Bilateral Brachial Plexus Block Research Articles

Bilateral brachial plexus block and avoiding its complications : A case report

Literature on bilateral brachial plexus blocks is rare as it’s seldom performed due to its complications. We present a case of a patient with anticipated difficult airway who underwent bilateral upper limb surgery where brachial plexus blocks were used as the sole mode of anaesthesia. Blocks were performed with plain 0.5% bupivacaine below its maximum safe dose under ultrasound guidance. A good postoperative 24-hour patient satisfaction was noted with no opioid consumption. Potential complications of diaphragmatic paralysis, local anaesthesia systemic toxicity and pneumothorax were mitigated with ultrasound guidance, correct patient selection, while using the knowledge on different types of brachial plexus blocks and local anaesthetic pharmacokinetics.

Bilateral Brachial Plexus Block and Avoiding Its Complications: A Case Report

Literature on performing bilateral brachial plexus blocks is rare as it’s seldom performed due to the reluctance of anaesthesiologist. It’s due to the fear of the associated complications such as hemi-diaphragmatic paralysis, local anaesthetic systemic toxicity, and pneumothorax and block failure. We present the case of a 21-year-old patient flowing a road traffic accident with anticipated difficult airway, who underwent bilateral upper limb surgery where bilateral brachial plexus blocks were used as the sole mode of anaesthesia. Through careful patient selection, use of ultrasound guidance to reduce the minimum effective volume of local anaesthetic and to identify anatomy to prevent inadvertent injury, prevention of rapid rise of plasma concentration of local and using a combination of brachial plexus blocks the potential complications can be mitigated.

Compassionate use of ultrasound-guided bilateral infraclavicular brachial plexus block with phenol in a case of obliterative thromboangitis

Compassionate use of ultrasound-guided bilateral infraclavicular brachial plexus block with phenol in a case of obliterative thromboangitis

Bilateral Brachial Plexus Block Using Chloroprocaine For Surgery Of Bilateral Radial Fractures.

We report a case of a 41-year-old male with anticipated difficult airway undergoing a repair of a bilateral radial fracture under bilateral sequential brachial plexus block. Anesthesiologists are reluctant to perform bilateral blocks because of the fear of complications like diaphragmatic paralysis, local anesthetic (LA) toxicity, and pneumothorax. We advise that with the correct application of LA pharmacokinetics, careful patient selection and usage of ultrasound, bilateral blocks can be done safely. We used chloroprocaine as an LA in one of the blocks to reduce the dose required for the more toxic LAs. chloroprocaine’s fast metabolism also helped us to prevent the overlapping of peak plasma concentration of different LAs. To our knowledge, this is the first reported case in the literature where chloroprocaine was used for bilateral brachial plexus block.

Efficacy and safety of ultrasound-guided or neurostimulator-guided bilateral axillary brachial plexus block

Objective: To explore the efficacy and safety of bilateral axillary brachial plexus block under the guidance of ultrasound or neurostimulator. Methods: From February 2012 to April 2014, 120 patients undergoing bilateral hand/forearm surgery in Beijing Jishuitan Hospital were enrolled and anaesthetized with bilateral axillary brachial plexus block. All patients were divided into two groups randomly using random number table: the ultrasound-guided group (group U, n=60) and the neurostimulator-guidedgroup (group N, n=60). The block was performed with 0.5% ropivacaine. Patients' age, sex and operation duration were recorded. Moreover, success rate, performance time, onset of sensor and motor block, performance pain, patient satisfaction degree and the incidence of related complications were also documented. Venous samples were collected at selected time points and the total and the plasma concentrations of ropivacaine were analyzed with HPLC. Results: The performance time, the onset of sensor block and the onset of motor block of group U were (8.2±1.5), (14.2± 2.2)and (24.0±3.5)min respectively, which were markedly shorter than those in group N( (14.6±3.9), (19.9±3.8), (28.8±4.2)min, respectively), and the differences were statistically significant(t=11.74, 10.09, 6.73, respectively, all P<0.01). The performance pain score of group N was (25.5± 13.2), which was obviously more serious than group U (31.7± 11.2) and a significant statistical difference was detected (t=2.856, P<0.05). The patient satisfaction degree of group U was 95.0%, which was significantly higher than group N (83.3%) and a markedly statistical difference was detected (χ(2)=4.227, P<0.05). Fifty min after performance, the total plasma concentration of ropivacaine of group U was(1.76±0.48)mg/L, which was significantly lower than group N (1.88±0.53)mg/L and a significant statistical difference was detected (t=2.43, P<0.05), while no significant differences were detected at the other time points between two groups (P>0.05). No analgesic was superadded and no other anesthesia methods were applied. No complications were detected perioperatively. Conclusions: The bilateral axillary brachial plexus block under the guidance of ultrasound or neurostimulator are both effective and safe for bilateral hand/forearm surgery. However, the ultrasound-guided block may be more clinically beneficial because of its shorter performance time, rapid onset and higher patient satisfaction degree.

The efficacy of simultaneous bilateral axillary brachial plexus block under the guidance of neurostimulator or ultrasound: a prospective study.

This study was designed to investigate the risk of local anesthetic toxicity and efficacy of simultaneous bilateral axillary brachial plexus block performed under the guidance of ultrasound or a neurostimulator. One hundred and twenty patients who were anesthetized with bilateral axillary plexus block simultaneously between February 2012 and March 2014 were enrolled in the study. The patients were anesthetized under the guidance of a neurostimulator (group N, n=60) or ultrasound (group U, n=60). The block performance time, procedure-related pain, adverse events, total and free plasma concentrations of ropivacaine, and other data were recorded. The comparison was analyzed statistically. The block performance time, and onset of the sensory and motor block, of group N was longer than that of group U (p<0.001). The procedure-related pain of group N was more serious than that of group U (p<0.05). The patient satisfaction rate of group U was higher than that of group N (p<0.05). The total plasma concentrations of ropivacaine in group N were comparable to those of group U, except for the value at 50min after injection (p<0.05). The free plasma concentrations of ropivacaine of group N at 5min were significantly higher than that of group U (p<0.001). No apparent serious adverse events were observed perioperatively in both groups. Simultaneous bilateral axillary brachial plexus block guided by neurostimulator or ultrasound in bilateral distal upper extremity surgery seems to have a low risk of local anesthetic toxicity and to be effective. The ultrasound-guided block is superior in terms of providing the same degree of anesthesia with shorter duration, less pain, and faster onset of sensory and motor blockades, which is important in clinical practice.

Bilateral variant locations of the musculocutaneous nerve during ultrasound-guided bilateral axillary brachial plexus block -A case report-

Bilateral variant locations of the musculocutaneous nerve during ultrasound-guided bilateral axillary brachial plexus block -A case report-

Bilateral brachial plexus block. Case reporting and systematic review of literature

Abstract Background The bilateral brachial plexus block is considered a contraindication, due to the possible development of complications, such as toxicity from local anaesthetics or bilateral diaphragmatic paralysis. However, with the real time visualisation provided by the ultrasound scan, these complications have decreased and it is a safer procedure. Clinical cases Four cases are presented where the bilateral block was performed using guided ultrasound, as the patients were unable to receive general anaesthesia due to a history of adverse effects or the use of opioids in the post-operative or by the prediction of a difficult airway associated with obesity. A systematic review of the literature from January 1993 to June 2013, was also performed by using a search in the MEDLINE, EMBASE, ARTEMISA, LILACS, Google data bases, in Spanish and English language with the following words: bilateral brachial plexus block, bilateral interscalene block, bilateral infraclavicular block, bilateral supraclavicular block, bilateral lateral supraclavicular block, bilateral axillary block, ultrasound-guided bilateral brachial plexus block. Conclusion Based on the evidence found, ultrasound-guided bilateral brachial plexus block in selected patients and expert hands, is no longer a contraindication.

Identification of location of nerve catheters using pumping maneuver and M-Mode—a novel technique

BackgroundOptimum positioning of the nerve catheter is crucial for a successful nerve block. We present a novel technique for confirmation of catheter position. MethodsWe are describing a novel technique for localization of the shaft and tip of the peripheral nerve catheter. After introduction of the catheter 3 to 5 cm beyond the needle tip and removal of the needle, the guide wire was reintroduced and was moved inward and outward rapidly. This movement produced the color Doppler effect along the track of the catheter and the catheter tip that helped us verify the proper positioning of the catheter. ResultsWe used our technique in a cadaveric study for bilateral supraclavicular brachial plexus block, followed by a series of 5 patients undergoing femoral, sciatic (anterior approach), popliteal (2 patients), and brachial plexus blocks. Catheters were also identified on M-Mode sonography during pumping maneuver and during the injection of medications. ConclusionPumping maneuver and M-Mode can be additional tools in the array of modalities applied to verify proper positioning of a nerve catheter.

Ultrasound-guided bilateral brachial plexus blockade with propofol-ketamine sedation

We report the use of ultrasound-guided bilateral brachial plexus block in a patient with bilateral radius fractures. An axillary block was performed on the patient's right and a supraclavicular block on her left using an in-plane (long-axis) needle insertion technique. Into each side was injected 20 ml 0.5% ropivacaine, giving a total volume (dose) of 40 ml (200 mg). Provisions were made for rescue analgesia or unplanned conversion to general anesthesia during the operation, but these were not needed; furthermore, no perioperative complications were observed. General anesthesia has traditionally been used for simultaneous surgery involving the bilateral upper extremities because of concerns relating to local anesthetic toxicity, phrenic nerve blockade, and pneumothorax. The ultrasound-guided technique facilitates a reduction in the minimal effective volume of local anesthetic and can prevent potentially critical complications. Moreover, the technique can be performed within the recommended safe dose limits of the anesthetic, rendering it an important option for bilateral upper extremity surgery.

Bilateral Brachial Plexus Home Going Catheters After Digital Amputation for Patient With Upper Extremity Digital Gangrene

Peripheral nerve catheter placement is used to control surgical pain. Performing bilateral brachial plexus block with catheters is not frequently performed; and in our case sending patient home with bilateral brachial plexus catheters has not been reported up to our knowledge. Our patient is a 57 years old male patient presented with bilateral upper extremity digital gangrene on digits 2 through 4 on both sides with no thumb involvement. The plan was to do the surgery under sequential axillary blocks. On the day of surgery a right axillary brachial plexus block was performed under ultrasound guidance using 20 ml of 0.75% ropivacaine. Patient was taken to the OR and the right fingers amputation was carried out under mild sedation without problems. Left axillary brachial plexus block was then done as the surgeon was closing the right side, two hours after the first block was performed. The left axillary block was done also under ultrasound using 20 ml of 2% mepivacaine. The brachial plexus blocks were performed in a sequential manner. Surgery was unremarkable, and patient was transferred to post anesthetic care unit in stable condition. Over that first postoperative night, the patient complained of severe pain at the surgical sites with minimal pain relief with parentral opioids. We placed bilateral brachial plexus catheters (right axillary and left infra-clavicular brachial plexus catheters). Ropivacaine 0.2% infusion was started at 7 ml per hour basal rate only with no boluses on each side. The patient was discharged home with the catheters in place after receiving the appropriate education. On discharge both catheters were connected to a single ON-Q (I-flow Corporation, Lake Forest, CA) ball pump with a 750 ml reservoir using a Y connection and were set to deliver a fixed rate of 7 ml for each catheter. The brachial plexus catheters were removed by the patient on day 5 after surgery without any difficulty. Patient's postoperative course was otherwise unremarkable. We concluded that home going catheters are very effective in pain control postoperatively and they shorten the period of hospital stay.KeywordsBrachial plexus; Home going catheters; Post-operative pain

Regional Anaesthesia for Bilateral Upper Limb Surgery: A Review of Challenges and Solutions

Regional anaesthesia for bilateral upper limb surgery can be challenging, yet surgeons are becoming increasingly interested in performing bilateral procedures at the same operation. Anaesthetists have traditionally avoided bilateral brachial plexus block due to concerns about local anaesthetic toxicity, phrenic nerve block and pneumothorax. We discuss these three concerns and review whether advances in ultrasound guidance and nerve catheter techniques should make us reconsider our options. A search of Medline and EMBASE from 1966 to January 2009 was conducted using multiple search terms to identify techniques of providing anaesthesia or analgesia for bilateral upper limb surgery and potential side-effects. Ultrasound imaging and nerve catheter techniques have led to a reduction in dose requirements for effective blocks without side-effects. Effective regional anaesthesia can be performed for bilateral surgery while remaining within recommended safe dose limits. Spacing blocks apart in time can further reduce potential toxicity issues, such that peak absorption rates for each block do not coincide. Since phrenic nerve block remains an issue even with low doses of local anaesthesia, bilateral interscalene blocks are still not recommended. Peripheral nerve blocks have excellent safety profiles and are ideal for ultrasound guidance. Regional anaesthesia can be a suitable option for bilateral upper limb surgery.

Kasuistik interaktiv: Beidseitige Anästhesie des Plexus brachialis - Zugangswege, Dosierung und Erfolgsrate

A young man squeezed both hands in a bending machine with the result of complex hand injuries. Because of a high risk for general anesthesia, operation as well as postoperative analgesia was performed under bilateral brachial plexus block with the axillary approach. We discuss the considerations concerning the possible approaches with bilateral anesthesia of the brachial plexus under consideration of side effects and effectiveness. The needed dosage of the local anesthetics will be discussed.

Dialysis access.

Optimum positioning of the nerve catheter is crucial for a successful nerve block. We present a novel technique for confirmation of catheter position.We are describing a novel technique for localization of the shaft and tip of the peripheral nerve catheter. After introduction of the catheter 3 to 5 cm beyond the needle tip and removal of the needle, the guide wire was reintroduced and was moved inward and outward rapidly. This movement produced the color Doppler effect along the track of the catheter and the catheter tip that helped us verify the proper positioning of the catheter.We used our technique in a cadaveric study for bilateral supraclavicular brachial plexus block, followed by a series of 5 patients undergoing femoral, sciatic (anterior approach), popliteal (2 patients), and brachial plexus blocks. Catheters were also identified on M-Mode sonography during pumping maneuver and during the injection of medications.Pumping maneuver and M-Mode can be additional tools in the array of modalities applied to verify proper positioning of a nerve catheter.

Interscalene and Infraclavicular Block for Bilateral Distal Radius Fracture

Brachial plexus blockade is a suitable technique for surgery of the forearm, because it provides good intraoperative anesthesia as well as prolonged postoperative analgesia when long-acting local anesthetics are used. However, simultaneous blockade of both upper extremities has rarely been performed (1), because local anesthetic toxicity caused by the amount of drug needed to achieve an efficient block on both sides may be a problem. We report a case of successful bilateral brachial plexus block with ropivacaine in a patient with bilateral distal radius fracture, with each fracture requiring an open osteosynthesis. This case report presents the performance of a simultaneous blockade of both upper extremities in a patient who sustained a bilateral distal radius fracture. The patient was known to be difficult to intubate and to have a severe hypersensitivity to opioids.