Surgery of the axilla with combined brachial plexus and intercostobrachial nerve block in the subpectoral intercostal plane

Randomized comparison between ultrasound-guided proximal and distal approaches of intercostobrachial nerve block as an adjunct to supraclavicular brachial plexus block for upper arm arteriovenous access procedures

BACKGROUNDS

Ultrasound-guided proximal and distal approaches of the intercostobrachial nerve (ICBN) blocks facilitate analgesia for upper arm and axillary surgery, though success rates vary and lack clinical comparison. This study compared their anesthetic and analgesic efficacy as an adjunct to the supraclavicular brachial plexus block for upper arm arteriovenous access surgery.

METHODS

60 end-stage renal disease patients undergoing upper arm arteriovenous access were randomly assigned to receive either proximal or distal ICBN block using 10 mL of a mixture of levobupivacaine and lidocaine with epinephrine. The primary outcome was a successful ICBN block, defined as a cutaneous sensory blockade at both the medial upper arm and axilla 30 min after the block. Secondary outcomes included block performance, block-related complications, rate of surgical anesthesia, and postoperative analgesia.

RESULTS

The proximal approach had a higher percentage of sensory blockade at the axilla (96.7% vs 73.3%, p=0.03), but comparable rates at the medial upper arm (96.7% vs 96.7%, p=1.00). Consequently, the proximal approach had a higher overall success rate (96.7% vs 73.3%, difference: 23.3%; 95% CI: 6.3%, 40.4%; p=0.03). Both groups had similar surgical anesthesia rates of 93.3%. No significant differences were found in performance time, procedural pain, or postoperative pain intensity.

CONCLUSIONS

Proximal ICBN block consistently reduced sensation in the medial upper arm and axilla, while one-quarter of distal blocks spared the axilla. Both approaches, in combination with a supraclavicular brachial plexus block, were effective for upper arm arteriovenous access procedures. However, the proximal approach may be preferable for axillary surgery.

TRIAL REGISTRATION NUMBER

TCTR20200730006.

Combinations of nerve blocks in surgery for post COVID-19 pulmonary sequelae patient: A case report and review of literature

BACKGROUND

Regional anesthesia is a promising method in patients with post coronavirus disease 2019 (COVID-19) pulmonary sequelae for preserving pulmonary function and preventing postoperative pulmonary complications, compared with general anesthesia.

CASE SUMMARY

We provided surgical anesthesia and analgesia suitable for breast surgery by performing pectoral nerve block type II (PECS-II), parasternal, and intercostobrachial nerve blocks with intravenous dexmedetomidine administration in a 61-year-old female patient with severe pulmonary sequelae after COVID-19 infection.

CONCLUSION

Sufficient analgesia for 7 h was provided via PECS-II, parasternal, and intercostobrachial blocks perioperatively.

Ultrasound to the Rescue: Axillary Clearance under Complete Regional Blockade

No single regional anaesthetic technique is capable of complete anaesthesia of the axillary region. Regional or interfascial nerve blockade could be an effective alternative where administering general anaesthesia is not feasible, with superior analgesia, favourable haemodynamics, and reduced opiate related adverse effects. Ultrasound guidance improves effectiveness and safety profile. We report a case of a successful axillary clearance conducted under combined regional blocks for an axillary nodal recurrence following mastectomy for a breast carcinoma, in a patient who was not fit for general anaesthesia due to a persistent lobar pneumonia and recurrent asthma exacerbations. Our experience and current evidence supersede the initial conceptions of difficult ultrasonic intercostobrachial nerve (ICBN) visualization.

Cadaveric study identifying clinical sonoanatomy for proximal and distal approaches of ultrasound-guided intercostobrachial nerve block

Background and objectives

The intercostobrachial nerve (ICBN) has significant anatomical variation. Localization of the ICBN requires an operator’s skill. This cadaveric study aims to describe two simple ultrasound-guided plane blocks of the ICBN when it emerges at the chest wall (proximal approach) and passes through the axillary fossa (distal approach).

Methods

The anatomical relation of the ICBN and adjacent structures was investigated in six fresh cadavers. Thereafter, we described two potential techniques of the ICBN block. The proximal approach was an injection medial to the medial border of the serratus anterior muscle at the inferior border of the second rib. The distal approach was an injection on the surface of the latissimus dorsi muscle at 3–4 cm caudal to the axillary artery. The ultrasound-guided proximal and distal ICBN blocks were performed in seven hemithoraxes and axillary fossae. We recorded dye staining on the ICBN, its branches and clinically correlated structures.

Results

All ICBNs originated from the second intercostal nerve and 34.6% received a contribution from the first or third intercostal nerve. All ICBNs gave off axillary branches in the axillary fossa and ran towards the posteromedial aspect of the arm. Following the proximal ICBN block, dye stained on 90% of all ICBN’s origins. After the distal ICBN block, all terminal branches and 43% of the axillary branches of the ICBN were stained.

Conclusions

The proximal and distal ICBN blocks, using easily recognized sonoanatomical landmarks, provided consistent dye spread to the ICBN. We encourage further validation of these two techniques in clinical studies.

Addition of serratus-intercostal plane block/BRILMA for arteriovenous access surgery

ARTERIOVENOUS: access creation is mandatory in patients with end stage renal disease for hemodialysis treatment. It frequently involves upper arm or axillary dissection and general anesthesia is predominantly used as axillary compartment innervation is complex. Avoiding general anesthesia may be beneficial in these risk patients. We present two cases where serratus-intercostal plane block (SIPB/BRILMA) was used, along with ultrasound guided supraclavicular block and multimodal analgesia for proximal arm and axillary AV access surgery. Regional anesthesia combination of supraclavicular and serratus-intercostal/BRILMA block in arteriovenous fistula surgery was successful and should be considered by anesthesiologist in order to avoid general anesthesia.

Adding a PECS II block for proximal arm arteriovenous access - a randomised study

BACKGROUND

Brachial plexus block is often utilised for proximal arm arteriovenous access creation. However, the medial upper arm and axilla are often inadequately anaesthetised, requiring repeated, intraoperative local anaesthetic supplementation, or conversion into general anaesthesia. We hypothesised that the addition of a PECS II block would improve anaesthesia and analgesia for proximal arm arteriovenous access surgery.

METHODS

In this prospective, double-blinded, randomised proof-of-concept study, 36 consenting adults with end-stage renal disease aged between 21 and 90 years received either a combined supraclavicular and PECS II block (Group PECS, n = 18), or combined supraclavicular and sham block (Group SCB, n = 18) for proximal arm arteriovenous access surgery. Primary outcome was whether patients required intraoperative local anaesthetic supplementation by the surgeon.

RESULTS

In Group PECS, 33.3% (6/18) needed local anaesthetic supplementation vs. 100% (18/18) in Group SCB. Group SCB had three times (RR 3.0, 95% CI 1.6-5.8; P < 0.001) the risk of requiring intraoperative local anaesthetic supplementation. Group PECS required lower volume of supplemental local anaesthetic compared to Group SCB (0.0 ml, IQR 0.0-6.3 ml vs. 15.0 ml, IQR 7.4-17.8 ml; P < 0.001). Group SCB had twice [RR 2.2, 95% CI 1.1-4.4; (P = 0.019)] the risk of needing additional sedation or analgesia. There were no significant differences between the groups with respect to postoperative visual analogue scale pain scores, time to first rescue analgesia or patient satisfaction.

CONCLUSION

The results suggest that adding a PECS II block to a supraclavicular block improves regional anaesthesia for patients with end-stage renal disease undergoing proximal arm arteriovenous access surgery.

Aberrant Cutaneous Nerve Loops in the Axilla

During routine dissection classes, conducted for first year undergraduate medical students, we encountered a rare anatomical variation in relation to the intercostobrachial nerve (ICBN). The ICBN represents the lateral undivided cutaneous branch of second intercostal nerve. In this case, the ICBN formed nerve loops with branches of the lateral cutaneous branch of the third intercostal nerve. These loops eventually gave branches that probably supplied the floor of the axilla and proximal arm. Nowadays, this ICBN is gaining clinical importance during the axillary lymph node dissections and mammary gland surgeries. Damage to the ICBN, may results in the sensory deficits in patients undergoing surgery. In our case report, ICBN was making aberrant nerve loop along with the branches from the third intercostal nerve. Knowledge regarding the origin, formation and route of ICBN is of clinical significance to axillary surgeons, radiologist and anesthesiologists.