Comparison of 0.2% ropivacaine and 0.25% bupivacaine for axillary brachial plexus blocks in paediatric hand surgery

BACKGROUND: The purpose of this study was to compare the use of ropivacaine 0.2% with bupivacaine 0.25% for axillary brachial plexus block in children undergoing hand surgery. METHODS: In a double-blind, randomized study, 35 children undergoing hand surgery received axillary brachial plexus blocks with 0.5 ml.kg-1 of either 0.2% ropivacaine or 0.25% bupivacaine. Pain scores were noted at 0, 3, 6, 12 and 24 h after surgery. The time to first dose of codeine phosphate and the total doses of all analgesics given were recorded. RESULTS: There was no significant difference between the two groups in pain scores, the time to first dose of codeine phosphate or in analgesic requirements in the first 24 h. CONCLUSIONS: Ropivacaine 0.2% is as effective as bupivacaine 0.25% for axillary brachial plexus blocks in children undergoing hand surgery.     

Efficacy and safety of axillary brachial plexus block for operations on the hand.

An axillary brachial plexus nerve block by a transarterial approach is commonly used to achieve regional anaesthesia for hand surgery. We designed a retrospective study to evaluate efficacy and safety of the technique for acute and elective operations. Anaesthetic records of 189 of all 5520 patients (1996-2000) who had axillary brachial plexus blocks for hand surgery were reviewed, and results compared with complications recorded in the anaesthetic register and in the hand surgery records. Successful axillary block was achieved in 5128/5520 (93%) of patients, according to anaesthetic charts, and primarily in 157/189 (83%), and after supplementation in 171/189 (90%), according to anaesthetic records. Four patients had a toxic drug reaction or axillary haematoma with a transient neurological deficit. Medical complications were recorded in the anaesthetic register in less than 0.7% of axillary brachial plexus procedures. Axillary brachial plexus block by a transarterial approach is effective and safe in hand surgery.     

A modified coracoid approach to infraclavicular brachial plexus blocks using a double-stimulation technique in 300 patients

Infraclavicular brachial plexus block is used less than other techniques of regional anesthesia for upper-limb surgery. We describe a modified coracoid approach to the infraclavicular brachial plexus using a double-stimulation technique and assess its efficacy. Patients undergoing orthopedic surgery of the upper limb were included in this prospective study. The landmarks used were the coracoid process and the clavicle. The needle was inserted in the direction of the top of the axillary fossa (in relation to the axillary artery), with an angle of 45 degrees. Using nerve stimulation, the musculocutaneous nerve was identified first and blocked with 10 mL of 1.5% lidocaine with 1:400,000 epinephrine. The needle was then withdrawn and redirected posteriorly and medially. The radial, ulnar, or median nerve was then blocked. The block was tested every 5 min for 30 min. The overall success rate, i.e., adequate sensory block in the 4 major nerve distributions at 30 min, was 92%, and 6% of the patients required supplementation. Five patients required general anesthesia. No major complications were observed. This modified infraclavicular brachial plexus block using a double-stimulation technique was easy to perform, had frequent success, and was safe in this cohort.     

Quality of axillary brachial plexus block

A perivascular catheter technique (PVT) and a nerve stimulator technique (NST) for axillary brachial plexus block were compared in terms of quality: complete, incomplete or failed blocks. In a randomised series, 30 PVT blocks and 30 NST blocks were performed by three staff anaesthetists. In the NST group, surgical anaesthesia was always achieved, whereas in the PVT group, four blocks required supplementation with general anaesthesia. In both groups eight patients needed supplementation with additional conduction blocks of 1-3 peripheral nerves. It is concluded that a nerve stimulator technique may increase the success rate of axillary brachial plexus block to some extent.     

Continuous axillary brachial plexus block

Continuous axillary brachial plexus block was performed in 597 patients undergoing prolonged operations on the hand. The technique required placement of a 5 cm 23 gauge teflon intravenous catheter in the axillary perivascular sheath. Lidocaine 1.5 per cent or mepivicaine 1.5 per cent (20-40 ml) were used for the initial block dose. Surgery was completed in 77.2 per cent of patients (460) with the axillary block alone while in 19.1 per cent of patients (114) supplementary narcotic administration or additional regional blocks were required. In 3.7 per cent of patients (22) the technique was considered a complete failure. Complications included local anaesthetic toxic reactions (2.85 per cent, 17 cases), nerve injury (0.50 per cent, three cases) and one case of major haematomaformation. The advantages of this technique and the possible complications are discussed.     

Continuous axillary brachial plexus analgesia in a patient with severe hemophilia

Until now, the safety of continuous axillary brachial plexus block in a patient with hemophilia has not been reported. We describe the use of continuous axillary brachial plexus block for postoperative pain control in a patient with severe hemophilia after an elbow surgery.     

Quantifizierung der Perfusionsänderung des Armes nach Plexusanästhesie mittels Farbdopplersonographie

The axillary brachial plexus block is a well-known technique for intra- and postoperative analgesia and sympathetic blockade in hand and microsurgery. The aim of this study was to show the influence of the axillary brachial plexus block on the blood flow as a side effect. Methods. We used a colour-coded sonography unit (Toshiba) with a 7.5-MHz transducer. A total of 12 patients with no clinical signs of vascular diseases were enrolled in this study. We measured the peak blood flow velocity and the peak flow at the bifurcation of the brachial artery and vein and the proximal and distal radial artery before and after the plexus block. In addition, we were able to take the morphological aspects of the analysed vessels into consideration as we also used conventional sonography. This was done to detect any early signs of vascular malformation or arteriosclerosis, either of which might have affected the measurements. Results. The average arterial peak blood flow after the plexus block was 1.9 times that before. On the venous side, the block effect caused an average increase of the blood flow to 8.6 times than before the block. In general, an additional and immediate effect of the block was a significant rise in blood flow velocity with an increase in cross-section area. Conclusions. The brachial plexus block combines two advantages: pain relief and pain management plus temporary sympathectomy. In conclusion, it prevents vasospasms and improves the circulation of the hand in patients undergoing reimplantation of limbs and those with nutritional disorders.     

超声引导下患儿肋锁间隙臂丛神经阻滞的研究进展

肋锁间隙(CCS)臂丛神经阻滞是一种锁骨下臂丛神经阻滞方式。臂丛内侧束、外侧束、后束在CCS集中于腋动脉外侧,位置关系固定,使用较少的局麻药即可达到良好的阻滞效果。近年来,CCS臂丛神经阻滞逐渐应用于患儿区域麻醉。患儿CCS臂丛神经解剖位置表浅,易于超声定位,但血管、神经、胸膜等结构距离较近,超声引导增加了患儿CCS臂丛神经阻滞的有效性和安全性。本文就CCS臂丛神经阻滞的解剖基础及超声定位、阻滞方法及药物用量、患儿临床应用和相关并发症进行综述,以期为患儿CCS臂丛神经阻滞的应用提供参考。     

Technique du bloc plexique prolongé par voie axillaire

A technique of continuous axillary brachial plexus block, using an epidural Tuohy needle and an epidural catheter, is described. Studies were carried out in ten patients using this technique with bupivacaine as a local anesthetic drug. The catheter remained indwelling during a mean period of five days. Good analgesia was obtained in nine out of the ten patients. Thus this technique allows pain-free postoperative period in hand surgery.     

Improving postoperative analgesia after axillary brachial plexus anesthesia with 0.75% ropivacaine. A double-blind evaluation of adding clonidine

BACKGROUND: The aim of this prospective, randomized, double-blind study was to evaluate the effects of adding 1 microg/kg clonidine to 20 ml of ropivacaine 0.75% for axillary brachial plexus anesthesia. METHODS: With Ethical Committee approval and written consent, 30 ASA physical status I-II in-patients, undergoing upper extremity orthopedic procedures were randomly allocated to receive axillary brachial plexus block with 20 ml of 0.75% ropivacaine alone (group ropivacaine, n = 15) or 0.75% ropivacaine + 1 microg/kg clonidine (group ropivacaine-clonidine, n = 15). Nerve blocks were placed using a nerve stimulator with the multiple injection technique (stimulation frequency was 2 Hz; stimulation intensity was decreased to < or = 0.5 mA after each muscular twitch; the anesthetic volume was equally divided among arm flexion, arm extension, wrist flexion, and thumb adduction). A blinded observer recorded the time required to achieve surgical block [loss of pinprick sensation in the innervation areas of the hand (C6-C8) with concomitant inability to move the wrist and hand] and first analgesic request. RESULTS: No differences in demography, degree of sedation, peripheral oxygen saturation, and hemodynamic variables were observed between the two groups. Readiness for surgery required 15 min (5-36 min) with 0.75% ropivacaine and 20 min (5-30 min) with the ropivacaine-clonidine mixture. The degree of pain measured at first analgesic request, and consumption of postoperative analgesics were similar in the two groups; while first postoperative analgesic request occurred after 13.8 h (25th-75th percentiles: 9.1-13 h) in the ropivacaine group and 15.2 h (25th-75th percentiles: 10.7-16 h) in the ropivacaine-clonidine group (p = 0.04). CONCLUSIONS: Adding 1 microg/kg clonidine to 20 ml of ropivacaine 0.75% for axillary brachial plexus anesthesia provided a 3 h delay in first analgesic request postoperatively, without clinically relevant effects on the degree of sedation and cardiovascular homeostasis.     

0.75% and 0.5% ropivacaine for axillary brachial plexus block: a clinical comparison with 0.5% bupivacaine

BACKGROUND AND OBJECTIVES: Although ropivacaine has been extensively studied for epidural anesthesia, very few reports exist on brachial plexus block. We therefore decided to investigate the clinical features of axillary brachial plexus anesthesia with two different concentrations of ropivacaine (0.5% and 0.75%) and to compare the results with those obtained with 0.5% bupivacaine. METHODS: Three groups of patients were randomized and prospectively studied. They received, in a double-blind fashion, 32 mL of the local anesthetic solution into the midaxilla, by a nerve-stimulator technique. Onset time in each of the stimulated nerves was recorded both for the sensory and motor block. Peak time (ready to surgery), rate of supplemental blocks, need for intraoperative opioids, duration of sensory and motor block, postoperative analgesic requirements, and patient satisfaction were also recorded. RESULTS: The rate of complete sensory and motor block observed with both ropivacaine groups was higher at 10, 15, and 20 minutes postinjection (P < .001). The mean peak time was shorter with ropivacaine than with bupivacaine (R50 = 16.37 minutes, R75 = 14.7 minutes, B = 22.3 minutes, P < .05). The quality of the anesthesia was higher with ropivacaine, as measured by the intraoperative needs for opioids and the overall patient's satisfaction (P < .05). No significant differences were noted with all the other studied parameters. CONCLUSION: Ropivacaine showed advantages over bupivacaine for axillary brachial plexus block. Because no statistical differences were found between the two ropivacaine groups, we therefore conclude that 0.75% does not add benefit and that 0.5% ropivacaine should be used to perform axillary brachial plexus blocks.     

Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anaesthesia performed with ropivacaine

BACKGROUND: The aim of this prospective, randomized, double-blind study was to evaluate the effects of adding 1 microg. kg-1 fentanyl to ropivacaine 7.5 mg. ml-1 for axillary brachial plexus anaesthesia. METHODS: With Ethics Committee approval and written consent, 30 ASA physical status I-II in-patients, scheduled for orthopaedic hand procedures were randomly allocated to receive axillary brachial plexus block with 20 ml of either ropivacaine 7.5 mg. ml-1 (n=15) or ropivacaine 7.5 mg. ml-1+1 microg. ml-1 fentanyl (n=15). Nerve blocks were placed using a nerve stimulator with the multiple injection technique. A blinded observer recorded the time to onset of surgical block (loss of pinprick sensation in the innervation areas of the hand (C6-C8) with concomitant inability to flex the wrist against gravity and move the fingers when squeezing the hand) and first request for pain medication after surgery. RESULTS: No differences in demography, degree of sedation or peripheral oxygen saturation were observed between the two groups. Median (range) time required to achieve readiness for surgery was 15 min (5-36 min) with ropivacaine alone and 15 min (5-40 min) with the ropivacaine-fentanyl mixture. No differences in the intraoperative quality of nerve block were reported between the two groups. Four patients receiving ropivacaine plain and two patients receiving the ropivacaine-fentanyl mixture did not require analgesics during the first 24 h after surgery (P=0.62). The degree of pain experienced at first analgesic request in those patients asking for pain medication, as well as median consumption of postoperative analgesics, were similar in the two groups. First postoperative analgesic request was made at 11 h (25th-75th percentiles: 9.1-14 h) in patients receiving ropivacaine alone and at 11.8 h (25th-75th percentiles: 9.8-15 h) in patients receiving the ropivacaine-fentanyl mixture (P=0.99). CONCLUSION: The addition of fentanyl 1 microg. ml-1 to ropivacaine 7.5 mg. ml-1 does not improve the nerve block characteristics of axillary brachial plexus anaesthesia for orthopaedic procedures involving the hand.     

Brachial plexus blocks: a review of approaches and techniques

PURPOSE: The purpose of this narrative review is to summarize the evidence derived from randomized controlled trials (RCTs) regarding established approaches and techniques for brachial plexus anesthesia. SOURCE: Using the MEDLINE (January 1966 to November 2006) and EMBASE (January 1980 to November 2006) databases, key words "brachial plexus", "nerve blocks", "interscalene", "cervical paravertebral", "suprascapular", "supraclavicular", "infraclavicular", "axillary", "brachial canal" and "humeral canal" were searched for full text articles pertaining to the evaluation of recognized approaches and techniques for brachial plexus anesthesia. The search was limited to RCTs involving human subjects and published in the English language. Seventy-six RCTs were identified. PRINCIPAL FINDINGS: Many of the published studies were underpowered and contained various methodological limitations. We found that, for shoulder and proximal humeral surgery, interscalene and cervical paravertebral approaches to the brachial plexus appear to provide equally effective surgical anesthesia. Intersternocleidomastoid supraclavicular blocks are not associated with improved postoperative analgesia despite eliciting more complete anesthesia of the brachial plexus. For surgery at or below the elbow, an infraclavicular block may result in decreased performance time and block-related pain while providing similar efficacy compared to (multiple-stimulation) axillary and brachial canal approaches. With respect to technique, it is unclear if nerve stimulation provides a more effective interscalene block than elicitation of paresthesiae. For supraclavicular blocks, nerve stimulation with a minimal threshold of 0.9 mA is recommended, whereas a double-stimulation technique is optimal for infraclavicular blocks. For the axillary approach, a triple-stimulation technique, involving injections of the musculocutaneous, median and radial nerves, is the most effective option. CONCLUSIONS: Published reports of RCTs provide evidence to formulate limited recommendations regarding optimal approaches and techniques for brachial plexus anesthesia. Further well-designed and meticulously executed RCTs are warranted, particularly in light of new techniques involving ultrasound or combining neurostimulation and echoguidance.     

Sufentanil does not prolong the duration of analgesia in a mepivacaine brachial plexus block: a dose response study

To date, results of studies evaluating the efficacy of opioids and local anesthetic combinations in the brachial plexus are inconclusive. We examined whether increasing sufentanil in doses of 5, 10, and 20 microg decreased onset time or increased duration of an axillary brachial plexus block. Ninety-two patients scheduled for carpal tunnel release under axillary brachial plexus block were enrolled in the study. Patients were randomized to receive axillary plexus block with 40 mL 1.5% mepivacaine and saline (Group 1), sufentanil 5 microg (Group 2), 10 microg (Group 3), or 20 microg (Group 4). Onset and duration of sensory and motor block were measured. Opioid-related side effects were recorded. The addition of sufentanil did not improve speed of onset or increase the duration of sensory or motor block. Paradoxically, duration of sensory and motor block was longest in the control group: sensory, 241 min (188-284) and motor, 234 min (128-305), and decreased with increasing doses of sufentanil in Group 4: sensory, 216 min (115-315) and motor, 172 min (115-260) (P < 0.05). Side effects occurred in 55% of patients belonging to Groups 2 and 4, and in 60% of the patients in Group 3. In contrast, only 10% of the patients reported side effects in the control group. We conclude that sufentanil added to mepivacaine does not increase the onset or prolong the duration of an axillary plexus block. Furthermore, the addition of sufentanil was associated with a frequent incidence of side effects. IMPLICATIONS: This study demonstrates that the addition of sufentanil in a dose-dependent manner to 1.5% mepivacaine in the axillary plexus does not improve onset or duration of blockade, and that this admixture is associated with an increased incidence of side effects.     

Percutaneous central venous catheterization in small infants: axillary block can facilitate the insertion rate

Central venous cannulation through a peripheral vein is the technique of choice in awake nonsedated critically ill infants. Such a technique has a high failure rate. We undertook a retrospective study to determine whether a brachial plexus block performed via the axillary approach could improve the success rate for the insertion of a central venous catheter from a peripheral vein of the upper limb in small infants. Data from 128 infants, submitted or not submitted to the axillary block, were analysed. The failure rate for insertion of the central venous catheter was 27% in the group without the use of the axillary block and 9% with the axillary block (P<0.05). The use of brachial plexus block via the axillary route, although evaluated retrospectively, improves the success rate for the insertion of small diameter central venous silicon catheter from a peripheral vein of the upper limb in small infants.     

Continuous brachial plexus infusion of butorphanol-mepivacaine mixtures for analgesia after upper extremity surgery

We have recently reported that continuous administration of butorphanol into the brachial plexus neurovascular sheath provided superior analgesia compared with that obtained with continuous i.v. administration. Furthermore, we found that analgesia was most pronounced when a mixture of mepivacaine and butorphanol was given and that butorphanol alone ranked next. In this study, we increased the dose of butorphanol, compared with that used in our previous reports, and an initial bolus dose of butorphanol was administered into the brachial plexus neurovascular sheath just after surgery had ended. Thereafter, postoperative pain relief was estimated. In patients undergoing upper extremity surgery with continuous axillary brachial plexus block, group A received a bolus of 1 ml of physiological saline with 1.5% mepivacaine, 10 ml into the brachial plexus sheath followed by a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/ 72 h. Group B was given a bolus of butorphanol 1 mg (1 ml) with 1.5% mepivacaine, 10 ml into the brachial plexus sheath and a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/72 h. After operation, VAS scores did not differ between the two groups. The time to first use of supplementary analgesia did not differ significantly between the two groups and there were no significant differences in the number of patients who required supplementary analgesia. These results indicate that continuous butorphanol 2 mg day-1 with 0.5% mepivacaine provided sufficient postoperative analgesia after upper limb surgery.      

A comparison of 1% prilocaine with 0.5% ropivacaine for outpatient-based surgery under axillary brachial plexus block.

We compared the use of 1% prilocaine with 0.5% ropivacaine for axillary brachial plexus anesthesia in a double-blinded manner in day-stay patients to determine the better of the two local anesthetics in terms of onset time and duration of motor block. Sixty patients scheduled for outpatient upper-limb surgery were allocated randomly to receive either prilocaine (28 patients) or ropivacaine (32 patients) at a volume of 0.7 mL/kg. The brachial plexus was located with a plexus needle and nerve stimulator. By 20 min after injection of prilocaine or ropivacaine, there was no difference in analgesic effect. By this time, it was apparent whether or not a block was going to be adequate for surgery. Pain returned after a mean of 278 min (SD 111 min; range, 160-630 min) with prilocaine as compared with 636 min (SD 284 min; range, 210-1440 min) with ropivacaine. Analgesia use was similar in both groups. Duration of motor block with prilocaine was a mean of 254 min (SD 62 min; range, 130-385 min), as compared with 642 min (SD 199 min; range, 350-1080 min) with ropivacaine. We conclude that there is no clinically important difference between 1% prilocaine and 0.5% ropivacaine in time to onset of axillary brachial plexus block when they are injected in equal volumes. There is a significantly longer duration of action with ropivacaine, which may make it less suitable for day-stay upper-limb surgery because of the handicap from reduced muscle power. Implications: This study compares two local anesthetics to determine which is most suitable for day-stay upper-limb surgery under axillary brachial plexus block.Prilocaine 1% is more suitable than ropivacaine 0.5% because of a more prolonged duration of action of ropivacaine, although this could be useful in other circumstances.     

Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade

Different additives have been used to prolong regional blockade. We designed a prospective, randomized, double-blind study to evaluate the effect of dexamethasone added to lidocaine on the onset and duration of axillary brachial plexus block. Sixty patients scheduled for elective hand and forearm surgery under axillary brachial plexus block were randomly allocated to receive either 34 mL lidocaine 1.5% with 2 mL of isotonic saline chloride (control group, n = 30) or 34 mL lidocaine 1.5% with 2 mL of dexamethasone (8 mg) (dexamethasone group, n = 30). Neither epinephrine nor bicarbonate was added to the treatment mixture. We used a nerve stimulator and multiple stimulations technique in all of the patients. After performance of the block, sensory and motor blockade of radial, median, musculocutaneous, and ulnar nerves were recorded at 5, 15, and 30 min. The onset time of the sensory and motor blockade was defined as the time between last injection and the total abolition of the pinprick response and complete paralysis. The duration of sensory and motor blocks were considered as the time interval between the administration of the local anesthetic and the first postoperative pain and complete recovery of motor functions. Sixteen patients were excluded because of unsuccessful blockade. The duration of surgery and the onset times of sensory and motor block were similar in the two groups. The duration of sensory (242 +/- 76 versus 98 +/- 33 min) and motor (310 +/- 81 versus 130 +/- 31 min) blockade were significantly longer in the dexamethasone than in the control group (P < 0.01). We conclude that the addition of dexamethasone to lidocaine 1.5% solution in axillary brachial plexus block prolongs the duration of sensory and motor blockade.     

Fentanyl improves analgesia but prolongs the onset of axillary brachial plexus block by peripheral mechanism

We evaluated the effects of fentanyl added to lidocaine for axillary brachial plexus block in 66 adult patients scheduled for elective hand and forearm surgery. In this double-blinded study, all patients received 40 mL of 1.5% lidocaine with 1:200,000 epinephrine, injected into the brachial plexus sheath using the axillary perivascular technique, and they were randomized into three groups. Group 1 was given lidocaine containing 2 mL of normal saline plus 2 mL of normal saline IV. Patients in Group 2 received lidocaine containing 100 microg fentanyl plus 2 mL of normal saline IV. Group 3 patients received lidocaine containing 2 mL of normal saline plus 100 microg fentanyl IV. Sensory and motor blockade were evaluated by using a pinprick technique and by measuring the gripping force, respectively. The success rate of sensory blockade for radial and musculocutaneous nerves and the duration of the sensory blockade significantly increased in Group 2 (323 +/- 96 min) as compared with Group 1 (250 +/- 79 min). However, onset time of analgesia was prolonged in every nerve distribution by adding fentanyl to brachial plexus block. IV fentanyl had no effect on the success rate, onset, or duration of blockade. We conclude that the addition of fentanyl to lidocaine causes an improved success rate of sensory blockade but a delayed onset of analgesia, although this may be accounted for by the decreased pH caused by the fentanyl. Implications: It is still unclear whether the addition of a peripheral opioid is useful for nerve blockade in humans. Peripheral application of fentanyl to lidocaine for axillary brachial plexus blockade in this study provided an improved success rate of sensory blockade and prolonged duration.