Ultrasound-guided peripheral nerve blockade of the upper extremity

Current Opinion in Anaesthesiology

Volumn 25, Issue 2, 2012, Pages 253-259

  Koscielniak Nielsen, Zbigniew J ^a   Dahl, Jörgen B ^a  

^a Rigshospitalet   (Denmark)

Author keywords

Brachial plexus; Complications; Nerve block; Regional anesthesia; Ultrasound guidance; Upper extremity

Indexed keywords

ADRENALIN PLUS BUPIVACAINE; BUPIVACAINE; CLONIDINE; DEXAMETHASONE; DEXMEDETOMIDINE; LIDOCAINE; LOCAL ANESTHETIC AGENT; MEPIVACAINE; PIRITRAMIDE; ROPIVACAINE; TRAMADOL;

ADD ON THERAPY; BRACHIAL PLEXUS ANESTHESIA; CATHETER; CATHETERIZATION; CHRONIC PAIN; CONTINUOUS INFUSION; DIAPHRAGM PARALYSIS; DOSE CALCULATION; ECHOGRAPHY; HUMAN; INJECTION SITE DISCOMFORT; INTERSCALENE BLOCKADE; INTRAEPINEURIAL INJECTION; MEDIAN NERVE; NERVE BLOCK; NERVE ROOT; NERVE SHEATH; NEUROLOGICAL COMPLICATION; NEUROPRAXIS; PAIN; PAIN ASSESSMENT; PATIENT CONTROLLED ANALGESIA; PRIORITY JOURNAL; RADIAL NERVE; RANDOMIZED CONTROLLED TRIAL; RECOVERY ROOM; REVIEW; SEIZURE; SHOULDER PAIN; SHOULDER SURGERY; SKELETAL MUSCLE; SUPRACLAVICULAR BLOCKADE; SUPRASCAPLAR NERVE BLOCK; SUPRASPINATUS MUSCLE; SYSTEMIC DISEASE; ULNAR NERVE; UNCONSCIOUSNESS; UPPER EXTREMITY PERIPHERAL NERVE BLOCKADE;

ANESTHETICS, LOCAL; BRACHIAL PLEXUS; CATHETERIZATION; DEXAMETHASONE; HUMANS; NERVE BLOCK; ULTRASONOGRAPHY, INTERVENTIONAL; UPPER EXTREMITY;

EID: 84859768158     PISSN: 09527907     EISSN: 14736500     Source Type: Journal    
DOI: 10.1097/ACO.0b013e32835069c2     Document Type: Review

References (44)

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2. Koscielniak-Nielsen ZJ. Ultrasound-guided peripheral nerve blocks: What are the benefits? Acta Anesthesiol Scand 2008; 52:727-737. (Pubitemid 351829487)
3. Frederickson 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; 112:1374-1381. The optimal volume of ropivacaine is 20 ml and the optimal concentration is 0.375%. After 24 h pain scores were similar to the 30 ml, 0.5% group.
4. Renes SH, Rettig HC, Gielen MJ, et al. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med 2009; 34:498-502.
5. Sinha SK, Abrams JH, Barnett JT, et al. Decreasing the local anesthetic volume from 20 to 10 ml for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med 2011; 36:17-20. Spirometry showed significant and equivalent reduction in FVC, FEV1 and PEF in both groups 15 min after the block and upon discharge home. 10 ml is still too much.
6. Renes SH, Van Geffen GJ, Rettig HC, et al. Minimum effective volume of local anesthetic for shoulder analgesia by ultrasound-guided block at root C7 with assessment of pulmonary function. Reg Anesth Pain Med 2010; 35:529-534. The MEAV 50 and MEAV 95 for shoulder analgesia were 2.9 and 3.6 ml, respectively. Spirometric values before the block and 2 h after surgery were unchanged. Low volumes may be necessary to avoid diaphragmatic paresis.
7. McNaught A, Shastri U, Carmichael N, et al. Ultrasound reduces the minimum effective local anaesthetic volume compared with peripheral nerve stimulation for interscalene block. Br J Anaesth 2011; 106:124-130. The MEAV 50 in ultrasound group was 0.9 ml compared with 5.4 ml in the nerve stimulator group. Still, probably very few anesthesiologists will use such a low volumes.
8. Gupta PK, Pace NL, Hopkins PM. Effect of body mass index on ED50 volume of bupivacaine 0.5% for supraclavicular brachial plexus block. Br J Anaesth 2010; 104:490-495. ED50 does not increase with increasing BMI and varies between 8.9 and 13.4 ml. Obese patients may actually need less local anesthetic.
9. Duggan E, El Beheiry H, Perlas A, et al. Minimum effective volume of local anesthetic for ultrasound-guided supraclavicular brachial plexus block. Reg Anesth Pain Med 2009; 34:215-218.
10. Tran De Q.H, Dugani S, Correa JA, et al. Minimum effective volume of lidocaine for ultrasound-guided supraclavicular block. Reg Anesth pain Med 2011; 36:466-469.
11. Harper GK, Stafford MA, Hill DA. Minimum volume of local anaesthetic required to surround each of the constituent nerves of the axillary brachial plexus, using ultrasound-guidance: A pilot study. Br J Anaesth 2010; 104:633-636. Between 2 and 4 ml of local anesthetic is sufficient to surround each of the four main nerves, but the quality of the resulting block is poor.
12. O'Donnell B, Riordan J, Ahmad I, Iohom G. A clinical evaluation of block characteristics using one milliliter of 2% lidocaine in ultrasound-guided brachial plexus block. Anesth Analg 2010; 111:808-810. Unusually high success rate with 1 ml of lidocaine per nerve. A possibility of intraneural injections?
13. Marhofer P, Eichenberger U, Stoeckli S, et al. Ultrasonographic guided axillary plexus blocks with low volumes of local anaesthetics: A crossover volunteer study. Anaesthesia 2010; 65:266-271. Four ml of 1% mepivacaine resulted in 90% block success and 14.8 ml resulted in 100% block success of the radial, median and ulnar nerves. Musculocutaneous nerve was not included.
14. Eichenberger U, Stoeckli S, Marhofer P, et al. Minimal local anesthetic volume for peripheral nerve block: A new ultrasound-guided nerve-dimension based method. Reg Anesth Pain Med 2009; 34:242-246.
15. Ponrouch M, Bouic N, Bringuier S, et al. Estimation and pharmacodynamic consequences of the minimum effective anesthetic volumes for median and ulnar nerve blocks: A randomized, double-blind, controlled comparison between ultrasound and nerve stimulation guidance. Anest Analg 2010; 111:1059-1064. Ultrasound guidance compared with nerve stimulator reduced the MEAV50 of mepivacaine for the median nerve block in humeral canal by half, from 4 to 2 ml.
16. De Jong RH. Dynamics of nerve block. In Local anesthetics. Mosby-Year Book Inc. 1994 (ISBN 0-8016-6931-6).
17. Al-Nasser B, Hubert C, Negre M. Role of local anesthetic spread patter and electrical stimulation in ultrasound-guided musculocutaneous nerve block. J Clin Anesth 2010; 22:334-339. Circumferential local anesthetic spread is unusual in nerve stimulator-guided blocks. Despite this, higher volumes result in successful blocks. These results should be confirmed for larger nerves.
18. Gutton C, Choquet O, Antonini F, Grossi P. Ultrasound-guided interscalene block: Influence of anatomic variations in clinical practice. Ann Fr An Reanim 2010; 29:770-775 (article in French). Anatomical variations of C5, C6 or both nerve roots are common, but do not affect block effectiveness. Aberrant vessels may be close to the plexus trunks.
19. Peng PWH, Wiley MJ, Liang J, Bellingham GA. Ultrasound-guided suprascapular nerve block: A correlation with fluoroscopic and cadaveric findings. Can J Anaesth 2010; 57:143-148. The structure previously identified on ultrasound images as transverse ligament is the fascia of the supraspinatus muscle, but local anesthetic injections are made close to the nerve.
20. Peng PWH, Narouze S. Ultrasound-guided interventional procedures in pain medicine: A review of anatomy, sonoanatomy and procedures. Reg Anesth Pain Med 2009; 34:458-474.
21. Borglum J, Bartholdy A, Hautopp H, et al. Ultrasound-guided continuous suprascapular nerve block for adhesive capsulitis: One case and a short topical review. Acta Anaesthesiol Scand 2011; 55:242-247.
22. Vieira PA, Pulai I, Tsao GC, et al. Dexamethasone with bupivacaine increases duration of analgesia in ultrasound-guided interscalene brachial plexus blockade. Eur J Anaesthesiol 2010; 27:285-288. 8mg of dexamethasone prolongs sensory and motor block and reduces postoperative opioid use.
23. Parrington SJ, O'Donnell D, Chan VWS, et al. Dexamenthasone added to mepivacaine prolongs the duration of analgesia after supraclavicular brachial plexus blockade. Reg Anesth Pain Med 2010; 35:422-426. 8mg of dexamethasone prolongs analgesia but neither reduces intra nor postoperative opioid consumption.
24. Frederickson MJ, Ball CM, Dagleish AJ. Analgesic effectiveness of a continuous versus single-injection interscalene block for minor arthroscopic shoulder surgery. Reg Anesth Pain Med 2010; 35:28-33. Ropivacaine infusion and PC boluses improve analgesia during the first 24 h postoperatively. Unfortunately the study is neither blinded nor placebo controlled.
25. Goebel S, Stehle J, Schwemmer U, et al. Interscalene brachial plexus block for open-shoulder surgery: A randomized, double-blind, placebo-controlled trail between single-shot anesthesia and patient controlled catheter system. Arch Orthop Trauma Surg 2010; 130:533-540. A double-blind, placebo-controlled study of PC boluses of ropivacaine without basal infusion. No significant differences in postoperative pain intensity, but higher opioid consumption in the single-shot group on the first postoperative day. Multimodal pain treatment starting on the morning of surgery may eliminate this difference.
26. Mariano ER, Sandhu NS, Loland V, et al. A randomized comparison of infraclavicular and supraclavicular continuous peripheral nerve blocks for postoperative analgesia. Reg Anesth Pain Med 2011; 36:26-31. A very important study showing that infraclavicular catheters placed under the axillary artery provide superior analgesia up to 24 h after elbow, forearm surgery compared with supraclavicular catheters placed between the plexus and the subclavian artery. The infraclavicular catheters are also easier to keep in place.
27. Mariano ER, Loland VJ, Sandhu NS, et al. A trainee-based randomized comparison of stimulating interscalene perineural catheters with a new technique using ultrasound guidance alone. J Ultrasound Med 2010; 29:329-336. One of several small studies from this group showing that ultrasound guidance significantly reduces catheter placement time.
28. Mariano ER, Cheng GS, Choy LP, et al. Electrical stimulation versus ultrasound guidance for popliteal-sciatic catheter insertion. Reg Anesth Pain Med 2009; 34:480-485.
29. Heil JW, Ilfeld BM, Loland VJ, Mariano ER. Preliminary experience with a novel ultrasound-guided supraclavicular perineural catheter insertion technique for perioperative analgesia of the upper extremity. J Ultrasound Med 2010; 29:1481-1485. All 10 patients had a successful catheter placement. However, the median time for insertion was unusually long (mean 24 min) and three catheters had to be removed prematurely.
30. Gürkan Y, Takin M, Acar S, et al. Is nerve stimulation needed during an ultrasound-guided lateral sagittal infraclavicular block. Acta Anaesthesiol Scand 2010; 54:403-407. A large RCT showing significant reduction of block performance time using ultrasound guidance alone. Similar block onset and success rates. Nerve stimulation has no clinical advantages.
31. Imasogie N, Ganapathy S, Singh S, et al. A prospective, randomized, doubleblind comparison of ultrasound-guided axillary brachial plexus blocks using 2 versus 4 injections. Anesth Analg 2010; 110:1222-1226. Large RCT showing no significant differences in block effectiveness. However, in the two-injection group the needle was re-directed to assure local anesthetic spread around the artery. Neither the number of patients requiring these redirections nor number of needle passes are reported, so the authors could have compared two groups with multiple local anesthetic injections.
32. Tran De QH, Bertini P, Zaouter C, et al. A prospective, randomized comparison between single-and double-injection ultrasound-guided infraclavicular brachial plexus block. Reg Anesth Pain Med 2010; 35:16-21. A single local anesthetic injection posterior to the axillary artery is sufficient.
33. Frederickson MJ, Wolstencroft P, Kejriwal R, et al. Single versus triple injection ultrasound-guided infraclavicular block: Confirmation of the effectiveness of the single injection technique. Anesth Analg 2010; 111:1325-1327. A single local anesthetic injection posterior to the axillary artery is sufficient.
34. Bowens C, Gupta RK, O'Byrne WT, et al. Selective local anesthetic placement using ultrasound guidance and neurostimulation for infraclavicular brachial plexus block. Anesth Analg 2010; 110:1480-1485. Single-shot local anesthetic injections at the posterior BP cord resulted in better success rates and lower postoperative pain scores compared with local anesthetic injections at the lateral or the medial cord. One injection in the middle of the plexus is sufficient.
35. Bloc S, Mercadal L, Garnier T, et al. Comfort of the patient during axillary block placement: A randomized comparison of the neurostimulation and the ultrasound-guidance techniques. Eur J Anaesthesiol 2010; 27:628-633. Ultrasound-guided needle advancement using out-of-plane technique causes only minimal discomfort and takes less time than in-plane or nerve stimulator-guided techniques.
36. Frederiksen BS, Koscielniak-Nielsen ZJ, Jakobsen RB, et al. Procedural pain of an ultrasound-guided brachial plexus block: A comparison of axillary and infraclavicular approaches. Acta Anaesthesiol Scand 2010; 54:408-413. No significant differences in procedural pain but faster performance of the infraclavicular block.
37. Dufour E, Cymerman A, Nourry G, et al. An ultrasonographic assessment of nerve-stimulation guided median nerve block at the elbow: A local anesthetic spread, nerve size and clinical efficacy study. Anesth Analg 2010; 111:561-567. A large study confirming that nerve stimulator-guided blocks often result in intraneural local anesthetic injections. No major neurological complications observed. Poor efficacy of extraneural injections. We may need intraneural injections for rapid and effective blocks.
38. Bigeleisen PE, Moayeri N, Groen GJ. Extraneural versus intraneural stimulation thresholds during ultrasound-guided supraclavicular block. Anesthesiology 2009; 110:1235-1243.
39. Morfey D, Brull R. Ultrasound-guided supraclavicular block: What is intraneural? Anesthesiology 2010; 112:250-251. This letter very accurately describes the controversies of so called 'intraneural' local anesthetic injections and advocates injections within the plexus, in-between trunks or divisions. Supraclavicular local anesthetic injections within the BP are also a current standard in our hospital.
40. Koscielniak-Nielsen ZJ, Frederiksen BS, Rasmussen H, Hesselbjerg L. A comparison of ultrasound-guided supraclavicular and infraclavicular blocks for upper extremity surgery. Acta Anaesthesiol Scand 2009; 53:620-626.
41. Orebaugh SL, McFadden K, Skorupan H, Bigeleisen PE. Subepineurial injection in ultrasound-guided interscalene needle tip placement. Reg Anesth Pain Med 2010; 35:450-454. In-plane needle guidance did not prevent intraneural injections in over half of the cadavers. No histological injury was evident. However, this may be different in clinical practice where larger volumes are used.
42. Liu SS, Gordon MA, Shaw BS, et al. A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery. Anesth Analg 2010; 111:617-623. A large study confirming, high efficacy and safety of ultrasound-guided blocks in day-case surgery. Five cases of transient neuropathy after interscalene block, none after supraclavicular block. Supraclavicular approach may be a better alternative for shoulder surgery.
43. Cohen JM, Gray AT. Functional deficits after intraneural injection during interscalene block. Reg Anesth Pain Med 2010; 35:397-399. New onset sensory and motor block on the first postoperative day resolving within few weeks.
44. Dooley J, Fingerman M, Melton S, Klein SM. Contralateral local anesthetic spread from an outpatient interscalene catheter. Can J Anesth 2010; 57:936-939. Symptoms appearance on the second postoperative day suggest excessive spread of local anesthetic. Ropivacaine infusion 8 ml/h in obese patient may be too much.