High-definition ultrasound imaging defines the paraneural sheath and fascial compartments surrounding the cords of the brachial plexus at the costoclavicular space and lateral infraclavicular fossa

2021 ◽  
pp. rapm-2020-102304
Author(s):  
Pornpatra Areeruk ◽  
Manoj Kumar Karmakar ◽  
Miguel A Reina ◽  
Louis Y H Mok ◽  
Ranjith Kumar Sivakumar ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Ultrasound Imaging ◽  
Brachial Plexus Block ◽  
Ultrasound Images ◽  
High Definition ◽  
Link Type ◽  
Before And After ◽  
Registration Number ◽  
Local Anesthetic Injection ◽  
Plexus Block

Background and objectivesThe paraneural sheath is a multilayered network of collagen fibers that surround the brachial plexus. Currently, there are no sonographic data on the paraneural sheath of the brachial plexus, which this study aimed to evaluate.MethodsUltrasound imaging datasets of 100 patients who received a costoclavicular brachial plexus block, using high-definition ultrasound imaging, were retrospectively reviewed. Video files, representing sonograms before and after the local anesthetic injection, from the costoclavicular space and lateral infraclavicular fossa were collated and reviewed by three experienced anesthesiologists. Frequency (yes/no) of ultrasound visualization of the paraneural sheath, septum, and the anterior and posterior compartments was assessed. Representative sonograms from the costoclavicular space and lateral infraclavicular fossa were visually correlated with archived cadaver microanatomic sections from the same location.ResultsDatasets of the 98 patients who achieved surgical anesthesia were evaluated. The paraneural sheath, septum, and the anterior and posterior compartments were visualized in 17.3%, 7.1%, 5.1% and 5.1%, respectively, at the costoclavicular space before the brachial plexus block; this contrasts (p<0.001) with their visibility post-block (94.9%, 75.5%, 75.5% and 75.5%, respectively). At the lateral infraclavicular fossa, the corresponding visibility of these structures post-block were 67.7%, 81.5%, 81.5% and 81.5%, respectively. Ultrasound images of the paraneural sheath and septum correlated well with that in the cadaver microanatomic sections.ConclusionWe have demonstrated the paraneural sheath and fascial compartments surrounding the cords of the brachial plexus at the costoclavicular space and lateral infraclavicular fossa using high-definition ultrasound imaging.Trial registration numberClinicalTrials.gov Registry (NCT04370184), (https://www.clinicaltrials.gov/).

High definition ultrasound imaging of the individual elements of the brachial plexus above the clavicle

2020 ◽  
Vol 45 (5) ◽  
pp. 344-350 ◽  
Author(s):  
Manoj Kumar Karmakar ◽  
Jatuporn Pakpirom ◽  
Banchobporn Songthamwat ◽  
Pornpatra Areeruk
Keyword(s):  
Brachial Plexus ◽  
Ultrasound Imaging ◽  
Transverse Process ◽  
Reverse Direction ◽  
Limited Data ◽  
High Definition ◽  
Supraclavicular Fossa ◽  
Registration Number ◽  
Main Components ◽  
The Individual

Background and objectivesUltrasonography of the brachial plexus (BP) has been described but there are limited data on visualization of the T1 ventral ramus and the inferior trunk. This prospective observational study aimed to evaluate a high definition ultrasound imaging technique to systematically identify the individual elements of the BP above the clavicle.MethodsFive healthy young volunteers underwent high definition ultrasound imaging of the BP above the clavicle. The ultrasound scan sequence (transverse oblique scan) commenced at the supraclavicular fossa after which the transducer was slowly swept cranially to the upper part of the interscalene groove and then in the reverse direction to the supraclavicular fossa. The unique sonomorphology of the C7 transverse process was used as the key anatomic landmark to identify the individual elements of the BP in the recorded sonograms.ResultsThe neural elements of the BP that were identified in all volunteers included the ventral rami of C5–T1, the three trunks, divisions of the superior trunk, and formation of the inferior trunk (C8–T1). The C6 ventral ramus exhibited echogenic internal septation with a split (bifid) appearance in four of the five volunteers. In three of the four volunteers with a bifid C6 ventral ramus, the C7 ventral ramus was also bifid.ConclusionWe have demonstrated that it is feasible to accurately identify majority of the main components of the BP above the clavicle, including the T1 ventral ramus and the formation of the inferior trunk, using high definition ultrasound imaging.Trial registration numberChiCTR1900021749.

Intertruncal approach to the supraclavicular brachial plexus, current controversies and technical update: a daring discourse

2020 ◽  
Vol 45 (5) ◽  
pp. 377-380 ◽  
Author(s):  
Urooj Siddiqui ◽  
Anahi Perlas ◽  
Kijinn Chin ◽  
Miguel A Reina ◽  
Xavier Sala-Blanch ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Local Anesthetic ◽  
Brachial Plexus Block ◽  
New Approach ◽  
Pleural Surface ◽  
Improved Outcomes ◽  
Supraclavicular Brachial Plexus Block ◽  
Intraneural Injection ◽  
Local Anesthetic Injection ◽  
Plexus Block

We propose a new approach to local anesthetic injection for the supraclavicular brachial plexus block: an intertruncal approach by which local anesthetic is deposited in the two adipose tissue planes between the upper and middle and the middle and lower trunks. We present sonographic and microscopic images to illustrate the relevant anatomy. This approach offers potential advantages over the ‘corner pocket’ technique in that it results in consistent local anesthetic spread to the three plexus trunks and the needle endpoint lies farther away from the pleural surface which is important for the prevention of pneumothorax. It also offers an advantage over the ‘intracluster’ approach as it purposefully avoids intraneural injection respecting the integrity of the epineurium of individual trunks. Comparative studies are required to confirm that these anatomic and technical advantages result in improved outcomes.

scholarly journals Two cases of late-onset cardiovascular toxicities after a single injection of local anesthetics during supraclavicular brachial plexus block - A report of two cases -

2021 ◽  
Author(s):  
Ji Yeon Kim ◽  
Beom Il Park ◽  
Min Hee Heo ◽  
Kyoung Woo Kim ◽  
Sang-Il Lee ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Local Anesthetics ◽  
Brachial Plexus Block ◽  
Late Onset ◽  
Single Injection ◽  
Vital Signs ◽  
Radius Fractures ◽  
Supraclavicular Brachial Plexus Block ◽  
Local Anesthetic Injection ◽  
Plexus Block

Background: Local anesthetics systemic toxicity (LAST) is a grave complication of regional anesthesia that usually occurs immediately after local anesthetics injection. Here, we report on rare late-onset toxicity cases after supraclavicular brachial plexus blocks.Case: Two patients underwent surgery for radius fractures. We used lidocaine 100 mg and ropivacaine 150 mg for blocking and infused dexmedetomidine for intraoperative sedation. The 63-year-old male patient’s blood pressure dropped to 87/60 mmHg after 3 h 15 min after blocking. Ventricular fibrillation occurred 10 min later. After five defibrillations, electrocardiography showed ventricular tachycardia that was normalized through one cardioversion. The 54-year-old female patient’s heart rate decreased to 35 beats/min 2 h 30 min after blocking. Her vital signs returned to normal after administering atropine, ephedrine, epinephrine, and lipid emulsion.Conclusions: Physicians should remember that LAST may occur long after local anesthetic injection and be aware of factors that may adversely affect the course of LAST.

scholarly journals Hemidiaphragmatic paralysis following costoclavicular versus supraclavicular brachial plexus block: a randomized controlled trial

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Boohwi Hong ◽  
Soomin Lee ◽  
Chahyun Oh ◽  
Seyeon Park ◽  
Hyun Rhim ◽  
...  
Keyword(s):  
Pulmonary Function ◽  
Brachial Plexus ◽  
Chest Radiograph ◽  
Brachial Plexus Block ◽  
Controlled Trial ◽  
Risk Difference ◽  
Before And After ◽  
Supraclavicular Brachial Plexus Block ◽  
Supraclavicular Block ◽  
Plexus Block

AbstractCostoclavicular brachial plexus block is emerging as a promising infraclavicular approach performed just below the clavicle. However, there are relatively little data regarding the hemidiaphragmatic paralysis (HDP) compared to the commonly performed supraclavicular block. We hypothesized that the incidence of HDP in costoclavicular block is lower than supraclavicular block like classical infraclavicular approach. Eighty patients were randomly assigned to ultrasound-guided supraclavicular (group S) or costoclavicular (group C) block with 25 mL of local anesthetics (1:1 mixture of 1% lidocaine and 0.75% ropivacaine). The primary outcome was the incidence of HDP, defined as less than 20% of fractional change in the diaphragm thickness on ultrasound M-mode. Also, pulmonary function test and chest radiograph were assessed before and after the surgery. The incidence of HDP was 4/35 (11.4%) in the group C and 19/40 (47.5%) in the group S (risk difference, − 36%; 95% CI − 54 to − 17%; P = 0.002). The mean (SD) change of DTF values were 30.3% (44.0) and 56.9% (39.3) in the group C and S, respectively (difference in means, − 26.6%; 95% CI − 45.8 to − 7.4%; P = 0.007). The pulmonary function was more preserved in group C than in group S. The determined diagnostic cut off value of the diaphragm elevation on chest radiograph was 29 mm. Despite the very contiguous location of the two approaches around the clavicle, costoclavicular block can significantly reduce the risk of HDP compared with supraclavicular block.

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