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
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
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.
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References
1 W.F. Urmey, K.H. Talts, N.E. Sharrock One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography Anesth Analg., 72 (1991), pp. 498-503
2 S. Riazi, N. Carmichael, I. Awad, R.M. Holtby, C.J. McCartney Effect of local anaesthetic volume (20 vs. 5 mL) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block Br J Anaesth., 101 (2008), pp. 549-556
3 O. Stundner, M. Meissnitzer, C.M. Brummett, et al. Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs. low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: a randomized, controlled trial Br J Anaesth., 116 (2016), pp. 405-412
4 D.Q. Tran, M.F. Elgueta, J. Aliste, R.J. Finlayson Diaphragm-sparing nerve blocks for shoulder surgery Reg Anesth Pain Med., 42 (2017), pp. 32-38
5 D. Burckett-St Laurent, V. Chan, K.J. Chin Refining the ultrasound-guided interscalene brachial plexus block: the superior trunk approach Can J Anaesth., 61 (2014), pp. 1098-1102
6 A. Siegenthaler, B. Moriggl, S. Mlekusch, et al. Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach Reg Anesth Pain Med., 37 (2012), pp. 325-328
7 N. Hussain, G. Goldar, N. Ragina, L. Banfield, J.G. Laffey, F.W. Abdallah Suprascapular and interscalene nerve block for shoulder surgery: a systematic review and meta-analysis Anesthesiology., 127 (2017), pp. 998-1013
8 D.H. Kim, Y. Lin, J.C. Beathe, et al. Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial Anesthesiology., 131 (2019), pp. 521-533
9 H. Sehmbi, M. Johnson, S. Dhir Ultrasound-guided subomohyoid suprascapular nerve block and phrenic nerve involvement: a cadaveric dye study Reg Anesth Pain Med., 44 (2019), pp. 561-564
10 A.A. Lookman Brachial plexus infiltration; single injection technique Anaesthesia., 13 (1958), pp. 5-18
11 L.F. Falc.·o, M.V. Perez, I. de Castro, A.M. Yamashita, M.A. Tardelli, J.L. Amaral Minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasound-guided interscalene brachial plexus block Br J Anaesth., 110 (2013), pp. 450-455
12 S.D. Petrar, M.E. Seltenrich, S.J. Head, S.K. Schwarz Hemidiaphragmatic Paralysis Following Ultrasound-Guided Supraclavicular Versus Infraclavicular Brachial Plexus Blockade. A Randomized Clinical Trial Reg Anesth Pain Med., 40 (2015), pp. 133-138
13 S.H. Renes, H.H. Spoormans, M.J. Gielen, H.C. Rettig, G.J. van Geffen Hemidiaphragmatic paresis can be avoided in ultrasound-guided supraclavicular brachial plexus block Reg Anesth Pain Med., 34 (2009), pp. 595-599
14 F.W. Abdallah, D.N. Wijeysundera, A. Laupacis, et al. Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery: A Multicenter Randomized Trial Anesthesiology., 132 (2020), pp. 839-853
15 P.B. Cornish, C.J. Leaper, J.L. Hahn The ..úaxillary tunnel..Ñ: an anatomic reappraisal of the limits and dynamics of spread during brachial plexus blockade Anesth Analg., 104 (2007), pp. 1288-1291
16 C.D. Franco, A. Rahman, G. Voronov, J.M. Kerns, R.J. Beck, C.C.3rd. Buckenmaier Gross anatomy of the brachial plexus sheath in human cadavers Reg Anesth Pain Med., 33 (2008), pp. 64-69
17 D. Nieuwveld, V. Mojica, A.E. Herrera, J. Pom..s, A. Prats Sala-Blanch. Medial approach of ultrasound-guided costoclavicular plexus block and its effects on regional perfussion Rev Esp Anestesiol Reanim., 64 (2017), pp. 198-205
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