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Zhao Y, Qin S, Yang X, Gao C, Yuan X, Li T, Chen Z. Comparison of the anesthesia effect of ultrasound-guided middle and low interscalene brachial plexus block: a randomized, controlled, non-inferiority trial. BMC Anesthesiol 2023; 23:1. [PMID: 36597045 PMCID: PMC9808947 DOI: 10.1186/s12871-022-01963-4] [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] [Received: 08/19/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Ultrasound-guided low interscalene brachial plexus block (LISB) can provide satisfactory anesthesia for surgery at or below the elbow. However, the anesthesia effect of ultrasound-guided middle interscalene brachial plexus block (MISB) has not been fully investigated. We hypothesized that MISB provides a non-inferior anesthesia effect to LISB for surgery at or below the elbow. METHODS A total of 82 patients with ASA I-III (18-65 years) scheduled for elective surgery at or below the elbow were randomized to the MISB group or the LISB group equally, located 1/2 or 2/3 of the caudal distance from C6 to the clavicle. Both groups were administered 15 mL 0.5% ropivacaine at the lower part of the brachial plexus with the first injection and equivalent volume at the upper part with the second injection. RESULTS For the primary outcome, 92.3% in the MISB group experienced successful anesthesia compared to 94.6% in the LISB group [difference: -2.3%, 95% confidence interval (CI) -13.4% to 8.8%], exceeding the predefined non-inferiority margin -15%. For the secondary outcomes, the incidence of pleura suppression for the first injection (7.7% vs. 45.9%, P < 0.001) and the time to perform the block (9.9 ± 1.3 vs. 10.7 ± 1.3 min, P = 0.006) were significantly less in MISB compared to LISB. No significant differences were observed in the consumption of perioperative rescue analgesics, VAS score, and adverse events within the two groups. CONCLUSIONS MISB provides a non-inferior anesthesia effect to LISB for surgery at or below the elbow. TRIAL REGISTRATION Chinese Clinical Trial Register (identifier: ChiCTR2100054196).
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Affiliation(s)
- Yang Zhao
- grid.413387.a0000 0004 1758 177XDepartment of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, No. 1 The South of Maoyuan Road, Nanchong, Sichuan 637000 People’s Republic of China ,grid.412594.f0000 0004 1757 2961Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, No. 22 Shuangyong Road, 530021 Guangxi, People’s Republic of China
| | - Shiming Qin
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
| | - Xue Yang
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
| | - Chongmei Gao
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
| | - Xia Yuan
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
| | - Tao Li
- grid.440164.30000 0004 1757 8829Department of Radiology, Chengdu Second People’s Hospital, Chengdu, 610017 Sichuan China
| | - Zhaohui Chen
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
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Regional Anesthesia for Orthobiologic Procedures. Phys Med Rehabil Clin N Am 2022; 34:291-309. [DOI: 10.1016/j.pmr.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sivakumar RK, Samy W, Pakpirom J, Songthamwat B, Karmakar MK. Ultrasound-guided selective trunk block: Evaluation of ipsilateral sensorimotor block dynamics, hemidiaphragmatic function and efficacy for upper extremity surgery. A single-centre cohort study. Eur J Anaesthesiol 2022; 39:801-809. [PMID: 35950709 DOI: 10.1097/eja.0000000000001736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Selectively locating and blocking the individual trunks of the brachial plexus with small volumes of local anaesthetic, a selective trunk block (SeTB), may produce anaesthesia of the entire upper extremity except for the T2 dermatome. OBJECTIVE This study aimed to evaluate the effects of an ultrasound-guided (USG) SeTB on ipsilateral sensorimotor block dynamics, hemidiaphragmatic function, and efficacy as an all-purpose regional anaesthetic technique for upper extremity surgery. DESIGN Prospective cohort study. SETTING Single-centre, university hospital in Hong Kong, China from February 2021 to July 2021. PATIENTS Thirty patients (aged 53.2 ± 14.8 years and BMI 23.8 ± 3.6 kg m - 2 ), ASA physical status I to III, scheduled for upper extremity surgery under a brachial plexus block. INTERVENTIONS USG SeTB with 25 ml (7, 8 and 10 ml to the superior, middle and inferior trunks, respectively) of a 1 : 1 mixture of 2% lidocaine with 1 : 200 000 epinephrine and 0.5% levobupivacaine. MAIN OUTCOME MEASURES Ipsilateral sensorimotor blockade of the suprascapular (only motor), axillary, radial, ulnar, median and musculocutaneous nerves were assessed at regular intervals for 45 min. Ipsilateral hemidiaphragmatic excursion was also measured, at 30 min after the SeTB, using M-mode ultrasound. The SeTB was considered a success if it was possible to complete surgery without any rescue analgesia or conversion to general anaesthesia. RESULTS Complete motor blockade of the suprascapular nerve was achieved in median [range] 5 [5 to 15] min. Complete sensory and motor blockade were achieved in all the other 5 nerves in 17.5 [10 to 30] and 15 [10 to 30] min respectively. The SeTB was successful in 93% and ipsilateral hemidiaphragmatic paresis (HDP) was present in 82%, of patients. CONCLUSION SeTB produces sensorimotor blockade of the entire upper extremity, causes ipsilateral HDP, and is effective as the sole anaesthetic for surgery from the proximal humerus to the hand. TRIAL REGISTRION ClinicalTrials.gov, Trial Registration No: NCT04752410, Date submitted for Registration: 09 February 2021, Date first posted: 12 February 2021, Dates of patient enrolment: 19 February 2021 to 27 July 2021 ( https://clinicaltrials.gov/ct2/show/NCT04752410 ).
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Affiliation(s)
- Ranjith Kumar Sivakumar
- From the Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China (RKS, WS, JP, BS, MKK)
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Songthamwat B, Luangjarmekorn P, Kampitak W, Sivakumar RK, Karmakar MK. Ultrasound-guided selective trunk block (SeTB): a cadaver anatomic study to evaluate the spread of dye after a simulated injection. Reg Anesth Pain Med 2022; 47:414-419. [PMID: 35450932 DOI: 10.1136/rapm-2022-103630] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Recent reports suggest that a selective trunk block (SeTB) can produce sensorimotor blockade of the entire upper extremity, except for the T2 dermatome. There are no data demonstrating the anatomic mechanism of SeTB. This cadaver study aimed to evaluate the spread of an injectate after a simulated ultrasound-guided (USG) SeTB. METHODS USG SeTB (n=7) was performed on both sides of the neck in four adult human cadavers with 25 mL of 0.1% methylene blue dye. Anatomic dissection was performed to document staining (deep, faint, and no stain) of the various elements of the brachial plexus from the level of the roots to the cords, including the phrenic, dorsal scapular, and long thoracic nerves. Only structures that were deeply stained were defined as being affected by the SeTB. RESULTS All the trunks and divisions of the brachial plexus, as well as the ventral rami of C5-C7 and suprascapular nerve, were deeply stained in all (100%) the simulated injections. The ventral rami of C8 and T1 (86%), dorsal scapular and long thoracic nerve (71%), and the phrenic nerve (57%) were also deeply stained in a substantial number of the injections. CONCLUSION This cadaver study demonstrates that an USG SeTB consistently affects all the trunks and divisions of the brachial plexus, as well as the suprascapular nerve. This study also establishes that SeTB may not be phrenic nerve sparing. Future research to evaluate the safety and efficacy of SeTB as an all-purpose brachial plexus block technique for upper extremity surgery is warranted. TRIAL REGISTRATION NUMBER Registered at https://www.thaiclinicaltrials.org on December 13, 2021 under the trial registration number TCTR20211213005.
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Affiliation(s)
- Banchobporn Songthamwat
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Pobe Luangjarmekorn
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wirinaree Kampitak
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Ranjith Kumar Sivakumar
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Faculty of Medicine, Shatin, New Territories, Hong Kong, SAR, China
| | - Manoj Kumar Karmakar
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Faculty of Medicine, Shatin, New Territories, Hong Kong, SAR, China
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Oliver-Fornies P, Espinosa Morales K, Fajardo-Pérez M, Salazar-Zamorano CH, Yamak-Altinpulluk E, Vilches LV, Ureña RA, Aragón-Benedí C, Lopez Arribas I, Centeno-Perez A, Llavador JJ, Galluccio F. Modified supraclavicular approach to brachial plexus block. J Clin Anesth 2021; 76:110585. [PMID: 34775349 DOI: 10.1016/j.jclinane.2021.110585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Pablo Oliver-Fornies
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Department of Anesthesia and Pain Medicine, Hospital Universitario de Mostoles, Madrid, Spain.
| | - Karla Espinosa Morales
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Department of Anesthesia and Pain Medicine Hospital de Trauma, Centro Integral de Salud de Puriscal, San José, Costa Rica
| | - Mario Fajardo-Pérez
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Department of Anesthesia and Pain Medicine, Hospital Universitario de Mostoles, Madrid, Spain
| | - Carlos H Salazar-Zamorano
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Department of Anesthesia, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ece Yamak-Altinpulluk
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Department of Outcomes Research Consortium, Cleveland Clinic Foundation, Cleveland, OH, USA; Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Luis Valdes Vilches
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain
| | - Ricardo Aguilar Ureña
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain
| | - Cristian Aragón-Benedí
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Punto vital Medical Center, Zaragoza, Spain
| | - Irene Lopez Arribas
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Department of Anesthesia and Pain Medicine, Hospital Universitario de Mostoles, Madrid, Spain
| | - Alejandro Centeno-Perez
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Department of Anesthesia and Pain Medicine, Hospital Universitario de Mostoles, Madrid, Spain
| | - Juan Jose Llavador
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain; Department of Anesthesia and Pain Medicine, Hospital Universitario de Mostoles, Madrid, Spain
| | - Felice Galluccio
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain
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Karmakar MK, Areeruk P, Mok LYH, Sivakumar RK. Ultrasound-Guided Selective Trunk Block to Produce Surgical Anesthesia of the Whole Upper Extremity: A Case Report. A A Pract 2020; 14:e01274. [PMID: 32909721 DOI: 10.1213/xaa.0000000000001274] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
None of the classical brachial plexus block techniques can reliably produce surgical anesthesia of the whole upper extremity that is from shoulder to hand. We describe ultrasound-guided "selective trunk block" (SeTB) that was successfully used to produce surgical anesthesia of the whole ipsilateral upper extremity in a patient undergoing intramedullary nailing of the humerus for a pathological fracture. The 3 trunks of the brachial plexus were individually identified and selectively blocked with 2 separate injections. We conclude that SeTB is a viable option when surgical anesthesia of the whole upper extremity, except for the intercostobrachial nerve (T2) territory, is being considered.
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Affiliation(s)
- Manoj Kumar Karmakar
- From the Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
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Effects of C8 nerve root block during interscalene brachial plexus block on anesthesia of the posterior shoulder in patients undergoing arthroscopic shoulder surgery: study protocol for a prospective randomized parallel-group controlled trial. Trials 2019; 20:533. [PMID: 31455407 PMCID: PMC6712618 DOI: 10.1186/s13063-019-3624-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
Background A classical approach to produce interscalene brachial plexus block (ISBPB) consistently spares the posterior aspect of the shoulder and ulnar sides of the elbow, forearm, and hand, which are innervated by the lower trunk of the brachial plexus (C8–T1). As an alternative to the classical approach, a caudal approach to ISBPB successfully produces anesthesia of the ulnar sides of the elbow, forearm, and hand. However, its beneficial effects on anesthesia in the posterior aspect of the shoulder have not been investigated. In addition, the C8 nerve root is not routinely selectively blocked during ISBPB. Therefore, we will compare the C5 to C7 and C5 to C8 nerve root blocks during a caudal approach to ISBPB to assess the clinical benefit of C8 nerve blocks for the surgical anesthesia of the posterior aspect of the shoulder. Methods/design In this prospective parallel-group single-blind randomized controlled trial, 74 patients scheduled to undergo arthroscopic shoulder surgery under ISBPB are randomly allocated to receive the C5 to C7 or C5 to C8 nerve root block at a 1:1 ratio. The primary outcome is pain intensity, which is rated as 0 (no pain), 1 (mild pain), or 2 (severe pain), during the introduction of a posterior portal into the glenohumeral joint. The secondary outcomes are (1) the extent of the ipsilateral sensory, motor, hemidiaphragmatic, and stellate ganglion blockade, (2) changes in the results of a pulmonary function test, (3) incidence of complications related to ISBPB, (4) postoperative numerical pain rating scale scores, (5) patients’ satisfaction with the ISBPB, (6) dose and frequency of analgesic use, and (7) incidence of conversion to general anesthesia. Discussion This study is the first to evaluate the beneficial effects of the C8 nerve root block during ISBPB, which has rarely been performed due to the technical challenge in visualizing and blocking the C8 nerve root. It is expected that a C8 nerve root block performed during ISBPB will provide sufficient surgical anesthesia of the posterior aspect of the shoulder, which cannot be achieved by a classical approach to ISBPB. Trial registration ClicnicalTrials.gov, NCT03487874. Registered on 4 April 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3624-9) contains supplementary material, which is available to authorized users.
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Park SK, Sung MH, Suh HJ, Choi YS. Ultrasound Guided Low Approach Interscalene Brachial Plexus Block for Upper Limb Surgery. Korean J Pain 2016; 29:18-22. [PMID: 26839666 PMCID: PMC4731546 DOI: 10.3344/kjp.2016.29.1.18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/08/2015] [Accepted: 10/16/2015] [Indexed: 11/05/2022] Open
Abstract
Background The interscalene brachial plexus block is widely used for pain control and anesthetic purposes during shoulder arthroscopic surgeries and surgeries of the upper extremities. However, it is known that interscalene brachial plexus block is not appropriate for upper limb surgeries because it does not affect the lower trunk (C8-T1, ulnar nerve) of the brachial plexus. Methods A low approach, ultrasound-guided interscalene brachial plexus block (LISB) was performed on twenty-eight patients undergoing surgery of the upper extremities. The patients were assessed five minutes and fifteen minutes after the block for the degree of block in each nerve and muscle as well as for any complications. Results At five minutes and fifteen minutes after the performance of the block, the degree of the block in the ulnar nerve was found to be 2.8 ± 2.6 and 1.1 ± 1.8, respectively, based on a ten-point scale. Motor block occurred in the median nerve after fifteen minutes in 26 of the 28 patients (92.8%), and in all of the other three nerves in all 28 patients. None of the patients received additional analgesics, and none experienced complications. Conclusions The present study confirmed the achievement of an appropriate sensory and motor block in the upper extremities, including the ulnar nerve, fifteen minutes after LISB, with no complications.
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Affiliation(s)
- Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Min Ha Sung
- Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hae Jin Suh
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Yun Suk Choi
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
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Abstract
PURPOSE OF REVIEW There has been an increasing use of peripheral nerve blocks (PNBs) in ambulatory surgery. Several recent reports have contributed to our understanding of the optimal PNB technique for specific surgical procedures in this setting. In this review, we have summarized the available literature on indications of PNBs for outpatient surgery of the upper extremity. RECENT FINDINGS Although many of the recent studies focus on technical aspects of PNBs, few center on evidence-based indications or their utility in the ambulatory setting. The available literature suggests that although multiple techniques have been reported for outpatient shoulder surgery, interscalene brachial plexus block (ISBPB) is currently the most preferred technique. Supraclavicular, infraclavicular, and axillary brachial plexus blocks, however, are all commonly used and effective PNBs for outpatient surgery and analgesia of the arm, forearm, and hand. SUMMARY ISBPB is currently the most beneficial PNB for outpatient shoulder surgery. Supraclavicular block functionally can be considered an alternative to the traditional ISBPB; however, additional studies are required before routine use can be recommended. Although the review identified several reports with benefits of one PNB technique over the others, the existing literature suggests that many of these techniques may be interchangeable with regards to procedures of the distal upper extremity. Future studies are indicated to help standardize the techniques, selection, and postoperative management of PNBs for specific surgical indications.
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Ip VHY, Tsui BCH. Lower interscalene approach for elbow surgery. Can J Anaesth 2013; 60:600-1. [DOI: 10.1007/s12630-013-9913-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/20/2013] [Indexed: 10/27/2022] Open
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Review of interscalene block for postoperative analgesia after shoulder surgery in obese patients. ACTA ACUST UNITED AC 2012; 50:29-34. [DOI: 10.1016/j.aat.2012.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 01/05/2012] [Accepted: 01/10/2012] [Indexed: 11/17/2022]
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Goebel S, Broscheit J. [Perioperative pain therapy in interventions for elbow stiffness]. DER ORTHOPADE 2011; 40:291-5. [PMID: 21344321 DOI: 10.1007/s00132-010-1663-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Conservative treatment and surgical release of a stiff elbow requires correct pain management which should be oriented to the individual needs of the patient. Regional anesthesia in combination with opioids is necessary postoperatively to obtain sufficient pain relief. There is a need for prospective randomized studies to develop an optimal pain therapy concept following operations for elbow stiffness.
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Affiliation(s)
- S Goebel
- Orthopädische Klinik König-Ludwig-Haus, Universitätsklinikum Würzburg, Brettreichstr. 11, 97074, Würzburg.
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Aguirre J, Ekatodramis G, Ruland P, Borgeat A. Interscalene block should be a block for shoulder and proximal humerus surgery, and nothing else. J Clin Anesth 2010; 22:151; author reply 151-2. [DOI: 10.1016/j.jclinane.2009.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 06/03/2009] [Accepted: 07/04/2009] [Indexed: 10/19/2022]
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