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      Axillary Brachial Plexus Block

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      Publication date (Electronic):
      Journal: Anesthesiology Research and Practice
      Publisher: Hindawi Publishing Corporation

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          Abstract

          The axillary approach to brachial plexus blockade provides satisfactory anaesthesia for elbow, forearm, and hand surgery and also provides reliable cutaneous anaesthesia of the inner upper arm including the medial cutaneous nerve of arm and intercostobrachial nerve, areas often missed with other approaches. In addition, the axillary approach remains the safest of the four main options, as it does not risk blockade of the phrenic nerve, nor does it have the potential to cause pneumothorax, making it an ideal option for day case surgery. Historically, single-injection techniques have not provided reliable blockade in the musculocutaneous and radial nerve territories, but success rates have greatly improved with multiple-injection techniques whether using nerve stimulation or ultrasound guidance. Complete, reliable, rapid, and safe blockade of the arm is now achievable, and the paper summarizes the current position with particular reference to ultrasound guidance.

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          Ultrasound guidance improves success rate of axillary brachial plexus block.

          Carol Chan, Sherif Abbas, Anahi Perlas … (2007)
          The purpose of this study is to determine if real time ultrasound guidance improves the success rate of axillary brachial plexus blockade. Patients undergoing elective hand surgery were randomly assigned to one of three groups. Axillary blocks were performed using three motor response endpoints in the nerve stimulator (NS) Group, real-time ultrasound guidance in the ultrasound (US) Group and combined ultrasound and nerve stimulation in the USNS Group. Following administration of a standardized solution containing 2% lidocaine with 1:200,000 epinephrine and 0.5% bupivacaine (total 42 mL), sensory and motor functions were assessed by a blinded observer every five minutes for 30 min. A successful block was defined as complete sensory loss in the median, radial and ulnar nerve distribution by 30 min. The need for local and general anesthesia supplementation and post-block adverse events were documented. One hundred and eighty-eight patients completed the study. Block success rate was higher in Groups US and USNS (82.8% and 80.7%) than Group NS (62.9%) (P = 0.01 and 0.03 respectively). Fewer patients in Groups US and USNS required supplemental nerve blocks and/or general anesthesia. Postoperatively, axillary bruising and pain were reported more frequently in Group NS. This study demonstrates that ultrasound guidance, with or without concomitant nerve stimulation, significantly improves the success rate of axillary brachial plexus block.
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            Ultrasound guidance speeds execution and improves the quality of supraclavicular block.

            Patrick Harris, Lisa G Fore Arcand, Monique Ruel … (2003)
            In this prospective study, we assessed the quality, safety, and execution time of supraclavicular block of the brachial plexus using ultrasonic guidance and neurostimulation compared with a supraclavicular technique that used anatomical landmarks and neurostimulation. It was hypothesized that ultrasonic guidance would increase the proportion of successful blocks, decrease block execution time, and reduce the incidence of complications such as pneumothorax and neuropathy. Eighty patients were randomized into two groups of 40, Group US (supraclavicular block guided in real time by a two-dimensional ultrasonic image, with neurostimulator confirmation of correct needle position) and Group NS (supraclavicular block using the subclavian perivascular approach, also with neurostimulator confirmation). Blocks were performed using bupivacaine 0.5% and lidocaine 2% (1:1 vol) with epinephrine 1:200000 as the anesthetic mixture. The onset of motor and sensory block for the musculocutaneous, median, radial, and ulnar nerves was evaluated over a 30 min period. At 30 min 95% of patients in Group US and 85% of patients in Group NS had a partial or complete sensory block of all nerve territories (P = 0.13) and 55% of patients in Group US and 65% of patients in Group NS had a complete block of all nerve territories (P = 0.25). Surgical anesthesia without supplementation was achieved in 85% of patients in Group US and 78% of patients in Group NS (P = 0.28). No patient in Group US and 8% of patients in Group NS required general anesthesia (P = 0.12). The quality of ulnar block was significantly inferior to the quality of block in other nerve territories in Group NS, but not in Group US; the quality of ulnar block was not significantly different between Groups NS and US. The block was performed in an average of 9.8 min in Group NS and 5.0 min in Group US (P = 0.0001). No major complication occurred in either group. We conclude that ultrasound-guided neurostimulator-confirmed supraclavicular block is more rapidly performed and provides a more complete block than supraclavicular block using anatomic landmarks and neurostimulator confirmation. Ultrasound-guided neurostimulator-confirmed supraclavicular block is more rapidly performed and provides a block of better quality than supraclavicular block using anatomic landmarks and neurostimulator confirmation.
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              Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks.

              S Kapral, C Weinstabl, H Koinig … (1997)
              The use of ultrasound reduces the onset time, improves the quality of sensory block, and minimizes the risks associated with the supraclavicular approach for brachial plexus and stellate ganglion blockade. The present study was designed to evaluate whether ultrasound also facilitates the approach for 3-in-1 blocks. Forty patients (ASA physical status II or III) undergoing hip surgery after trauma were randomly assigned to two groups. In the ultrasound (US) group, 20 mL bupivacaine 0.5% was administered under US guidance, whereas in the control group, the same amount and concentration of local anesthetic was administered with the assistance of a nerve stimulator (NS). After US- or NS-based identification of the femoral nerve, the local anesthetic solution was administered, and the distribution of the local anesthetic solution was visualized and recorded on videotape in the US group. The quality and the onset of the sensory block was assessed by using the pinprick test in the central sensory region of each of the three nerves and compared with the same stimulation on the contralateral leg every 10 min for 60 min. The rating was performed using a scale from 100% (uncompromised sensibility) to 0% (no sensory sensation). Heart rate, noninvasive blood pressure, and oxygen saturation were measured at short intervals for 60 min. The onset of sensory blockade was significantly shorter in Group US compared with Group NS (US 16 +/- 14 min, NS 27 +/- 16 min, P < 0.05). The quality of the sensory block after injection of the local anesthetic was also significantly better in Group US compared with Group NS (US 15% +/- 10% of initial value, NS 27% +/- 14% of initial value, P < 0.05). A good analgesic effect was achieved in 95% of the patients in the US group and in 85% of the patients in the NS group. In the US group, visualization of the cannula tip, the femoral nerve, the major vessels, and the local anesthetic spread was possible in 85% of patients. Incidental arterial puncture (n = 3) was observed only in the NS group. We conclude that an US-guided approach for 3-in-1 block reduces the onset time, improves the quality of the sensory block and minimizes the risks associated with this regional anesthetic technique. The onset time and the quality of a regional anesthetic technique for the lower extremity is improved by ultrasonographic nerve identification compared with older techniques.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Anesthesiol Res Pract
                Journal ID (publisher-id): ARP
                Title: Anesthesiology Research and Practice
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 1687-6962
                ISSN (Electronic): 1687-6970
                Publication date (Print): 2011
                Publication date (Electronic): 22 May 2011
                Volume: 2011
                Electronic Location Identifier: 173796
                Affiliations
                Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
                Author notes
                *David M. Coventry: david.coventry@ 123456nhs.net

                Academic Editor: Sridhar Kollipara

                Article
                DOI: 10.1155/2011/173796
                PMC ID: 3119420
                PubMed ID: 21716725
                SO-VID: 79bedaf3-06f6-48eb-977b-1b14c0d28243
                Copyright © Copyright © 2011 A. R. Satapathy and D. M. Coventry.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 23 December 2010
                Date accepted : 13 March 2011
                Categories
                Subject: Review Article

                ScienceOpen disciplines: Anesthesiology & Pain management
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management

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