Continuous Brachial Plexus Research Articles

Ultrasound-Guided Percutaneous Cryoneurolysis of the Antebrachial Cutaneous Nerves for the Management of Prolonged Acute Post-Surgical Forearm Pain: A Report of Two Cases.

Prolonged acute postsurgical pain (PAPSP) contributes to the development of chronic postsurgical pain, impaired rehabilitation, longer hospital stays, and decreased quality of life. For upper extremity analgesia, the duration of postoperative pain management with continuous brachial plexus peripheral nerve blocks is limited due to the risk of infection. Ultrasound-guided percutaneous cryoneurolysis provides extended analgesia and avoids the risks and inconveniences of indwelling catheters. We present 2 cases of PAPSP of the forearm effectively managed by the use of ultrasound-guided percutaneous cryoneurolysis to treat the medial, lateral, and posterior antebrachial cutaneous nerves.

Enhancing pain control in elbow rehabilitation; A case report of variable ropivacaine dosages through Brachial Plexus Catheter

Managing postoperative pain and discomfort during physiotherapy for upper arm injuries, including complex fractures or traumatic amputations, is crucial. Challenges include severe pain, stiffness, and limited range of motion. Physiotherapy is vital for preventing muscle atrophy, promoting joint mobility, and facilitating functional recovery.The successful management of postoperative pain and pain during physiotherapy in a 27-year-old female, who sustained multiple injuries including a displaced distal humerus fracture and a traumatic right-hand amputation, was achieved through the utilization of a continuous brachial plexus block with variable doses of ropivacaine. The patient’s history revealed a complex array of injuries, including a displaced distal humerus fracture and traumatic right-hand amputation, necessitating open reduction and internal fixation for the fracture and subsequent hand debridement. Despite addressing stiffness through capsulectomy, persistent concerns arose regarding postoperative pain and discomfort during physiotherapy sessions. To address these concerns, a continuous supraclavicular catheter was placed under ultrasound guidance, providing effective pain relief and facilitating physiotherapy interventions for optimal recovery. The patient underwent open reduction and internal fixation for the humerus fracture which was subsequently managed with amputation of several fingers and a hand debridement procedure. Following the surgeries, the patient complained of a stiff elbow, which was addressed through capsulectomy. However, concerns persisted regarding postoperative pain and pain during physiotherapy sessions, leading to the decision to place a continuous supraclavicular catheter. The catheter was accurately positioned under ultrasound guidance and tunneled under the skin, providing effective pain relief for seven days. Ropivacaine was administered as per the patient’s requirements, with a background infusion of 0.2% ropivacaine at 8-hour intervals, a 10 ml bolus of 0.2% ropivacaine administered half an hour before physiotherapy, and 10 ml of 0.5% ropivacaine during physiotherapy sessions if pain levels exceeded 4 on the numerical rating scale. This case highlights the utility of continuous brachial plexus blockade for prolonged postoperative analgesia and pain management during physiotherapy in patients with upper extremity injuries.

Comparison of bupivacaine and levobupivacaine in continuous axillary brachial plexus block

Aims: This study compares bupivacaine – lidocaine and levobupivacaine – lidocaine administrations in terms of initiation and duration of motor and sensorial blockage, total number of additional analgesic applications, analgesic amount consumed in 24 hours, side-effects and hemodynamic effects in continuous axillary brachial pleksus block in hand and forearm surgery. Methods: Thirty ASA I & II physical status patients, scheduled hand or forearm surgery were enrolled for of the two groups in a randomized study. Axillary catheter duly placed in both group with appropriate guided techniques. Patients in group B received 0. 5% bupivacaine 20 ml + 2% lidocaine 20 ml and group L received 0. 5% levobupivacaine 20 ml + 2% lidocaine 20 ml through the axillary catheter. Initiation and duration of motor and sensorial block, total number of additional analgesic applications and analgesic amount consumed in postoperative 24 hours were recorded. Pre-block, peri-operative and post-operative blood pressures and heart beat rates were also recorded. Block application duration, operation duration, tourniquet duration and demographic data of patients (age, sex, weight, and length) were recorded. Demanded and applied analgesic doses by the patient controlled analgesia devices, side effects and complications were also recorded. Results: There was no statistically significant difference between two groups in terms of initiation and duration of motor and sensorial block, amount of analgesic consumed in 24 hours, demanded and applied analgesic doses by the patient controlled analgesia devices and hemodynamic data (p>0. 05). There is a mild and positive relation between block application duration and patient weight. (p=0. 014; r=0. 444) Conclusion: Both bupivacaine+lidocaine and levobupivacaine+lidocaine combinations can safely be used in axillary continuous brachial plexus block without any difference in terms of initiation and duration of block, total analgesic amount consumed. Their duration of action and effect on hemodynamic responses are similar.

A Randomized Controlled Trial Comparing Single-Injection versus Continuous Brachial Plexus Block for Postoperative Pain Control after Open Reduction and Internal Fixation of Distal Radius Fractures

A Randomized Controlled Trial Comparing Single-Injection versus Continuous Brachial Plexus Block for Postoperative Pain Control after Open Reduction and Internal Fixation of Distal Radius Fractures

Response to the Comment on the Article Titled: "Combined Reconstruction of the Ulnar Nerve After its Wide Resection by Nerve Grafting at the Site of the Resection and Distal Transfer of the Anterior Interosseus Nerve to the Deep Branch of the Ulnar Nerve".

The authors thank very much for the critical comment on our article. We agree with all critical arguments concerning not really correct selection of the patient to this type of operation. We agree with an argument that long time of complete ulnar nerve palsy might cause degeneration of the motor end plates at the time of reconstruction. In this situation neither reconstruction done in our patient had chance to work. Nevertheless, the final outcome was surprisingly good, in spite of no improvement of the ulnar nerve function. As we stated in the article, it may be partly explained by successful treatment of the pain that the patient experienced for a long time. The uncontrolled pain in the course of CRPS constituted the primary problem in our patient at presentation and it was successfully eliminated by continuous brachial plexus analgesia. Likewise, the resection of a large fragment of the nerve with recurrent tumours probably resulted in additional alleviating the pain. There was also no recurrence of the pain after main operation. Accepting all critical comments the authors believe that this case can incline surgeons to more careful consideration the treatment options which are the most beneficial for the patient with long-lasting nerve palsy. The lesson we learned from this case and from the comment is that sophisticated surgery is not necessary the best solution in difficult clinical case and that ground for decision making should not be surgeons’ ambitions, but scientific evidence and rational thinking.

Anesthesia in Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis.

For shoulder arthroplasty, regional anesthesia is safer when compared with general anesthesia. There is insufficient evidence to demonstrate the superiority of regional anesthesia with respect to pulmonary complications and hospital length of stay. Infiltration of the shoulder with local anesthetics offers no additional benefits compared with single-shot or continuous brachial plexus blocks for shoulder arthroplasty. There is high-quality evidence (Level I) demonstrating lower pain scores and lower perioperative opioid requirements after a continuous peripheral nerve block compared with a single-shot nerve block. However, catheter dislodgment and logistical issues with catheter insertion are impediments to the widespread usage of a continuous nerve block with an indwelling catheter. Liposomal bupivacaine is comparable with non-liposomal local anesthetic agents with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after total shoulder arthroplasty. Perioperative dexamethasone administration improves postoperative pain control, decreases perioperative opioid requirements, and reduces postoperative nausea.

Continuous Brachial Plexus Blockade for Replantation of an Amputated Finger by Dog Bite - A Case Report

Continuous Brachial Plexus Blockade for Replantation of an Amputated Finger by Dog Bite - A Case Report

Comparison of the Infraclavicular and Axillary Approaches for Continuous Ultrasound-guided Brachial Plexus Block.

Comparison of the Infraclavicular and Axillary Approaches for Continuous Ultrasound-guided Brachial Plexus Block.

Successful Treatment of medically refractory scleroderma digital gangrene with long-term continuous brachial plexus block

Raynaud’s phenomenon (RP) is the earliest and most common clinical manifestation of scleroderma, occurring in 90 to 98% of patients [1]. A combination of sympathetically mediated vasospasm and vasoocclusive disease has been implicated in the etiology of digital ischemic phenomenon [2,3], and treatment of RP is directed towards relieving vasospasm and restoring blood flow. Therefore, cervicothoracic or peripheral sympatholysis and digital artery reconstruction have been performed for medically refractory RP with scleroderma even though all procedures have some limitations. Thoracoscopic symapthectomy has recently been shown to have an initial improvement, although almost always relapses 6 months after the treatment [4,5]. Surgery of the hand, including digital sympathectomy and arterial reconstruction, for scleroderma might have favorable outcomes [6,7]. However, it would be a limited treatment option because of a recurrent ulcer after surgery [8], delayed wound healing [8,9], and development of complex regional pain syndrome [10]. Another alternative and less invasive treatment for blocking the sympathetic outflow would be a sympathetic block with local anesthetics [11,12]. These therapies are based on the premise that excessive sympathetic activity may be involved in the pathogenesis of digital ischemia.

Pain control in chronic, refractory CRPS by continuous brachial plexus analgesia.

Each patient underwent a mean of 4.4 (range 2-8) spinal catheter implantations. A rapid and strong analgesic effect was observed immediately after the injection of bupivacaine solution was started: Pain decreased from a mean of 8.3 to 1.6. The duration of maintaining the catheter in the brachial plexus and achieving effective analgesia was 5.3 months (range 2-12). After the removal of the catheter, the pain returned to baseline. No patient achieved a permanent, or at least partial, reduction of pain after completing this therapy.

Efficacy of continuous brachial plexus block guided by different methods: comparison of effectiveness, safety and comfort

Objective To compare the effectiveness, safety and comfort of continuous brachial plexus block (BPB) guided by different methods. Methods A total of 189 patients of both sexes, of American Society of Anesthesiologists physical status Ⅰor Ⅱ, aged 18-64 yr, weighing 46-90 kg, undergoing elective internal fixation after elbow fracture under general anesthesia, were divided into 3 groups (n=63 each) using a random number table: ultrasound combined with nerve stimulator-guided axillary approach to continuous BPB group (group A), ultrasound combined with nerve stimulator-guided subclavian coracoid approach to continuous BPB group (group B) and ultrasound-guided subclavian coracoid approach to continuous BPB group (group C). Brachial plexus nerve block was performed with 0.2% ropivacaine 30 ml, and anesthesia was induced by IV injection of sufentanil 0.3 μg/kg, propofol 2-3 mg/kg and rocuronium 0.6 mg/kg after confirmation of satisfactory block using the acupuncture method in the three groups.Anesthesia was maintained by inhalation of 1.5%-2.5% sevoflurane and IV infusion of propofol 2-4 mg·kg-1·h-1.Patient-controlled nerve block analgesia was performed after removal of endotracheal tube at the end of surgery.Analgesia solution contained 0.2% ropivacaine which was diluted to 200 ml in normal saline.Parameter settings were adjusted with background infusion at rate 5 ml/h, 5 ml bolus dose and 60 min lockout interval.Analgesia lasted until 72 h after surgery, maintaining a visual analog scale score less than or equal to 3.When the visual analog scale score was more than 3, tramadol 100 mg was intramuscularly injected as a rescue analgesic.Comfort scores, requirement for rescue analgesic within 72 h after surgery, development of pneumothorax, local anesthetic intoxication and intravascular puncture during puncture operation and development of postoperative adverse reactions such as tube shedding, nausea and vomiting and nerve damage were recorded. Results Compared with group A, the comfort score was significantly increased, and the requirement for rescue analgesic was decreased in B and C groups (P 0.05). There was no significant difference in the incidence of adverse reactions between the three groups (P>0.05). Conclusion The effectiveness and comfort of subclavian coracoid approach to continuous BPB is better than those of axillary approach, and the comfort of subclavian coracoid approach to continuous BPB under only ultrasound guidance is superior to that under ultrasound combined with nerve stimulator guidance. Key words: Brachial plexus; Nerve block

Rehabilitation with continuous brachial plexus block after surgical treatment for posttraumatic stiff elbow -Two case reports

Rehabilitation with continuous brachial plexus block after surgical treatment for posttraumatic stiff elbow -Two case reports

Efficacy of ultrasound-guided continuous brachial plexus block for analgesia after fixation of upper extremity fractures in pediatric patients

Objective To evaluate the efficacy of ultrasound-guided continuous brachial plexus block for analgesia after fixation of upper extremity fractures in the pediatric patients. Methods Sixty American Society of Anesthesiologists physical status Ⅰpediatric patients of both sexes, aged 3-10 yr, weighing 13-46 kg, with body height of 97-152 cm, scheduled for open reduction and internal fixation of distal humeral fractures, were selected and divided into 2 groups (n=30 each) using a random number table: intravenous analgesia group (group V) and continuous brachial plexus block group (group B). Surgery was completed under brachial plexus block combined with general anesthesia in the two groups.At the end of surgery, patient-controlled intravenous analgesia was used in group V, and continuous brachial plexus block was performed with 0.1% ropivacaine 250 ml (background infusion 0.1 ml·kg-1·h-1, bolus dose 0.2 mlkg, lockout interval 30 min) in group B. Tramadol was given as rescue analgesic when necessary.Ramsay sedation scores were assessed and recorded at 2, 4, 8, 12, 24, 36 and 48 h after surgery, and the development of over-sedation was recorded.The requirement for rescue analgesics and development of respiratory depression, dizziness, nausea and vomiting, pruritus and urinary retention during analgesia were recorded.The development of adverse reactions such as vascular and nerve injury, local hematoma and pneumothorax was recorded in group B. Family′s satisfaction with analgesia was assessed and scored. Results Compared with group V, Ramsay sedation scores at 2-12 h after surgery, the incidence of over-sedation, nausea and dizziness and requirement for tramadol were significantly decreased (P 0.05). The adverse reactions such as vascular and nerve injury, local hematoma or pneumothorax were not found in group B. Conclusion Ultrasound-guided continuous brachial plexus block can be safely and effectively used for analgesia after fixation of upper extremity fractures in the pediatric patients. Key words: Brachial plexus; Nerve block; Child; Fracture fixation

Use of Continuous Brachial Plexus Blockade for Treatment of Accidental Intra-Arterial Injection

Introduction: Unintentional intra-arterial injection of drugs has serious problems and morbidity such as pain, ischemia, gangrene, and infection. Aberrant vascularization is a frequent cause of intra-arterial injection.Case Report: We describe a pediatric case of accidental cannulation of aberrant arterial vessel during venous insertion and our brachial plexus block treatment to obtain continuous vasodilatation to prevent ischemic effects.Conclusion: Sympatholysis with peripheral nerve blocks may decrease morbidity providing an additional benefit to pharmacological treatment by increasing blood flow to the tissue after the intra-arterial injection

Clinical Application of Ultrasound-Guided, Continuous Infra-Clavicular Brachial Plexus Blockade in Burn Patients on Full Thickness Skin Graft Surgery

Clinical Application of Ultrasound-Guided, Continuous Infra-Clavicular Brachial Plexus Blockade in Burn Patients on Full Thickness Skin Graft Surgery

Continuous versus single shot brachial plexus block and their relationship to discharge barriers and length of stay

Brachial plexus block has been associated with improved pain control and decreased length of stay in patients undergoing upper extremity arthroplasty. Continuous delivery is associated with a shorter length of stay; however, comparisons to single-shot delivery in this setting are scarce. As the paradigm shifts to outpatient arthroplasty in the era of bundled payments, there exists a strong impetus to identify the most effective mode of analgesia associated with the least risk to patients. This is a retrospective review of 697 patients undergoing upper extremity arthroplasty comparing the rate of complications and incidence of potential barriers to discharge and length of stay of patients receiving continuous vs. single-shot perineural brachial plexus block. No difference was observed in the complication rate between indwelling (n = 63 [12%]) and single-shot groups (n = 30 [17%]; P = .137). The majority of complications were pulmonary, 72% attributable to oxygen desaturation. The indwelling catheter group had 1.61 times higher odds (95% confidence interval, 1.07-2.42; P = .023) of exhibiting any potential barrier to discharge and exhibited a longer length of stay (P = .002). There was no demonstrated disparity in the rate of complications associated with single-shot vs. continuous brachial plexus block. However, the continuous indwelling catheter was associated with an increased incidence of potential barriers to discharge and an increased length of stay compared with patients receiving single-shot regional anesthesia.

The influence of ultrasound-guided continuous brachial plexus block on the blood flow in brachial artery-basilic vein arteriovenous graft

Objective To investigate the effects of ultrasound-guided continuous brachial plexus block on the blood flow in brachial artery-basilic vein arteriovenous graft (AVG). Methods A total of 78 patients undergoing brachial artery-basilic vein AVG were randomly assigned to an experiment group that was received single-injection brachial plexus block (SBB), or to a control group that was received continuous-injection brachial plexus block group (CBB). Operation was conducted by ultrasound-guided technique. CBB group used patient-controlled nerve analgesia (PCNA) after surgery. The difference of artery diameter preoperative (T0), artery diameter, fistula blood flow, and postoperative success at 4 h (T1), 20 h (T2), 7 d (T3), 3 m (T4) were compared between two groups. The remedia painkiller times, analgesia satisfaction and anesthesia-related complication in 48 h were compared. Results The artery diameter, fistula blood flow at T2, T3, T4 after surgery in CBB group [(4.2±0.3)mm, (4.6±0.3)mm, (5.2±0.3)mm, (325±15.2)ml/min, (625±32.5)ml/min, and (1 125±90.2)ml/min] were significantly increased than those in SBB group [(3.8±0.2)mm, (4.1±0.2)mm, (4.7±0.3)mm, (162±9.8)ml/min, (442±20.3)ml/min, and (778±40.2)ml/min] (P<0.05). Compared to the group SBB, the remedia painkiller times in 48 h after surgery were significantly decreased, and the analgesia satisfaction was significantly increased in the group CBB (P<0.05). Conclusions Compared to the group SBB, group CBB could significantly relieve postoperative pain, and provide higher blood flow in the brachial artery-basilic vein AVG. Key words: Ultrasonography; Nerve block; Brachial plexus; Brachial artery/TR; Veins/TR; Fistula/CO

An Expedited Care Pathway With Ambulatory Brachial Plexus Analgesia Is a Cost-effective Alternative to Standard Inpatient Care After Complex Arthroscopic Elbow Surgery

(Abstracted from Anesthesiology, 123:1256–1266, 2015) The current standard practice for complex arthroscopic elbow surgery is inpatient admission for 72 hours with intensive physiotherapy via continuous passive motion, 24 hours a day for 3 days, and continuous brachial plexus analgesia for pain. The authors of the current study tested an expedited care pathway, with only 24 hours of hospital admission and ambulatory brachial plexus analgesia and continuous passive motion performed at home.

Efficacy of Continuous Brachial Plexus Block for Intractable Cancer Pain in a Terminal Patient

We report a case of terminal cancer in which continuous peripheral nerve block provided effective relief for cancer-related pain that was difficult to control with pharmacotherapy. A 70-year-old woman with thyroid cancer, paraplegia due to multiple bone metastases, and cauliflower-like proliferation of skin metastasis on the left upper arm was receiving inpatient palliative care. Intractable pain during treatment of the tumor and when changing body position due to metastatic tumor and pathological fracture of the left humerus was difficult to control with pharmacotherapy. Continuous interscalene brachial plexus block was therefore performed, resulting in effective pain relief over the subsequent 38 days before death. Ultrasound-guided continuous peripheral nerve block can be performed at the bedside in patients in poor general condition who cannot tolerate neuraxial block, and should be considered in cases of terminal cancer patient suffering from intractable pain despite pharmacotherapy.

Brachial Plexus Block for Cancer-Related Pain: A Case Series

Neoplastic brachial plexopathy (NBP) is caused by a cancerous infiltration into the brachial plexus, presenting often as severe pain in the affected upper extremity. Such pain can be resistant to medical treatment. Invasive interventions such as brachial plexus neurolysis with phenol or cordotomy may result in severe complications including permanent neurological damage and death. Continuous brachial plexus and paravertebral block with local anesthetic have been reported to successfully control pain from NBP, but these techniques are logistically challenging and frequently have catheter-related complications. We report a series of patients who received single-shot brachial plexus blocks with a mixture of local anesthetic and corticosteroid (bupivacaine 0.25% with methyl-prednisolone 20 – 120 mg) for the treatment of refractory cancer-related pain in the brachial plexus territory, mostly from NBP. Theoretically, such blocks could provide immediate analgesia from the local anesthetic and a longer-lasting analgesia from the slow-release steroids. Responders reported a sustained decrease in their pain (lasting from 2 weeks to 10 months), a significant decrease in their opioid and non-opioid (ketamine, gabapentin) consumption, overall satisfaction with the block, and unchanged or improved function of their limb. The ideal candidate for this procedure is a patient who has pain that is predominantly neuropathic from a lesion within the brachial plexus and with anatomy amenable to ultrasound-guided nerve block. Our case series suggests that, in the appropriately selected patient, this technique can safely and effectively alleviate pain from NBP. The procedure is simple, spares limb function, and can be diagnostic, predicting response to more complex procedures. To the best of our knowledge, this is the first report using this technique for NBP. Key words: Brachial plexus block, neoplastic brachial plexopathy, intractable pain, cancer pain, pain intervention