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A Clinical Evaluation of Block Characteristics UsingOne Milliliter 2% Lidocaine in Ultrasound-GuidedAxillary Brachial Plexus Block Brian O’Donnell, MB, FCARCSI, MSc, John Riordan, MB, FCARCSI, Ishtiaq Ahmad, MBBS, FCARCSI,and Gabriella Iohom, FCARCSI, MD, PhD We report onset and duration of ultrasound-guided axillary brachial plexus block using 1 mL of2% lidocaine with 1:200,000 epinephrine per nerve (total local anesthetic volume 4 mL). Blockperformance time, block onset time, duration of surgery, and block duration were measured.
Seventeen consecutive patients were recruited. The mean (SD) block performance and onset timeswere 271 (67.9) seconds and 9.7 (3.7) minutes, respectively. Block duration was 160.8 (30.7)minutes. All operations were performed using regional anesthesia alone. The duration of anesthesiaobtained is sufficient for most ambulatory hand surgery. (Anesth Analg 2010;111:808–10) Ultrasound guidance has been integrated into re- WA)witha38-mmhigh-frequency(7–10MHz)lineararray gional anesthesia clinical practice. When compar- transducer (L38). The ultrasound-guided axillary brachial ing ultrasound to nerve stimulator techniques, plexus block was performed as previously described10 by a higher success rates1–3 and shorter onset times3–5 have been single anesthesiologist (BOD) without the supplemental reported. Visualization of needle, nerve, and injectate per- use of nerve stimulation. Once appropriate perineural mits effective peripheral nerve blockade using low local needle placement was visualized, 1 mL of 2% LidoEpi was anesthetic doses.6–9 Our group reported successful injected in 0.2- to 0.3-mL aliquots using a 2.5-mL syringe.
ultrasound-guided axillary block with low-dose local anes- Dynamic needle manipulation during injection facilitated thetic in upper limb trauma surgery.10 In addition, we circumferential perineural injectate placement. Intraneural demonstrated successful ultrasound-guided axillary block injection (evidenced by increase in cross-sectional nerve with 1 mL per nerve of 2% lidocaine with 1:200,000 diameter) and paraesthesia were avoided at all times epinephrine (2% LidoEpi).11 The use of a very low dose of during the block procedure. The median, ulnar, radial, and local anesthetic in peripheral nerve block has been reported musculocutaneous nerves were individually sought and blocked in this order. The block performance time was Our initial low-dose study11 failed to accurately mea- defined as the interval from needle insertion to final sure block duration. We designed a prospective observa- tional study to measure the duration of ultrasound-guidedaxillary brachial plexus block using 1 mL per nerve 2% LidoEpi in patients undergoing upper limb surgery.
An independent assessor evaluated the presence and de-gree of motor and sensory blockade in each nerve territory (Table 1). Sensory and motor functions were simulta- The Cork Teaching Hospitals Research Ethics Committee neously compared in the contralateral limb. Block assess- granted approval for this study. After written informed ment was performed at 5-minute intervals beginning at consent, patients aged 18 to 80 years, ASA grade I to III, completion of the final perineural injection. Block assess- undergoing unilateral upper limb surgery with an expected ment was halted when either surgical anesthesia was duration of Ͻ90 minutes were enrolled in the study.
achieved or 30 minutes had elapsed. Surgical anesthesia Intravenous access was established and standard moni- was defined as a motor score of Յ2, with absent apprecia- toring was attached (noninvasive arterial blood pressure, tion of cold and pinprick sensation. Each nerve was as- electrocardiography, and pulse oximetry). The operative sessed individually. The block onset time was defined as arm was abducted and externally rotated. The elbow was the interval from final perineural injection to attainment of flexed to 90°. Ultrasound examination of the axilla was performed using a SonoSite Titan unit (SonoSite®, Bothell, Block failure was defined as absence of surgical anes- thesia at 30 minutes in Ն1 of the 4 nerve territories. Blockfailure was to be managed by either the performance of a From the Department of Anaesthesia, Cork University Hospital and Univer-sity College Cork, Cork, Ireland.
“rescue block” or conversion to general anesthesia.
Accepted for publication April 27, 2010.
The independent assessor reexamined the blocked limb This study was presented in part at the European Society for Regional every 15 minutes from completion of surgery to block Anaesthesia Annual Meeting, Salzburg, Austria, September 2009.
regression. Because the operative limb was covered in Supported by internal departmental resources.
surgical dressings, assessment of sensory function was Disclosure: The authors report no conflicts of interest.
limited to exposed portions of skin on dorsal and palmar Address correspondence and reprint requests to Dr. Brian O’Donnell, aspects of the fingers. Regression of surgical anesthesia was Department of Anaesthesia, Cork University Hospital, Wilton Rd., Cork, deemed to have occurred once pinprick and cold sensation Ireland. Address e-mail to [email protected]
Copyright 2010 International Anesthesia Research Society September 2010 • Volume 111 • Number 3 Two Percent Lidocaine in Ultrasound-Guided Axillary Block All patients underwent surgery necessitating the placement of an arm tourniquet inflated to 250 mm Hg. The duration of surgery was defined as the time interval from tourniquet All patients received 1 g IV acetaminophen and 75 mg diclofenac sodium during surgery. Postoperative analgesia consisted of oral acetaminophen 1 g 6 hourly and diclofe- nac sodium 75 mg twice daily for 72 hours after surgery.
Oxycodone 5 mg was prescribed for rescue analgesia after Ability to move relevant muscle group against gravity but inability to move againstresistance Summary data were calculated using EpiInfo™ 2002 (Cen- Flicker of movement in relevant muscle group ters for Disease Control and Prevention, Atlanta, GA) statistics software and presented as median (range) ormean (SD) as appropriate.
Seventeen consecutive patients completed the study proto- col (Table 2). There were no block failures and no patients The mean (SD) block duration was 160.8 (30.7) minutes, block onset time was 9.7 (3.7) minutes, and the block performance time was 271 (67.9) seconds (Table 3). Anxio- lytic sedation was requested in 5 of 17 cases. No patients required either a “rescue block” or conversion to general Patients 3–5, 7, 8, 10, 12, 16, and 17 Fasciectomy anesthesia. The block durations for each individual nerve The mean (SD) duration of surgery was 74.6 (33.3) minutes. Tourniquet discomfort was not reported, and rescue opiate analgesics were not required. There were no adverse incidents during the study period, and all patientswere discharged within 24 hours of surgery. No patients Sedation was provided upon patient request using eithermidazolam 2 mg or a propofol infusion, titrated to a Ramsay sedation score of 3 (responsiveness to voice Ultrasound guidance has made the performance of low- dose peripheral nerve block possible. Our initial study of Table 3. Block Onset and Offset Times in Minutes September 2010 • Volume 111 • Number 3 4. Marhofer P, Schrogendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N. Ultrasonographic guidance improves sensoryblock and onset time of three-in-one blocks. Anesth Analg1997;85:854 –7 5. Casati A, Danelli G, Baciarello M, Corradi M, Leone S, Di Cianni S, Fanelli G. A prospective, randomized comparisonbetween ultrasound and nerve stimulation guidance for mul-tiple injection axillary brachial plexus block. Anesthesiology2007;106:992– 6 6. Marhofer P, Schrogendorfer K, Wallner T, Koinig H, Mayer N, Kapral S. Ultrasonographic guidance reduces the amount oflocal anesthetic for 3-in-1 blocks. Reg Anesth Pain Med1998;23:584 – 8 7. Willschke H, Bo¨senberg A, Marhofer P, Johnston S, Kettner S, Eichenberger U, Wanzel O, Kapral S. Ultrasonographic- Figure 1. Box and whisker plot representation of block duration guided ilioinguinal/iliohypogastric nerve block in pediatric achieved with 1 mL per nerve 2% lidocaine with 1:200,000 epineph- anesthesia: what is the optimal volume? Anesth Analg rine in ultrasound-guided axillary block. Values on the vertical axis represent block duration in minutes.
8. Casati A, Baciarello M, Di Cianni S, Danelli G, De Marco G, Leone S, Rossi M, Fanelli G. Effects of ultrasound guidance onthe minimum effective anaesthetic volume required to blockthe femoral nerve. Br J Anaesth 2007;98:823–7 low-dose lidocaine axillary brachial plexus anesthesia10 9. Danelli G, Ghisi D, Fanelli A, Ortu A, Moschini E, Berti M, failed to accurately measure block duration. In this obser- Ziegler S, Fanelli G. The effects of ultrasound guidance andneurostimulation on the minimum effective anesthetic volume vational study, we addressed this by measuring the dura- of 1.5% mepivacaine required to block the sciatic nerve using tion of axillary block in adults undergoing upper limb the subgluteal approach. Anesth Analg 2009;109:1674 – 8 surgery. The observed duration of block was comparable to 10. O’Donnell BD, Ryan H, O’Sullivan O, Iohom G. Ultrasound- previous reports of LidoEpi use15,16 and was sufficient for guided axillary brachial plexus block with 20 milliliters localanesthetic mixture versus general anesthesia for upper limb procedures performed during the study period. A short trauma surgery: an observer-blinded, prospective, random- block duration can be beneficial in the ambulatory setting, ized, controlled trial. Anesth Analg 2009;109:279 – 83 particularly when there are concerns regarding home dis- 11. O’Donnell BD, Iohom G. An estimation of the minimum charge with an insensate limb17 despite evidence to the effective anesthetic volume of 2% lidocaine in ultrasound- contrary.18–20 Our patients did not experience significant guided axillary brachial plexus block. Anesthesiology2009;111:25–9 pain requiring opiate analgesia before hospital discharge, 12. Eichenberger U, Stockli S, Marhofer P, Huber G, Willimann P, and there were no unanticipated readmissions for pain Kettner SC, Pleiner J, Curatolo M, Kapral S. Minimal local anesthetic volume for peripheral nerve block: a new We acknowledge that this study is limited by both its ultrasound-guided, nerve dimension-based model. Reg AnesthPain Med 2009;34:242– 6 size and scope. However, the study addresses an important 13. Marhofer P, Eichenberger U, Stockli S, Huber G, Kapral S, question as to whether the duration of brachial plexus Curatolo M, Kettner S. Ultrasonographic guided axillary anesthesia with 2% LidoEpi is sufficient for ambulatory plexus blocks with low volumes of local anaesthetics: a cross- upper limb surgery. The small number of patients included over volunteer study. Anaesthesia 2010;65:266 –71 14. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled (n ϭ 17) and the superficial nature of the surgical proce- sedation with alphaxalone-alphadolone. BMJ 1974;2:656 –9 dures performed may further limit the external validity of 15. Kaabachi O, Ouezini R, Koubaa W, Ghrab B, Zargouni A, Ben Abdelaziz A. Tramadol as an adjuvant to lidocaine for axillary In summary, the duration of anesthesia resulting from brachial plexus block. Anesth Analg 2009;108:367–70 16. Dogru K, Duygulu F, Yildiz K, Kotanoglu MS, Madenoglu H, ultrasound-guided axillary brachial plexus block with 1 mL Boyaci A. Hemodynamic and blockade effects of high/low of 2% LidoEpi per nerve (4 mL total) was sufficient for our epinephrine doses during axillary brachial plexus blockade patient cohort undergoing soft tissue ambulatory hand with lidocaine 1.5%: a randomized double-blinded study. Reg 17. Klein SM, Evans H, Nielsen KC, Tucker MS, Warner DS, Steele SM. Peripheral nerve block techniques for ambulatory surgery.
1. Williams SR, Chouinard P, Arcand G, Harris P, Ruel M, 18. Klein SM, Pietrobon R, Nielsen KC, Warner DS, Greengrass Boudreault D, Girard F. Ultrasound guidance speeds execution RA, Steele SM. Peripheral nerve blockade with long-acting and improves the quality of supraclavicular block. Anesth local anesthetics: a survey of the Society for Ambulatory 2. Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, Abbas S.
19. Klein SM, Nielsen KC, Greengrass RA, Warner DS, Martin A, Ultrasound guidance improves success rate of axillary brachial Steele SM. Ambulatory discharge after long-acting peripheral plexus block. Can J Anaesth 2007;54:176 – 82 nerve blockade: 2382 blocks with ropivacaine. Anesth Analg 3. Lo N, Brull R, Perlas A, Chan VW, McCartney CJ, Sacco R, El-Beheiry H. Evolution of ultrasound guided axillary brachial 20. Davis WJ, Lennon RL, Wedel DJ. Brachial plexus anesthesia for plexus blockade: retrospective analysis of 662 blocks. Can J outpatient surgical procedures on an upper extremity. Mayo

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