Endpoint for successful, ultrasound-guided infraclavicular brachial plexus block

Lévesque, Simon; Dion, Norbert; Desgagné, Marie-Christine; Morimoto, Maki; Popović, Jovan; Kim, Jung T.; Kiamzon, Harald; Rosenberg, Andrew D.

doi:10.1007/bf03017210

Cited by 16 publications

(10 citation statements)

References 5 publications

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Section: Discussionmentioning

confidence: 99%

“…It has been suggested that injection of local anaesthetic at this point results in a reliable, rapid onset block within minutes [3]. On the other hand, other workers have reported excellent results with the lateral sagittal infraclavicular approach [6], specifically when local anaesthetic is placed deep to the septum posterolateral to the axillary artery [7,8].Block onset time has clinical importance in many settings in that it can influence the feasibility of brachial plexus block (compared with general anaesthesia) as the primary anaesthesia for minor wrist and hand surgery. Therefore, the primary aim of this study was to test the hypothesis that…”

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confidence: 99%

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Speed of onset of ‘corner pocket supraclavicular’ and infraclavicular ultrasound guided brachial plexus block: a randomised observer‐blinded comparison

Fredrickson¹,

Patel²,

Young³

et al. 2009

Anaesthesia

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SummaryThis prospective, randomised, observer blinded study compared the onset time of brachial plexus block using 2% lidocaine 25-30 ml with adrenaline 5 lg.ml )1 into the 'corner pocket' inferolateral ⁄ lateral to the subclavian artery (supraclavicular, n = 30) or to a triple point injection around the axillary artery (infraclavicular, n = 30). Mean (SD) onset time for complete pinprick sensory blockade assessed by a blinded observer in all four distal nerves was similar in both groups: supraclavicular = 22 (9.4) min, infraclavicular = 21 (7.1) min, p = 0.59. Complete sensory blockade in all four nerve territories at 30 min was achieved in 57% in group supraclavicular and 70% in group infraclavicular (p = 0.28). Painless surgery without the requirement for block supplementation was higher in group infraclavicular (28 ⁄ 30, 93%) compared with group supraclavicular (19 ⁄ 30, 67%; p = 0.01). Of the 11 failures in group supraclavicular, nine were due to incomplete ulnar nerve territory anaesthesia. These results do not support the concept of rapid onset successful supraclavicular block via a simple ultrasound-guided local anaesthetic injection inferolateral to the subclavian artery. The widespread availability of portable ultrasound equipment has re-ignited interest in brachial plexus blockade around the level of the clavicle. These blocks are increasingly being used for distal upper extremity surgery as an alternative to general anaesthesia. Compared with the axillary approach, brachial plexus block at the level of the clavicle can anaesthetise all four distal upper extremity nerve territories without the requirement for a separate block of the musculocutaneous nerve. The supraclavicular approach has the additional anatomical advantage of blockade at a level where the brachial plexus elements are tightly grouped, which facilitates a single point injection and is thought to result in a very rapid onset block [1]; the aptly named 'spinal of the arm'. However, prior to the widespread availability of portable ultrasound machines, the popularity of both approaches was limited by reports of pneumothorax [2]. It is believed that the risk of pneumothorax can be reduced through real-time ultrasound imaging of both needle tip and pleura.Recently, a new technique for ultrasound guided supraclavicular block has been described, the so-called 'eight ball corner pocket' technique [3], and promising results have been reported by several workers [4,5]. This technique involves local anaesthetic injection without concomitant nerve stimulation in the pocket bordered inferiorly by the first rib and medially by the subclavian artery. It has been suggested that injection of local anaesthetic at this point results in a reliable, rapid onset block within minutes [3]. On the other hand, other workers have reported excellent results with the lateral sagittal infraclavicular approach [6], specifically when local anaesthetic is placed deep to the septum posterolateral to the axillary artery [7,8].Block onset time has clinical importance in m...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Speed of onset of ‘corner pocket supraclavicular’ and infraclavicular ultrasound guided brachial plexus block: a randomised observer‐blinded comparison

Fredrickson¹,

Patel²,

Young³

et al. 2009

Anaesthesia

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“…The needle was advanced until a fascial click was felt when its tip reached the posterior aspect of the axillary artery (6 o’clock position) which indicated penetration of the septum posterolateral to the artery, confirming a good needle position with a high chance of block success [3, 4]. At this point, local anaesthetic was deposited incrementally each time after a negative aspiration, ensuring a U-shaped distribution of local anaesthetic with anterior displacement of the axillary artery, known as ‘double bubble sign’ [3, 4].…”

Section: Methodsmentioning

confidence: 99%

“…At this point, local anaesthetic was deposited incrementally each time after a negative aspiration, ensuring a U-shaped distribution of local anaesthetic with anterior displacement of the axillary artery, known as ‘double bubble sign’ [3, 4]. …”

Section: Methodsmentioning

confidence: 99%

Posterior parasagittal in-plane ultrasound-guided infraclavicular brachial plexus block–a case series

et al. 2015

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BackgroundThe brachial plexus at the infraclavicular level runs deeper compared to its course proximally, giving rise to impaired needle visualisation due to the steep angle of needle insertion with the current ultrasound-guided approach. A new posterior parasagittal in-plane ultrasound-guided infraclavicular approach was introduced to improve needle visibility. However no further follow up study was done.MethodsWe performed a case series and a cadaveric dissection to assess its feasibility in a single centre, University of Malaya Medical Centre, Kuala Lumpur, Malaysia from November 2012 to October 2013. After obtaining approval from the Medical Ethics Committee, University Malaya Medical Centre, 18 patients undergoing upper limb surgery were prospectively recruited. A cadaveric dissection was also performed. The endpoints of this study were the success rate, performance time, total anaesthesia-related time, quality of anaesthesia and any incidence of complications.ResultsAll patients had 100 % success rate. The imaging time, needling time and performance time were comparable with previously published study. There were no adverse events encountered in this study. The cadaveric dissection revealed a complete spread of methylene blue dye over the brachial plexus.ConclusionThis study demonstrated that the posterior parasagittal in-plane approach is a feasible and reliable technique with high success rate. Future studies shall compare this technique with the conventional lateral parasagittal in-plane approach.Trial registrationClinicalTrials.gov NCT02312453. Registered on 8 December 2014.

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“…4 Despite the ease of the technique, its success rate and fast onset, several concerns remain when performing a single-injection ultrasound-guided ICB. Indeed, the fascial ''click'' described during the block procedure, suggestive of a good-quality block, 5 may also raise some concerns regarding the safety of the technique. Although the exact nature of the anatomic structure(s) responsible for this tactile feeling is not well understood, patients frequently report a transient tingling sensation in the upper extremity, which may be secondary to penetration of the epineurium of the brachial plexus components.…”

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confidence: 99%

Complications of single-injection ultrasound-guided infraclavicular block: a cohort study

Lecours

Lévesque

Dion

et al. 2012

Can J Anesth/J Can Anesth

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Introduction In recent studies on ultrasound-guided infraclavicular block (ICB), the authors have favoured a single injection posterior to the axillary artery rather than multiple injections; however, procedural complications and success rates associated with single-injection ultrasound-guided ICB are not well known. We undertook an observational study to evaluate the success rates of experienced and non-experienced operators performing ICBs and to identify the complications associated with ultrasound-guided single-injection ICB. Methods We conducted an observational cohort study of all ultrasound-guided single-injection ICBs performed over a two-year period (2008)(2009)(2010). We identified the subjects for our study using a local database and excluded patients younger than 18 yr and those who received a continuous ICB. Complications (non-neurological and neurological) and ICB success rates were the primary and secondary end points, respectively. We collected the following data from patients' charts: patient demographics, types of complications and their respective frequencies, and the experience of the clinician performing the ICBs, and we identified potential late complications by telephone interview. Using a seven-point Likert scale, two experts in regional anesthesia evaluated the likelihood of a relationship between the identified neurological signs or symptoms and the ICB. A neurologist then evaluated the complications identified as being potentially related to the ICB. Summary data were collated, and 95% confidence intervals (CI) were calculated. Results We reviewed 627 ICB procedures, and 496 (79%) patients received telephone interviews. Most patients were males who had undergone either plastic or orthopedic surgery. Mepivacaine 1.5% was used in 96% of cases with a median volume of 30 mL [interquartile range [30][31][32][33][34][35][36][37][38]. We identified 131 cases of neurological signs or symptoms. Four cases were retained as possible links to the ICB, but they underwent complete resolution of symptoms at the time of evaluation. Two possible cases of local anesthetic toxicity were observed. There was a 93% success rate (95% CI 91 to 95) and the results were comparable between the experienced and the non-experienced operators (94% vs 93%, respectively).Author contributions All authors contributed substantially to the conception and design of the study, participated in data interpretation, and critically reviewed the manuscript. Myle`ne Lecours, Simon Le´vesque, Nicolas Dion, Marie-Jose´e Nadeau, and Annie Dionne acquired the data. Myle`ne Lecours, Simon Le´vesque, and Alexis F. Turgeon analyzed the data and drafted the manuscript. Discussion We observed few complications associated with a single-injection ultrasound-guided ICB and a high success rate regardless of the operator's expertise. The technique appears to be reliable, easy to perform, and safe. Résumé

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Endpoint for successful, ultrasound-guided infraclavicular brachial plexus block

Cited by 16 publications

References 5 publications

Speed of onset of ‘corner pocket supraclavicular’ and infraclavicular ultrasound guided brachial plexus block: a randomised observer‐blinded comparison

Speed of onset of ‘corner pocket supraclavicular’ and infraclavicular ultrasound guided brachial plexus block: a randomised observer‐blinded comparison

Posterior parasagittal in-plane ultrasound-guided infraclavicular brachial plexus block–a case series

Complications of single-injection ultrasound-guided infraclavicular block: a cohort study

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