A Quick Guide: Ultrasound Guided Nerve Blocks

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Vol 2 | Issue 1 | January-June 2021 | Page 02-03 | Vrushali Ponde, Kapil Gupta, Neha Singh

DOI: 10.13107/ijra.2021.v02i01.016

Authors: Vrushali Ponde [1], Kapil Gupta [2], Neha Singh [3]

[1] National President and Ex founder secretary, Academy of Regional Anaesthesia, India.
[2] Department of Anaesthesia, V.M.M.C & Safdarjung Hospital, New Delhi, India.
[3] Department of Anaesthesia, AIIMS, Bhubaneshwar, Odisha, India.

Address of Correspondence
Dr. Vrushali Ponde,
National President and Ex founder secretary, Academy of Regional Anaesthesia, India.
E-mail: vrushaliponde@gmail.com

Ultrasound Machine and Image Acquisition Scanning Preparation
1. Obtain written informed consent for the block- AORA Written Consent Form
2. Re-examine the patient before administering the block
3. Checklist ticked before the block –(anaesthesiologist and nurse to be present)

AORA Checklist
– Ensure we have correct patient/block and marked site/side of block
– Check Documents and Equipment before initiating the procedure
– I.V cannula secured before performing the block
-Minimum ASA standard monitoring (pulse oxymeter, NIBP, ECG) started

4. Ergonomics- Ultrasound machine should be in direct line of sight of the anaesthesiologist performing the block
5. Selection of Pre-Set in certain machines to better visualize that structure (eg: Nerves/ Musculoskeletal/Vascular)
6. Probe selection – High frequency probe (13-6 MHz) for superficial nerves/structures and Low frequency probe (5-2 MHz) for deeper nerves/structures and neuraxial blocks
7. Tegaderm, Cling Wrap or Camera Cover wrapped around the probe for sterility
8. Oxygen administration via ventimask /nasal prongs
9. I.V. sedation like Midazolam /Fentanyl I.V. before initiating the block, but after finishing timeout/checklist
10. Maintenance of strict asepsis during the block procedure- AORA Sterility Precautions
11. Skin infiltration with 1% Lignocaine 1 min before inserting the needle; at the site of needle entry
12. Probe holding: Pen holding method is preferable for most blocks
13. At end of procedure- probe should be cleaned with Soap and water

Image Optimisation
The following movements of the probe can be utilized for optimization of image:
Transducer Movements:
1. Sliding
2. Tilting
3. Rocking
4. Rotation
5. Compression

Needle Approaches
In Plane- Whole length of the needle is visualized
Out of Plane- Only needle tip is visualized

Clinical Pearls
1. Optimize the image by setting the appropriate focus, depth and gain
2. Focus the target in centre of the screen
3. Ensure that the skin sterilizing solution has dried, before inserting the needle for block, as contact of sterilizing solution with the nerve can lead to nerve injury (neuropraxia /neurotemesis /axonotemesis)
4. Incremental injection of Local Anaesthetic in 2-3 ml aliquots after repeated aspiration
5. Stop administration of perineural drug, if the patient complains of pain during injection; as it can be a feature of intraneural injection of drug and lead to nerve injury
6. When using peripheral nerve stimulator, never inject the drug, if muscle contraction occurs at current less than 0.3 MA; as it can be a feature of intraneural (intrafascicular) administration of drug and cause nerve injury
7. Scan with the Colour Doppler while doing Brachial Plexus Block (especially Interscalene and Infraclavicular blocks); to avoid inadvertent intravascular injection
These practical tips decrease the potential complications, making ultrasound guided regional anaesthesia a safer technique. Acquisition of a better image improves the success rate of the block.

From the protocols and guidelines committee of AORA

Dr. Kapil Gupta
Professor, Anesthesiology,
V.M.M.C & Safdarjung Hospital, New Delhi, India.

Dr. Neha Singh
Additional Professor, Anesthesiology,
AIIMS, Bhubaneshwar, Odisha, India.

How to Cite this Article: Ponde V, Gupta K, Singh N | A Quick Guide: Ultrasound-Guided Nerve Blocks | International Journal of Regional Anaesthesia | January-April 2021; 2(1): 02-03.

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Abdominal Wall Blocks in Abdominal Surgery: An Update

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Vol 2 | Issue 1 | January-June 2021 | Page 47-53 | TVS Gopal, Amjad Maniar, Arunangshu Chakraborty,
Rammurthy Kulkarni

Authors:  TVS Gopal [1], Amjad Maniar [2], Arunangshu Chakraborty [3], Rammurthy Kulkarni [2]

[1] Department of Anaesthesia, Care Hospitals, Banjara Hills, Hyderabad, Andhra Pradesh, India.
[2] Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, India.
[3] Department of Anaesthesia, Tata Medical Center, Kolkata, India.

Address of Correspondence
Dr. TVS Gopal,
Clinical Director, Care Hospitals, Banjara Hills, Hyderabad, Andhra Pradesh, India.
E-mail: tvsgopal@gmail.com

Abstract

Abdominal wall blocks provide an alternative to the gold standard, epidural analgesia, as a part of a multimodal analgesic regime for pain relief following a variety of abdominal surgeries. The ubiquitous availability of ultrasound and the paradigm shift to deposition of local anaesthetic into interfascial planes popularized abdominal wall blocks. Over the years, a better understanding of cadaveric, clinical sonoanatomy, and techniques have emerged. However, with certain abdominal wall blocks, the spread of local anaesthetic is neither consistent nor predictable. This concise update presents details pertaining to ultrasound-guided abdominal wall blocks.

References

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2. Schliech D. Schmerzlose Operationen. In Springer Verlag; 1899.p.240-58 (4th edition)
3. Thomas H Seldon. Regional anesthesia for surgery of the thorax and abdominal wall. Section on Anesthesia 1941, Mayo Clinic, Rochester, Minnesota; Vol.2.
4. Rafi AN. Abdominal field block ; a new approach via the lumbar triangle. Anaesthesia 2001; 56(10) : 1024-6.
5. Mc Donnell JG, O’Donnell BD, Farrell T et al. Transversus abdominis plane block ; a cadaver and radiological evaluation. Reg Anesth Pain med.2001; 32 ;399-404.
6. Hebbard P, Fujiwara Y, Shibata Y, Royse C. ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive care 2007 Aug; 35(4) : 616-7.
7. Ki Jinn Chin, John G McDonnell, Brendan Carvalho et al. essentials of our current understanding : abdominal wall blocks. Reg Anesth Pain Med 2017; 42 : 133-183.
8. DN Onwochei, J Borglum, A Pawa. Abdominal wall blocks for intra-abdominal surgery. BJA Education 2018; Vol.18, No.10.
9. FH Willard, A Vleeming, MD Schuenke et al. the thoracolumbar fascia : anatomy, function and clinical considerations. Journal of Anatomy 2012; 221(6) : 507-536.
10. Ferguson S, Thomas V, Lewis I. the rectus sheath block in pediatric anaesthesia : new indications for an old technique ? Pediatric Anesthesia 1996 Dec; 6(6) : 463-6.
11. Melesse DY, Chekol WB, Tawuye HY, Denu ZA et al. Assessment of the analgesic effectiveness of rectus sheath block in patients who had an emergency midline laparotomy : prospective observational cohort study. International Journal of Surgery open 2020; 24 :27-31.
12. Lee THW, Barrington MJ, Tran TNM, Wong D, Hebbard P. Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block. Anaesthesia and Intensive care 2010 May; 38(3): 452-460.
13. Yoshiyoma S, Ueshima H, Sakai R, Otake H. A posterior TAP block provides more effective analgesia than a lateral TAP block in patients undergoing laparoscopic gynaecologic surgery : a retrospective study. Anesthesiology Research and Practice 2016; 2016 :1-5.
14. Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesthesia and Analgesia 2008; 106(2).
15. Klaassen Z, Marshall E, Tubbs RS, Louis RGJ et al. Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat. 2011 May; 24(4) : 454-61.
16. Hebbard P. Transversalis fascia plane block, a novel ultrasound guided abdominal wall nerve block. Can J Anesth. 2009 Aug; 56(8) :618-20.
17. Hesham Elsharkawy, Kariem El-Boghdadly, Michael Barrington. Quadratus lumborum block : anatomical concepts, mechanisms and techniques. Anesthesiology Feb 2019; Vol.130, No.2.
18. Sauter AR, Ullensvang K, Niemi G, Lorentzen HT, Bensten TF, Borglum J. The shamrock lumbar plexus block : a dose finding study. Eur J Anaesthesiol 2015; 32 : 764-70.
19. Murouchi T. Quadratus lumborum block intramuscular approach for pediatric surgery. Acta Anesthesiologica Taiwanica 2016.
20. TVS Gopal. Ultrasound guided transmuscular quadratus lumborum plane catheters : in the plane or out of it ? Editorial- Indian J Anaesth 2019; 63 :609-10.
21. Diwan S, Kulkarni M, Kulkarni N, Nair A. A radiological inquest to determine the destiny of ultrasound guided transmuscular quadratus lumborum plane catheters. Indian J Anaesth 2019; 63 : 667-70.
22. Lancaster P, Chadwick M. Liver trauma secondary to ultrasound-guided transversus abdominis plane block. Br J Anaesth. 2010 Apr;104(4):509–10.
23. Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block. Reg Anesth Pain Med. 2008 Jun;33(3):274–5.
24. Frigon C, Mai R, Valois-Gomez T, Desparmet J. Bowel hematoma following an iliohypogastric-ilioinguinal nerve block. Paediatr Anaesth. 2006 Sep;16(9):993–6.
25. Yuen PM, Ng PS. Retroperitoneal hematoma after a rectus sheath block. J Am Assoc Gynecol Laparosc. 2004 Nov;11(4):448.
26. Griffiths JD, Barron FA, Grant S, Bjorksten AR, Hebbard P, Royse CF. Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block. Br J Anaesth. 2010 Dec;105(6):853–6.
27. Hessian EC, Evans BE, Woods JA, Taylor DJ, Kinkel E, Bjorksten AR. Plasma ropivacaine concentrations during bilateral transversus abdominis plane infusions. British Journal of Anaesthesia. 2013 Sep 1;111(3):488–95.
28. Shivashanmugam T, Kundra P, Sudhakar S. Iliac compartment block following ilioinguinal iliohypogastric nerve block. Paediatr Anaesth. 2006 Oct;16(10):1084–6.
29. Ghani KR, McMillan R, Paterson-Brown S. Transient femoral nerve palsy following ilio-inguinal nerve blockade for day case inguinal hernia repair. J R Coll Surg Edinb. 2002 Aug;47(4):626–9.
30. Manatakis DK, Stamos N, Agalianos C, Karvelis MA, Gkiaourakis M, Davides D. Transient femoral nerve palsy complicating “blind” transversus abdominis plane block. Case reports in anesthesiology. 2013;2013:874215.
31. Quek KHY, Phua DSK. Bilateral rectus sheath blocks as the single anaesthetic technique for an open infraumbilical hernia repair. Singapore Med J. 2014 Mar;55(3):e39-41.
32. Rajwani KM, Butler S, Mahomed A. In children undergoing umbilical hernia repair is rectus sheath block effective at reducing post-operative pain? Best evidence topic (bet). International Journal of Surgery. 2014;12(12):1452–5.
33. Tudor ECG, Yang W, Brown R, Mackey PM. Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery. Ann R Coll Surg Engl. 2015 Oct;97(7):530–3.
34. Godden AR, Marshall MJ, Grice AS, Daniels IR. Ultrasonography guided rectus sheath catheters versus epidural analgesia for open colorectal cancer surgery in a single centre. Ann R Coll Surg Engl. 2013 Nov;95(8):591–4.
35. Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The Analgesic Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block in Adult Patients: A Meta-Analysis. Anesthesia & Analgesia. 2015 Dec;121(6):1640–54.
36. De Oliveira GS, Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus Abdominis Plane Block to Ameliorate Postoperative Pain Outcomes After Laparoscopic Surgery: A Meta-Analysis of Randomized Controlled Trials. Anesthesia & Analgesia. 2014 Feb;118(2):454–63.
37. Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anesth/J Can Anesth. 2012 Aug;59(8):766–78.
38. Hannallah RS, Broadman LM, Belman AB, Abramowitz MD, Epstein BS. Comparison of caudal and ilioinguinal/iliohypogastric nerve blocks for control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology. 1987 Jun;66(6):832–4.
39. Markham SJ, Tomlinson J, Hain WR. Ilioinguinal nerve block in children. A comparison with caudal block for intra and postoperative analgesia. Anaesthesia. 1986 Nov;41(11):1098–103.
40. Reid MF, Harris R, Phillips PD, Barker I, Pereira NH, Bennett NR. Day-case herniotomy in children. A comparison of ilio-inguinal nerve block and wound infiltration for postoperative analgesia. Anaesthesia. 1987 Jun;42(6):658–61.
41. Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015 Nov;32(11):812–8.
42. Mieszkowski MM, Mayzner-Zawadzka E, Tuyakov B, Mieszkowska M, Żukowski M, Waśniewski T, et al. Evaluation of the effectiveness of the Quadratus Lumborum Block type I using ropivacaine in postoperative analgesia after a cesarean section – a controlled clinical study. Ginekol Pol. 2018;89(2):89–96.
43. Ishio J, Komasawa N, Kido H, Minami T. Evaluation of ultrasound-guided posterior quadratus lumborum block for postoperative analgesia after laparoscopic gynecologic surgery. J Clin Anesth. 2017 Sep;41:1–4.
44. Öksüz G, Bilal B, Gürkan Y, Urfalioğlu A, Arslan M, Gişi G, et al. Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Children Undergoing Low Abdominal Surgery: <em>A Randomized Controlled Trial</em>. Reg Anesth Pain Med. 2017 Sep 1;42(5):674..
45. Aditianingsih D, Pryambodho, Anasy N, Tantri AR, Mochtar CA. A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy. BMC Anesthesiology. 2019 Dec 5;19(1):221.

How to Cite this Article: Gopal TVS, Maniar A, Chakraborty A, Kulkarni R | Abdominal Wall
Blocks in Abdominal Surgery: An Update | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 47-53.

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“Coming Together is a Beginning; Keeping Together is Progress; Working Together is Success”……Henry Ford

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Vol 2 | Issue 1 | January-June 2021 | Page 01 | Vrushali Ponde

DOI: 10.13107/ijra.2021.v02i01.015

Authors: Vrushali Ponde [1]

[1] National President and Ex founder secretary Academy of Regional Anaesthesia, India.

Address of Correspondence

Dr. Vrushali Ponde,
National President and Ex founder secretary
Academy of Regional Anaesthesia, India.
E-mail: vrushaliponde@gmail.com

“Team AORA” has come a long way in learning, teaching and researching and innovating regional anaesthesia. From hands-on workshops to full-fledge post-doctoral fellowships of a year’s duration looks like a joyous journey done together.
As I write this, the enthusiasm towards honing skills in regional anaesthesia, RA, is palpable. Even in the most trying times of the current pandemic scenario’s, RA stood to its promise of safety. Not just towards the patients, on this occasion, the safety of the personal in the operation theatres too. Such is the scope and play of this subject.
I take this opportunity to present to you the various protocols and simple practical clinical pearls charted out by the AORA committee of protocols and guidelines. These are done considering the uniqueness of Indian work culture and practices. This can be looked into as a bridge between the most ideal and yet practically implementable work patterns. (Annexure 1, 2 and 3)
I submit my heartfelt thanks to our editor in chief, Dr Sandeep Diwan, to have taken the initiative of embarking on and continuing with the International Journal of Regional Anaesthesia, the official publication of AORA, India.

How to Cite this Article: Ponde V | Coming Together is a Beginning; Keeping Together is Progress; Working Together is Success”……Henry Ford | International Journal of Regional Anaesthesia | January-April 2021; 2(1): 01.

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Sterility Protocols During Regional Anaesthesia: An AORA Initiative

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Vol 2 | Issue 1 | January-June 2021 | Page 05-12 | Rammurthy Kulkarni, Amjad Maniar, Neha Singh, Vrushali Ponde, Kapil Gupta, Mohammad Azam Danish, Ritesh Roy, Archana Areti

Authors: Rammurthy Kulkarni [1], Amjad Maniar [1], Neha Singh [6], Vrushali Ponde [4], Kapil Gupta [3], Mohammad Azam Danish [5], Ritesh Roy [2], Archana Areti [7]

[1] Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, Karnataka, India.
[2] Department of Anaesthesia, AIIMS, Bhubhaneshwar, Odisha, India.
[3] Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
[4] Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India.
[5] Department of Anaesthesia, B. M. Jain Hospital, Bengaluru, Karnataka, India.
[6] Associate Clinical Director and HOD, Care Hospitals, Bhubaneshwar, Odisha, India.
[7] Department of Anaesthesia, Mahatma Gandhi Medical College Research Institute Puducherry, India.

Address of Correspondence
Dr. Vrushali Ponde, Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
E-mail: vrushaliponde@gmail.com

Introduction

The frequency of infection following peripheral nerve block (PNB) is not very clear. The major reason for the paucity of literature is under-reporting of infectious complications. Though rare, the infectious complications associated with peripheral nerve blocks can be devastating and occasionally fatal.1 One case of necrotising fasciitis following an axillary approach to brachial plexus blockade for carpal tunnel release has been reported where the PNB was directly attributed to the infection. With the increase in the number of peripheral nerve block procedures being performed (both single injection and continuous techniques), it is expected that the infectious complication rate may also increase.
There is no uniform consensus amongst anaesthesiologists across the globe regarding the appropriate sterile technique that should be practised during the administration of regional anaesthesia. In a UK and Ireland based survey of obstetric anaesthesiologists, only half of the responders wore a face mask for both neuraxial (spinal and epidural) techniques. One-third of those who did not wear a mask believed that the mask actually increased the risk of infection.2 It can be easily assumed that a similar attitude is present while performing PNBs.
The aseptic chain starts right from hand washing and ends after the block needle has been taken out from the patient’s body (in a single injection technique) or till the perineural catheter is completely removed (in a continuous technique). Any breach in this chain may increase the chances of introducing infection.

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50. BURSTAL R, WEGENER F, HAYES C, LANTRY G. Subcutaneous Tunnelling of Epidural Catheters for Postoperative Analgesia to Prevent Accidental Dislodgement: A Randomized Controlled Trial. Anaesth Intens Care 1998; 26: 147-151.
51. Bougher RJ, Corbett AR, Ramage DTO. The effect of tunnelling on epidural catheter migration. Anaesthesia. 1996; 51: 191-194.
52. Sellmann T, Bierfischer V, Schmitz A, Weiss M, Rabenalt S, MacKenzie C, et al. Tunneling and Suture of Thoracic Epidural Catheters Decrease the Incidence of Catheter Dislodgement. The Scientific World Journal Volume 2014, Article ID 610635, 9 pages.
53. Byrne KPA, Freeman VY. Force of removal for untunnelled, tunnelled and double-tunnelled peripheral nerve catheters. Anaesthesia. 2014; 69: 245–248.
54. Bomberg H, Kubulus C, Herberger S, Wagenpfeil S, Kessler P, Steinfeldt T, et al. Tunnelling of thoracic epidural catheters is associated with fewer catheter-related infections: a retrospective registry analysis. British Journal of Anaesthesia. 2016; 116 (4): 546–53.
55. Compe`re V, Legrand JF, Guitard PG, Azougagh K, Baert O, Ouennich A, et al. Bacterial Colonization After Tunneling in 402 Perineural Catheters: A Prospective Study. Anesth Analg 2009; 108: 1326–30.
56. MANN TJ, ORLIKOWSKI CE, GURRIN LC, KEIL AD. The Effect of the Biopatch, a Chlorhexidine Impregnated Dressing, on Bacterial Colonization of Epidural Catheter Exit Sites. Anaesth Intensive Care 2001; 29: 600-603.
57. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. Journal of Antimicrobial Chemotherapy. 2006; 58: 281–287.
58. Kerwat K, Eberhart L, Kerwat M, Hörth D, Wulf H, Steinfeldt T, et al. Chlorhexidine Gluconate Dressings Reduce Bacterial Colonization Rates in Epidural and Peripheral Regional Catheters. BioMed Research International Volume 2015, Article ID 149785, 5 pages http://dx.doi.org/10.1155/2015/149785.
59. Schroeder KM, Jacobs RA, Guite C, Gassner K, Anderson B, Donnelly MJ. Use of a chlorhexidine-impregnated patch does not decrease the incidence of bacterial colonization of femoral nerve catheters: a randomized trial. Can J Anesth. 2012; 59: 950–957.
60. Bomberg H, Krotten D, Kubulus C, Wagenpfeil S, Kessler P, Steinfeldt T, et al. Single-dose Antibiotic Prophylaxis in Regional Anesthesia. Anesthesiology 2016; 125:505-15.

How to Cite this Article: Kulkarni R, Maniar A, Singh N, Ponde V, Gupta K, Danish MA, Roy R, Areti A | Sterility Protocols During Regional Anaesthesia: An AORA Initiative | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 05-12.

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Landmark and PNS Guided Forearm Blocks

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Vol 2 | Issue 1 | January-June 2021 | Page 67-71 | Surajit Giri

Authors: Surajit Giri [1]

[1] Department of Anaesthesia, Pragati Hospital & Research Centre, Sivasagar, Assam.

Address of Correspondence
Dr. Surajit Giri,
Department of Anaesthesia, Pragati Hospital & Research Centre, Sivasagar, Assam.
E-mail: drsurajit_1234@yahoo.com

Introduction

Elbow block is used to provide anaesthesia and analgesia for hand and forearm surgery [1]. Primarily it is used to supplement or augment a proximal brachial plexus block if it is partial or patchy. Therefore elbow block is termed as rescue block by many Anaesthesiologists. In recent years, Ultrasonography(USG) guided distal blocks are studied with proximal brachial plexus block to accelerates anaesthesia onset time and block consistency for forearm surgeries [2]. Good anatomical knowledge of forearm nerves (Fig A) is utmost mandatory to use elbow block as a primary anaesthetic technique for forearm and hand surgeries [3, 4].

References

1. Maga JM, Cooper L, Gebhard RE. Outpatient regional anaesthesia for upper extremity surgery update (2005 to present) distal to shoulder. Int Anaesthesia Clin 2012;50:47-55.
2. Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: Evidence-based indications. Curr Opin Anaesthesiology 2013;26:467-74.
3. Fredrickson MJ, Ting FS, Chinchanwala S, Boland MR. Concomitant infraclavicular plus distal median, radial, and ulnar nerve blockade accelerates upper extremity anaesthesia and improves block consistency compared with infraclavicular block alone. Br J Anaesth 2011;107:236-42.
4. Stranding S, editor. Upper arm. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. London: Churchill Livingstone; 2016. p. 837-61.
5. Gisela Meier,Johannes Buettner.Atlas of Peripheral Regional Anaesthesia: Anatomy & Technique.3rd edition.Thieme;2013.p.244-63.
6. Sehmbi H, Madjdpour C, Shah UJ, Chin KJ. Ultrasound guided distal peripheral nerve block of the upper limb: A technical review. J Anaesthesiol Clin Pharmacol 2015;31:296-307.
7. Fredrickson MJ, Price DJ. Analgesic effectiveness of ropivacaine 0.2% vs 0.4% via an ultrasound-guided C5-6 root/superior trunk perineural ambulatory catheter. Br J Anaesth 2009;103:434-9.
8. RA McCahon, NM Bedforth. Peripheral nerve block at the elbow and wrist. Continuing Education in Anaesthesia, Critical Care & Pain 2007; 7:42-44.

How to Cite this Article: Giri S | Landmark and PNS Guided Forearm Blocks | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 67-71.

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Block Efficacy Above the Clavicle: Volume of Local Anaesthetic Agents

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Vol 2 | Issue 1 | January-June 2021 | Page 35-39 | T. Sivashanmugam, Archana Areti

Authors: T. Sivashanmugamb [1], Archana Areti [1]

[1] Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute,
Sri Balaji Vidyapeeth Deemed-to-be University, Puducherry, India.

Address of Correspondence

Dr. T. Sivashanmugam,
Professor, Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute,
Sri Balaji Vidyapeeth Deemed-to-be University, Puducherry, India.

E-mail: drsiva95@gmail.com

Introduction

The regional anaesthesiologist’s primary goal is to deposit adequate local anaesthetic (LA) in the vicinity of nerves for the desired effect without complications. Our inability to visualise nerves, during landmark and peripheral nerve stimulation techniques, was the biggest obstacle against accurate deposition. Ultrasound (US) guidance enables accurate deposition of local anaesthetics due to objective and consistent visualisation of target nerves [1]. However, the minimum effective local anaesthetic volume (MELAV) varies among clinicians. Stephan Kapral in 1994 described the first ultrasound-guided supraclavicular brachial plexus block [2]. However, the image quality and the injection technique similar to our present-day practice appeared in 2003, where Vincent Chan et al injected 40 ml of local anaesthetic (LA) volume to achieve a 95% success rate [3]. This article reviews the studies that explored the MELAV for US-guided brachial plexus blocks (BPB) above the clavicle and explores the possible reasons for variations reported by authors and to direct future research for identification of safe and effective local anaesthetic volume for the BPB above the clavicle.

References

1. Karmakar MK, Pakpirom J, Songthamwat B, Areeruk P. High definition ultrasound imaging of the individual elements of the brachial plexus above the clavicle. Regional Anesthesia & Pain Medicine. 2020 May;45(5):344–50.
2. Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-Guided Supraclavicular Approach for Regional Anesthesia of the Brachial Plexus: Anesthesia & Analgesia. 1994 Mar;78(3):507-513.
3. Chan VWS, Perlas A, Rawson R, Odukoya O. Ultrasound-Guided Supraclavicular Brachial Plexus Block: Anesthesia & Analgesia. 2003 Nov;1514–7.
4. Saranteas T, Finlayson RJ, Tran DQH. Dose-Finding Methodology for Peripheral Nerve Blocks: Regional Anesthesia and Pain Medicine. 2014;39(6):550–5.
5. Strichartz GR, Pastijn E, Sugimoto K. Neural physiology and local anesthetic action. In: Cousins MJ, Carr DB, Horlocker TT, Bridenbaugh PO, editors. Cousins and Bridenbaugh’s Neural Blockade in Clinical Anaesthesia and Pain Medicine. 4th ed. Lippincott Williams & Wilkins; 2012. 41–43 p.
6. Berthold CH, Martin R, Waxman SG, Kocsis JD, Stys PK. Morphology of normal peripheral axons. In: The Axon [Internet]. Oxford University Press; 1995 [cited 2021 Jan 15]. 22–4 p. Available from: http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780195082937.001.0001/acprof-9780195082937
7. Tran DQH, Dugani S, Correa JA, Dyachenko A, Alsenosy N, Finlayson RJ. Minimum Effective Volume of Lidocaine for Ultrasound-Guided Supraclavicular Block: Regional Anesthesia and Pain Medicine. 2011 Sep;36(5):466–9.
8. Prateek P. Estimation of Minimum Effective Volume of Ropivacaine 0.5% in Ultrasound Guided Supraclavicular Brachial Plexus Nerve Block: A Prospective Clinical Trial. Journal of Anesthesia & Intensive Care Medicine [Internet]. 2018 Feb 27 [cited 2021 Jan 11];5(5). Available from: https://juniperpublishers.com/jaicm/JAICM.MS.ID.555671.php
9. Gupta PK, Hopkins PM. Effect of concentration of local anaesthetic solution on the ED 50 of bupivacaine for supraclavicular brachial plexus block † †Preliminary data from this study were presented to a meeting of Anaesthetic research society and European Society of Regional Anaesthesia. British Journal of Anaesthesia. 2013 Aug;111(2):293–6.
10. Raymond SA, Scott c.Steffensen, Laverne D. Gugino, Gary R. Strichartz. The Role of Length of Nerve Exposed to Local Anesthetics in Impulse Blocking Action. Anesthesia & Analgesia. 1989;(68):563–70.
11. Duggan E, El Beheiry H, Perlas A, Lupu M, Nuica A, Chan VWS, et al. Minimum Effective Volume of Local Anesthetic for Ultrasound-Guided Supraclavicular Brachial Plexus Block: Regional Anesthesia and Pain Medicine. 2009 May;34(3):215–8.
12. Song JG, Jeon DG, Kang BJ, Park KK. Minimum effective volume of mepivacaine for ultrasound-guided supraclavicular block. Korean Journal of Anesthesiology. 2013;65(1):37.
13. Sivashanmugam T, Ray S, Ravishankar M, Jaya V, Selvam E, Karmakar MK. Randomized Comparison of Extrafascial Versus Subfascial Injection of Local Anesthetic During Ultrasound-Guided Supraclavicular Brachial Plexus Block: Regional Anesthesia and Pain Medicine. 2015;40(4):337–43.
14. Sivashanmugam T, R Sripriya, J Gobinath, R Charulatha, M Ravishankar. Truncal injection brachial plexus block: A Description of a novel injection technique and dose finding study. Indian Journal of Anaesthesia. 2020;64(5):415–21.
15. Fredrickson MJ, Smith KR, Wong AC. Importance of Volume and Concentration for Ropivacaine Interscalene Block in Preventing Recovery Room Pain and Minimizing Motor Block after Shoulder Surgery. Anesthesiology. 2010 Jun 1;112(6):1374–81.
16. Bonnel F. Microscopic anatomy of the adult human brachial plexus: An anatomical and histological basis for microsurgery. Microsurgery. 1984;5(3):107–17.
17. Moayeri N, Bigeleisen PE, Groen GJ. Quantitative Architecture of the Brachial Plexus and Surrounding Compartments, and Their Possible Significance for Plexus Blocks. Anesthesiology. 2008 Feb 1;108(2):299–304.
18. Pavičić Šarić J, Vidjak V, Tomulić K, Zenko J. Effects of age on minimum effective volume of local anesthetic for ultrasound-guided supraclavicular brachial plexus block: Brachial plexus block in the elderly. Acta Anaesthesiologica Scandinavica. 2013 Jul;57(6):761–6.
19. Gautier P, Vandepitte C, Ramquet C, DeCoopman M, Xu D, Hadzic A. The Minimum Effective Anesthetic Volume of 0.75% Ropivacaine in Ultrasound-Guided Interscalene Brachial Plexus Block: Anesthesia & Analgesia. 2011 Oct;113(4):951–5.
20. Falcão LFR, Perez MV, de Castro I, Yamashita AM, Tardelli MA, Amaral JLG. Minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasound-guided interscalene brachial plexus block. British Journal of Anaesthesia. 2013 Mar;110(3):450–5.
21. Choi S, Wang JJ, Awad IT, McHardy P, Safa B, McCartney CJ. The minimal effective volume (MEAV 95) for interscalene brachial plexus block for surgical anesthesia under sedation: A prospective observational dose finding study. Canadian Journal of Pain. 2017 Jan 1;1(1):8–13.

How to Cite this Article: Sivashanmugam | Block Efficacy Above the Clavicle: Volume of Local Anaesthetic Agents | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 35-39.

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Anatomy of Brachial Plexus Above The Clavicle

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Vol 2 | Issue 1 | January-June 2021 | Page 29-34 | Shivaprakash S, Georg Feigl, Sandeep M. Diwan

Authors: Shivaprakash S [1], Georg Feigl [2], Sandeep M. Diwan [3]

[1] Department of Anatomy, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India.
[2] Private Universitat Witten/Herdecke gGmbH Alfred-Herrhausen-StraBe 50, D-58448 Witten.
[3] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Sandeep Diwan,
Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.
E-mail: sdiwan14@gmail.com

Introduction

The neck is a compact structure which hosts the aero-digestive and neurovascular structures. Nerve roots arising from the spinal cord form an important network of nerves the ‘Brachial Plexus (BP)’ that innervates the upper limb and lies partly in the posterior triangle of neck and partly in the axilla. The BP is complex matrix sandwiched between muscles proximally and muscles and vessels distally at and above the level of clavicle. It consists of roots, trunks, cords & branches (figure 1). Roots and trunks are supraclavicular, divisions are retro clavicular, cords and their branches are infraclavicular. The position of the plexus relative to the clavicle varies, it is higher in the erect position and lower when recumbent [1]. It is broad and presents little of a plexiform arrangement at its commencement, is narrow opposite the clavicle, divides opposite the coracoid process into numerous branches and becomes broad and forms a denser interlacement in the axilla [2]. Brachial plexus is formed by the ventral rami of lower four cervical nerves and the first thoracic spinal nerves with variable contribution (slender twigs) from the fourth cervical and second thoracic nerve.

References

(1) G.J.Romanes. Cunningham’s Manual of Practical Anatomy, vol 3. 15th ed.Oxford.Oxford university press;2014.Side of the Neck; 26-8.
(2) Henry Gray F.R.S. Gray’s Anatomy: Descriptive and Surgical. London. Parragon . book;2001( Reprint). Brachial plexus; 521-2.
(3) Lanz T, Wachsmuth W. Praktische Anatomie. Berlin, Heidelberg, New York: Springer, 2004.
(4) Hafferl A. Lehrbuch der topographischen Anatomie. Berlin, Heidelberg, New York : Springer, 1969
(5) Feigl GC, Litz RJ, Marhofer P. Reg Anesth Pain Med 1-8; doi:10.1136/rapm-2020- 101435
(6) Singal , T. Gupta, D. Sahni , A. Aggarwal Anatomy of scalenovertebral triangle: A vade mecum for clinicians Anatomie du triangle scalénovertébral : un vade mecum pour les cliniciens A. Morphologie 2020 104 174-181
(7) Reiner A, Kasser R. Relative frequency of a subclavian vs. a transverse cervical origin for the dorsal scapular artery in humans. Anat Rec 1996;244:265–8.
(8) Murata, Hiroaki Sakai, Akiko ; Hadzic, Admir; Sumikawa, Koji The Presence of Transverse Cervical and Dorsal Scapular Arteries at Three Ultrasound Probe Positions Commonly Used in Supraclavicular Brachial Plexus Blockade; Anesthesia & Analgesia: August 2012 – Volume 115 – Issue 2 – p 470-473,

How to Cite this Article: Shivaprakash S, Feigl G, Diwan SM | Anatomy of Brachial Plexus Above The Clavicle | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 29-34.

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Cadaveric Workshop and Implications in Regional Anaesthesia

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Vol 2 | Issue 1 | January-June 2021 | Page 22-28 | Ramkumar Mirle, Sajana Mukundan

Authors: Ramkumar Mirle [1], Sajana Mukundan [1]

[1] Department of Anaesthesia, Columbia Asia Referral Hospital, Yeshwanthpur, Bangalore, Karnataka, India.

Address of Correspondence
Dr. Ram Kumar M. M,
Consultant Anaesthesiologist, Columbia Asia Referral Hospital, Yeshwanthpur, Bangalore, Karnataka, India.
E-mail: mirleram@gmail.com

Introduction

The human cadavers have always been an immense source of knowledge from time immemorial and have been aptly termed as “Silent teachers” [1]. Cadaver dissection has been the basis of teaching anatomy to aspiring anaesthesiologist to develop their skills in regional anaesthesia. The practice of regional anaesthesia has evolved from the landmark based technique eliciting paraesthesia to peripheral nerve stimulation-guided technique and in the recent times to use of ultrasound guided (USG) technique alone or a combination of (PNS) and USG – Dual Modality. Successful regional nerve block technique can be a combination of any of these techniques with the most reliable modality depending on the expertise of the performer. In order to excel we need to be appropriately trained akin to a real-life scenario. The cadaver workshop has not only facilitated understanding anatomy but also helped in acquiring practical clinical skills.

References

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2. Ghosh SK. Human cadaveric dissection: A historical account from ancient Greece to the modern era. Anat Cell Biol. 2015;48(3):153–69.
3. Bohl M, Bosch P, Hildebrandt S. Medical students’ perceptions of the body donor as a “First Patient” or “Teacher”: A pilot study. Anat Sci Educ. 2011;4(4):208–13.
4. Bharambe V, Puranam V, Manvikar PR, Bajpayee P. Anatomy acts in India: a review. Eur J Anat. 2019;23(6):469–77.
5. Kirchmair L, Entner T, Wissel J, Moriggl B, Kapral S, Mitterschiffthaler G. A study of the paravertebral anatomy for ultrasound-guided posterior lumbar plexus block. Anesth Analg. 2001;93(2):477–81.
6. Wedel DJ. Don’t try this at home! Vol. 91, Anesthesia and analgesia. United States; 2000. p. 771–2.
7. Eisma R, Wilkinson T. From “Silent Teachers” to Models. PLoS Biol. 2014;12(10):1–5.
8. Tsui BCH, Dillane D, Walji AH. Cadaveric ultrasound imaging for training in ultrasound-guided peripheral nerve blocks: Upper extremity. Can J Anesth. 2007;
9. Chuan A, Lim YC, Aneja H, Duce NA, Appleyard R, Forrest K, et al. A randomised controlled trial comparing meat-based with human cadaveric models for teaching ultrasound-guided regional anaesthesia. Anaesthesia. 2016;71(8):921–9.
10. Diwan S, Feigl GESRA19-0487 Cadaveric studies and its impact on regional anaesthesiaRegional Anesthesia & Pain Medicine 2019;44:A60-A62.
11. McDonnell JG, O’Donnell BD, Farrell T, Gough N, Tuite D, Power C, et al. Transversus Abdominis Plane Block: A Cadaveric and Radiological Evaluation. Reg Anesth Pain Med. 2007;32(5):399–404.
12. Tran TMN, Ivanusic JJ, Hebbard P, Barrington MJ. Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: A cadaveric study. Br J Anaesth. 2009;102(1):123–7.
13. Sharma M, Macafee D, Pranesh N, Horgan AF. Construct validity of fresh frozen human cadaver as a training model in minimal access surgery. J Soc Laparoendosc Surg. 2012;16(3):345–52.
14. Munirama S, Eisma R, Columb M, Corner GA, McLeod GA. Physical properties and functional alignment of soft-embalmed Thiel human cadaver when used as a simulator for ultrasound-guided regional anaesthesia. Br J Anaesth. 2016;116(5):699–707.
15. Tsui BCH, Dillane D, Pillay J, Walji A. Ultrasound imaging in cadavers: Training in imaging for regional blockade at the trunk. Can J Anesth. 2008;55(2):105–11.
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18. Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P. Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: A cadaveric study. Anaesthesia. 2009;64(7):745–50.
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20. Carline L, McLeod GA, Lamb C. A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. Br J Anaesth. 2016;117(3):387–94.
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How to Cite this Article: Mirle R, Mukundan S | Cadaveric Workshop and Implications in Regional Anaesthesia | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 22-28.

Acknowledgment: M S Ramaiah Advanced Learning Centre, Bangalore, Karnataka, India.

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