A Case Report on Bilateral Ultrasound Guided Brachial Plexus Block in a Paediatric Patient with Unusual Congenital Anomalies
Vol 5 | Issue 2 | July-December 2024 | Page 27-30 | Anupama Triparhi Srikanth, Pooja Patil, Anitha Pramod, Srikanth V
DOI: https://doi.org/10.13107/ijra.2024.v05.i02.104
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2024; The Author(s).
Submitted: February 10-07-2024; Reviewed: 02-08-2024; Accepted: 03-10-2024; Published: 10-12-2024
Authors: Anupama Triparhi Srikanth [1], Pooja Patil [1], Anitha Pramod [1], Srikanth V [1]
[1] Department of Anaesthesiology, Manipal Hospitals, Old airport road, Bangalore, Karnataka, India.
Address of Correspondence
Dr. Pooja Patil
Department of Anaesthesiology, Manipal Hospitals, Old airport road, Bangalore, Karnataka, India.
Email id: patil24992pooja@gmail.com
Abstract
Background: Performing bilateral brachial plexus blocks (BPB) in paediatric patients is a rare practice due to concerns like diaphragmatic paralysis, local anaesthetic systemic toxicity, pneumothorax and hematoma formation. The introduction of ultrasound in regional anaesthesia has revolutionized precision, allowing reduced local anaesthetic doses and increased success rates.
Case Description: We present the case of an 11-year-old male, who underwent uneventful surgical repair for Tetralogy of Fallot at 8 months of age, posted for right index finger pollicization and left-hand distractor frame application. Auscultatory finding of loud S2 and ejection systolic murmur corroborated with echo finding of mild pulmonary regurgitation, intact VSD patch, and good biventricular function. After administering general anaesthesia with controlled ventilation, ultrasound-guided axillary approach bilateral BPB with 11 ml 0.33% Ropivacaine (equal volume mixture of 0.5% and 0.2% Ropivacaine after calculation of maximum allowable dose) was given sequentially on each side with an interval of 2.5 hours. The overall outcome was safe and uneventful.
Discussion: According to the Pediatric Regional Anaesthesia Network, only 3% of all regional anaesthetics (RA) in children involve upper limb blocks. Literature supporting bilateral BPB in children is scarce. RA improves haemodynamic stability, reduces the incidence of postoperative respiratory complications, decreases catecholamine production and the metabolic stress response to surgery and promotes a fast return of gut function and feeding, all of which benefited this child with known cardiac comorbidity. Improvement in the accuracy of ultrasound imaging has undoubtedly boosted regional anaesthetic techniques making nerve blocks safe and well tolerated in children.
Conclusion: Our case report demonstrates successful incorporation of US guided bilateral axillary brachial plexus block in a child with preexisting cardiac illness coming for major upper limb surgeries resulting in a painfree child, satisfied parents and happy surgeons.
Keywords: Bilateral brachial plexus blocks (BPB), Pediatric Regional Anaesthesia, Ultrasound.
References
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| How to Cite this Article: Srikanth AT, Patil P, Pramod A, V Srikanth | A Case Report on Bilateral Ultrasound Guided Brachial Plexus Block in a Paediatric Patient with Unusual Congenital Anomalies | International Journal of Regional Anaesthesia | July-December 2024; 5(2): 27-30 | DOI: https://doi.org/10.13107/ijra.2024.v05.i02.104 |
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Continuous Erector Spinae Plane Block for Unilateral Multiple Rib Fracture- A Case Report
Vol 5 | Issue 2 | July-December 2024 | Page 23-26 | Navveen PM, Sandeep Diwan
DOI: https://doi.org/10.13107/ijra.2024.v05.i02.102
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2024; The Author(s).
Submitted: February 22-11-2024; Reviewed: 28-11-2024; Accepted: 08-12-2024; Published: 10-12-2024
Authors: Navveen PM [1], Sandeep Diwan [2]
[1] AORA Fellow, Sancheti Hospital for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
[2] Department of Anaesthesiology, Sancheti Hospital for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Navveen PM
Department of Anaesthesia, Sancheti Institute of orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Email id: dr.navveen@gmail.com
Abstract
Patients with chest trauma have high morbidity due to rib fractures, lung contusion, hemo/pneumothorax leading to prolonged hospital stay. Adequate pain relief is the key for early recovery following rib fracture. Pain due rib fracture can cause lung atelectasis, flail chest, hypoventilation leading to hypoxia, respiratory failure and further pulmonary complications. Erector spinae plane (ESP) block is an inter-fascial plane block which has been proposed as a regional anaesthesia technique in acute pain management for multiple rib fractures (MRF’s).
Keywords: Multiple rib fracture, Chest trauma, Erector spinae plane block.
References
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4. Diwan S, Garud R, Nair A. Thoracic paravertebral and erector spinae plane block: A cadaveric study demonstrating different site of injections and similar destinations. Saudi J Anaesth. 2019 Oct-Dec;13(4):399-401. doi: 10.4103/sja.SJA_339_19. PMID: 31572102; PMCID: PMC6753759.
5. L May, C Hillermann, S Patil, Rib fracture management, BJA Education, Volume 16, Issue 1, 2016,
6. Diwan, S., Nair, A., Adhye, B. et al. Dual erector spinae plane block for complex traumas of upper and lower limb: an opioid reduction strategy—a case series. Ain-Shams J Anesthesiol 15, 81 (2023). https://doi.org/10.1186/s42077-023-00380-0
7. Diwan, Sandeep; Nair, Abhijit1. Unilateral erector spinae plane block for managing acute pain arising from multiple unilateral injuries: A case report. Indian Journal of Anaesthesia 64(1):p 79-80, January 2020. | DOI: 10.4103/ija.IJA_609_19
8. Periosteal Infusion of Local Anesthetics as an Alternative to Bilateral Subpectoral Interfascial Plane Catheters in Patients with Sternal Fractures, Regional Anesthesia & Pain Medicine. Paul, Barry. 2017/05/01.
9. Rashmi Syal, Sadik Mohammed, Rakesh Kumar, Nidhi Jain, Pradeep Bhatia, Continuous erector spinae plane block for analgesia and better pulmonary functions in patients with multiple rib fractures: a prospective descriptive study, Brazilian Journal of Anesthesiology (English Edition), Volume 74, Issue 1, 2024.
| How to Cite this Article: PM Navveen, Diwan S | Continuous Erector Spinae Plane Block for Unilateral Multiple Rib Fracture- A Case Report | International Journal of Regional Anaesthesia | July-December 2024; 5(2):23-26 | DOI: https://doi.org/10.13107/ijra.2024.v05.i02.102 |
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C5 Anomaly and Scalene Muscle Variation- Case Report
Vol 5 | Issue 2 | July-December 2024 | Page 20-22 | Reshma Nath, Sandeep Diwan
DOI: https://doi.org/10.13107/ijra.2024.v05.i02.100
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2024; The Author(s).
Submitted: February 19-11-2024; Reviewed: 26-11-2024; Accepted: 05-12-2024; Published: 10-12-2024
Authors: Reshma Nath [1], Sandeep Diwan [2]
[1] AORA Fellow, Sancheti Hospital for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
[2] Department of Anaesthesiology, Sancheti Hospital for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Reshma Nath
Department of Anaesthesiology, Sancheti Hospital for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Email id: resham.vj@gmail.com
Abstract
The brachial plexus is formed by the ventral primary rami of the lower four cervical and upper thoracic nerve roots, with variable contribution from C4 (prefix) & T2 (postfix). Anatomical variations are from the roots to the cord level. A better understanding of such variations is crucial for achieving successful results in regional anaesthesia.
Keywords: Brachial plexus, Anatomical variation, Dual guidance
References
1. Patel NT, Smith HF. Clinically Relevant Anatomical Variations in the Brachial Plexus. Diagnostics (Basel). doi: 10.3390/diagnostics13050830. PMID: 36899974; PMCID: PMC10001373.2023 Feb 22;13(5):830.
2. Han, Yueyin & An, Mingjie & Zilundu, Prince & Zhuang, Zhuokai & Chen, Junyu & Jiang, Zhen & Gu, Liqiang & Yang, Jiantao & Wang, Dong & Xu, Dazheng & Zhou, Li‐Hua. (2024). Anatomical variations of the brachial plexus in adult cadavers: A descriptive study and clinical significance. Microsurgery. 44. 10.1002/micr.31182. https://www.researchgate.net/publication/380924213_Anatomical_variations_of_the_brachial_plexus_in_adult_cadavers_A_descriptive_study_and_clinical_significance
3. ATOTW 369 – Anatomical variation of the brachial plexus and its clinical implications (26th Dec 2017) Page 1-9 https://resources.wfsahq.org/atotw/anatomical-variation-of-the-brachial-plexus-and-its-clinical-implications/
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5. Developmental anomalies at the thoracic outlet: An analysis of 200 consecutive cases Makhoul, Raymond G. et al.Journal of Vascular Surgery, Volume 16, Issue 4, 534 – 545.
| How to Cite this Article: Nath R, Diwan S | C5 Anomaly and Scalene Muscle Variation- Case Report | International Journal of Regional Anaesthesia | July-December 2024; 5(2): 20-22 | DOI: https://doi.org/10.13107/ijra.2024.v05.i02.100 |
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Redefining Limits: Shoulder Disarticulation Under Regional Anaesthesia Alone
Vol 5 | Issue 2 | July-December 2024 | Page 16-19| Vandana Mangal, Momoson Maring Tontanga, Chitra Singh, Tuhin Mistry
DOI: https://doi.org/10.13107/ijra.2024.v05.i02.98
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2024; The Author(s).
Submitted: February 18-11-2024; Reviewed: 25-11-2024; Accepted: 02-12-2024; Published: 10-12-2024
Authors: Vandana Mangal [1], Momoson Maring Tontanga [1], Chitra Singh [1], Tuhin Mistry [2]
[1] Department of Anaesthesiology and Critical Care, SMS Medical College, Jaipur, Rajasthan, India.
[2] Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre and Hospitals Pvt Ltd, Coimbatore, India
Address of Correspondence
Dr. Tontanga Momoson Maring
Department of Anaesthesiology and Critical Care, SMS Medical College, Jaipur, Rajasthan, India.
Email id: drmomoson@gmail.com
Abstract
Shoulder disarticulation following of animal bites is not uncommon and is often performed for various indications, including vascular insufficiency. General anaesthesia is usually the preferred choice in optimized patients, with or without regional anaesthesia. Phantom limb pain is a distressing and frequently encountered condition following limb amputation. In addition to their well-established benefits, nerve blocks not only provide effective perioperative analgesia but may also reduce the incidence of phantom limb pain. In this case, we undertook shoulder disarticulation exclusively under regional anaesthesia, as the patient’s respiratory condition was not optimal for general anaesthesia.
Keywords: Shoulder disarticulation, Regional anaesthesia, Subclavian perivascular block, Superficial cervical plexus block, Pectoserratus plane block.
References
1. Mahajan, A., Luther, A., & Chhabra, A. (2015). Brachial artery injury caused by camel bite. Indian Journal of Vascular and Endovascular Surgery, 2(1), 33. https://doi.org/10.4103/0972-0820.152834
2. Abu-Zidan FM, Hefny AF, Eid HO, Bashir MO, Branicki FJ. Camel-related injuries: Prospective study of 212 patients World J Surg. 2012;36:2384–9
3. Maduri P, Akhondi H. Upper Limb Amputation. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540962/
4. Donnelly, M. R., & Hacquebord, J. H. (2023). Shoulder level amputation: Forequarter and brachial plexus-level amputation. Operative Techniques in Orthopaedics, 33(3), 101056. https://doi.org/10.1016/j.oto.2023.101056
5. Kilicaslan A, Gok F, Colak TS, Keklicek O, Kucuksen MF. Combined interscalene, superficial cervical plexus and thoracic intertransverse process blocks for surgical anaesthesia of the shoulder disarticulation. Anaesth Rep. 2024;12(1):e12306. Published 2024 May 29. doi:10.1002/anr3.12306
6. Mbabazi P, Mwaniki M, Wambua G, Kagua S, Kamau RW, Daggett J, Nthumba PM. Successful Shoulder Disarticulation under Local Anesthesia in the COVID-19 Era. Plast Reconstr Surg Glob Open. 2023 Sep 13;11(9):e5266. doi: 10.1097/GOX.0000000000005266. PMID: 37711723; PMCID: PMC10499080.
7. Duggappa DR, Rao GV, Kannan S. Anaesthesia for patient with chronic obstructive pulmonary disease. Indian J Anaesth. 2015 Sep;59(9):574-83. doi: 10.4103/0019-5049.165859. PMID: 26556916; PMCID: PMC4613404.
8. Miniato MA, Anand P, Varacallo MA. Anatomy, Shoulder and Upper Limb, Shoulder. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536933/
9. Hamadnalla, H., Elsharkawy, H., Shimada, T. et al. Cervical erector spinae plane block catheter for shoulder disarticulation surgery. Can J Anesth/J Can Anesth 66, 1129–1131 (2019). https://doi.org/10.1007/s12630-019-01421-9
10. Mbabazi P, Mwaniki M, Wambua G, Kagua S, Kamau RW, Daggett J, Nthumba PM. Successful Shoulder Disarticulation under Local Anesthesia in the COVID-19 Era. Plast Reconstr Surg Glob Open. 2023 Sep 13;11(9):e5266. doi: 10.1097/GOX.0000000000005266. PMID: 37711723; PMCID: PMC10499080.
| How to Cite this Article: Mangal V, Tontanga MM, Singh C, Mistry T | Redefining Limits: Shoulder Disarticulation Under Regional Anaesthesia Alone | International Journal of Regional Anaesthesia | July-December 2024; 5(2): 16-19 | DOI: https://doi.org/10.13107/ijra.2024.v05.i02.98 |
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Brachial Plexus Block above the level of clavicle in Multi-Comorbid Patients with Difficult Surface Landmarks and Cervical Ankylosing Spondylosis
Vol 5 | Issue 2 | July-December 2024 | Page 10-12| Nitin Gawai, Sandeep Diwan, Ganesh Bhong, Sunil Dixit, Parag Sancheti
DOI: https://doi.org/10.13107/ijra.2024.v05.i02.94
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2024; The Author(s).
Submitted: February 18-07-2024; Reviewed: 12-09-2024; Accepted: 14-10-2024; Published: 10-12-2024
Authors: Nitin Gawai [1], Sandeep Diwan [1], Ganesh Bhong [2], Sunil Dixit [1], Parag Sancheti [3]
[1] Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India.
[2] Anesthesiology Consultant, Pune, Maharashtra, India.
[3] Department of Orthopaedics, Sancheti Hospital, Pune, Maharashtra, India.
Address of Correspondence
Dr. Nitin Gawai,
Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India.
E-mail: drnitingawai@yahoo.com
Abstract
Blocks above the clavicle [BAC- interscalene and supraclavicular] are routinely performed with surface anatomical landmark, and recently with ultrasound. Landmark techniques involving mid-point of clavicle is routinely used. However, with abnormal topography of the clavicle anatomy, the landmarks are distorted. Both, neurostimulation and ultrasound face stiff challenges in patients with abnormal clavicle anatomy. In four patients, with abnormal clavicle, BAC was attempted for surgical corrections of proximal and shaft of humerus. Though landmark and ultrasound guided blocks were successful, we reveal the importance of alternative landmarks and possible complications that might may be associated with abnormal anatomical landmarks.
Keywords: Brachial Plexus Block, Multi-Comorbid Patients, Difficult Surface Landmarks, Cervical Ankylosing Spondylosis
References
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3. Haleem, Shahla; Siddiqui, Ahsan K.; Mowafi, Hany A. Nerve Stimulator Evoked Motor Response Predicting a Successful Supraclavicular Brachial Plexus Block; More Anesthesia & Analgesia. 110(6):1745-1746, June 2010.
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5. Anand M. Sardesai, Roger Patel, Nicholas M. Denny, David K. Menon, Adrian K. Dixon, Martin J. Herrick, Alan W. Harrop-Griffiths; Interscalene Brachial Plexus Block: Can the Risk of Entering the Spinal Canal Be Reduced? A Study of Needle Angles in Volunteers Undergoing Magnetic Resonance Imaging. Anesthesiology 2006; 105:9–13.
6. Albrecht, J. Mermoud, N. Fournier, C. Kern and K. R. Kirkham A systematic review of ultrasound-guided methods for brachial plexus blockade Anaesthesia 2016, 71, 213–227.
7. 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. Anesth Analg. 2011 Oct;113(4):951-5.
8. Gregg A. Korbon, Harold Carron and Christopher J. Lander, First Rib Palpation: A Safer, Easier Technique for Supraclavicular Brachial Plexus Block ANESTH ANALG 1989;68:682-5.
9. Duggan E, El Beheiry H, Perlas A, Lupu M, Nuica A, Chan VW, Brull R. Minimum effective volume of local anesthetic for ultrasound-guided supraclavicular brachial plexus block. Reg Anesth Pain Med. 2009 May-Jun;34(3):215-8.
10. 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. Acta Anaesthesiol Scand. 2013 Jul;57(6):761-6.
11. Verelst P, van Zundert A. Respiratory impact of analgesic strategies for shoulder surgery. Reg Anesth Pain Med. 2013 Jan-Feb;38(1):50-3. doi: 10.1097/AAP.0b013e318272195d. PMID: 23132510. 12.
12. Plante T, Rontes O, Bloc S, Delbos A. Spread of local anesthetic during an ultrasound-guided interscalene block: does the injection site influence diffusion? Acta Anaesthesiol Scand. 2011 Jul;55(6):664-9.
| How to Cite this Article: Gawai N, Diwan S, Bhong G, Dixit S, Sancheti P | Brachial Plexus Block above the level of clavicle in Multi-Comorbid Patients with Difficult Surface Landmarks and Cervical Ankylosing Spondylosis | International Journal of Regional Anaesthesia | July-December 2024; 5(2): 10-12 | DOI: https://doi.org/10.13107/ijra.2024.v05.i02.94 |
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Comparison of the Efficacy of Intravenous and Regional Dexamethasone in Brachial Plexus Nerve Block
Vol 5 | Issue 2 | July-December 2024 | Page 4-9| Sushmitha K, Shripad Mahadik, Deepak Phalgune, Sandeep Mutha, Sudhir Patil
DOI: https://doi.org/10.13107/ijra.2024.v05.i02.92
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2024; The Author(s).
Submitted: February 27-10-2024; Reviewed: 10-11-2024; Accepted: 18-11-2024; Published: 10-12-2024
Authors: Sushmitha K [1], Shripad Mahadik [1], Deepak Phalgune [2], Sandeep Mutha [1], Sudhir Patil [1]
[1] Department of Anaesthesiology, Poona Hospital & Research Centre, Pune, Maharashtra, India.
[2] Department of Research, Poona Hospital & Research Centre, Pune, Maharashtra, India.
Address of Correspondence
Dr. Deepak Phalgune,
Department of Research, Poona Hospital & Research Centre, Pune, Maharashtra, India.
E-mail: dphalgune@gmail.com
Abstract
The brachial plexus nerve block (BPNB) is a widely employed regional nerve block of the upper extremity. Some trials report longer duration of analgesia with perineural compared to intravenous (IV) dexamethasone, other studies have failed to detect significant differences between the two modalities in BPNB. The present study aims to compare the efficacy of IV and perineural dexamethasone as an adjuvant in BPNB. One hundred ten patients aged between 18 and 60 years, scheduled to undergo upper limb surgery under BPNB were randomly divided into two groups by computer-generated table. Group A patients received IV dexamethasone 8 mg immediately after receiving BPNB with adrenalized lignocaine and bupivacaine. Group B patients received dexamethasone 8 mg along with adrenalized lignocaine and bupivacaine perineurally. The onset time of the sensory block (OTSB), the time for the complete sensory block (TCSB), the onset time of the motor block (OTMB), the time for the complete motor block (TCMB), and the period of sensory and motor blockade were recorded. The visual analogue scale (VAS) score was noted. The mean OTSB, TCSB, OTMB, and TCMB were significantly higher in Group A than in Group B, whereas the mean duration of sensory and motor blockade was significantly higher in Group B than in Group A. The mean VAS score at 16 and 24 hours postoperatively was significantly higher in Group A than in Group B. The efficacy of dexamethasone along with local anaesthetic perineurally was higher than IV dexamethasone in BPNB.
Keywords: Dexamethasone, intravenous, Motor block, Perineural, Sensory block
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| How to Cite this Article: Sushmitha K, Mahadik S, Phalgune D, Mutha S, Patil S | Comparison of the Efficacy of Intravenous and Regional Dexamethasone in Brachial Plexus Nerve Block | International Journal of Regional Anaesthesia | July-December 2024; 5(2): 4-9 | DOI: https://doi.org/10.13107/ijra.2024.v05.i02.92 |
