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Bingül ES, Canbaz M, Güzel M, Şalvız EA, Akalın BE, Berköz Ö, Emre Demirel E, Sungur Z, Savran Karadeniz M. Comparing the clinical features of lateral and medial approaches of costoclavicular technique versus traditional lateral sagittal technique as infraclavicular brachial plexus block methods: a randomized controlled trial. BMC Anesthesiol 2024; 24:254. [PMID: 39054425 PMCID: PMC11270787 DOI: 10.1186/s12871-024-02645-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/18/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND It is aimed to compare the block onset times and performance features of costoclavicular techniques (medial and lateral approach) versus lateral sagittal technique. METHODS Patients were randomized into three groups. For costoclavicular techniques, ultrasound probe was placed parallel to clavicle obtaining nerve cords, axillary artery and axillary vein visual from lateral-to-medial, respectively. The block needle was advanced from lateral (Group CLB) or medial (Group CMB) to perform costoclavicular block. For lateral sagittal technique (Group LSB), ultrasound probe was placed sagittal and perpendicular below the coracoid process to obtain sagittal artery image with the cords around. Total 20 ml of 0.5% bupivacaine and 10 ml of 2% lidocaine were deposited for all groups. Sensory and motor block onset times, block performance properties, complications, and patient/surgeon satisfactions were investigated. RESULTS Among 56 patients, the primary outcome, sensory block onset time was shorter in Group CLB than Group CMB and Group LSB (10 [5-15], 10 [10-20], and 15 [10-15] minutes, respectively, p < 0.05). Motor block onset was also fastest in Group CLB (15 [10-20] mins for CLB, 20 [15-20] mins for LSB, and 22.5 [15-25] mins for CMB, p = 0.004). Block performance properties did not differ between the groups. The only complication observed was vascular puncture with an incidence of 28% in Group CMB. CONCLUSIONS Lateral approach costoclavicular technique provides fastest block onset than the other techniques. Considering the success and safety profile, this technique stands as a good alternative in clinical practice. TRIAL REGISTRATION This study is prospectively registered to clinicaltrials.gov on 20/02/2022 (NCT05260736).
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Affiliation(s)
- Emre Sertaç Bingül
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Mert Canbaz
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Güzel
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Emine Aysu Şalvız
- Department of Anesthesiology, Regional Anesthesia & Acute Pain, Washington University in St Louis, School of Medicine, St. Louis, USA
| | - Bora Edim Akalın
- Department of Aesthetic, Plastic and Reconstructive Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ömer Berköz
- Department of Aesthetic, Plastic and Reconstructive Surgery, Division of Hand Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ebru Emre Demirel
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zerrin Sungur
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Meltem Savran Karadeniz
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Saraswat RK, Deganwa M, Verma K, Bharadwaj A. Diaphragmatic and Pulmonary Functions Following an Ultrasound-Guided Supraclavicular Approach Versus a Costoclavicular Approach of a Brachial Plexus Block: A Randomized Study. Cureus 2024; 16:e62586. [PMID: 39027757 PMCID: PMC11257650 DOI: 10.7759/cureus.62586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION A costoclavicular brachial plexus block is an emerging infraclavicular approach that targets the cords lateral to the axillary artery, providing rapid onset of sensory-motor blockade. However, the incidence of hemi-diaphragmatic paralysis (HDP), a potential complication, remains unclear compared to the widely used supraclavicular (SC) approach. This study aimed to compare the incidence of HDP between ultrasound-guided costoclavicular and SC brachial plexus blocks. OBJECTIVES To compare the influence of ultrasound-guided SC and costoclavicular brachial plexus blocks on diaphragmatic excursion, thickness, and contractility along with pulmonary function. MATERIALS AND METHODS This prospective, randomized, observer-blinded controlled trial included 60 patients undergoing below-shoulder surgeries. Patients were randomized to receive either ultrasound-guided SC (Group S) or costoclavicular (Group C) brachial plexus block with 0.5% levobupivacaine. The diaphragmatic function was assessed using ultrasonographic evaluation of diaphragm thickness and diaphragmatic thickness fraction (DTF) pre- and postblock. Pulmonary function tests (PFTs) (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and peak expiratory flow rate (PEFR)) were performed preblock and two hours postblock. Block characteristics were compared. RESULTS The SC group exhibited a significantly larger reduction in DTF from preblock to postblock compared to the costoclavicular group (mean ΔDTF: 34.38% vs. 14.01%, p<0.01). Both groups showed significant declines in FVC, FEV1, and PEFR postblock, but the magnitude of deterioration was significantly greater in the SC group, displaying no significant difference in block characteristics. CONCLUSION The costoclavicular brachial plexus block demonstrated superior preservation of diaphragmatic contractility and lesser deterioration of PFTs compared to the SC approach while being equally effective. These findings highlight the potential benefits of the costoclavicular technique in minimizing diaphragmatic dysfunction and respiratory impairment, particularly in patients at risk for respiratory complications.
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Affiliation(s)
- Rajkumar K Saraswat
- Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Jaipur, IND
| | - Mangilal Deganwa
- Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Jaipur, IND
| | - Kalpana Verma
- Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Jaipur, IND
| | - Avnish Bharadwaj
- Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Jaipur, IND
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Tekin E, Aydin ME, Turgut MC, Karagoz S, Ates I, Ahiskalioglu EO. Can ultrasound-guided infraclavicular block be an alternative option for forearm reduction in the emergency department? A prospective randomized study. Clin Exp Emerg Med 2022; 8:307-313. [PMID: 35000358 PMCID: PMC8743679 DOI: 10.15441/ceem.20.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/23/2020] [Indexed: 11/23/2022] Open
Abstract
Objective Ultrasound-guided infraclavicular nerve block (IB) has become a well-established method in several outpatient procedures; however, its use in emergency departments (EDs) remains limited. The aim of this study was to compare procedural sedation and anlagesia (PSA) and IB in the pain management for patients who underwent forearm fracture reduction in the ED. Methods This prospective randomized study included 60 patients aged 18 to 65 years, who visited the ED with forearm fractures. They were randomly divided into two groups: Group PSA (n=30) and Group IB (n=30). The pain scores of patients were evaluated before and during the procedure with the visual analog scale. Complications and patient and operator satisfaction levels were recorded. Results There was no difference between the two groups in terms of demographic characteristics. The median (interquartile range) pain scores observed during the procedures were significantly higher in Group PSA than in Group IB (4 [4–6] vs. 2 [0–2], respectively; P<0.001). Patient and operator satisfaction levels were significantly higher in Group IB (P<0.001). Oxygen desaturation was statistically higher in Group PSA than in Group IB (40.00% vs. 3.33%, respectively; P=0.002). Conclusion IB was an effective alternative for reducing pain and increasing patient satisfaction in ED patients undergoing forearm fracture reduction.
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Affiliation(s)
- Erdal Tekin
- Department of Emergency Medicine, Ataturk University School of Medicine, Erzurum, Turkey
| | - Muhammed Enes Aydin
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey.,Clinical Research, Development and Design Application and Research Center, Ataturk University School of Medicine, Erzurum, Turkey
| | - Mehmet Cenk Turgut
- Department of Orthopedic Surgery, Erzurum City Hospital, Erzurum, Turkey
| | - Selahattin Karagoz
- Department of Emergency Medicine, Ataturk University School of Medicine, Erzurum, Turkey
| | - Irem Ates
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - Elif Oral Ahiskalioglu
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey.,Clinical Research, Development and Design Application and Research Center, Ataturk University School of Medicine, Erzurum, Turkey
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Comparison of the onset time between 0.375% ropivacaine and 0.25% levobupivacaine for ultrasound-guided infraclavicular brachial plexus block: a randomized-controlled trial. Sci Rep 2021; 11:4703. [PMID: 33633231 PMCID: PMC7907375 DOI: 10.1038/s41598-021-84172-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/12/2021] [Indexed: 12/02/2022] Open
Abstract
At centers with pressure on rapid operating room turnover, onset time is one of the important considerations for choosing a local anesthetic drug. To hasten the onset of the block, higher concentrations of local anesthetics are sometimes used. However, the use of diluted local anesthetics may be safer. Therefore, we aimed to compare the onset times of equipotential levobupivacaine and ropivacaine at low concentrations for infraclavicular brachial plexus block. Adult patients undergoing upper extremity surgery under ultrasound-guided infraclavicular brachial plexus block at our center were randomly allocated to the levobupivacaine and ropivacaine groups. Infraclavicular brachial plexus block was induced with 0.25% levobupivacaine or 0.375% ropivacaine depending on the assigned group. The degrees of sensory and motor blockade were assessed for 40 min after the administration of local anesthetics. A total of 46 patients were included in the analysis. Infraclavicular brachial plexus block with 0.25% levobupivacaine and 0.375% ropivacaine provided sufficient surgical anesthesia. The sensory onset time of 0.375% ropivacaine was shorter than that of 0.25% levobupivacaine (group R, 15 [15.0–22.5] min; group L, 30 [17.5–35.0] min, p = 0.001). There were no significant differences in other block characteristics and clinical outcomes between the two groups. Thus, when a quicker block onset is required, 0.375% ropivacaine is a better choice than 0.25% levobupivacaine. Trial registration ClinicalTrials.gov (NCT03679897).
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Diwan S, Sethi D, Gaikwad A, Sancheti P, Nair A. Subcoracoid tunnel block as an alternative infraclavicular brachial plexus approach -a case series. Korean J Anesthesiol 2020; 73:450-454. [PMID: 32773725 PMCID: PMC7533173 DOI: 10.4097/kja.20372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGRUOND Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tunnel beneath the pectoralis minor. With an ultrasound scan along the brachial line, the brachial plexus cords in the subcoracoid tunnel can be targeted using an in-plane needle approach. We describe this new approach to the infraclavicular block called the "subcoracoid tunnel block." CASE Twenty patients were administered with the ultrasound-guided subcoracoid tunnel block for the below-elbow surgery. The contact of the needle tip with cords was visible in all 20 patients. With neurostimulation, the posterior cord was identified in 11 (55%) and medial cord in 9 (45%) patients on the first needle pass. The subcoracoid tunnel block was successful in 16 patients (80%). CONCLUSIONS Our case series shows that the subcoracoid tunnel block is an excellent alternative technique for the infraclavicular block. Its advantages include better needle-cord visibility and easy identification of the brachial plexus cords.
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Affiliation(s)
- Sandeep Diwan
- Department of Anesthesiology, Sancheti Institute of Orthopedics and Rehabilitation, Pune, India
| | - Divya Sethi
- Department of Anesthesia, Employees' State Insurance Cooperation Postgraduate Institute of Medical Sciences and Research (ESIC-PGIMSR), New Delhi, India
| | - Avinash Gaikwad
- Department of Anesthesiology, Sancheti Institute of Orthopedics and Rehabilitation, Pune, India
| | - Parag Sancheti
- Department of Orthopedics, Sancheti Institute of Orthopedics and Rehabilitation, Pune, India
| | - Abhijit Nair
- Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India
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Blanco AFG, Laferrière-Langlois P, Jessop D, D’Aragon F, Sansoucy Y, Albert N, Tétreault P, Echave P. Retroclavicular vs Infraclavicular block for brachial plexus anesthesia: a multi-centric randomized trial. BMC Anesthesiol 2019; 19:193. [PMID: 31656165 PMCID: PMC6815364 DOI: 10.1186/s12871-019-0868-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/16/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The coracoid approach is a simple method to perform ultrasound-guided brachial plexus regional anesthesia (RA) but its simplicity is counterbalanced by a difficult needle visualization. We hypothesized that the retroclavicular (RCB) approach is not longer to perform when compared to the coracoid (ICB) approach, and improves needle visualization. METHODS This randomized, controlled, non-inferiority trial conducted in two hospitals, included patients undergoing distal upper limb surgery. Patients were randomly assigned to a brachial plexus block (ICB or RCB). The primary outcome was performance time (sum of visualization and needling time), and was analyzed with a non-inferiority test of averages. Depth of sensory and motor blockade, surgical success, total anesthesia time, needle visualization, number of needle passes and complications were also evaluated. Subgroup analysis restricted to patients with higher body mass index was completed. RESULTS We included 109 patients between September 2016 and May 2017. Mean RCB performance time was 4.8 ± 2.0 min while ICB was 5.2 ± 2.3 min (p = 0.06) with a 95% CI reaching up to 5.8% longer. RCB conferred an ultrasound-needle angle closer to 0° and significantly improved needle visibility after the clavicle was cleared and before local anesthetic administration. No differences were found in the secondary outcomes. Similar results were found in the subgroup analysis. CONCLUSION RCB approach for brachial plexus anesthesia was similar to ICB approach in terms of time performance. Needle visibility, which represent an important clinical variable, was superior and angle between needle and ultrasound probe was close to 0° in the RCB group. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT02913625), registered 26 September 2016.
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Affiliation(s)
- Andrés Felipe Gil Blanco
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4 Canada
| | - Pascal Laferrière-Langlois
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4 Canada
| | - David Jessop
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Laval (CHUL), 2705 boul Laurier, Quebec, G1V 4G2 QC Canada
| | - Frédérick D’Aragon
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4 Canada
| | - Yanick Sansoucy
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4 Canada
| | - Natalie Albert
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Laval (CHUL), 2705 boul Laurier, Quebec, G1V 4G2 QC Canada
| | - Pascal Tétreault
- Department of Biomedical Engineering, Faculty of medicine and Dentistry, University of Alberta, 1098 Research Transition Facility, Edmonton, T6G 2V2 AB Canada
| | - Pablo Echave
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4 Canada
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Infraclavicular brachial plexus block in adults: a comprehensive review based on a unified nomenclature system. J Anesth 2019; 33:463-477. [PMID: 31076946 DOI: 10.1007/s00540-019-02638-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 03/28/2019] [Indexed: 12/12/2022]
Abstract
Over the last decade, considerable progress has been made regarding infraclavicular brachial plexus block (ICB) in adults, especially since the introduction of ultrasound guidance. The advancements in ICB have been attributed to the development of various approaches to improve the success rate and reduce complications. This has also necessitated a unified nomenclature system to facilitate comparison among different approaches. This review aimed to propose an anatomical nomenclature system by classifying ICB approaches into proximal and distal ones to aid future research and provide practice advisories according to recent updates. We also comprehensively discuss various aspects of this nomenclature system. Our review suggests that ultrasound-guided ICB should be categorized as an advanced technique that should be performed under supervision and dual guidance. For one-shot block, the conventional distal approach is still preferred but should be modified to follow ergonomic practice, with the arm in the proper position. For continuous ICB, the proximal approach is promising for reducing local anesthetic volume and increasing efficacy. Nevertheless, further studies are warranted in this direction. We provide practice advisories to maximize safety and minimize adverse events, and recommend designing future studies on ICB according to these findings based on the unified nomenclature system.
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Retrospective Analysis of Ultrasound-Guided Infraclavicular Block: Effect of Experience of Anesthesiologists on Volume of Local Anesthetic Administered. Pain Res Manag 2019; 2019:4846956. [PMID: 31198476 PMCID: PMC6526514 DOI: 10.1155/2019/4846956] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/01/2019] [Accepted: 04/23/2019] [Indexed: 01/31/2023]
Abstract
Performing a block under ultrasound guidance effectively requires skill; however, inexperienced anesthesiologists often use high-dose LA to ensure success. We aimed to share our experience with the ultrasound-guided infraclavicular brachial plexus block (USGICB) for upper extremity surgeries and to determine changes in failure rate and local anesthetic dose administered with gaining adequate experience. With approval from the local ethics committee, a retrospective review of records of 2953 patients who underwent USGICB between November 2011 and March 2015 was performed for evaluating the following data: age, sex, height, weight, operation type, American Society of Anesthesiologists physical status score, local anesthetic volume, complications, and success of USGICB. The patients were divided into 4 groups of 10 months each from November 2011 to March 2015: first 10-month period, 628 cases (group I); second 10-month period, 672 (group II); third 10-month period, 720 (group III); and the fourth 10-month period, 933 cases (group IV). Nine anesthesiologists with the same baseline experience in USG performed the blocks. During the initial period, when anesthesiologists had insufficient experience, local anesthetic (LA) dose, success rate, failed blocks, and complications were investigated. The LA volume administered in group I (33.7 ± 4.2 ml) was significantly higher than that in groups II, III, and IV (p < 0.05). Although a reduction in LA volume administered with increasing anesthesiologist experience was not statistically significant, a volume reduction of over 30 ml was observed in groups II, III, and IV compared with group I. Furthermore, in group I, failure rate (3.2%) was higher than that in groups II, III, and IV (p < 0.05). We concluded that sonographic guidance ensures a high success rate and that increased experience of anesthesiologists is associated with reduced complications and failure rate of blocks, in addition to prevention of LA overdose.
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Langlois PL, Gil-Blanco AF, Jessop D, Sansoucy Y, D'Aragon F, Albert N, Echave P. Retroclavicular approach vs infraclavicular approach for plexic bloc anesthesia of the upper limb: study protocol randomized controlled trial. Trials 2017; 18:346. [PMID: 28732521 PMCID: PMC5521069 DOI: 10.1186/s13063-017-2086-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 07/05/2017] [Indexed: 11/10/2022] Open
Abstract
Background The coracoid approach is recognized as the simplest approach to perform brachial plexus anaesthesia, but needle visualization needs to be improved. With a different needle entry point, the retroclavicular approach confers a perpendicular angle between the ultrasound and the needle, which theoretically enhances needle visualization. This trial compares these two techniques. The leading hypothesis is that the retroclavicular approach is comparable to the infraclavicular coracoid approach in general aspects, but needle visualization is better with this novel approach. Methods We designed a multicentre, randomized, non-inferiority trial. Patients eligible for the study are older than 18 years, able to consent, will undergo urgent or elective upper limb surgery distal to the elbow and are classified with American Society of Anaesthesiologists risk score (ASA) I-III. They will be excluded if they meet contraindicated criteria to regional anaesthesia, have affected anatomy of the clavicle or are pregnant. Randomization will be done by a computer-generated randomization schedule stratified for each site and in 1:1 ratio, and concealment will be maintained with opaque, sealed envelopes in a locked office. The primary outcome, the performance time, will be analyzed using non-inferiority analysis while secondary outcomes will be analyzed with superiority analysis. Needle visualization will be ranked on a Likert scale of 1–5 that is subjective and represents a pitfall. Two separate persons will rank needle visualization to compensate this pitfall. According to previous studies, 49 patients per group are required for statistical power of 0.90 and one-sided type I error of 0.05. Discussion The conduct of this study will bring clear answers to our questions and, if our hypothesis is confirmed, will confer an anatomic alternative to difficult coracoid infraclavicular brachial blocks or could even become a standard for brachial plexus anaesthesia. Trial registration ClinicalTrials.gov, NCT02913625. Registered on 12 September 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2086-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- P L Langlois
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, J1H5N4, QC, Canada.
| | - A F Gil-Blanco
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, J1H5N4, QC, Canada
| | - D Jessop
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Laval (CHUL), Quebec, QC, Canada
| | - Y Sansoucy
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, J1H5N4, QC, Canada
| | - F D'Aragon
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, J1H5N4, QC, Canada
| | - N Albert
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Laval (CHUL), Quebec, QC, Canada
| | - P Echave
- Department of Anesthesiology, Medicine and Health Sciences Faculty, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001, 12e Avenue Nord, Sherbrooke, J1H5N4, QC, Canada
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Luftig J, Mantuani D, Herring AA, Nagdev A. Ultrasound-guided retroclavicular approach infraclavicular brachial plexus block for upper extremity emergency procedures. Am J Emerg Med 2017; 35:773-777. [PMID: 28126454 DOI: 10.1016/j.ajem.2017.01.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 10/20/2022] Open
Abstract
The America Society of Anesthesiology guidelines recommend multimodal analgesia that combines regional anesthetic techniques with pharmacotherapy to improve peri-procedural pain management and reduce opioid related complications. Commonly performed emergency procedures of the upper extremity such as fracture and dislocation reduction, wound debridement, and abscess incision and drainage are ideal candidates for ultrasound-guided (USG) regional anesthesia of the brachial plexus. However, adoption of regional anesthesia by emergency practitioners has been limited by concerns for potential complications and perceived technical difficulty. The Retroclavicular Approach to The Infraclavicular Region (RAPTIR) is a newly described USG brachial plexus block technique that optimizes sonographic needle visualization as a means of making regional anesthesia of the upper extremity safer and easier to perform. With RAPTIR a single well-visualized injection distant from key anatomic neck and thorax structures provides extensive upper extremity anesthesia, likely reducing the risk of complications such as diaphragm paralysis, central block, nerve injury, vascular puncture, and pneumothorax. Additionally, patient positioning for RAPTIR is well suited for the awake, acutely injured ED patient as the upper extremity remains adducted in a position of comfort at the patient's side. Thus, RAPTIR is a potentially ideal combination of infraclavicular targeting, excellent needle visualization, single injection, safety, comprehensive upper extremity analgesia, rapid performance, and comfortable patient positioning. Herein we present the first description of the RAPTIR utilized in the ED. Our initial experience suggests this is a promising new technique for brachial plexus regional anesthesia in the ED setting.
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Affiliation(s)
- Josh Luftig
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA, United States.
| | - Daniel Mantuani
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA, United States; Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Andrew A Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA, United States; Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Arun Nagdev
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA, United States; Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States
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Brattwall M, Jildenstål P, Warrén Stomberg M, Jakobsson JG. Upper extremity nerve block: how can benefit, duration, and safety be improved? An update. F1000Res 2016; 5. [PMID: 27239291 PMCID: PMC4874442 DOI: 10.12688/f1000research.7292.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 02/06/2023] Open
Abstract
Upper extremity blocks are useful as both sole anaesthesia and/or a supplement to general anaesthesia and they further provide effective postoperative analgesia, reducing the need for opioid analgesics. There is without doubt a renewed interest among anaesthesiologists in the interscalene, supraclavicular, infraclavicular, and axillary plexus blocks with the increasing use of ultrasound guidance. The ultrasound-guided technique visualising the needle tip and solution injected reduces the risk of side effects, accidental intravascular injection, and possibly also trauma to surrounding tissues. The ultrasound technique has also reduced the volume needed in order to gain effective block. Still, single-shot plexus block, although it produces effective anaesthesia, has a limited duration of postoperative analgesia and a number of adjuncts have been tested in order to prolong analgesia duration. The addition of steroids, midazolam, clonidine, dexmedetomidine, and buprenorphine has been studied, all being off-label when administered by perineural injection, and the potential neurotoxicity needs further study. The use of perineural catheters is an effective option to improve and prolong the postoperative analgesic effect. Upper extremity plexus blocks have an obvious place as a sole anaesthetic technique or as a powerful complement to general anaesthesia, reducing the need for analgesics and hypnotics intraoperatively, and provide effective early postoperative pain relief. Continuous perineural infusion is an effective option to prolong the effects and improve postoperative quality.
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Affiliation(s)
- Metha Brattwall
- Department of Anaesthesiology and Intensive Care, Unit of Day Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Pether Jildenstål
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden
| | - Margareta Warrén Stomberg
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan G Jakobsson
- Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institute, Danderyds University Hospital, Stockholm, Sweden
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Gurnaney HG, Fiadjoe JE, Levin LS, Chang B, Delvalle H, Gálvez J, Rehman MA. Anesthetic management of the first pediatric bilateral hand transplant. Can J Anaesth 2016; 63:731-6. [PMID: 26951450 DOI: 10.1007/s12630-016-0625-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/03/2016] [Accepted: 02/25/2016] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The purpose of this case report is to describe the anesthetic and case management of the first vascularized composite allograft pediatric bilateral hand transplant. CLINICAL DETAILS Our patient was an eight-year-old male with a medical history of Staphylococcus aureus sepsis at one year of age that resulted in end-stage renal disease as well as bilateral upper and lower extremity amputations. After referral for bilateral hand transplantation, the transplantation team, with expertise in all aspects of perioperative care (surgery, anesthesiology, nephrology, renal transplantation, pediatric intensive care, and therapeutic pharmacy), was consulted to help develop anesthetic and other perioperative protocols for surgery. Prior to activation of the transplantation team, the lead surgeon evaluated potential donors by comparing a three-dimensional printed model of the recipient's forearm with the donor's upper extremities to ensure an adequate match. The anesthesia team inserted bilateral ultrasound-guided infraclavicular catheters to provide a sympathetic block to facilitate blood flow to the upper extremities and to provide both intraoperative and postoperative pain control. The patient remained in the operating room for 13 hr 37 min for a surgical time of ten hours 39 min. He remained in the hospital for 34 days after the procedure and was then transferred to an inpatient rehabilitation facility for a further 15 days. The patient is currently doing well in a postoperative rehabilitation program. He has demonstrated motor power to the hands using the forearm muscles but is not expected to reach his maximum sensory function for at least one to two years. CONCLUSION This report describes the anesthetic management of the first pediatric bilateral hand transplant. This procedure required considerable preoperative planning and communication between various teams to ensure all resources needed to deliver the care for this complex and novel transplant surgery were readily available.
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Affiliation(s)
- Harshad G Gurnaney
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
| | - John E Fiadjoe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - L Scott Levin
- Department of Orthopaedic Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin Chang
- Department of Plastic and Reconstructive Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Delvalle
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Jorge Gálvez
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed A Rehman
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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13
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Impact of Regional Anesthesia on Perioperative Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0101-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Jakobsson JG. Pain management in ambulatory surgery-a review. Pharmaceuticals (Basel) 2014; 7:850-65. [PMID: 25061796 PMCID: PMC4167203 DOI: 10.3390/ph7080850] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/27/2014] [Accepted: 07/09/2014] [Indexed: 02/07/2023] Open
Abstract
Day surgery, coming to and leaving the hospital on the same day as surgery as well as ambulatory surgery, leaving hospital within twenty-three hours is increasingly being adopted. There are several potential benefits associated with the avoidance of in-hospital care. Early discharge demands a rapid recovery and low incidence and intensity of surgery and anaesthesia related side-effects; such as pain, nausea and fatigue. Patients must be fit enough and symptom intensity so low that self-care is feasible in order to secure quality of care. Preventive multi-modal analgesia has become the gold standard. Administering paracetamol, NSIADs prior to start of surgery and decreasing the noxious influx by the use of local anaesthetics by peripheral block or infiltration in surgical field prior to incision and at wound closure in combination with intra-operative fast acting opioid analgesics, e.g., remifentanil, have become standard of care. Single preoperative 0.1 mg/kg dose dexamethasone has a combined action, anti-emetic and provides enhanced analgesia. Additional α-2-agonists and/or gabapentin or pregabalin may be used in addition to facilitate the pain management if patients are at risk for more pronounced pain. Paracetamol, NSAIDs and rescue oral opioid is the basic concept for self-care during the first 3–5 days after common day/ambulatory surgical procedures.
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Affiliation(s)
- Jan G Jakobsson
- Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds Hospital, 182 88 Stockholm, Sweden.
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Abstract
Peripheral nerve blocks (PNBs) provide significant improvement in postoperative analgesia and quality of recovery for ambulatory surgery. Use of continuous PNB techniques extend these benefits beyond the limited duration of single-injection PNBs. The use of ultrasound guidance has significantly improved the overall success, efficiency, and has contributed to the increased use of PNBs in the ambulatory setting. More recently, the use of ultrasound guidance has been demonstrated to decrease the risk of local anesthetic systemic toxicity. This article provides a broad overview of the indications and clinically useful aspects of the most commonly used upper and lower extremity PNBs in the ambulatory setting. Emphasis is placed on approaches that can be used for single-injection PNBs and continuous PNB techniques.
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Affiliation(s)
- Francis V Salinas
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98101-2756, USA.
| | - Raymond S Joseph
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98101-2756, USA
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