Minimum effective concentration of bupivacaine for axillary brachial plexus block guided by ultrasound

Alexandre Takeda; Leonardo Henrique Cunha Ferraro; André Hosoi Rezende; Eduardo Jun Sadatsune; Luiz Fernando dos Reis Falcão; Maria Angela Tardelli

doi:10.1016/j.bjane.2013.11.007

Scientific Article

Minimum effective concentration of bupivacaine for axillary brachial plexus block guided by ultrasound

Concentração mínima efetiva de bupivacaína para o bloqueio do plexo braquial via axilar guiado por ultrassom

Alexandre Takeda; Leonardo Henrique Cunha Ferraro; André Hosoi Rezende; Eduardo Jun Sadatsune; Luiz Fernando dos Reis Falcão; Maria Angela Tardelli

http://dx.doi.org/10.1016/j.bjane.2013.11.007 Braz J Anesthesiol, vol.65, n3, p.163-169, 2015

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Abstract

INTRODUCTION: The use of ultrasound in regional anesthesia allows reducing the dose of local anesthetic used for peripheral nerve block. The present study was performed to determine the minimum effective concentration (MEC90) of bupivacaine for axillary brachial plexus block. METHODS: Patients undergoing hand surgery were recruited. To estimate the MEC90, a sequential up-down biased coin method of allocation was used. The bupivacaine dose was 5 mL for each nerve (radial, ulnar, median, and musculocutaneous). The initial concentration was 0.35%. This concentration was changed by 0.05% depending on the previous block; a blockade failure resulted in increased concentration for the next patient; in case of success, the next patient could receive or reduction (0.1 probability) or the same concentration (0.9 probability). Surgical anesthesia was defined as driving force ≤2 according to the modified Bromage scale, lack of thermal sensitivity and response to pinprick. Postoperative analgesia was assessed in the recovery room with numeric pain scale and the amount of drugs used within 4 h after the blockade. RESULTS: MEC90 was 0.241% [R 2: 0.978, confidence interval: 0.20-0.34%]. No patient, with successful block, reported pain after 4 h. CONCLUSION: This study demonstrated that ultrasound guided axillary brachial plexus block can be performed with the use of low concentration of local anesthetics, increasing the safety of the procedure. Further studies should be conducted to assess blockade duration at low concentrations.

Keywords

Regional anesthesia, Brachial plexus block, Bupivacaine, Ultrasound, Axillary block, Minimum effective concentration

Resumo

INTRODUÇÃO: O uso do ultrassom na anestesia regional permite a redução da dose de anestésico local utilizada para o bloqueio de nervos periféricos. O presente estudo foi conduzido com o objetivo de determinar a concentração mínima efetiva (CME90) de bupivacaína para o bloqueio do plexo braquial via axilar (BPVA). MÉTODOS: Pacientes submetidos a cirurgias da mão foram recrutados. Foi usado um método de alocação "biased coin" seqüencial "up-down" para estimar a CME90. A dose de bupivacaína foi de 5 mL para cada nervo (radial, ulnar, mediano e musculocutâneo). A concentração inicial de era 0,35%. Essa concentração era alterada em 0,05% dependendo do bloqueio anterior: a falha do bloqueio resultava em aumento da concentração para o próximo paciente; no caso de sucesso, o próximo paciente poderia receber ou redução (probabilidade de 0,1) ou mesma concentração (probabilidade 0,9). A anestesia cirúrgica foi definida como força motora ≤ 2 segundo a escala de Bromage modificada, ausência de sensibilidade térmica e de resposta ao pinprick. A analgesia pós-operatória foi verificada na sala de recuperação anestésica com escala numérica de dor e a quantidade de analgésicos utilizados até 4 horas após o bloqueio. RESULTADOS: A CME90 foi de 0,241% [R2: 0,978, Intervalo de Confiança: 0,20%-0,34%]. Além disso, nenhum paciente com sucesso do bloqueio apresentou dor após 4 horas. CONCLUSÃO: Este estudo demonstrou que pode-se realizar o BPVA guiado por ultrassom utilizando-se baixas concentrações de anestésico local, aumentando a segurança do procedimento. Novos estudos devem ser realizados para avaliar a duração de bloqueios com baixas concentrações.

Palavras-chave

Anestesia regional, Bloqueio do plexo braquial, Bupivacaina, Ultrassom, Bloqueio axilar, Concentração mínima efetiva

References

Thompson GE, Rorie DK. Functional anatomy of the brachial plexus sheaths. Anesthesiology.. ;59:117-122.

Klaastad O, Smedby O, Thompson GE. Distribution of local anesthetic in axillary brachial plexus block: a clini- cal and magnetic resonance imaging study. Anesthesiology.. ;96:324-315.

Vester-Andersen T, Christiansen C, Sorensen M. Perivas- cular axillary block II: influence of injected volume of local anaesthetic on neural blockade. Acta Anaesthesiol Scand.. ;27:98-95.

Groban L. Central nervous system and cardiac effects from long-acting amide local anesthetic toxicity in the intact animal model. Reg Anesth Pain Med.. ;8:3.

Maher LE, Copeland SE, Ladd LA. Acute toxicity of local anesthetics: underlying pharmacokinetic and pharmacodynamic concepts. Reg Anesth Pain Med.. ;30:566-553.

O'Donnell BD, Iohom G. An estimation of the minimum effective anesthetic volume of 2% lidocaine in ultrasound-guided axillary brachial plexus block. Anesthesiology.. ;111:25-29.

Marhofer P, Schrogendorfer K, Wallner T. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med.. ;23:584-588.

Casati A, Baciarello M, Di Cianni S. Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth.. ;98:827-823.

Willschke H, Bosenberg A, Marhofer P. Ultrasonographic- guided ilioinguinalIiliohypogastric nerve block in pediatric anesthesia: what is the optimal volume?. Anesth Analg.. ;102:684-680.

Falcão LF, Perez MV, de Castro I. Minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasound- guided interscalene brachial plexus block. Br J Anaesth.. ;110:450-455.

Ferraro LHC, Takeda A, Rezende AH. Determination of the minimum effective volume of bupivacaine 0.5% for ultrasound- guided axillary brachial plexus block. Rev Bras Anestesiol.. ;64:53-49.

Hadzic A, Dewaele S, Gandhi K. Volume and dose of local anesthetic necessary to block the axillary brachial plexus using ultrasound guidance. Anesthesiology.. ;111:9-8.

Pace NL, Stylianou MP. Advances in and limitations of up- and-down methodology: a précis of clinical us, study design, and dose estimation in anesthesia research. Anesthesiology.. ;107:144-152.

Cappelleri G, Aldegheri G, Ruggieri F. Minimum effec- tive anesthetic concentration (MEAC) for sciatic nerve block: subgluteus and popliteal approaches. Can J Anaesth.. ;54:289-283.

Lesklw U, Weinberg GL. Lipid resuscitation for local anes- thetic toxicity: is it really lifesaving?. Curr Opin Anaesthesiol.. ;22:667-671.

Bem S, Akpa BS, Kuo I. Lipid resuscitation: a life-saving antidote for local anesthetic toxicity. Curr Pharm Biotechnol.. ;12:313-319.

Casati A, Fanelli G, Borghi B. Ropivacaine or 2% mepiva- caine for lower limb peripheral nerve blocks. Anesthesiology.. ;90:1052-1047.

Krenn H, Deusch E, Balogh B. Increasing the injection volume by dilution improves the onset of motor blockade, but not sensory blockade of ropivacaine for brachial plexus block. Eur J Anaesthesiol.. ;20:25-21.

Pippa P, Cuomo P, Panchetti A. High volume and low concentration of anaesthetic solution in the perivas- cular interscalene sheath determines quality of block and incidence of complications. Eur J Anaesthesiol.. ;23:855-860.

Yang S, Abrahams MS, Hurn PD. Local anesthetic Schwann cell toxicity is time and concentration dependent. Reg Anesth Pain Med.. ;36:451-444.

Fredrickson MJ, Smith KR, Wong AC. Importance of volume and concentration for ropivacaine interescalene block in preventing recovery room pain and minimizing motor block after shoulder surgery. Anesthesiology.. ;112:1374-1381.

Fredrickson MJ, White R, Danesh-Clough TK. Low-volume ultrasound-guided nerve block provides inferior postoperative analgesia compared to a higher-volume landmark technique. Reg Anesth Pain Med.. ;36:393-398.

Minimum effective concentration of bupivacaine for axillary brachial plexus block guided by ultrasound

Concentração mínima efetiva de bupivacaína para o bloqueio do plexo braquial via axilar guiado por ultrassom

Alexandre Takeda; Leonardo Henrique Cunha Ferraro; André Hosoi Rezende; Eduardo Jun Sadatsune; Luiz Fernando dos Reis Falcão; Maria Angela Tardelli

Abstract

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