Axillary Plexus Research Articles

Experiences with 925 outpatient operations of carpal tunnel syndrome

In the era of cost containment in our health care system the demand is made of increasing outpatient surgery e. g. for carpal tunnel syndrome. To show the possibilities of carpal tunnel release performed under outpatient conditions we analysed 925 consecutive cases during 1. 1. 1981 to 30. 4. 2001. A tourniquet was used in all cases. In 814 cases we used axillary plexus anaesthesia. 107 surgical interventions were done under local anesthesia. Two of these patients could not tolerate the tourniquet. Analgesia was complete in all but two cases. In two cases revision due to after bleeding was necessary. There were no further complications seen. The mean time for return to work was 21.3 days (min: 14, max: 36 days). The mean follow-up for these patients was 36 months. Numbness and paresthesias were relieved in 98 %, pain was relieved in 90 %, motoric weakness was relieved in 95 % of the hands. The overall satisfaction rate was 94 %. Carpal tunnel release can be performed safely and unexpensively under outpatient conditions.

Axillary plexus block using multiple nerve stimulation: A European view

Axillary plexus block using multiple nerve stimulation: A European view

Comparaison de la lidocaïne 1,5 % adrénalinée et de la mépivacaïne 1,5 % dans le bloc axillaire du plexus brachial

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.

Neostigmine added to lidocaine axillary plexus block for postoperative analgesia

Background and objective We have assessed the analgesic efficacy and side-effects of neostigmine when added to lidocaine for axillary brachial plexus block, in a prospective, randomized, double-blind, placebo-controlled study. Methods We studied 34 ASA I or II patients undergoing elective ambulatory carpal tunnel release. Axillary brachial plexus block was performed using a peripheral nerve stimulator to locate the median nerve. All patients were administered 1.5% lidocaine 450 mg and epinephrine 5 μg mL−1. Patients were allocated randomly to one of two groups. Neostigmine 500 μg was added in group N, and saline 1 mL in group S. Results The duration of analgesia did not significantly differ between groups [mean (SD)]: 812.5 (456.9) for group S vs. 746.7 (474.1) min for group N (P>0.05). The need for supplementary analgesia did not significantly differ between groups: 4.4 (1.5) extra doses for group S vs. 3.8 (2.2) extra doses for group N (P>0.05). Visual analogue pain scores and occurrence of side-effects did not significantly differ between groups. Conclusion Neostigmine does not seem to be of clinical value for peripheral nerve blocks.

Room H, 10/17/2000 2: 00 PM - 4: 00 PM (PS) Does Increased Supervision in the Use of Nerve Stimulation Techniques Improve the Success of Axillary Plexus Block?

<b>Room H, 10/17/2000 2: 00 PM - 4: 00 PM (PS) Does Increased Supervision in the Use of Nerve Stimulation Techniques Improve the Success of Axillary Plexus Block?</b>

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 μg 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 μg (Group 2), 10 μg (Group 3), or 20 μg (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.

Evaluation of efficacy and plasma concentrations of ropivacaine in continuous axillary brachial plexus block: High dose for surgical anesthesia and low dose for postoperative analgesia

Ropivacaine is a potent local anesthetic that, experimentally at low concentrations, produces an effective block of pain conducting nerve fibers. Therefore, it was hypothesized that 0.1% and 0.2% ropivacaine would provide clinically adequate postoperative analgesia in continuous axillary plexus block. Sixty patients (ASA I-II) scheduled for elective hand or forearm surgery received 5 mg/kg of 0.75% ropivacaine for axillary block using nerve stimulator technique. One hour later, in random order, a continuous infusion of either 0.1% ropivacaine (0.125 mg/kg/h), 0.2% ropivacaine (0.25 mg/kg/h) or saline 6 to 11 mL/h was started. The mean total ropivacaine dose for the surgical block was 5.1 to 5.2 mg/kg with the supplementation. All patients were pain free for the first 12 to 15 hours after the block. The need for postoperative analgesics during the infusion was similar in all groups. After the initial block, the maximum plasma concentrations (mean 2.5 microg/mL) were measured at 45 or 60 minutes after injection. The highest individual plasma concentration was 4.2 microg/mL. Despite the high venous peak concentration, no toxic reactions were observed. The mean peak plasma concentration (Cmax) was 2.2+/-0.5 microg/mL for saline, 2.6+/-0.8 microg/mL for 0.1% ropivacaine, and 2.6+/-0.7 microg/mL for 0.2% ropivacaine. During the continuous infusion of 24 hours, the ropivacaine concentration declined steadily. Ropivacaine is safe and effective for axillary brachial plexus block. The continuous infusion of 0.1% or 0.2% ropivacaine was no more beneficial than an infusion of saline in relieving postoperative pain in patients having elective hand surgery. None of the infusions were sufficient to adequately treat the patients' pain without the addition of adjunct agents.

Morphogenesis of the primary arterial trunks of the forelimb in the rat embryos: the trunks originate from the lateral surface of the dorsal aorta independently of the intersegmental arteries.

It has been believed that the primary arterial trunk of the mammalian forelimb is derived from the 7th intersegmental artery. Here we examined the early morphogenesis of the arteries and nerves in the forelimb region by adopting a method that combined intravascular dye-injection with nerve staining to whole mounted rat embryos. The study was carried out on greater numbers of specimens at smaller intervals of embryonic stages and from earlier stages than those in previous reports. We report that: (1) The multiple primary arterial trunks in the forelimb region (primary subclavians) originate directly from the lateral surface of the dorsal aorta independently of the intersegmental arteries, previous to the formation of limb buds. (2) The tips of the 8th (and the 9th) primary subclavians that originate from the aorta near the origin of the 8th (or the 9th) intersegmental artery bend cranially and/or caudally. With the formation of limb bud, they extend to form the longitudinal trunks in the presumptive axillary region. The primary arteries in the free arm region branch off from this longitudinal trunk, and one of them develops into the axial artery. (3) The origins of the primary subclavians shift their positions on the surface of the dorsal aorta and approach the origins of the neighboring intersegmental arteries to join them, and then replace the latter. Consequently, the primary subclavians appear to be "the lateral branches of the in tersegmental arteries." (4) The 8th primary subclavian is dominant at first, but is replaced by the 7th primary subclavian, which develops into the definitive subclavian artery. (5) With the brachial nerve plexus formation, the axillary arterial plexus derived from the longitudinal trunk develops to form two stems of the axillary artery.

Double-injection method using peripheral nerve stimulator is superior to single injection in axillary plexus block

Background and Objectives. Axillary block using a single-injection method does not always provide effective analgesia. This study examined whether a double axillary block injection technique is superior to a single injection axillary block. Methods. Fifty patients were randomly allocated to two groups. In group 1 (single injection), the whole volume of local anesthetic (0.7 mL/kg) was injected after locating only one of the median, radial, or ulnar nerves. In group 2 (double injection), half of the volume was injected after locating one nerve and the other half after locating another peripheral nerve. Bupivacaine 0.5% and prilocaine 1% (1:1 volumes) were used as local anesthetic. A peripheral nerve stimulator was used to identify the nerves. Sensory block of seven nerves and motor block of four nerves were tested after 40 minutes. Results. Complete sensory and motor block (scores 2 or 3 on scale 0–3) in all four main nerves (median, ulnar, radial, musculocutaneous) was achieved in 3 (12%) versus 20 (80%) patients in groups 1 and 2, respectively ( P = .000001). Primary success rate (no need for supplemental nerve block) was 52% in group 1 and 92% in group 2 ( P = .0016). Conclusions. A double-injection method in axillary block provides excellent analgesia and motor block compared with a single-injection method. Moreover, the need for supplemental nerve blocks is significantly decreased.

Double-Injection Method Using Peripheral Nerve Stimulator Is Superior to Single Injection in Axillary Plexus Block

Double-Injection Method Using Peripheral Nerve Stimulator Is Superior to Single Injection in Axillary Plexus Block

The novel analgesic neostigmine and the morning after: Nothing more than sedation, nausea and vomiting?

Abstract Since the introduction of opioids as spinally active analgesics into the field of pain research and management, the spinal cord and the peripheral nervous system have been explored for numerous different physiological and pharmacological pain modulating systems. Thereby the use of cholinergic agonists and acetylcholinesterase-inhibitors was investigated with respect to their specific antinociceptive activity, any potential side effects and also with regard to any potential toxicity after their spinal administration. Besides analgesia, spinal cholinergic agonists will also result in motor weakness. Neostigmine, a clinically well-known acetylcholine (ACh)-esterase inhibitor, was found however to result in dose-dependent, potent analgesia after spinal and peripheral administration in preclinical and clinical trials. The clinical studies exploiting spinal or epidural administration of neostigmine revealed an analgesic effect for neostigmine 50–100 μg comparable to that of spinally applied morphine. Neostigmine lacks any neurotoxicity after intrathecal injection, although its spinal and epidural use might be limited by another side effect — the high incidence of nausea and vomiting. Based on the findings of a peripheral analgesic action of opioids, neostigmine's peripheral analgesic effects were also demonstrated in acute pain states. Here it is shown that postoperative analgesia can be accomplished by intra-articular neostigmine and by co-delivery of neostigmine with mepivacaine in axillary plexus blockade. However, further studies on the underlying mechanisms of peripheral antinociception are warranted before the routine clinical use of neostigmine as a peripheral acting analgesic can be recommended. In conclusion, due to its potential side effects, the use of the otherwise very effective spinal analgesic neostigmine will be limited to certain specific pain states or as a co-drug with other analgesics.

Stability of local anesthetics in heparinized blood, plasma and sulfuric acid.

This study was undertaken to investigate the stability of local anesthetics in different media. 60 patients with axillary plexus block, using prilocaine, mepivacaine or lidocaine 1%, or with lumbar epidural catheter-anesthesia, using bupivacaine 0.5%, were investigated. Stability was evaluated in heparinized whole blood for 24 h at +4 degrees C, in plasma for 8 week at -25 degrees C and in sulfuric acid for 6 months at -25 degrees C. Mean recovery rates were between 96.4% and 102.6% in all local anesthetics and media. No statistical significance became obvious for differences between recovery rates and initial values. Stability of prilocaine, mepivacaine, lidocaine and bupivacaine can be expected when samples are stored as heparinized whole blood for 24 h at +4 degrees C, plasma for 8 weeks at -25 degrees C, and after preparation into sulfuric acid for 6 months at -25 degrees C.

Neurological symptoms after axillary plexus block - a comparison of three techniques

Neurological symptoms after axillary plexus block - a comparison of three techniques

Neurological symptoms after axillary plexus block - a comparison of three techniques

Neurological symptoms after axillary plexus block - a comparison of three techniques

The Use of a Selective Axillary Nerve Block for Outpatient Hand Surgery

Although no guidelines concerning discharge criteria after axillary plexus block are available, many institutions consider recovery of motor function as a critical factor.With the midhumeral approach, the four main nerves of the upper extremity can be blocked separately using a peripheral nerve stimulator. The aim of this double-blind study was to block the radial (R) and musculocutaneous (MC) nerves with lidocaine, and the median (M) and ulnar (U) nerves with bupivacaine to recover motor function of the elbow and wrist more rapidly while maintaining long-lasting postoperative analgesia at the operative site. Patients undergoing surgery for Dupuytren's contracture were randomized into two groups in a double-blind fashion: in the control group (n = 17), each of the four nerves was infiltrated with 10 mL of a mixture of 2% lidocaine and 0.5% bupivacaine, whereas in the selective group (n = 17), the R and MC nerves were blocked with 10 mL of 2% lidocaine each and the M and U nerves were blocked with 10 mL of 0.5% bupivacaine each. Recovery of motor block was significantly faster in the selective group (231 +/- 91 vs 466 +/- 154 min). However, time to first sensation of pain was not different between groups (707 +/- 274 vs 706 +/- 291 min). In conclusion, this new approach at the midhumeral level enables the anesthesiologist to selectively administer local anesthetics on different nerves. Implications: In outpatients undergoing surgery for Dupuytren's contracture, a midhumeral block was used with the musculocutaneous and radial nerves blocked by lidocaine and the median and ulnar nerves blocked with bupivacaine. Recovery of motor function and time to discharge were shorter compared with patients who received the mixture on all four nerves. (Anesth Analg 1998;86:746-8)

THE EFFECT OF NEOSTIGMINE ADDED TO AXILLARY BRACHIAL PLEXUS BLOCKADE

S260 INTRODUCTION: Recently new interest has focused on cholinergic systems that modulate pain perception and transmission. It was shown that central co-administration of the acetylcholineesterase-inhibitor neostigmine to local anesthetics will result in potent analgesia. However, so far the role of neostigmine in peripherally mediated analgesia remains to be defined. Therefore we evaluated the effect of neostigmine added to mepivacaine axillary plexus blockade. METHODS: Following IRB approval, informed consent was obtained from forty patients (ASA I to II) undergoing upper extremity surgery under axillary plexus blockade. These patients were randomized to receive in a double-blind manner either 50 ml mepivacaine and vehicle or 50 ml mepivacaine and 500 mg neostigmine. Visual analog pain scores (VAS), duration of anesthesia and analgesia, first demand of supplementary pain medication and subsequent 24 hour analgesic consumption, motor function and cardiovascular parameters were assessed. RESULTS: Addition of neostigmine revealed no significant differences in cardiovascular parameters, time until onset and recovery of anesthesia or motor function. Postoperative analgesic consumption trended to be lower in the neostigmine group, whereas a significant prolonged postoperative pain relief was observed for this group (see Figure 1). Data are presented as mean +/- SEM. *=p<.05.Figure 1CONCLUSION: The results of this study suggest a peripheral site of analgesic action of theacetylcholineesterase-inhibitor neostigmine.

Axillary brachial plexus block--an underused technique in the accident and emergency department.

OBJECTIVE: To compare axillary brachial plexus block and Bier's block as methods of providing upper limb anaesthesia. METHODS: Axillary brachial plexus or Bier's blocks were performed on all patients requiring...

Survey of regional anesthetic practice among French residents at time of certification

A survey of anesthesia practice was conducted among French residents in anesthesia at the end of their training. This study was performed mainly to evaluate the residents' experience in peripheral nerve blocks. Two short clinical cases were proposed to all French residents during a telephone interview immediately before their certification. The first described the case of a young asthmatic patient admitted for an elbow fracture. The second described an elderly woman with severe aortic stenosis admitted for a supracondylar fracture of the femur. A questionnaire had been prepared and was filled in during the interview. Each resident was asked to answer according to the actual choice he or she would have made. For both cases, when general anesthesia was chosen first, the next question was to discuss which regional anesthesia would be used if general anesthesia had to be discarded. In that way, the practical knowledge about most common peripheral nerve blocks learned during residency was investigated. Of 77 residents registered as being at the end of their residency, 8 were on either sabbatical or maternity leave. Regional anesthesia was the first choice in 78% and 57% of cases for the first and second clinical cases, respectively. The regional anesthetic techniques chosen were axillary block (66%), interscalene block (31%), and intravenous regional anesthesia (3%) for case 1 and combined lumbar plexus and sciatic block (36%), epidural anesthesia (30%), single-shot spinal anesthesia (18%), and continuous spinal anesthesia (16%) for case 2. Throughout the residency of the group, 32 +/- 2 axillary blocks, 12 +/- 2 interscalene blocks (axillary vs interscalene, P < .0001), 21 +/- 3 femoral blocks, and 10 +/- 2 sciatic blocks (femoral vs sciatic, P < .0001) had been performed (mean +/- SEM). They had also performed 2.5 +/- 0.5 continuous spinal anesthesias and 17 +/- 3 intravenous regional anesthesias respectively. Upper extremity blocks were more often used during residency than lower extremity blocks (44 +/- 3 vs 31 +/- 4, P < .01). A peripheral nerve stimulator was routinely used by 83% of residents. French residents in anesthesiology at time of certification are better trained for peripheral nerve blocks of the upper extremity than for those of the lower extremity. Axillary plexus and femoral nerve block are the most widely used blocks, probably reflecting the techniques the most mastered among teachers. Finally, the extensive use of a peripheral nerve stimulator by residents is probably the result of the widespread use of this device by teachers in France.

A.217 Comparison between conventional axillary plexus block and a new approach at the midhumeral level

A.217 Comparison between conventional axillary plexus block and a new approach at the midhumeral level

Determination the quality of axillary brachial plexus block using a peripheral nerve stimulator

This study was designed to determine the quality and success rate of axillary plexus block using 1.5% prilocaine. Fifty ASA status I to II patients, aged 16-72, who were undergoing axillary brachial plexus block for upper extremity surgery were studied. Peripheral nerve stimulators and 22 gauge insulated block needles were used in all cases. The reference electrode was connected to an electrocardiogram pad on the opposite shoulder, and needles were connected to the negative terminal. Anatomical landmarks, needle direction and other technical details were as described in standard references for the axillary approach. Initial stimulating current was 1 mA with a frequency of 2 Hz. Needle position was adjusted or current decreased until visually observable or palpable hand muscle twitches were present with a minimum stimulating current of less than 0.5 mA. 30 mL prilocaine 1.5% was then injected without repositioning the needle. Intercostobrachial nerve block was performed for the pneumatic tourniquet. Sensory changes were assessed with a 22 SW gauge needle 15, 25 and 40 min after injection of local anaesthetic in the areas supplied by the following nerves: axillary, musculocutaneous, radial, median, ulnar, medial cutaneous nerve of forearm and medial cutaneous nerve of arm. The results were recorded using a scale of 0-2; 0=no sensory loss, 1=loss of pinprick sensation; 2=complete loss of sensation. The power of the arm was assessed 40 min after injection of the test drug. The results were recorded on a scale of 0-3; 0=no motor loss, 1=slight loss of power; 2=very weak power; 3=complete loss of power. The side, type and duration of surgery and the incidence of complications were also recorded. The stimulating current was 0.29 ± 0.028 mA, tourniquet tolerance was 100%. Motor loss occurred in 6.46 ± 4.52 min. The success of the sensory block was 88%, 84%, 96%, 96%, 96%, 92% respectively for the axillary, musculocutaneous, radial, median, ulnar nerves, medial cutaneous nerve of the forearm, medial cutaneous nerve of arm. Motor blockade was determined to be grade 3 in 60% grade 2 in 24% and grade 1 in 16% of the cases. Axillary brachial plexus blockade using 1.5% prilocaine and a peripheral stimulator was found to be successful and is suggested as an appropriate technique for intermediate duration surgery on the upper extremity.