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.
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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.
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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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