Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2020.10.015
Brazilian Journal of Anesthesiology
Original Investigation

An alternative approach for blocking the superior trunk of the brachial plexus evaluated by a single arm clinical trial

Uma abordagem alternativa para o bloqueio do tronco superior do plexo braquial avaliada por um ensaio clínico de braço único

Thiago Nouer Frederico, Rioko Kimiko Sakata, Luiz Fernando dos Reis Falcão, Paulo César Castello Branco de Sousa, Fernanda Melhmann, Cesar Augusto Simões, Leonardo Henrique Cunha Ferraro

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Abstract

Background
Interscalene brachial plexus block is associated with phrenic nerve paralysis. The objective of this study was to evaluate an alternative approach to interscalene brachial plexus blocks in terms of efficacy, grade of motor and sensory blockade and phrenic nerve blockade.

Methods
The study was prospective and interventional. The ten living patients studied were 18 to 65 years old, ASA physical status I or II, and submitted to correction of rotator cuff injury. A superior trunk blockade was performed at the superior trunk below the omohyoid muscle, without blocking the phrenic nerve. The needle was advanced below the prevertebral layer until contacting the superior trunk. In order to guarantee the correct positioning of the needle tip, an intracluster pattern of the spread was visualized. The block was performed with 5 mL of 0.5% bupivacaine in ten patients. In the six cadavers, 5 mL of methylene blue was injected. Diaphragmatic excursion was assessed by ultrasonography of the ipsilateral hemidiaphragm. In three patients, pulmonary ventilation was evaluated with impedance tomography. Pain scores and analgesic consumption were assessed in the recovery room for 6 h after the blockade.

Results
In the six cadavers, methylene blue didn’t reach the phrenic nerve. Ten patients underwent arthroscopic surgery, and no clinically phrenic nerve paralysis was observed. No patient reported pain during the first 6 h.

Conclusions
This study suggests that this new superior trunk approach to block the superior trunk may be an alternative technique to promote analgesia for shoulder surgery in patients with impaired respiratory function.

Keywords

Ultrasonography;  Brachial plexus;  Nerve block

Resumo

Justificativa: O bloqueio do plexo braquial interescalênico está associado à paralisia do nervo frênico. O objetivo deste estudo foi avaliar uma abordagem alternativa aos bloqueios interescalênicos do plexo braquial quanto à eficácia, grau de bloqueio motor e sensitivo e bloqueio do nervo frênico. Métodos: O estudo foi prospectivo e intervencionista. Os dez pacientes vivos estudados tinham idade entre 18 e 65 anos, estado físico ASA I ou II, e submetidos à correção da lesão do manguito rotador. O bloqueio do tronco superior foi realizado no tronco superior abaixo do músculo omo-hióideo, sem bloqueio do nervo frênico. A agulha foi avançada abaixo da camada pré-vertebral até entrar em contato com o tronco superior. Para garantir o correto posicionamento da ponta da agulha, foi visualizado um padrão intracluster do spread. O bloqueio foi realizado com 5mL de bupivacaína a 0,5% em dez pacientes. Nos seis cadáveres foram injetados 5mL de azul de metileno. A excursão diafragmática foi avaliada por ultrassonografia do hemidiafragma ipsilateral. Em três pacientes, a ventilação pulmonar foi avaliada com tomografia de impedância. Escores de dor e consumo de analgésicos foram avaliados na sala de recuperação por 6h após o bloqueio. Resultados: Nos seis cadáveres, o azul de metileno não atingiu o nervo frênico. Dez pacientes foram submetidos à cirurgia artroscópica, e clinicamente não foi observada paralisia do nervo frênico. Nenhum paciente relatou dor nas primeiras 6h. Conclusões: Este estudo sugere que esta nova abordagem do tronco superior para bloqueio do tronco superior pode ser uma técnica alternativa para promover analgesia para cirurgia do ombro em pacientes com função respiratória prejudicada.

Palavras-chave

Ultrassonografia; Plexo braquial; Bloqueio de nervo

References

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