Comparison of clonidine and tramadol added to prilocaine brachial plexus block - analgesia, sensory and motor block

In a randomized, double-blind study we investigated the effect of clonidine and tramadol added to prilocaine on duration of analgesia, sensory and motor brachial plexus block. 60 patients were randomized in three groups. Group A received 40 ml prilocaine 1,5 % with tramadol 1,5 mg/kg KG, group B 40 ml prilocaine 1,5 % plus clonidine 1,5 microg/kg KG and group C 40 ml prilocaine 1,5 % without any additional medication. We recorded heart rate, blood pressure, oxygen saturation and sedation score at regular intervals. The onset of sensory and motor block was tested every five minutes for thirty minutes. The duration of analgesia, sensory and motor block were evaluated by using a questionnaire. There was no difference between the three groups concerning onset of brachial plexus block and duration of analgesia. But there was a significant prolongation of the duration of sensory and motor block in group B. Haemodynamic parameters remained stable in all patients, there were no significant changes in blood pressure and sedation.     

右美托咪定与肾上腺素作为局部麻醉药佐剂对臂丛神经阻滞效果的对比

目的 对比常用剂量的右美托咪定(dexmedetomidine,Dex)和肾上腺素作为罗哌卡因的佐剂对锁骨上臂丛神经阻滞影响的差异. 方法 选择Colle's骨折患者60例,ASA分级Ⅰ、Ⅱ级,其中男性40例,女性20例;年龄44～68岁,体重50～75kg.采用随机数字表法分为3组(每组20例):生理盐水对照组(C组)、Dex组(D组)和肾上腺素组(E组).各组均在超声引导下行锁骨上臂丛神经阻滞.C组使用1 ml生理盐水,D组将0.75 μg/kg Dex稀释至1 ml,E组将盐酸肾上腺素100 μg稀释至1 ml.上述溶液分别加入10 ml 1％盐酸罗哌卡因和10 ml生理盐水配制的局部麻醉药物中.比较感觉及运动阻滞的起效时间、持续时间、开始静脉镇痛的时间,入室时(T0)及给药后10 min(T1)、20min(T2)、30 min(T3)、40 min (T4)、50 min(T5)、60 min(T6)的HR、MAP、SpO2、BIS以及麻醉并发症的情况. 结果 D组感觉、运动阻滞的起效时间比C、E组短,差异有统计学意义(P＜0.05),而C、E两组间差异无统计学意义(P＞0.05).D、E两组感觉、运动阻滞的持续时间、静脉镇痛的开始时间均比C组晚,差异有统计学意义(P＜0.05),但两组间差异无统计学意义(P＞0.05).MAP的组间比较,D组在T4～T5时段低于C组,在T3～T5时段低于E组,差异有统计学意义(P＜0.05).E组在T3时刻高于C组,差异有统计学意义(P＜0.05).HR的组间比较,D组在T3～T6时段低于C,E两组,E组在T3～T5时段显著高于C组,差异有统计学意义(P＜0.05).BIS值的组间比较,D组在T2～T6时段显著低于C、E组,差异有统计学意义(P＜0.05). 结论 与100 μg肾上腺素相比,0.75 μg/kg Dex具有类似的增强臂丛神经阻滞的作用,还具有镇静及降低心血管应激的作用,适用于肾上腺素禁忌证者.     

Adiuvants in the axillary brachial plexus blockade. Comparison between clonidine, sufentanil and tramadol

BACKGROUND: Evaluated effects of tramadol used as adiuvant in brachial plexus block and compared with clonidine and sufentanil. METHODS: Randomized, prospectic study with 80 patients, ASA status I-II, undergoing carpal tunnel release performed under axillary plexus block with ropivacaine 0.75% 20 ml divided in 4 study groups: tramadolo 100 mg (Group T), clonidina 1.5 g/kg (Group C), sufentanil 20 g (Group S) in 5 ml. of NaCl. Control (Group F) NaCl 5 ml. Adeguacy of the block was evaluated using pinprick test ( three points scale) and a temperature test. Onset time, duration of analgesia and anesthesia were recorded. Also during the surgery the sedation score on a five-point scale was evaluated and were recorded episodes of hypotension, bradycardia, Sp02<90% and other side effects. Results are reported as median+/-SD. For statistical analysis ANOVA test, Bonferroni test and c2 test were used. RESULTS: Onset time of anesthesia showed significant difference between three study groups than control group, while no significant differences was recordered between groups S, C and T (S: 11+/-7 min; C: 12+/-4 min; T: 14+/-8 min; F: 20+/-11 min.). Same results were obtained among duration of anesthesia and analgesia, that were lower in F group. An adeguate quality of block for surgery was obtained in 79 patients. Only one patients of F group needed surgical infiltration. A significant difference was recordered among quality of anesthesia between group F and other three study groups. Highest sedation score was noted in C and S groups. Significantly highest incidence of bradycardia and hypotension episodes were observed in group C. CONCLUSIONS: The use of tramadol as adiuvant provides a significative redution of onset time. Also provides a prolongation of anesthesia and analgesia with a quality of block similar that obtained with clonidine and sufentanil and a lower incidence of side effects of clonidine (sedation, bradycardia and hypotension) and sufentanil(itch and sedation). We conclude that tramadol may be a useful alternative, as adiuvant in periferic block, with same effects of other drugs commonly used and a lower incidence of side effects.     

Comparison between 1.5% lidocaine with adrenaline and 1.5% plain mepivacaine in axillary brachial plexus block]

OBJECTIVES: To evaluate the distribution of sensory blockade, the onset time and the duration of the axillary plexus block obtained after the administration of 40 mL of 1.5% lignocaine with adrenaline or 40 mL of plain 1.5% mepivacaine. STUDY DESIGN: Prospective, randomised, comparative, double blind study. PATIENTS AND METHODS: One hundred and fifty five patients undergoing hand surgery were randomised into two groups: in group L, 73 patients were given 1.5% lignocaine with 1/200,000 adrenaline and in group M, 82 patients received 1.5% mepivacaine. The entire volume was injected on the first evoked motor activity obtained for a current less than 0.5 mA. Sensory and motor block of each of the four major nerves of the hand and forearm were assessed using light touch and motor strength respectively. The block was considered complete when all nerves were anaesthetised (median, radial, musculocutaneous and ulnar). RESULTS: The percentage of complete sensitive blockade was 22% in group L and 24% in group M. Complete motor blockade was respectively 27% in group L and 40% in group M. The median time required to obtain a complete sensory blockade was 18 min for both group. The median time required to obtain a complete motor blockade was 17 min in-group L and 16 min in-group M. The duration of the sensory blockade was not different for both groups (i.e., 255 +/- 76 min versus 231 +/- 70 min in group L and M respectively. The duration of the motor blockade was longer in group L compared to group M (199 +/- 64 min versus 231 +/- 74 min respectively, p < 0.05). CONCLUSION: Following axillary plexus block, 1.5% mepivacaine improves neither the extension nor the duration of sensory blockade achieved by 1.5% lignocaine with adrenaline.     

超声引导喙突处锁骨下臂丛神经阻滞与逆行锁骨下臂丛神经阻滞的比较

目的 比较超声引导喙突处锁骨下臂丛神经阻滞与逆行锁骨下臂丛神经阻滞的临床麻醉效果.方法 拟行前臂或手部手术患者60例,随机分为两组,分别行超声引导下喙突处锁骨下臂丛神经阻滞(观察组)和超声引导逆行锁骨下臂丛神经阻滞(对照组),每组30例.记录麻醉成功率、麻醉操作时间、持续时间及并发症发生例数、各臂丛神经的起效时间.结果 对照组尺神经、前臂内侧皮神经起效时间较观察组短(P＜0.05).对照组有5例Homer's综合征,1例误入血管.结论 超声引导喙突处锁骨下臂丛神经阻滞和逆行锁骨下臂丛神经阻滞均是可行有效的区域麻醉方法.     

Cardiac arrest after interscalene brachial plexus block with ropivacaine and lidocaine

Serious adverse reactions to ropivacaine and lidocaine are rare. In this report, we describe a case of sudden cardiac arrest after an interscalene brachial plexus block with a mixture of 150 mg of ropivacaine and 360 mg of lidocaine in a previously healthy, 34-year-old, 97-kg man. Severe hypotension occurred after successful resuscitation, necessitating an infusion of epinephrine. The patient developed pulmonary oedema, and was mechanically ventilated for 22 h. He eventually made a good recovery. We conclude that although ropivacaine and lidocaine are often considered relatively safe local anesthetics, serious cardiovascular complications can occur after the use of these drugs.     

罗哌卡因单独或复合肾上腺素用于臂丛麻醉的药代动力学比较

目的 研究罗哌卡因加和不加肾上腺素用于臂丛麻醉的药代动力学特征。方法 18例择期骨科下肢手术病人（ASAⅠ-Ⅱ级 ),分成两组,Ⅰ组为不加肾上腺素组（n＝9）,Ⅱ组加肾上腺素1：2000,000（n＝9）,0．75％罗哌卡因20ml加生理盐水10ml,共30ml,肌间沟径路径臂丛麻醉,操作在1min内完成。分别在给药前及给药后10、20、30、45、60、90min、3、4、6、9、12h采取颈内静脉血,用高效液相色谱仪测定罗哌卡因血药浓度,用药代动力学计算程序（3P97）统计处理。结果 两组血药浓度峰值（Cmax)、达峰值时间（tmax)及血药浓度曲线下面积（AUC）比较均没有统计差异（P＞0．05）。结论 加肾上腺素并不能改变罗哌卡因用于臂丛麻醉的药代动力学参数。     

Brachial plexus block with bupivacaine: effects of added alpha-adrenergic agonists: comparison between clonidine and epinephrine

The effects of clonidine and epinephrine, administered into the brachial plexus sheath, were evaluated in 60 patients who underwent surgery of the upper limb. All patients received 40 to 50 ml of 0.25% bupivacaine, injected into the brachial plexus sheath, using the supraclavicular technique. The patients were randomly allocated to two groups so that 30 patients received 150 micrograms clonidine hydrochloride (Group I), and 30 received 200 micrograms epinephrine (Group II). The quality and the duration of analgesia were assessed as well as the possible side-effects. The block produced with the addition of clonidine was longer (994.2 +/- 34.2 vs 728.3 +/- 35.8 min) and superior to that with epinephrine (P less than 0.001). No major side-effects were recorded. We conclude that the injection of clonidine into the brachial plexus sheath is an attractive alternative to epinephrine to prolong the duration of analgesia following upper limb surgery under conduction anaesthesia.     

The effects of clonidine added to mepivacaine for paronychia surgery under axillary brachial plexus block

We hypothesized that onset of sensory block is delayed in infected versus healthy tissues within the same nerve distribution after axillary brachial plexus block (ABPB) and that clonidine added to mepivacaine would enhance anesthesia and postoperative analgesia. Forty-one outpatients undergoing thumb/index paronychia surgery under ABPB were randomly assigned to receive in a double-blind fashion 400 mg mepivacaine plus either 100 microg clonidine (clonidine group, n = 21) or 2 mL saline (placebo group, n = 20). Onset of sensory block in the infected area was delayed compared with healthy areas of the same nerve distribution (24.7 +/- 5.5 min versus 21.3 +/- 7.2; P = 0.02 for median and 21.6 +/- 7.8 min; P = 0.04 for radial) within the placebo group. In the clonidine group, when compared to placebo i) onset of sensory block in both the median and radial nerve territories was accelerated (11.1 +/- 5.6 and 10.5 +/- 5.2 versus 21.3 +/- 7.2 and 21.6 +/- 7.8 min, respectively; P < 0.001), ii) onset of sensory block in the region of infection was accelerated (9.1 +/- 1.9 versus 24.7 +/- 5.5 min; P < 0.001), iii) duration of anesthesia (275 +/- 75 versus 163 +/- 57; P = 0.04) and time to first analgesic requirement (279 +/- 87 versus 197 +/- 84 min; P = 0.002) were prolonged with decreased visual analog scale scores at this time (30 +/- 18 versus 70 +/- 24; P < 0.001), and iv) verbal numeric rating scores were decreased at 24 h (1.7 +/- 2.2 versus 4.1 +/- 3.0; P = 0.002) and 48 h (0.1 +/- 0.5 versus 1.5 +/- 2.4; P = 0.01) postoperatively. Our findings suggest that in the setting of distal infected tissue surgery under ABPB infected tissues are resistant to anesthesia compared with healthy areas within the same nerve distribution and clonidine added to mepivacaine enhances both anesthesia and postoperative analgesia.     

Bilateral brachial plexus block

Bilateral regional anesthesia techniques in general and bilateral brachial plexus blocks in particular are rarely performed because they have few clinical indications. We present the case of a patient who presented to the operating room for bilateral upper extremity procedures where we thought regional anesthesia was appropriate. The anesthesia management is discussed as well as potential problems and complications. IMPLICATIONS: Reports on bilateral regional blocks are extremely rare in the literature. Whereas they have the potential for more complications than a single technique, they can be very useful in specific clinical situations.     

Parascalene brachial plexus block

The supraclavicular brachial plexus block originated by Kulenkampff is useful but accompanies the danger of injury to the lung, i.e. pneumothorax, because the needle is directed caudad. Reviewing the anatomy of the brachial plexus in cadavers, we have found that the parascalene brachial plexus block originated by Vongvises is safer than Kulenkampff's method. We modified this block as follows: (1) An assistant pulls lightly the affected upper extremity caudad. (2) A 23-gauge 35 mm needle is inserted at right angles to the clavicle and directed cephalad at an angle of 0-30 degrees. One hundred and eighty four ASA I and II patients were operated under this block. Their ages ranged from 11 to 77, and there were 31 patients whose cervical spinal cord had been injured. Our success rate was 92%. The only complication we encountered was Horner's syndrome which occurred in 20% of our cases. None of our patients showed clinical symptoms of pneumothorax, hematoma, epidural as well as subarachnoideal block, recurrent nerve paralysis or phrenic nerve paralysis.     

Evaluation of brachial plexus block. Comparison between supraclavicular and interscalene approach (author's transl)]

A scheme for evaluating brachial plexus block was developed, which is based on anatomical structures and which utilizes simple neurological examination techniques. It facilitates the localization of the tip of the cannula near the plexus, gives an idea of the spread of the local anesthetic in the region of the trunks and cords, gives well timed judgement on the success of the block and allows a comparison of the development of the block when using various techniques. Using this scheme, the development of the block was examined following use of the supraclavicular and interscalene approach. With the supraclavicular technique, motor as well as sensory blockade of all nerves of the brachial plexus occurred with about the same frequency; with the interscalene technique, the centre of the block affected the caudal nerves of the cervical plexus and the cranial nerves of the brachial plexus. Following both approaches, the blockade developed from proximal to distal areas, the motor blockade preceding the sensory blockade.