Ultrasound-guided Axillary Brachial Plexus Block Research Articles

Diaphyseal forearm fracture management in adolescent patients from 2011 to 2020: A multicenter study of surgery and regional anesthesia trends

BackgroundDiaphyseal forearm fractures are common traumatic injuries among children. There has been much debate on the use of intramedullary nailing (IMN) or plate fixation in the adolescent population (10–16 years of age). Furthermore, as ultrasound technology has advanced, the safety and efficacy of ultrasound-guided axillary brachial plexus block for children has dramatically improved. Therefore, anesthesia options for adolescent patients have increased in recent years. This study aimed to investigate recent surgical and regional anesthesia trends of diaphyseal forearm fractures in patients 10 to 16 years of age in Japan through a multicenter epidemiological survey from 2011 to 2020. MethodsThis retrospective, multicenter study included 226 pediatric patients with diaphyseal forearm fracture aged 10–16 years treated from January 2011 to December 2020. We divided the patients into four groups according to the period in which they were treated: early (2011–2013), middle (2014–2016), late (2017–2019), and COVID-19 (2020). Information from medical records was used to investigate the number of surgeries, types of anesthesia administered, and internal fixation methods used for diaphyseal forearm fracture in adolescent patients during each period. ResultsThe number of surgeries was generally constant in each period but decreased during the COVID-19 period. In the early, middle, late, and COVID-19 periods, the percentages of surgeries performed under regional anesthesia were 67.7, 85.5, 87.0, and 100% respectively (p = 0.003). During the same periods, the percentages of patients receiving IMN were 41.5, 49.3, 58.0, and 66.7%, respectively (p = 0.033). ConclusionThe use of IMN and regional anesthesia to treat diaphyseal forearm fracture in patients 10 to 16 years of age steadily increased during the study period from 2011 to 2020. These results indicate that regional anesthesia is safe, effective, and well-tolerated by adolescent patients. The treatment strategy for diaphyseal forearm fractures in adolescents using regional anesthesia in combination with IMN worked well and was effective during COVID-19. Our evidence suggests this trend will continue. We anticipate that our findings can be extrapolated for upper extremity fractures in adolescent patients beyond the Tokai region of Japan where the study was based.

The motor effects of 0.25% bupivacaine vs 0.19 bupivacaine in ultrasound-guided axillary brachial plexus block in pediatrics undergoing below-elbow orthopedic surgeries: A randomized controlled study

ABSTRACT Background The standard dose of bupivacaine used in axillary brachial plexus block (ABPB) in pediatrics is 0.5 ml/kg of bupivacaine 0.25%. However, bupivacaine (0.19%) is still to be investigated for peripheral nerve block in pediatrics regarding the efficacy and adequacy of intra- and postoperative analgesia and degree of motor affection. We aimed to compare different concentrations (0.25%, 0.19%) of bupivacaine plus dexmedetomidine mixture to perform US-ABPB in pediatrics undergoing upper limb surgery distal to the elbow regarding affecting the postoperative motor power and adequacy of intra- and postoperative analgesia. Methods This prospective, randomised-controlled, double-blinded work was performed on 60 pediatric individuals presenting for upper limb orthopedic surgeries in the wrist, hand, and elbow distal to cubital fossa with surgical time planned to not exceed 1 h. 0.25% bupivacaine plus 1 µg/kg dexmedetomidine (Group A) or 0.19% bupivacaine in addition to 1 µg/kg dexmedetomidine (Group B) were given at random to participants. Motor power and pain were assessed using the Modified Bromage scale, Face, Legs, Activity, Cry, and Consolability (FLACC) score, respectively. Results A highly substantial variation was recorded between the two groups in Bromage 0 till Bromage 60 with higher values in group (B), and no substantial variation was found in Bromage 90 till Bromage 180 existed between the two groups. No substantial variation existed among the two groups with regard to FLACC score in FLACC0 (immediately after recovery), 1st hour after recovery, and 12th hour after recovery, and FLACC was significantly more (p < 0.05) in group B contrasted to group A in the 4th hour after recovery and 8th hour after recovery. Conclusion Using a lower concentration of bupivacaine (0.19%) plus dexmedetomidine (1 µg/kg) was associated with regain of postoperative motor power with the same postoperative analgesic efficacy compared to the standard concentration (0.25%) bupivacaine plus dexmedetomidine (1 µg/kg) in the early postoperative period in US-ABPB.

Neuropathies Following an Ultrasound-Guided Axillary Brachial Plexus Block.

Ultrasound-guided brachial plexus block (UGBPB) has interscalene, supraclavicular, infraclavicular, and axillary approaches. The axillary block is considered to be the safest and with fewer adverse events compared to the interscalene (eg, phrenic nerve block, spinal cord or vertebral artery puncture) and supraclavicular (eg, pneumothorax). However, with regard to postoperative neurological symptoms (PONS), it is controversial whether its incidence after an axillary block was higher than that after non-axillary approaches". In this study, we investigated whether the incidence of a neuropathy after an axillary block was higher than that after non-axillary approaches. This was a single-center, retrospective cohort study. All UGBPBs were performed under general anesthesia between January 2014 and March 2020. The outcomes included the overall incidence of PONS and neuropathies for axillary and non-axillary approaches. The etiology, symptoms, and outcomes of patients were investigated. Of the 992 patients, 143 (14%) and 849 (86%) were subjected to axillary and non-axillary approaches, respectively. Among 19 cases (19.2:1000; 95% confidence interval [CI], 18.2-20.1) of PONS, four (4.0:1000; 95% CI, 3.8-4.2) were neuropathies attributed to the UGBPB, three (21.0:1000; 95% CI, 18.1-23.8) to the axillary and one (2.8:1000; 95% CI, 2.6-3.1) to non-axillary approaches. The incidence of neuropathies after an axillary block was significantly higher than that after non-axillary approaches (P = 0.005). The incidence of neuropathies after US-guided axillary block under general anesthesia was significantly higher than that after non-axillary approaches.

Comparison of perineural brachial plexus block and proximal perivascular block in ultrasound-guided axillary brachial plexus block

The traditional axillary perineural (PN) approach for brachial plexus block is frequently used, but separate musculocutaneous nerve (MCN) block is required and increases procedure time and patient discomfort. We hypothesized that a block using the proximal perivascular (PPV) method at the MCN branching from the lateral cord would obviate the need for an MCN block while ensuring a quality similar to that of the PN method. For the PN group (n = 25), a needle was placed on each nerve, and 8 mL local anesthetic was infiltrated around the radial, ulnar, and median nerves (total: 24 mL). We then injected 6 mL local anesthetic around the MCN. In the PPV group (n = 25), we moved the probe proximally until the branching junction of the the MCN in the lateral cord. The needle tips were placed in the 12-o’clock and 6-o’clock positions of the axillary artery, and 15 mL local anesthetic was injected (total: 30 mL). The procedure time, number of needle passes, procedure-related complications, sensory/motor block level, and onset time were recorded. The PPV group had a significantly shorter procedure time than the PN group (3.9 ± 1.0 vs. 7.5 ± 3.3 min, p &lt; 0.001). Furthermore, the PPV group required fewer needle passes. The PN group showed a significantly faster onset time than the PPV group (6.4 ± 2.7 vs. 10.4 ± 2.9 min, p &lt; 0.001). The induction time did not show significant intergroup difference. Sensory blockade in the PN group occurred significantly faster than that in the PPV group at 5 and 10 min. There were no significant differences in motor nerve paralysis. PPV axillary block under ultrasound guidance was as effective as the PN axillary block. Therefore, the PPV axillary block is a simple, safe and effective regional technique for upper limb surgery.

超音波ガイド下腕神経叢ブロック腋窩アプローチ法における低用量 0.5％レボブピバカインによる術中および術後の鎮痛効果の検討

超音波ガイド下腕神経叢ブロック腋窩アプローチ法における低用量 0.5％レボブピバカインによる術中および術後の鎮痛効果の検討

General anesthesia versus ultrasound-guided axillary block for ambulatory hand surgery: randomized prospective study

BackgroundIn upper limb surgery, both axillary brachial plexus block (ABPB) and general anesthesia (GA) have been widely used. ABPB is one of the most popular and widely used procedures for brachial plexus blocks, as well as for achieving upper limb regional anesthesia.The aim of the study was to compare between both anesthetic techniques for ambulatory hand surgery regarding their effects on postoperative pain as primary outcome and postoperative nausea and vomiting and patient satisfaction and postoperative sleep disturbances as secondary outcomes.ResultsWe reviewed data from 40 patients for the primary outcome and found that group A (had general anesthesia) had a statistically significant higher postoperative VAS score than group B (got ultrasound guided axillary block), (P-value 0.05). In terms of secondary outcomes, postoperative nausea and vomiting were significantly higher in group A patients (P-value 0.001), and patient satisfaction was significantly higher in group B patients compared to group A patients (P-value 0.001). Furthermore, the Pittsburgh quality index (PSQI) for postoperative sleep disruptions was considerably higher in group A than in group B at 24 h postoperatively and at the first and second weeks postoperatively (P-value 0.001). Statistically, there is no difference between the two groups in the third week and one month after surgery.ConclusionsWhen compared to general anesthesia, ultrasound-guided axillary brachial plexus block offered good anesthesia, great analgesia, and a better postoperative sleep result after hand surgery.

Effects of local anaesthetic dilution on the characteristics of ultrasound guided axillary brachial plexus block: a randomised controlled study

Ultrasound guidance has led to marked improvement in the success rate and characteristics of peripheral nerveblocks. However, effects of varying the volume or concentration of a fixed local anaesthetic dose on nerve block remains unclear.The purpose of our study was to evaluate whether at a fixed dose of lidocaine, altering the volume and concentration willhave any effect on the onset time of ultrasound-guided axillary brachial plexus block. Twenty patientswere randomised to receive an ultrasound-guided axillary brachial plexus block with either lidocaine 2% with epinephrine (20ml, Group 2%) or lidocaine 1% with epinephrine (40 ml, Group 1%). The primary endpoint was block onset time. Secondaryoutcomes included duration of the block, performance time, number of needle passes, incidence of paraesthesia and vascularpuncture. The median [IQR] onset time of surgical anaesthesia was shorter in Group 1% when compared to Group2% (6.25 [5-7.5] min vs 8.75 [7.5-10] min; p=0.03). The mean (SD) overall duration of surgical anaesthesia was significantlyshorter in Group 1% compared to Group 2% (150.9±17.2 min vs 165.1±5.9 min; p=0.02). Group 1% had a shorter performancetime with fewer needle passes. The incidence of vascular puncture and paraesthesia was similar in the two groups. Ultrasound-guided axillary brachial plexus blocks performed using a higher volume of lower concentration lidocainewas associated with shorter onset time and duration of surgical anaesthesia.

Evaluation of Monitored Anesthesia Care Involving Sedation and Axillary Nerve Block for Day-Case Hand Surgery.

Background: Ultrasound-guided axillary brachial plexus block (ABPB) is a technique of choice for regional anesthesia during hand and forearm surgery. Intravenous sedation may facilitate this procedure, particularly for those suffering from anxiety; however, it can also be associated with respiratory, cardiovascular, and neurological side effects. The objective of this study was to evaluate the effect of intravenous sedation on perioperative respiratory depression for patients undergoing day-case hand surgery under ABPB. Methods: A prospective, observational, single-center study was conducted between 1 May and 1 November 2016. Results: A total of 2318 patients were included, with 501 patients in the group with IV sedation and 1817 in the group without. A multivariable propensity-score matched analysis showed that the variables associated with the number of desaturation were: (i) sedation (aRR 1.534 [95% CI: 1.283 to 1.836]), (ii) age and sex, (iii) type of surgery, and iv) Body Mass Index (BMI). Conclusions: Supplementing ABPB with IV sedation was associated with an increased rate of respiratory depression (episodes of desaturation) compared to fully awakened patients. The rate of oxygen administration was also higher in sedated patients even though they had fewer cases of chronic respiratory diseases and fewer were active smokers than non-sedated patients. Future research should consider precisely evaluating patient satisfaction, as well as the differences between sedation and drug-free approaches.

Effects of Clonidine as an Adjuvant to Lidocaine with Epinephrine in Ultrasound Guided Axillary Brachial Plexus Block: A Randomised Controlled Trial.

This study evaluated the effects of adding adjuvant clonidine to lidocaine with epinephrine on the characteristics of ultrasound-guided axillary brachial plexus block (ABPB) for upper extremity surgery. Twenty-four patients were randomised to receive an ultrasound guided ABPB with 20 mL of lidocaine 2% with 1:200,000 epinephrine plus 2 mL of either normal saline 0.9% (Group 1) or a mixture of clonidine 1 µg/kg and normal saline 0.9% (Group 2). The outcome measures that were recorded were the overall onset time and the duration of sensory and motor block. The median (IQR) overall onset time of sensory and motor block was significantly shorter in Group 2 vs. Group 1 (5 (5–7.5) min vs. 10 (8.8–12.5) min; p < 0.001) and (5 (2.5–7.5) min vs. 7.5 (6.3–7.5) min; p = 0.001), respectively. The median (IQR) overall duration of sensory and motor block was significantly longer in Group 2 vs. Group 1 (225 (200–231) min vs. 168 (148–190) min; p < 0.001) and (225 (208–231) min vs. 168(148–186) min; p < 0.001), respectively. In ultrasound-guided ABPB, the addition of clonidine to lidocaine with epinephrine resulted in shorter onset time and prolonged duration of sensory and motor block.

Minimum effective volume of 0.2% ropivacaine for ultrasound-guided axillary brachial plexus block in preschool-age children

Ultrasound-guided axillary brachial plexus block is increasingly used in preschool-age patients. However, the minimum effective volume of local anaesthetics has not been determined. With ethical committee approval and written informed consent from the guardians of all paediatric patients, we studied 27 consecutive patients aged 3 to 6 years who were scheduled for hand surgery. After general anaesthesia, eligible patients received a set volume of ultrasound-guided axillary brachial plexus block. We determined the volume of 0.2% ropivacaine for consecutive patients from the preceding patient’s outcome. The initial volume was 0.4 ml/kg. The testing interval was set at 0.05 ml/kg, and the lowest volume was 0.1 ml/kg. The following conditions were defined as a successful block: no heart rate changes, body movement, or ventilatory disorders during the operation; no use of fentanyl in the PACU; and a postoperative sensory block score < 3. The sequences of positive and negative blocks in consecutive patients were recorded. Using probit regression analysis, the 50% effective volume was 0.185 ml/kg (95% CI 0.123–0.234), and the 95% effective volume was 0.280 ml/kg (95% CI 0.232–0.593). EV50 and EV95 values of 0.2% ropivacaine for ultrasound-guided axillary brachial plexus block were 0.185 ml/kg and 0.280 ml/kg, respectively.

Recovery of motor function in ambulatory hand trauma using chloroprocaine 2%

Chloroprocaine 2% is an ester local anaesthetic offering a shorter onset, duration of action, and offset than other commonly used agents, making it particularly suitable for ambulatory surgery.1 Although established for short-acting spinal anaesthesia, it has only recently launched on the UK market for peripheral nerve block.2 We evaluated recovery of motor function in patients undergoing awake surgery using chloroprocaine 2% for ambulatory hand trauma procedures. Thirteen patients received an ultrasound-guided axillary brachial plexus block with 30 ml chloroprocaine 2%, of which 5 ml (100 mg) were specifically deposited around the musculocutaneous nerve. We established baseline biceps muscle strength (peak force over a 3-s period) with a handheld dynamometer (Lafayette). Patients also received supplemental distal blocks of the median, ulnar and superficial radial nerves as appropriate with levobupivacaine for postoperative analgesia. Biceps strength was assessed at fixed time points after block until >75% return of baseline function. Mean block performance time was 11 min (7–14 min). Surgery started 5–22 min (mean 12 min) thereafter with an operative time between 13 and 50 min (mean, 34 min). Median peak force immediately after block was 0% (0–25%) of pre-block strength. Six of 13 patients had >50% recovery of biceps strength by 70 min after block (Fig. 3). All had ≥75% recovery by 120 min (Table 1). Surgical conditions were excellent for all patients, and none received supplemental analgesia or reported tourniquet discomfort. Chloroprocaine 2% provided rapid onset block, good surgical conditions, and rapid recovery of motor function. In terms of offset and readiness for discharge, chloroprocaine 2% was a marked improvement on our previous awake surgery local anaesthetic mixture of lidocaine 1.5% with epinephrine. This has benefits for theatre efficiency, and patient safety and satisfaction. Of note patients were able to dress themselves in the PACU without aid. Five patients recorded higher peak force postoperatively compared with baseline, which may have been attributable to pain inhibition. We plan to recommend wider use of chloroprocaine 2% for procedures where operative duration is anticipated to be ≤1 h. Supplemental distal blocks can limit any concerns about postoperative analgesia.Table 1Biceps muscle strength post block.Duration since block finish (min)Median biceps muscle strength (% of baseline)00%7057%8085%12098% Open table in a new tab 1.Saporito A, Anselmi L, Borgeat A, Aguirre J. J Clinical Anesth 2016; 32: 119–262.Jafari S, Kalstein A, Nasrullah H, et al. Anesth Analg 2008; 107: 1746–50

A Comparative Study of Clonidine and Dexmedetomidine with 0.5% Levobupivacaine in ultrasound-guided Axillary Brachial Plexus Block for Upper Limb Surgeries

Background: Clonidine and Dexmedetomidine as an additive to Levobupivacaine in ultrasound-guided axillary brachial plexus block are not studied well. Hence, this study was designed to compare the efficacy of the Clonidine and Dexmedetomidine, used as an adjunct to Levobupivacaine in ultrasound-guided axillary brachial plexus block in upper limb elective surgery.Materials and Methods: Eighty patients of the American Society of Anesthesiologists Grade I/II undergoing upper limb elective surgery were divided into two equal age/gender-matched groups. Group-LD received ultrasound-guided axillary brachial plexus block using injection 0.5% Levobupivacaine 20 ml+dexmedetomidine (1 μg/Kg), and group LC received ultrasound-guided axillary brachial plexus block using injection 0.5% Levobupivacaine 20 ml + Clonidine (1.5 μg/Kg). The onset and duration of sensory and motor block, hemodynamics, and side effects were recorded. Results: The time for onset of sensory block and motor block in group LD was significantly faster than group LC (4.53±1.07 and 7.88±1.29 min vs. 5.90±0.81 and 8.85±1.81min, p<0.0001). The duration of motor block in group LD was significantly longer than group LC (Sensory and motor block: 662.50 ± 50.95 and 625.50 ± 51.95min, vs 567.75 ± 62.33 and 560.62 ± 67.19 min. p< 0.0001). The sedation score was highly significant at 30 min (p<0.0001) and was significant at 60 min (p<0.05), postoperatively. Conclusion: The addition of Dexmedetomidine (1μg/Kg) as an adjuvant to Levobupivacaine (0.5%) for upper limb surgeries by axillary brachial plexus block had provided the rapid onset of sensory block and motor block and enhanced duration of sensory and motor block with arousable sedation without any adverse effects compared to clonidine (1.5μg/Kg).

Analgesic Effect of the Topical Use of Dexamethasone in Ultrasound-Guided Axillary Brachial Plexus Blockade: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study.

IntroductionIncreasing the duration of regional anesthesia in orthopedic surgery is of vital importance, as it prolongs postoperative analgesia, allowing faster rehabilitation of patients. Dexamethasone has been found to extend the block duration in animal and human studies. The aim of this study is the assessment of the effect of the addition of dexamethasone to ropivacaine on the onset and duration of axillary brachial plexus block, along with the intensity of postoperative pain.MethodsForty patients undergoing below-elbow surgery under ultrasound-guided axillary brachial plexus block were randomly allocated to receive either 30 mL ropivacaine 0.75% with 2 mL of saline (Group A, n = 20) or 30 mL ropivacaine 0.75% with 2 mL of dexamethasone (4 mg) (Group B, n = 20). Sensory and motor blockade were assessed, with the use of the pinprick test and the modified Bromage scale, at five, 10, 15, and 20 min after the block. The duration of analgesia, intensity of postoperative pain, postoperative opioid consumption, overall satisfaction, and perioperative complications were compared between the two groups.ResultsWe found no difference at the mean onset time of the sensory and motor block between the two groups. The mean duration of postoperative analgesia was three hours higher in the dexamethasone group (15.85 ± 4.82 versus 11.75 ± 6.81, p-value = 0.035). Pain intensity was lower in the dexamethasone group, at six and 12 hours after surgery (3.45 ± 1.79 versus 4.65 ± 1.79, p-value = 0.040). Postoperative opioid consumption, patient overall satisfaction, and perioperative complications were not significantly different between groups.ConclusionsDexamethasone prolongs the duration of ropivacaine in an axillary brachial plexus block and decreases postoperative pain in patients subjected to below-elbow surgery.

Minimum Effective Volume of 0.75% Ropivacaine for Ultrasound-Guided Axillary Brachial Plexus Block.

BackgroundUltrasound-guided peripheral nerve block provides direct visualization of nerve and reduces the complications associated with classical landmark guided technique, by reducing the dosage of local anesthetic drugs. This study aims to determine the minimum effective volume (MEAV) of 0.75% ropivacaine for ultrasound-guided axillary brachial plexus block.MethodologyA total of 23 patients of age group 18-75 years belonging to ASA grade 1, 2, and 3 were selected based on inclusion criteria. The MEAV was determined by using Dixons & Massey Step-up and Step-down method. The initial volume was selected as 15 mL based on previous studies. Depending on block success or failure, 1 mL of the drug was decreased or increased. Block was assessed in terms of motor and sensory components. The study was aborted after attaining five cases of block failure, followed by five cases of a successful block.ResultsThe MEAV to be given for a successful block in 50% of patients (MEAV50) was 8.62 mL (95%CI 3.54-9.89). The MEAV to be given for a successful block in 90% of patients (MEAV 90) was 11.82 mL (95% CI 9.9-75.7).Conclusion Ultrasound guidance reduces the dosage of local anesthetic drugs to be used and provides surgical anesthesia without any complications or adverse effects.

Double Axillary Artery and an Owl Face during an Ultrasound-guided Axillary Brachial Plexus Block.

Double Axillary Artery and an Owl Face during an Ultrasound-guided Axillary Brachial Plexus Block.

Dexmedetomidine as an Adjuvant Agent to 0.5% Ropivacaine in Ultra Sound Guided Axillary Brachial Plexus Block in Orthopaedic Surgeries

Aim: The aim of this study was to evaluate the effects of adding Dexmedetomidine to Ropivacaine regarding the onset of sensory and motor blockade in ultrasound guided axillary brachial plexusblock. Materials and Method: Fifty-four ASA physical status I-II patients undergoing elective forearm and hand surgery under ultrasound-guided axillary brachial plexus block were allocated into two groups. Group A (n=27) received 20ml 0.5% Ropivacaine + Normal saline(1ml) and Group B (n=27) received 20ml 0.5% Ropivacaine + 0.5µg/kg Dexmedetomidine. Onset time of sensory and motor block and haemodynamic changes were assessed. Results: Onset time of sensory block for ulnar(6.48 minutes), radial(6.51minutes), median(6.59minutes), musculocutaneous (6.66minutes) was significantly faster in group B(p value&lt;0.00001).Onset time of motor block as in Modified Bromage grade 2(8.51minutes), grade 1(11.22minutes) and grade 0(15.40minutes) in group B was significantly faster(pvalue&lt;0.00001). Significant bradycardia was noted in group B. Conclusion: Our study indicated that Dexmedetomidine as an adjuvant to Ropivacaine for ultrasound guided axillary brachial plexus block fastened onset time of sensory and motor block.

Outpatient treatment of acute injuries of upper extremities with axillary plexus anesthesia in the emergency department-Is that possible without continuous anesthesia attendance?

The incorporation into the routine operating procedure of patients with small but acute hand and forearm injuries requiring surgery who present in the emergency admission department, represents a challenge due to limited resources. The prompt treatment in the emergency admission department represents an alternative. This article retrospectively reports the authors' experiences with a treatment algorithm in which emergency patients were treated by ultrasound-guided axillary brachial plexus blocks (ABPB) and surgery carried out in the emergency department without further anesthesia attendance. Patients were preselected by the surgeon if they were suitable for astandardized treatment without anesthesia attendance during surgery. If there were no anesthesiological or surgical contraindications patients received an ABPB in the holding area of the operating room (OR) under standard monitoring. Blocks were performed as a multi-injection, ultrasound-guided technique which is anatomically described in detail. Patients >60 kg received atotal volume of 30 ml of amixture of 10 ml 1% ropivacaine (100 mg) and 20 ml 2% prilocaine (400 mg). Patients <60 kg received the same mixture with areduced volume of 25 ml corresponding to 82.5 mg ropivacaine and 332.5 mg prilocaine. After controlling for block success patients were admitted to the emergency department and the surgical procedure was carried out under supervision by the surgeon without further anesthesia attendance. At discharge patients were explicitly instructed that in the case of any complications or acontinuation of the block for more than 24 h they should contact the emergency department. Between January 2013 and November 2017 a total of 566 patients (46.4years, range 11-88 years, 174.9 cm, range 140-211cm, 80.8 kg, range 42-178kg, ASA 1/2/3, 190/338/38, respectively) were treated according to astandardized protocol. The ABPBs were performed by 74anesthetists. In 5% of the patients the initial block was incomplete and rescue blocks were performed with a maximum of 2‑3ml 1% prilocaine per corresponding nerve. After completion the block was ensured and all patients underwent surgery without further analgesics or local anesthetic infiltration by the surgeon. Complications related to the ABPB and readmissions were not observed. It could be demonstrated that minor surgery could be carried out safely and effectively with a defined algorithm using ABPB in selected patients outside the OR without permanent anesthesia attendance: however, indispensable prerequisites for such procedures are careful patient selection, patient compliance, the safe and effective performance of the ABPB and reliable agreement with the surgeon.

Association of obesity with failure of ultrasound-guided axillary brachial plexus block: a two-centre, prospective, observational, cohort study.

The objective of this study was to evaluate whether the failure rate of ultrasound-guided axillary brachial plexus block is similar in obese patients compared with non-obese patients when performed as the primary anaesthetic technique. We recruited 105 obese (body mass index ≥30kg.m-2 ) and 144 non-obese patients to this prospective, observational, cohort study conducted at two Canadian centres. A perineural technique of axillary brachial plexus block was performed using 30ml ropivacaine 0.5% under real-time ultrasound guidance. Sensory and motor block assessment was carried out every 5min until 30min after block completion in all four terminal nerve distributions (radial, median, ulnar and musculocutaneous nerve). A composite score consisting of three sensory points and three motor points was used for assessment in each nerve distribution. A failed block was defined as a score of less than 14 points out of a possible 16 points, or a sensory block score less than 7 out of 8 points 30min after block completion. Thirty minutes after block completion, obese patients had a higher failure rate of 33.7% (34/101) compared with 17.8% (24/135) for non-obese patients, with a failure rate difference (95%CI) of 15.9% (6.4-27.1%) between the groups. The median (IQR [range]) time to achieve a successful block in obese patients was 25 (20-30 [5-30]) min, compared with non-obese patients at 20 (15-30 [5-30]) min (p=0.003). Despite a higher sensory-motor failure rate as per the composite score, the axillary brachial plexus block provided adequate surgical anaesthesia as indicated by a low need for conversion to general anaesthetic in obese (8.6%) and non-obese patients (7.0%; p=0.656). This study showed that despite ultrasound guidance, obese patients had a slower onset time and higher axillary brachial plexus block failure rate at 30min compared with non-obese patients.

Color Doppler Ultrasound-guided Axillary Brachial Plexus Block in Patient without Brachial Pulse: A Case Report

Color Doppler ultrasound-guided regional block like brachial plexus block lately changed other anesthesia and analgesia practice because of the accuracy and simplicity of practice to view the anatomy of blood vessels and nerves. With color Doppler ultrasound-guided regional block you can follow needle track to nerves and prevent any vessel puncture. It can be the standard for any regional block. The patient was a 64 years Iranian who had diabetes mellitus and hypertension and planned as an urgent right upper limb amputation surgery. Because of the acute exacerbation of COPD due to pneumonia we decided to use regional anesthesia for this patient. On the first physical examination there was no peripheral pulse in patient’s right hand. With ultra-sonographic color Doppler the pulselessness of right hand artery were monitored. With the anatomic and awareness of grey-scaled ultrasonography the nerves and vessels were found. Axillary brachial plexus block with guidance of grey-scaled ultrasonography were done and the surgery was successfully performed and patient transferred to ICU for post operation care after surgery.

Ultrasound-Guided Axillary Brachial Plexus Block Performed by OIrthopedic Surgeon for Distal Radius Fracture Surgery

Ultrasound-Guided Axillary Brachial Plexus Block Performed by OIrthopedic Surgeon for Distal Radius Fracture Surgery