group S and in 3 patients in Group T. Following supplementation, the block success rate was 95.8% in Group S and 98.5% in Group T. These results were not statistically significant. A septum preventing the proper distribution of local anesthetic was clearly visualized in 4 patients. The discomfort rate during the block was significantly higher in Group T (p < 0.05). Conclusion: In ultrasound-guided medial-approach infraclavicular blocks, single-injection and triple-injection techniques did not differ in terms of block success rates. The need for supplementary blocks was higher in single injections than with triple injections. The presence of a fascial layer could be the reason for improper distribution of local anesthetics around the cords.

Resumo Justificativa e objetivos: Avaliar as técnicas de injeção única e tripla no bloqueio infraclavicular, empregando-se acesso medial guiado por ultrassonografia, comparando-se o sucesso do bloqueio e a necessidade de bloqueios complementares. Método: O estudo incluiu 139 pacientes com indicação de cirurgia de membro superior eletiva ou de emergência. O Grupo T (n = 68 pacientes) recebeu bloqueio infraclavicular com técnica de injeção tripla e o Grupo S (n = 71), bloqueio infraclavicular com injeção única. Registrou-se o número de pacientes que necessitaram bloqueio complementar de nervo ou que apresentaram falha completa do bloqueio, o tempo de recuperação do bloqueio sensorial e as complicações precoces e tardias. Resultados: A taxa de sucesso do bloqueio infraclavicular, sem necessidade de bloqueio complementar de nervo, foi 84,5% e 94,1% para os Grupos S e T, respectivamente. No bloqueio infraclavicular foi necessário bloqueio de nervos periféricos distais em 8 e 3 pacientes dos Grupos S e T, respectivamente. Após a complementação, a taxa de sucesso do bloqueio foi 95,8% e 98,5% para os Grupos S e T, respectivamente. Os resultados não foram estatisticamente significantes. Imagem de septo impedindo a distribuição adequada do anestésico local foi claramente visualizada em quatro pacientes. A taxa de desconforto durante a realização do bloqueio foi estatatisticamente mais alta no Grupo T (p< 0,05). Conclusões: As técnicas de injeção única e tripla em bloqueio infraclavicular guiado por ultrasonografia com acesso medial não diferiram quanto à taxa de sucesso. A necessidade de bloqueio complementar foi maior com a técnica de injeção simples. A ocorrência de invólucro de fascia poderia justificar a distribuição inadequada do anestésico local ao redor dos fascículos do plexo.

A Comparative Prospective Randomized Clinical Study Between Supraclavicular Perivascular Technique And Infraclavicular Brachial Plexus Blockade For Below Elbow Surgeries

OBJECTIVE: To compare the efficacy of supraclavicular perivascular technique and vertical infraclavicular achial plexus block, using nerve locator for below elbow surgeries. MATERIALS AND METHODS: Eighty patients of ASA grade I or II of either sex undergoing below elbow surgeries (mostly orthopedic surgeries) were randomly allocated into group S and group I. Each group comprises of 40 patients. Surgery was done under Vertical Infraclavicular approach of Brachial plexus Block in Group I Supraclavicular perivascular approach of Brachial plexus block in GroupS. RESULTS: The supraclavicular perivascular technique and vertical infraclavicular achial plexus block, using nerve locator for below elbow surgeries to evaluate the Ease of technique ,Time taken for the onset of sensory and motor blockade ,Total duration of sensory and motor blockade and Occurrence of complications statistically showed no significant differences between the two groups. CONCLUSION: Nerve locator guided Infraclavicular block of achial plexus is similar to nerve locator guided supraclavicular block in the form of ease of technique, onset and duration of sensory & motor blockade and on complication rate.

Usefulness of ultrasound-guided infraclavicular brachial plexus block: a comparison with nerve stimulation method / 대한마취과학회지

BACKGROUND: Recently, ultrasound guidance in clinical procedures including brachial plexus block has gained popularity. This method has been considered to be an efficient and a useful method with real-time visualization. Many reports have showed the usefulness of ultrasound-guided brachial plexus block. We evaluated the usefulness of ultrasound guidance in infraclavicular brachial plexus block compared with nerve stimulation. METHODS: Thirty patients were randomized into two groups of US group (ultrasound-guided block) and NS group (nerve stimulation). Blocks were performed with mepivacaine 2% and bupivacaine 0.5% with epinephrine 1:200,000 (total volume 40 ml). Block execution time, onset time, success rate, patient's discomfort and complications were measured and statistically evaluated for the comparison. RESULTS: Block execution time were 88.3 +/- 48.1 sec in US group and 172.7 +/- 103.1 sec in group NS, respectively (P = 0.017). Onset time were 16.0 +/- 6.9 min and 17.7 +/- 7.8 min (P = 0.434). Success rates were 93.3% and 80.0% (P = 0.283). Patient's discomfort was not significantly different. Pain in patients with fractured arm was significantly lower in US group (P = 0.004). CONCLUSIONS: An ultrasound-guided infraclavicular brachial plexus block is useful with less time consumption and less discomfort in patients with fracture of arm. Success rate and onset time were acceptable.

A Simultaneous Application of Brachial Plexus Block and Combined Spinal-Epidural Anesthesia for the Reduction of Radioulnar Fracture and Iliac Bone Graft : A Case Report / 대한마취과학회지

Brachial plexus block is a suitable, technique for surgery of the forearm, because it provides good intraoperative anesthesia and prolonged postoperative analgesia when long-acting local anesthetics are used. An eighty-year-old male patient was admitted to our hospital for right radioulnar fracture. He had active pulmonary tuberculosis, severe valvular heart disease, hypertension, mild subarachnoid hemorrhage and a difficult airway. So, we performed an infraclavicular block to treat the fracture site and used a nerve stimulator when median nerve dital response and musculocutaneous nerve response were sought, and combined spinal-epidural block for the iliac bone graft at the same time. Regional anesthesia many advantages compared to general anesthesia in extremity operation. Peripheral nerve block and neuraxial block, when used properly in combination, should be able to replace general anesthesia in the majority of cases.