Opening Injection Pressure Consistently Detects Needle–Nerve Contact during Ultrasound-guided Interscalene Brachial Plexus Block

2014 ◽  
Vol 120 (5) ◽  
pp. 1246-1253 ◽  
Author(s):  
Jeff C. Gadsden ◽  
Jason J. Choi ◽  
Emily Lin ◽  
Allegra Robinson
Keyword(s):  
Brachial Plexus ◽  
Peak Pressure ◽  
Injection Pressure ◽  
Interscalene Block ◽  
Ultrasound Images ◽  
Interscalene Brachial Plexus Block ◽  
Pressure Manometer ◽  
Line Pressure ◽  
Plexus Block ◽  
The Relationship

Abstract Background: Needle trauma may cause neuropathy after nerve blockade. Even without injection, nerve injury can result from forceful needle–nerve contact (NNC). High opening injection pressures (OIPs) have been associated with intrafascicular needle tip placement and nerve damage; however, the relationship between OIP and NNC is unclear. The authors conducted a prospective, observational study to define this relationship. Methods: Sixteen patients scheduled for shoulder surgery under interscalene block were enrolled if they had clear ultrasound images of the brachial plexus roots. A 22-gauge stimulating needle was inserted within 1 mm of the root, and 1-ml D5W injected at 10 ml/min by using an automated pump. OIP was monitored using an in-line pressure manometer and injections aborted if 15 psi or greater. The needle was advanced to displace the nerve slightly (NNC), and the procedure repeated. Occurrence of evoked motor response and paresthesia were recorded. Results: Fifteen patients had at least one clearly visible root. OIP at 1 mm distance from the nerve was less than 15 psi (mean peak pressure 8.2 ± 2.4 psi) and the 1-ml injection could be completed in all but two cases (3%). In contrast, OIP during NNC was 15 psi or greater (mean peak pressure 20.9 ± 3.7 psi) in 35 of 36 injections. Aborting the injection when OIP reached 15 psi prevented commencement of injection in all cases of NNC except one. Conclusion: High OIP (≥15 psi) consistently detected NNC, suggesting that injection pressure monitoring may be useful in preventing injection against nerve roots during interscalene block.

scholarly journals Ultrasound guided interscalene brachial plexus block via lower approach for upper limb surgeries

2018 ◽  
Vol 5 (5) ◽  
pp. 1304
Author(s):  
Roopal R. Garaniya ◽  
Sheetal Shah ◽  
Noopur Prajapati
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Upper Limb ◽  
Brachial Plexus Block ◽  
Interscalene Block ◽  
Ultrasound Guided ◽  
Peripheral Nerve Stimulator ◽  
Interscalene Brachial Plexus Block ◽  
Plexus Block

Background: Brachial plexus block via interscalene approach is an excellent option for upper limb surgeries, but due to sparing of ulnar nerve (lower trunk, C8-T1) and its’ complications, it is not so popular. To overcome this problem, interscalene block via lower approach has been tried which has more advantage in view of ulnar nerve blockage and also less complications. In addition, ultrasound provides reliability, ease, rapidity and also patient comfort during block procedure. This prospective study was performed to evaluate the anaesthetic effect of lower approach interscalene block with the help of ultrasound and peripheral nerve stimulator.Methods: Ultrasound guided interscalene brachial plexus block via lower approach was given in randomly selected 30 patients, undergoing upper limb orthopaedic surgeries. After localisation of brachial plexus with ultrasound, the nerve roots were confirmed with the help of peripheral nerve stimulator, before injecting drug. At 5 and 15 min after block, all patients were assessed for the effect. Postoperatively they were assessed for any complication and also for their satisfaction level by Likert’s scale.Results: In territories of ulnar, radial and musculocutaneous nerve there was 100% effect while in median nerve territory 92.8% motor block was there. There was no need of analgesics during intra operative period in any patient and there were no major complications with this approach.Conclusions: Ultrasound guided interscalene block via lower approach is an excellent alternative for upper limb surgeries over classical approach in view of ulnar nerve blockage without any major complication.

Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery

2019 ◽  
Vol 131 (6) ◽  
pp. 1316-1326 ◽  
Author(s):  
RyungA Kang ◽  
Ji Seon Jeong ◽  
Ki Jinn Chin ◽  
Jae Chul Yoo ◽  
Jong Hwan Lee ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Postoperative Analgesia ◽  
Brachial Plexus Block ◽  
Group Versus ◽  
Shoulder Surgery ◽  
Interscalene Block ◽  
Block Group ◽  
Interscalene Brachial Plexus Block ◽  
Arthroscopic Shoulder Surgery ◽  
Plexus Block

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Interscalene brachial plexus block of the C5–C6 roots provides highly effective postoperative analgesia after shoulder surgery but usually results in hemidiaphragmatic paresis. Injection around the superior trunk of the brachial plexus is an alternative technique that may reduce this risk. The authors hypothesized that the superior trunk block would provide noninferior postoperative analgesia compared with the interscalene block and reduce hemidiaphragmatic paresis. Methods Eighty patients undergoing arthroscopic shoulder surgery were randomized to receive a preoperative injection of 15 ml of 0.5% ropivacaine and 5 μg · ml−1 epinephrine around either (1) the C5–C6 nerve roots (interscalene block group) or (2) the superior trunk (superior trunk block group). The primary outcome was pain intensity 24 h after surgery measured on an 11-point numerical rating score; the prespecified noninferiority limit was 1. Diaphragmatic function was assessed using both ultrasonographic measurement of excursion and incentive spirometry by a blinded investigator before and 30 min after block completion. Results Seventy-eight patients completed the study. The pain score 24 h postoperatively (means ± SDs) was 1.4 ± 1.0 versus 1.2 ± 1.0 in the superior trunk block (n = 38) and interscalene block (n = 40) groups, respectively. The mean difference in pain scores was 0.1 (95% CI, −0.3 to 0.6), and the upper limit of the 95% CI was lower than the prespecified noninferiority limit. Analgesic requirements and all other pain measurements were similar between groups. Hemidiaphragmatic paresis was observed in 97.5% of the interscalene block group versus 76.3% of the superior trunk block group (P = 0.006); paresis was complete in 72.5% versus 5.3% of the patients, respectively. The decrease in spirometry values from baseline was significantly greater in the interscalene block group. Conclusions The superior trunk block provided noninferior analgesia compared with interscalene brachial plexus block for up to 24 h after arthroscopic shoulder surgery and resulted in significantly less hemidiaphragmatic paresis.

scholarly journals Triple Monitoring May Avoid Intraneural Injection during Interscalene Brachial Plexus Block for Arthroscopic Shoulder Surgery: A Prospective Preliminary Study

2021 ◽  
Vol 10 (4) ◽  
pp. 781
Author(s):  
Giuseppe Pascarella ◽  
Alessandro Strumia ◽  
Fabio Costa ◽  
Stefano Rizzo ◽  
Romualdo Del Buono ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Nerve Stimulation ◽  
Motor Response ◽  
Brachial Plexus Block ◽  
Shoulder Arthroscopy ◽  
Injection Pressure ◽  
Shoulder Surgery ◽  
Interscalene Brachial Plexus Block ◽  
Arthroscopic Shoulder Surgery ◽  
Plexus Block

Nerve injury is a feared complication of peripheral nerve blockade. The aim of this study was to test the effectiveness of a triple monitoring (TM), i.e., a combination of ultrasound (US), nerve stimulation (NS) and opening injection pressure (OIP) during interscalene brachial plexus block (IBPB) for surgery of the shoulder. Sixty patients undergoing IBPB for shoulder arthroscopy received TM. BSmart®, an inline injection device connected to a 10 mL syringe, was used to detect OIP during IBPB. Nerve stimulation was set to 0.5 mA to rule out any motor response, and if OIP was below 15 PSI, 10 mL of local anaesthetic was injected under US guidance between the C5 and C6 roots. The main outcome was the ability of TM to detect a needle–nerve contact. Other outcomes including the duration of IBPB; pain during injection; postoperative neurologic dysfunction. Triple monitoring revealed needle–nerve contact in 33 patients (55%). In 18 patients, NS evoked motor responses despite first control with US; in a further 15 patients, BSmart® detected an OIP higher than 15 PSI, despite the absence of motor response to NS. Mean duration of IBPB was 67.2 ± 5.3 seconds; neither pain during injection nor postoperative neurologic dysfunctions were detected. Clinical follow up excluded the presence of postoperative neuropathies. Triple monitoring showed to be a useful and feasible tool while performing IBPB for arthroscopic shoulder surgery. Future studies will be needed to confirm our findings.

Evaluation of the Lateral Modified Approach for Continuous Interscalene Block after Shoulder Surgery

2003 ◽  
Vol 99 (2) ◽  
pp. 436-442 ◽  
Author(s):  
Alain Borgeat ◽  
Alexander Dullenkopf ◽  
Georgios Ekatodramis ◽  
Ladislav Nagy
Keyword(s):  
Patient Satisfaction ◽  
Brachial Plexus ◽  
Clinical Efficacy ◽  
Brachial Plexus Block ◽  
Shoulder Surgery ◽  
Interscalene Block ◽  
Neurologic Complications ◽  
Interscalene Brachial Plexus Block ◽  
Continuous Interscalene ◽  
Plexus Block

Background Continuous interscalene block is the technique of choice for postoperative pain relief treatment after shoulder surgery. The authors prospectively evaluated the modified lateral approach for the performance of the interscalene catheter block and monitored 700 patients for clinical efficacy and complications during the first 6 months after placement of the catheter. Methods A total of 700 adults scheduled to undergo elective shoulder surgery performed with an interscalene brachial plexus block through an interscalene catheter were included in this study. The interscalene brachial plexus block procedure was standardized for all patients. Difficulties in placement of the catheter, clinical efficacy of anesthesia and analgesia, patient satisfaction, and acute and chronic complications were recorded. Patients were observed daily for 5 days for any complications and were evaluated at 1, 3, and 6 months after surgery. Persistence of neurologic complication was investigated by electroneuromyography. Results A total of 700 adults completed the study. Easy placement of the catheter (one attempt) was achieved in 86% of the patients. Resistance to thread the catheter was encountered in 6%; no major complications were observed during injection of the initial bolus. The success rate for anesthesia was 97%. Postoperative analgesia was efficient in 99%. The concentration and the rate of infusion of ropivacaine had to be increased in 31 patients (6%). In five patients (0.7%), signs of local infection around the puncture point were noted; in one patient (0.1%), a collection of pus was surgically drained. Patient satisfaction was 9.6 on a scale of 0-10. Minor neurologic complications (paresthesias, dysesthesias, pain not related to surgery) were observed in 2.4%, 0.3%, and 0% at 1, 3, and 6 months, respectively. At 1 month, three sulcus ulnaris syndromes, one carpal tunnel syndrome, and one complex regional pain syndrome were diagnosed. Two patients (0.2%) had sensory-motor deficit, which necessitated 19 and 28 weeks to recover. Electromyography was suggestive of partial axonotmesis. Conclusion The lateral modified approach provides good conditions for placement of the interscalene catheter. Anesthesia and analgesia performed through the catheter are efficient. The rates of infection and neurologic complications are low, and patient satisfaction is high.

INTERSCALENE BRACHIAL PLEXUS BLOCK WITH A NERVE STIMULATOR FOR CLAVICULAR FRACTURE SURGERY

2014 ◽  
pp. 20-24
Author(s):  
Van Minh Nguyen
Keyword(s):  
Side Effects ◽  
Brachial Plexus ◽  
Brachial Plexus Block ◽  
Clavicle Fracture ◽  
Onset Time ◽  
Clavicular Fracture ◽  
Nerve Stimulator ◽  
Interscalene Brachial Plexus Block ◽  
Plexus Block ◽  
Fracture Surgery

Objective:To evaluate the effectiveness and side effects, complications of interscalene brachial plexus block with a nerve stimulator for clavicular fracture surgery. Materials and Methods:In a prospective descriptive study, fifty patients received interscalene brachial plexus block for fixation of clavicle fracture. The dose was 7 mg/kg of 1% lidocaine mixed with 1 : 200000 adrenaline. Results:The success rate was 94%, including 4% of patients needed sedation and small amount of narcotic, failure rate was 6%. The minimal stimulating current of the nerve location was 0.46 ±0.08 mA, the onset time of sensory block was 8.86 ±2.65min. There were 3 complications with one Horner’s syndrome and two hoarsenesses. Conclusion:We found that in patients undergoing fixation of clavicle fracture the interscalene block with a nerve stimulator was an effective anesthetic with a low rate of side effects and complications. Key words:Interscalene block, nerve stimulator, clavicular fracture surgery.

scholarly journals Local Anesthetic-Induced Central Nervous System Toxicity during Interscalene Brachial Plexus Block: A Case Series Study of Three Patients

2021 ◽  
Vol 10 (5) ◽  
pp. 1013
Author(s):  
Daniel Spitzer ◽  
Katharina J. Wenger ◽  
Vanessa Neef ◽  
Iris Divé ◽  
Martin A. Schaller-Paule ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Brachial Plexus ◽  
Local Anesthetic ◽  
Local Anesthetics ◽  
Brachial Plexus Block ◽  
Central Nervous System Toxicity ◽  
Interscalene Brachial Plexus Block ◽  
Plexus Block ◽  
System Toxicity

Local anesthetics are commonly administered by nuchal infiltration to provide a temporary interscalene brachial plexus block (ISB) in a surgical setting. Although less commonly reported, local anesthetics can induce central nervous system toxicity. In this case study, we present three patients with acute central nervous system toxicity induced by local anesthetics applied during ISB with emphasis on neurological symptoms, key neuroradiological findings and functional outcome. Medical history, clinical and imaging findings, and outcome of three patients with local anesthetic-induced toxic left hemisphere syndrome during left ISB were analyzed. All patients were admitted to our neurological intensive care unit between November 2016 and September 2019. All three patients presented in poor clinical condition with impaired consciousness and left hemisphere syndrome. Electroencephalography revealed slow wave activity in the affected hemisphere of all patients. Seizure activity with progression to status epilepticus was observed in one patient. In two out of three patients, cortical FLAIR hyperintensities and restricted diffusion in the territory of the left internal carotid artery were observed in magnetic resonance imaging. Assessment of neurological severity scores revealed spontaneous partial reversibility of neurological symptoms. Local anesthetic-induced CNS toxicity during ISB can lead to severe neurological impairment and anatomically variable cerebral lesions.

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