Block of the brachial plexus branches by the humeral route. A prospective study in 503 ambulatory patients. Proposal of a nerve-blocking sequence

BACKGROUND: Brachial plexus is usually approached by the supraclavicular or axillary route. A technique for selective blockade of the branches of the plexus at the humeral canal using electrolocation has recently been proposed. The aim of the present study was to assess the feasibility of this technique in the ambulatory patient and to determine the optimal sequence of nerve-blocking. METHODS: The nerves originating from the brachial plexus were located in the humeral canal, at the junction of the proximal and the middle third of the arm, with a stimulator and blocked using either lidocaine or a mixture of lidocaine and bupivacaine, depending on the anticipated duration of surgery. The minimal stimulating intensity eliciting an adequate response, type of local anaesthetic and injected volume, and time of onset of surgical anaesthesia were collected. RESULTS: The study included 503 consecutive ambulatory patients due to undergo surgery of the elbow, wrist or hand in one year. Suitable anaesthesia was obtained with the humeral blockade in 82.1% of cases. In the remaining 17.9%, an additional block at the elbow was required, mainly for ulnar and median nerves. The onset times of sensory blocks were the longest for the median nerve, similar for the radial and ulnar nerves, shorter for the musculocutaneous nerve and the shortest for the medial brachial and antebrachial cutaneous nerves. The difference was more significant with the lidocaine-bupivacaine mixture, than with lidocaine alone (P<0.001 vs P<0.05, respectively). The onset times of motor blocks were the longest for the median nerve (P<0.05) and the shortest for the musculocutaneous nerve (P<0.001). Neither nervous nor vascular complications occurred. CONCLUSION: This study shows that the nerve block at the humeral canal is an efficient and safe technique. Considering the onset times of nerve blocks, the following sequence for blockade can be recommended: median, ulnar, radial, musculocutaneous, medial (brachial and antebrachial) cutaneous nerves. The selective blockade of the main nerves of the upper limb at the humeral canal can be recommended for surgery of the forearm and the hand in the ambulatory patient.     

Impairment of the brachial plexus after harvest of the latissimus dorsi muscle for reanimation of a paralysed face

The one-stage neurovascular pedicled latissimus dorsi muscle transfer with a long thoracodorsal nerve for dynamic reanimation of long-standing facial paralysis offers several advantages over other options. However, extensive dissection of the thoracodorsal nerve risks injury to the brachial plexus. We reviewed 264 consecutive cases to assess the extent of the risk of impairment of the brachial plexus and to elicit factors that could possibly induce complications. Six patients had impairment of brachial plexus, but both sensory and motor disturbance disappeared about 11 months postoperatively. All symptoms had completely vanished by 18.5 months. The complications were thought to have resulted from positioning and excessive retraction in four cases. Direct invasion of the brachial cord may not be the main cause. Proper knowledge of the anatomy and optimum attention minimise the risk of severe complications associated with harvesting of the latissimus dorsi muscle.     

Infraclavicular brachial plexus block effects on respiratory function and extent of the block

Background and Objectives. Axillary block is devoid of severe respiratory complications. However, incomplete anesthesia of the upper limb is the main disadvantage of the technique. Theoretically, the more proximal infraclavicular approach would produce a more extensive block without the risk of pneumothorax. However, neither its effects on respiratory function nor a detailed characterization of the extent of neural block has been assessed. The goal of this study was to evaluate the possible changes in respiratory function and also the extent of the block after infraclavicular block. Methods. We performed an infraclavicular block with a mixture of 40 mL 1.5% plain mepivacaine and 4 mL 8.4% sodium bicarbonate in 20 patients. Forced expiratory volumes were measured before and 15 minutes after the injection of local anesthetic, and sensory and motor block were evaluated at 10 and 20 minutes. Results. We did not find significant differences from baseline in the forced expiratory volumes in any of the patients. Axillary and musculocutaneous nerve distributions had the lowest rate of sensory block at 20 minutes. Conclusions. Infraclavicular block does not produce a reduction in respiratory function.     

High-dose bupivacaine, levobupivacaine and ropivacaine in axillary brachial plexus block

BACKGROUND: Racemic bupivacaine is clinically similar to levobupivacaine, or ropivacaine. The drugs were compared in brachial plexus block for the first time in the same randomized and double-blind study. METHODS: In 90 patients scheduled for hand and forearm surgery, a perivascular axillary brachial plexus block was performed with 45 ml of 5 mg ml(-1) of either racemic bupivacaine-HCl, levobupivacaine-HCl, or ropivacaine-HCl. Sensory (cold) and motor (hand clasp, and movement of elbow) block were scored, and the patient was interviewed in the postoperative evening and the following morning. Time to normal function of the arm was registered. RESULTS: After similar onsets of sensory block, the sum of completely anaesthetized innervation areas of the four main nerves at 45 min was greater in the ropivacaine group than in the levobupivacaine group (P < 0.01). Simultaneously, complete motor block at the elbow was more frequent in the ropivacaine group (67%) than in the bupivacaine (47%) and levobupivacaine groups (30%) (P < 0.01). In the hand, the corresponding results were 83%, 77%, and 57%, respectively (NS). Two patients in the levobupivacaine and one in the ropivacaine group needed general anaesthesia. Mean duration of the blocks was similar in the bupivacaine, levobupivacaine and ropivacaine groups at 19.3 h, 19.5 h, and 17.3 h, respectively (NS). Two patients were dissatisfied with the long block duration. CONCLUSION: Ropivacaine-HCl 5 mg ml(-1) produced slightly better sensory and motor block intensity than the same dose of levobupivacaine-HCl. General success in relation to surgery and in the duration of the blocks was similar in the three groups.     

Vertical infraclavicular brachial plexus block in children: a preliminary study

BACKGROUND: Brachial plexus blockade is a well-established technique in upper limb surgery. Among the infraclavicular approaches, the vertical infraclavicular brachial plexus (VIP) block is easy to perform and has a large spectrum of nerve blockade. The aim of this preliminary study was to determine the ease, effectiveness, safety, and duration of the VIP block in pediatric trauma surgery. METHODS: Fifty-five patients (ASA physical status I and II, age range 5-17 years old) scheduled for upper limb trauma surgery received a VIP block under light general anesthesia, using 0.5 ml x kg(-1) of ropivacaine 0.5%. The number of attempts and time to perform the block, the occurrence of a surgical response, the visual analogue score (VAS) scores, the incidence of complications and the duration of the block were evaluated. RESULTS: The brachial plexus was found easily at the first or second attempt in 85% (47 of 55) of the cases, in 15% (eight of 55) of the cases it was localized after three to four attempts. The mean time to perform the block was 3.35 +/- 3.37 min. Ninety-eight percentage (54 of 55) of the blockades were effective for surgery and in just one case was ineffective. The VAS scores at the end of the procedure in 100% (55 of 55) of the cases were <3. There were no cases with clinical signs of pneumothorax nor inadvertent puncture of major vessels. Two patients developed a Horner's syndrome and in one a mild superficial hematoma at the puncture site occurred. The mean sensory block duration was 8.45 +/- 1.71 h and the mean motor block duration was 6.52 +/- 2.50 h. CONCLUSIONS: In this preliminary study, the VIP block was easy to perform, effective and free of major complications for pediatric trauma surgery. With the doses of ropivacaine we used it was useful for intra- and postoperative analgesia.     

Percutaneous left brachial catheterization usingl 5-French preformed (Judkins) catheters

A method is described combining percutaneous brachial catheterization techniques with the use of 5-French (F) preformed (Judkins) catheters. This method was used in 50 patients with one unsuccessful attempt to cannulate the brachial artery. There was one lost pulse requiring surgical thrombectomy but no other cardiac, vascular, or neurologic complications. Two moderately large hematomas occurred, which resolved without sequelae. Manipulation of 5-F Judkins catheters from the left arm was found to be quite acceptable with adequate visualization of the coronary arteries in all cases. We believe this technique to be an excellent alternative to brachial cutdown or transaxillary methods in patients with severe occlusive ileofemoral disease as well as an improved technique for out-patient catheterization.     

踝臂指数联合颈动脉斑块积分对老年人冠状动脉病变的预测分析

目的 探讨踝臂指数（ABI）联合颈动脉斑块积分（Crouse积分）对老年人冠状动脉病变的判定价值。方法 选择2013年11月1日至2014年4月30日在解放军总医院心内科住院并首次行冠状动脉造影的153例老年患者（＞60岁）,收集其ABI及颈动脉斑块Crouse积分的数值,根据冠状动脉造影的病变血管数量把患者分成冠状动脉正常组（0组）、单支病变组（1组）、双支病变组（2组）及多支病变组（3组）;再根据冠状动脉病变狭窄程度（Gessini积分）分为冠状动脉严重病变组和非严重病变组。结果 ABI在0组、1组、2组均与3组有统计学差异,Crouse积分在0组与2组、3组有统计学差异;分别对Crouse积分、ABI和冠状动脉病变血管数进行相关性分析,采用Spearman分析,在置信度（双侧）为0.01时,相关性是显著的,相关系数分别为0.484和-0.491;以ABI≤0.9为截断值,其预测冠状动脉严重病变的敏感性为24%,特异性为96.1%,以Crouse积分≥1.9为截断值,其预测冠状动脉严重病变的敏感度为76%,特异度为21.4%。结论 ABI、颈动脉Crouse积分的水平变化与冠状动脉的病变程度密切相关。对于冠状动脉是否存在严重病变,二者联合检测具有更高的预测价值。     

Continuous interscalene brachial plexus block: clinical efficacy, technical problems and bupivacaine plasma concentrations

Continuous interscalene brachial plexus block with a single dose of 0.5% bupivacaine 1.25 mg/kg, continued with an infusion of 0.25% bupivacaine 0.25 mg/kg/h, was performed on 24 patients to provide analgesia during shoulder surgery and in the postoperative period. The drugs for general anaesthesia included glycopyrrolate, thiopentone, vecuronium, enflurane and N2O/O2. All patients had signs of regional analgesia 30 min after the block without haemodynamic problems. The infusion of local anaesthetic was interrupted in six patients because of a failure in catheter function. Of the remaining 18 patients, nine needed no complementary analgesics and nine patients received, on average, 1.6 doses of oxycodone (0.15 mg/kg/dose) during a 24-h period. Displacement of the interscalene catheters could be prevented by a fixation suture to the skin. Two patients noted a metallic taste during the bupivacaine infusion. The most common complaints were numbness of the hand (n = 15) and hoarseness (n = 5). The mean (+/- s.e.mean) plasma concentrations of bupivacaine at 30, 60, 180 min and 24 h were 0.68 +/- 0.06, 0.62 +/- 0.05, 0.52 +/- 0.04 and 0.76 +/- 0.01 micrograms/ml, respectively. During the 24-h period, the alpha 1-acid glycoprotein (AAG) concentration (mean +/- s.e.mean) in plasma rose from 0.41 +/- 0.04 g/l to 0.54 +/- 0.04 g/l (P less than 0.001). The concentration of free bupivacaine was below detectable levels (less than 0.01 micrograms/ml) after the 24-h infusion. The rise in AAG probably increases binding of bupivacaine to plasma proteins, diminishing the risk of systemic toxicity.     

血液透析患者和同种异体肾移植患者动脉内皮细胞功能比较

心血管系统疾病是导致终末期肾病和肾移植患者死亡的一个重要原因[1],血管内皮细胞功能损伤是动脉硬化的早期改变,应用高频超声探测肱动脉内皮依赖性舒张与非内皮依赖性舒张,通过对比可无创性地判断血管内皮细胞功能[2].研究发现尿毒症患者和同种异体肾移植患者的动脉内皮细胞功能均有损伤[3-5],但这些研究的受试者大多伴有高血压、高脂血症、糖尿病等已知心血管危险因素,这些危险因素本身也可以引起动脉内皮细胞功能损伤.本研究排除了所有伴有这些危险因素的受试者,对血透患者和肾移植患者的动脉内皮细胞功能进行比较.