Anesthesia For Upper Limb Surgeries Research Articles

Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review protocol

BackgroundPeripheral nerve block is a single injection that inhibits the transmission of peripheral nerve impulses to the central nervous system. The inhibition of the nociceptive impulse may decrease the occurrence of muscle spasm following mobilization postoperatively. This mechanism may contribute to a better functional recovery following upper limb surgery. This systematic review will investigate the impact of peripheral nerve block on functional recovery after an upper limb surgery.MethodsWe will search studies comparing peripheral nerve block to general anesthesia for upper limb surgery in the following databases: CENTRAL, MEDLINE (Ovid), CINAHL, EMBASE, and Scopus. In duplicate, independent reviewers will assess eligibility, evaluate risk of bias, and abstract data on type of peripheral nerve block and functional outcome. Where possible, we will pool results using a random effects model. For each outcome, we will assess the quality of evidence using GRADE methodology.DiscussionWe aim to summarize the available evidence comparing functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery. These data will inform the design of a trial on the topic.Systematic review registrationPROSPERO CRD42018116298

Evaluation of Ketamine as an Adjuvant to Lidocaine in Intravenous Regional Anesthesia for Upper Limb Surgery

AbstractBackground: Intravenous regional anesthesia (IVRA) is used in outpatient hand surgery as an easily applicable and cost-effective technique but tourniquet pain is a limitation. Ketamine in subanesthetic dose is used as an adjuvant to IVRA to improve analgesia and to impair tourniquet pain.Aim of Study: Is to illustrate the effect of ketamine as adjuvant to lidocaine used for IVRA in patients undergoing upper limb surgery.Patients and Methods: This double-blind randomized controlled study was carried out on 60 patient, ASA I and II, 20-40 years, scheduled for elective minor upper limb surgery. Patients were classified into 2 groups (30 each): Group I (IVRA with lidocaine only) received 3mg/kg lidocaine 0.5% diluted with saline to 40ml and group II (IVRA with lidocaine and ketamine) received 3mg/kg lidocaine0.5% plus 50mg ketamine diluted with saline to 40ml. MAP, HR and SpO2 were measured before, after tourniquet application, during the surgery every 15 minute, and every 30 minutes after deflating the tourniquet. Type & duration of the operation, onset & duration of sensory & motor block were measured. VAS was recorded at 1, 2, 3, 6, 12, 18 and 24h after operation, time of first rescue analgesia, total analgesic given and any undesirable side effects.Results: Demographic data, duration of operation and hemodynamic changes (MAP, HR and SpO2) were comparable. Onset of sensory and motor block were shorter in Group II than in Group I, but the duration of sensory and motor block was prolonged. In Group II, first dose of IV analgesic was delayed and the amount of pethidine was significantly de-creased. VAS and severity of tourniquet pain in group II were significantly decreased.Conclusion: Adding ketamine 50mg to lidocaine for IVRA has faster and prolonged sensory and motor block and delayed tourniquet pain with better quality of postoperative analgesia.

Regional Anesthesia for Upper Limb Surgery: A Narrative Review

Regional anesthesia is an expanding subspecialty and is gaining increasing popularity due to its significant benefits over general anesthesia if appropriately accomplished, which includes superior intraoperative pain control, attenuation of the surgical stress response, minimal systemic impairment, lower incidence of postoperative nausea and vomiting, excellent localized postoperative analgesia, and decreased hospital cost and stay. Needle conduction guide toward the targets always has a great importance. The most commonly used local anesthetics include lidocaine, ropivacaine, bupivacaine, and mepivacaine. The type of local anesthetic, the concentration, the volume administered, and the location of the block will affect the onset, duration and depth /type of block. Due to ineffectivity of neuraxial block in upper limbs, upper extremity blocks may be considered as the sole substitute or supersede method of anesthesia for upper limb surgeries.

Retroclavicular vs supraclavicular brachial plexus block for distal upper limb surgery: a randomised, controlled, single-blinded trial

BackgroundRegional anaesthesia for upper limb surgery is routinely performed with brachial plexus blocks. A retroclavicular brachial plexus block has recently been described, but has not been adequately compared with another approach. This randomised controlled single-blinded trial tested the hypothesis that the retroclavicular approach, when compared with the supraclavicular approach, would increase the success rate. MethodsOne hundred and twenty ASA physical status 1–3 patients undergoing distal upper limb surgery were randomised to receive an ultrasound-guided retroclavicular or supraclavicular brachial plexus block with 30 mL of a 1:1 mixture of mepivacaine 1% and ropivacaine 0.5%, using a single-injection technique without needle tip repositioning. The primary outcome was block success rate 30 min after local anaesthetic injection, defined as a composite score of 14 of 16 points, inclusive of sensory and motor components. Secondary outcomes included needling time, time to first opioid request, oxycodone consumption, and pain scores (numeric rating scale, 0–10) at 24 h postoperatively. ResultsSuccess rates were 98.3% [95% confidence interval (CI): 90.8%, 99.9%] and 98.3% [95% CI: 90.9%, 99.9%] in the supraclavicular and retroclavicular groups, respectively (P=0.99). The mean needling time was reduced in the supraclavicular group [supraclavicular: 5.0 (95% CI: 4.7, 5.4) min; retroclavicular: 6.0 (95% CI: 5.4, 6.6) min; P=0.006]. The mean time to first opioid request was similar between groups [supraclavicular: 439 (95% CI: 399, 479) min; retroclavicular: 447 (95% CI: 397, 498) min; P=0.19] as were oxycodone consumption [supraclavicular: 10.0 (95% CI: 6.5, 13.5 mg; retroclavicular: 7.9 (95% CI: 4.8, 11.0) mg; P=0.80] and pain scores at 24 h postoperatively [supraclavicular: 1.2 (95% CI: 2.1, 2.7); retroclavicular: 1.5 (95% CI: 1.6, 2.4); P=0.09]. ConclusionsUltrasound-guided retroclavicular and supraclavicular brachial plexus blocks share identical success rates, while providing similar pain relief. Reduced needling time in the supraclavicular approach is not clinically relevant. Clinical trial registrationNCT02641613.

The estimation of minimum effective volume of 0.5% ropivacaine in ultrasound-guided interscalene brachial plexus nerve block: A clinical trial.

Background and Aims:Interscalene brachial plexus block (ISB) is the most commonly used mode of anesthesia for upper limb surgeries. Higher volume of local anesthetic used in ISB is associated with increased incidence of side effects, particularly phrenic nerve palsy. The aim of this study was to determine the minimum effective volume of 0.5% ropivacaine in 90% patients (MEV90) in ISB.Material and Methods:With target of 45 successful cases, phase 1 clinical trial was conducted based on the principles of biased coin design up-and-down method. After obtaining Ethical Committee's approval and patient's consent, patients with American Society of Anesthesiologist physical status (ASA PS) I and II, aged 18–60 years of either sex, undergoing upper arm surgery were recruited into the study until 45 successful cases. A 7 ml of 0.5% ropivacaine was used as starting dose, with patients receiving a higher or lower dose depending on previous patient's response. R package, SPSS 23, and Microsoft Excel were used for statistical analysis.Results:MEV90 of 0.5% ropivacaine for ISB was determined as 8.64 ml [confidence interval (CI) 95%, 8.28–9.02 ml]. Time for onset of sensory block and motor block was 5 min (5–15 min) and 10 min (5–20 min), respectively, while duration of analgesia was observed as 8.2 (4.8–12.5) h.Conclusions:This study observes that surgical anesthesia can be accomplished with 8.64 ml (95% CI: 8.28–9.02 ml) of 0.5% ropivacaine with ultrasound-guided ISB with multiple injection technique, without clinical deterioration in block onset and duration of analgesia.

Ketorolac versus Magnesium Sulphate as an Adjuvant to Lidocaine in Intravenous Regional Anesthesia for Upper Limb Surgeries

Background: intravenous regional anesthesia (IVRA) was first described almost a century ago by August Bier and has been used for the past 50 years. It is a safe anesthetic technique for upper or lower distal limb surgery. Purpose: to compare the onset time of sensory blockade when adding ketorolac versus adding magnesium to the IVRA solution, and to compare the duration of postoperative analgesia. Material and Methods: this is a randomized controlled trial in two groups. The study was performed in Ain Shams University Hospitals. Study period range was 1-2 years. Results: there are 146 patients participated in our study, patients were allocated to two groups 73 patients in each group, a group of which received magnesium sulphate solution and the other received ketorolac solution. Conclusion: we evaluated the effects of adding ketorolac and compared it to the effects of adding magnesium sulphate to the anesthetic solution used in IVRA and we found that magnesium sulphate addition can be of benefit in faster onset of sensory block in the operative limb. However, magnesium sulphate in the used concentration (10 ml MgSo4 10% in 40 ml solution) appeared to cause burning pain varying in intensity while injecting the anesthetic solution.

A Study to Compare the Analgesic Efficacy of Dexmedetomidine and Fentanyl as Adjuvants to Levobupivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block.

Background:Supraclavicular brachial plexus provides complete and reliable anesthesia for upper limb surgeries. Adjuvants are added to local anesthetists to improve various block characteristics. There are limited studies comparing the efficacy of dexmedetomidine and fentanyl as an adjuvant to levobupivacaine.Aims:The aim of the study was to evaluate and compare the effect of dexmedetomidine versus fentanyl as an adjuvant with levobupivacaine in ultrasound-guided supraclavicular brachial plexus block.Settings and Design:This study design was a prospective, randomized, double-blind controlled study.Subjects and Methods:A total of 120 patients in the age group of 30–55 years with physical status American Society of Anesthesiologists Classes I and II undergoing elective upper limb surgeries under ultrasound-guided supraclavicular brachial plexus block were randomly divided into three groups of forty each after taking informed consent and approval from Hospital Ethics Committee: Group A received 25 ml of 0.5% levobupivacaine with 5 ml normal saline (NS). Group B received 25 ml of 0.5% levobupivacaine with 1 μg/kg dexmedetomidine diluted to the volume of 5 ml NS. Group C received 25 ml of 0.5% levobupivacaine with 1 μg/kg fentanyl diluted to the volume of 5 ml NS. Onset and duration of sensory and motor block and duration of analgesia were noted and any side effects were observed.Statistical Analysis:The distribution of variables tested with Shapiro–Wilk test. Group comparison of values was made by Kruskal–Wallis test followed by Mann–Whitney test.Results:There was fastest onset time as well as longer duration of sensory and motor block in dexmedetomidine group, intermediate in fentanyl group as compared to levobupivacaine group.Conclusion:This study concludes that addition of dexmedetomidine to levobupivacaine for supraclavicular brachial plexus block shortens the onset time and prolongs the duration of sensory and motor blockade as compared to the addition of fentanyl.

Adenosine and Magnesium Sulphate Vs Bupivacaine in Infraclavicular Infusion for Upper Limb Surgeries and Post-Operative Analgesia: A Prospective Study

Background: Brachial plexus piece has reformed the field of regional anesthesia for upper limb surgeries. Infraclavicular subcoracoid approach gives complete block without significant difficulties. Aim: To compare the additives adenosine and magnesium sulphate with bupivacaine in infraclavicular infusion for upper limb surgeries and postoperative analgesia. Methods: This Prospective study was done at the Department of Anaesthesiology, Pacific Medical College and Hospital, Udaipur, Rajasthan. Around 30 patients scheduled for elective unilateral upper limb surgeries involving distal arm/ elbow/ forearm/hand divided into two groups A (n-15) and B (n-15) randomly. Group A - adenosine 6mgs with 28 ml 0.5% bupivacaine bolus followed by infusion of 0.25% bupivacaine 28ml with 6mgs of adenosine (2ml) at a rate of 5ml/hr. Group B - magnesium sulphate 75 mgs (in 2ml) with 28ml of 0.5% bupivacaine bolus followed by infusion of 0.25% bupivacaine 28ml with 75mgs of magnesium sulphate (in 2ml) at a rate of 5ml/hr in USG guided placement of infraclavicular catheter. Results: Result s showed that Group A had a faster Onset time of sensory and motor block and faster recovery when compared to group B. Group A needed more rescue analgesia than group B. Though Group B had a higher incidence of sedation and vomiting than group A, it was not significant. Conclusions: The addition of magnesium sulphate as an additive to bupivacaine in brachial plexus block may be a better choice when prolonged postoperative analgesia is required.

An evaluation of operating room throughput in a stand-alone soft-tissue trauma operating theatre.

Operating room time is a limited, expensive commodity in acute hospitals. Strategies aimed at reduction of non-operative time improve operating room throughput and capacity. We conducted a prospective study to evaluate and augment operating room throughput and capacity using context-specific work practice changes. Following institutional and ethical approval, an interdisciplinary group designed and introduced a series of work practice changes specific to a stand-alone soft tissue trauma theatre, comprising modifications to patient processing, staff behaviours and additional anaesthesiologist hours. Time intervals relating to each patient were measured during a 16 week period before and after implementing work practice changes. The primary outcome measure was non-operative time, with daily caseload and cancellations amongst secondary outcome measures. 251 procedures were included over 58 working days (8 to 17 Monday to Friday). Non-operative time [55.6 (31.1) vs 52.3 (9.8) minutes, p = 0.48], daily caseload [4 [1-9] vs 4 [2-7], p = 0.56], and the number of daily cancellations [3 [0-11] vs 5 [0-8], p = 0.38], did not differ between baseline and study phases. Regional anaesthesia for upper limb surgery increased during the study phase [26/59 (44.0%) vs 10/63 (15.9%), p = 0.014] with resultant decrease in mean duration of recovery room stay [20.7 (17.7) vs 30 (20.5) minutes, p = 0.0001] and increased recovery room bypass [26/116 (22.4%) vs 6/135 (4.4%), p = 0.0002]. Avoidable delays accounted for 124.8 (72.2) minutes of theatre time lost each day. In conclusion, additional attending anaesthesiologist hours combined with work practice changes did not impact on measures of theatre throughput and capacity. The study identified important variables that contribute to avoidable delays, and points the way for future research.

An open label randomized comparative study on axillary vis a vis supraclavicular approaches for brachial plexus block in forearm surgery

Aims and Objectives: Regional anesthesia like brachial plexus blocks are increasingly practiced now a day’s avoiding the complications of general anesthesia for upper limb surgery. Among the many techniques axillary and supraclavicular approaches are common though both have its merits and demerits. This study was planned to compare these two techniques in terms of onset, completion time of sensory and motor blockade, its duration and overall success during upper limb surgeries. Materials and Methods: After obtaining institutional ethics committee approval and written informed consent, 100 patients of American Society of Anesthesiologists grade I or II scheduled for forearm and hand surgeries were included in the study and were randomly allocated into two groups. 30ml of the 0.5% bupivacaine was injected either by supraclavicular or axillary route by a single trained experienced anesthetist. The onset and completion time of sensory and motor blockade, its duration and overall success were noted and the collected data was statistically analyzed.Results: The patients (n=100) predominantly female (56%) with comparable demographic profile found to have equal efficacy in onset of sensory block, extent of motor blockade, duration of block (analgesia) in both the group. However considering overall effectiveness of the techniques including their failure rates, axillary approach appeared to be more acceptable and a better technique (p<0.05).Conclusion: Axillary approach could be a safer choice among regional block for the conduct of upper limb surgery.Asian Journal of Medical Sciences Vol.8(1) 2017 71-76

Rapid Onset Long Acting Brachial Plexus Blocks in Hand Surgery

Axillary brachial plexus blocks are a widely used form of anaesthesia for upper limb surgery. This has largely replaced the need for a general anaesthetic. We hereby present our technique, describing a new formula of injection that permits a fast acting block without the need to wait as with the usual local anaesthetics used in most brachial plexus blocks.

Factors associated with failed brachial plexus regional anesthesia for upper limb surgery

IntroductionBrachial plexus block as an anesthetic technique for upper limb surgery has some advantages over general anesthesia. The technique is widely used in our practice, with high effectiveness and adequate safety profile. However, the relationship between block failure and failure-determining factors has not been measured. ObjectivesTo identify and quantify brachial plexus block failure-associated factors for upper limb surgery as an initial observation aimed at developing prevention-oriented risk profiles and strategies. Materials and methodsAn analytical observational study was conducted by collecting data from electronic medical records of upper limb surgery using brachial plexus block from the San Ignacio University Hospital between 2011 and 2012. Block failures were identified using standardized clinical criteria, measuring potentially associated factors. Dichotomous comparisons were made and uni-and multivariate logistic regression analysis was performed to identify potential statistically significant variables, based on failed cases and successful controls. ResultsNone of the proposed factors was independently associated with failure of brachial plexus block. A qualitative description of failed cases presented confounding factors associated with local practices and the failure characteristics did not show a clinically plausible trend. ConclusionsThere were no factors determined by patient, anesthetic procedure, surgical procedure and operator that could be independently associated with brachial plexus block failure. The suggestion is to fine-tune the definition of failures, not just in the research environment, but in the current clinical practice; to improve the anesthesia records to rise the numbers and the quality of data bases for a quantitative determination of the risk of peripheral regional anesthesia failure and design prevention strategies focused on risk groups.

COMPARISON OF FENTANYL AND DEXMEDETOMIDINE AS AN ADJUVANT TO BUPIVACAINE IN SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK: A RANDOMIZED-DOUBLE BLIND PROSPECTIVE STUDY

ABSTRACTObjectives: Supraclavicular block of brachial plexus provides complete and reliable anesthesia for upper limb surgeries. Using adjuvant to localanesthetics, blocks can be prolonged to long durations. Peripheral nerve blocks thus help in avoiding the hazards of general anesthesia. We comparedthe sensory blockade, motor blockade, and duration of analgesia with the addition of fentanyl or dexmedetomidine to bupivacaine for supraclavicularbrachial plexus block.Methods: A total of 50 American Society of Anesthesiologist’s Physical Status I and II patients scheduled for elective upper limb surgeries undersupraclavicular brachial plexus block were divided into two equal groups in a randomized double-blinded fashion. Group BF received 30 mlbupivacaine with fentanyl 50 µg and Group BD received 30 ml bupivacaine with dexmedetomidine 50 µg. The characteristics for anesthesia andanalgesia were assessed in both groups.Results: Duration of sensory and motor block was 363.4±38.36 minutes and 357±36.77 minutes, respectively, in Group BF while it was452.96±77.12 minutes and 441.52±48.46 minutes in Group BD. There was a statistically significant difference in onset of sensory and motorblock between the two groups. The duration of analgesia (time to requirement of rescue analgesia) in Group BD was longer than in Group BF(471.44±65.88 minutes vs. 366.48±38.02 minutes) with (p<0.0001). There were minimum hemodynamic disturbances and side effects in any groupexcept for Grade 3 sedation score which was more in Group BD.Conclusion: Dexmedetomidine, when added to bupivacaine in supraclavicular brachial plexus block, enhanced the duration of sensory and motorblock and also the duration of analgesia, more than when fentanyl was added to bupivacaine.Keywords: Fentanyl, Dexmedetomidine, Bupivacaine, Supraclavicular brachial block.

USG Guided Infraclavicular Perineural Infusion of Bupivacaine with Additives Adenosine and Magnesium Sulphate Compared for Upper Limb Surgeries

Background: Brachial plexus block has revolutionized the field of regional anesthesia for upper limb surgeries. Infraclavicular subcoracoid approach gives complete block without major complications. Aim: To compare the additives adenosine and magnesium sulphate with bupivacaine in infraclavicular infusion for upper limb surgeries and postoperative analgesia. Methods: 40 patients scheduled for elective unilateral upper limb surgeries involving distal arm/ elbow/ forearm/ hand divided into two groups A (n-20) and B (n-20) randomly. Group A - adenosine 6mgs with 28 ml 0.5% bupivacaine bolus followed by infusion of 0.25% bupivacaine 28ml with 6mgs of adenosine (2ml) at a rate of 5ml/hr. Group B magnesium sulphate 75 mgs (in 2ml) with 28ml of 0.5% bupivacaine bolus followed by infusion of 0.25% bupivacaine 28ml with 75mgs of magnesium sulphate (in 2ml) at a rate of 5ml/hr in USG guided placement of infraclavicular catheter. Results: Statistical analysis showed Group A had a faster onset time of sensory and motor block and faster recovery when compared to group B. Group A needed more rescue analgesia than group B. Though Group B had a higher incidence of sedation and vomiting than group A, it was not significant. Conclusion: Though the addition of adenosine and magnesium sulphate to bupivacaine as additive gives prolonged analgesia, magnesium sulphate exceeds adenosine in achieving prolonged postoperative analgesia and better pain score and may be a better choice than adenosine.

Comparison of Tramadol and Dexamethasone as an adjuvant to Bupivacaine in Supraclavicular brachial plexus block: A Randomised Comparative Study in Patients undergoing Elective Upper limb surgeries

Supraclavicular nerve block is good alternative to general anesthesia for upper limb surgery. This avoids the untoward effects of general anesthetic drugs and upper airway instrumentation. It achieves complete muscle relaxation, intraoperative hemodynamic stability, and postoperative analgesia. The objective is to compare the postoperative analgesia following supraclavicular brachial plexus block with Tramadol or Dexamethasone as an adjuvant to bupivacaine in elective upper extremity surgery. Total 60 patients of ASA I and II undergoing upper extremity surgery under brachial plexus block with Bupivacaine were randomly divided in to two groups; group A received Tramadol (2mg/kg) and group B received Dexamethasone (0.15mg/kg) as an adjuvant to Bupivacaine. The duration of postoperative analgesia was recorded in both groups using pain VAS score which was determined by maximum VAS score of 8-10 and when patient demands for additional analgesics. The mean duration of postoperative analgesia in the Dexamethasone group was 1023.87 ±161.01 minutes while in the tramadol group it was 454.47±44.29 minutes. Dexamethasone with local anaesthetic prolongs postoperative analgesia significantly than Tramadol (P<0.05) when used as admixture to local anaesthetic in brachial plexus block in upper extremity surgery.

Use of hyaluronidase as an adjuvant to ropivacaine to reduce axillary brachial plexus block onset time: a prospective, randomised controlled study.

When considering brachial plexus block as a practical alternative to general anaesthesia for upper limb surgery, the time to achieve complete sensory block is a clinically important variable. In this prospective randomised double-blind controlled trial, we investigated the hypothesis that addition of hyaluronidase to ropivacaine may reduce the time to achieve complete sensory block after axillary brachial plexus block. The patients were randomly assigned into a hyaluronidase group (n=24) and a control group (n=24). The hyaluronidase group received ropivacaine 0.5% with 100IU.ml(-1) of hyaluronidase, and the control group received ropivacaine alone. The primary endpoint was the time to achieve complete sensory block. The hyaluronidase group demonstrated significantly shorter mean (SD) sensory block onset time (13.8 (6.0) min) compared with the control group (22.5 (6.3)min, p<0.0001). Addition of hyaluronidase to ropivacaine resulted in a reduction in the time needed to achieve complete sensory block.

Study of 0.5% Lidocaine Alone and Combination of 0.25% Lidocaine with Fentanyl and Vecuronium in Intravenous Regional Anesthesia for Upper Limb Surgeries

Justificativa e objetivosA anestesia regional intravenosa (ARIV) para cirurgias de membros superiores com a tradicional alta dose de lidocaína pode levar a efeitos colaterais potencialmente letais. A fim de evitar esses efeitos, muitas técnicas modificadas de ARIV foram experimentadas com o uso de uma dose baixa de lidocaína, relaxante muscular e opioide. MétodosO presente estudo foi feito com 60 pacientes não medicados previamente, com classificação ASA 1-2, para comparar as características sensoriais e motoras, os parâmetros cardiorrespiratórios e os efeitos colaterais durante o período intraoperatório e de deflação póstorniquete entre os pacientes que receberam 40mL de lidocaína a 0,5% (n=30) e aqueles que receberam uma combinação de 40mL de lidocaína a 0,25% com 0,05mg de fentanil e 0,5mg de vecurônio (n=30) em ARIV para cirurgias ortopédicas de membros superiores. Os resultados foram analisados com o uso do teste t de Student pareado para identificar a significância estatística. Resultado: A diferença entre os dois grupos em relação ao tempo médio de início e completo bloqueio sensitivo e motor foi estatisticamente significante. Porém, houve completo bloqueio sensitivo e motor em ambos os grupos 15 minutos após a injeção da solução anestésica. ConclusãoEmbora a pequena demora observada no início e na obtenção completa dos bloqueios sensitivo e motor possa, teoricamente, atrasar o início da cirurgia em 10–15 minutos, clinicamente esse tempo seria gasto na preparação do campo cirúrgico. Portanto, essa combinação pode ser usada com segurança e eficácia em anestesia regional intravenosa para cirurgias ortopédicas de membros superiores com menor possibilidade de toxicidade anestésica local.

Study of 0.5% Lidocaine Alone and Combination of 0.25% Lidocaine with Fentanyl and Vecuronium in Intravenous Regional Anesthesia for Upper Limb Surgeries

Background and objective: Intravenous regional anesthesia (IVRA) for upper limb surgeries with traditional high dose of lidocaine can lead to life threatening side effects. In order to avoid these potential life threatening side effects, many modified techniques of IVRA have been attempted by using a low dose of lidocaine, muscle relaxant and opioid. MethodThe present study is carried out in sixty unpremedicated ASA Class 1 and 2 patients to compare the sensory and motor characteristics, cardio-respiratory parameters and side-effects during intra-operative and post-tourniquet deflation period between the patients who received 40mL of 0.5% lidocaine alone (n = 30) and those who received a combination of 40mL of 0.25% lidocaine with 0.05mg fentanyl and 0.5mg vecuronium (n = 30) in IVRA for upper limb orthopedic surgeries. The results were analyzed for statistical significance using a paired student t test. ResultsThe difference between the two groups regarding the mean time of onset and complete sensory and motor block was statistically significant. But 15minutes after the injection of anesthetic solution, there was complete sensory and motor block in both groups. ConclusionAlthough the short delay observed in the onset and attainment of complete sensory and motor block may theoretically delay the start of surgery for 10-15minutes but clinically that time will be spent in the preparation of surgical field. So this combination can be used safely and effectively in intravenous regional anesthesia for upper limb orthopedic surgeries with reduced chance of local anesthetic toxicity.

Ultrasound-guided regional anesthesia for upper limb surgery

The purpose of this module is to review the main ultrasound-guided approaches used for regional anesthesia of the upper limb. The anatomical configuration of the upper limb, with nerves often bundled around an artery, makes regional anesthesia of the arm both accessible and reliable. In-depth knowledge of upper limb anatomy is required to match the blocked territory with the surgical area. The interscalene block is the approach most commonly used for shoulder surgery. Supraclavicular, infraclavicular, and axillary blocks are indicated for elbow and forearm surgery. Puncture techniques have evolved dramatically with ultrasound guidance. Instead of targeting the nerves directly, it is now recommended to look for diffusion areas. Typically, local anesthetics are deposited around vessels, often as a single injection. Phrenic nerve block can occur with the interscalene and supraclavicular approaches. Ulnar nerve blockade is almost never achieved with the interscalene approach and not always present with a supraclavicular block. If ultrasound guidance is used, the risk for pneumothorax with a supraclavicular approach is reduced significantly. Nerve damage and vascular puncture are possible with all approaches. If an axillary approach is chosen, the consequences of vascular puncture can be minimized because this site is compressible. Upper limb regional anesthesia has gained in popularity because of its effectiveness and the safety profile associated with ultrasound-guided techniques.

Can bilateral bronchospasm be a sign of unilateral phrenic nerve palsy after supraclavicular brachial plexus block?

Ultrasound-guided peripheral nerve blocks facilitate ambulatory anesthesia for upper limb surgeries. Unilateral phrenic nerve blockade is a common complication after interscalene brachial plexus block, rather than the supraclavicular block. We report a case of severe respiratory distress and bilateral bronchospasm following ultrasound-guided supraclavicular brachial plexus block. Patient did not have clinical features of pneumothorax or drug allergy and was managed with oxygen therapy and salbutamol nebulization. Chest X-ray revealed elevated right hemidiaphragm confirming unilateral phrenic nerve paresis.