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104: Comparison of single, transarterial and multiple injection techniques, for axillary brachial plexus block for distal upper extremity surgery
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104. Comparison of single, transarterial and multiple injection techniques, for axillary brachial plexus block for distal upper extremity surgery A. Makris1, L. Palialexi1, A. Tsirogianni1, V. Zisopoulou1, Th. Mania2 1Anaesthesiology, General Hospital of Lamia, Lamia, Greece, 2Anaesthesiology, General Hospital of Veroia, Veroia, Greece Background & Aims: The axillary block is the most commonly performed variety of brachial plexus block. The aim of our study was to compare the effects of 3 techniques using single, transarterial and multiple injections. Methods: After institutional approval and informed consent, 48 patients scheduled for hand, wrist or forearm surgery, were randomly divided into 3 groups of 16 (A, B and C). All patients received axillary brachial plexus anesthesia, using 40ml ropivacaine 0,5 % solution. In group A, a single injection technique was used, inserting the needle in the plexus sheath, felt as a click or with the patient mentioning paresthesia. In group B, transarterial approach was used, injecting 20 ml deep to and 20 ml superficial to the axillary artery. In group C, multiple injection technique was used, involving 2, 3 or 4 separate terminal nerves identification with a nerve stimulator and injection of an amount of local anesthetic around each. We recorded onset time of anesthesia, success rate of the block, need for additional medication and patient satisfaction. All incomplete blocks were successfully supplemented by electrolocating the unblocked nerves. Results: Onset time and need for additional medication (fentanyl 100 g or nerve block supplementation) were less in group C (14-20 min, 12% respectively) than in groups A( 25-35min, 31%) and B(20-30 min, 25%).In group C, the more nerves detected by the nerve stimulator before injection of local anaesthetic, the higher the success rate of the block. Conclusions: The multiple injection technique produces faster and more extensive block than the transarterial technique and the latter, faster and more extensive block than the single injection technique. The single injection block is rapidly performed, is better tolerable by the patient, but gives unpredictable results. Block by multiple nerve stimulation technique gives better results, but takes longer to perform.
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Peripheral Nerve Blocks
101
122. Dupuytren’s fasciectomy under wrist block anaesthesia— our experience S. Quasim1, M. Kyi2, S. Giri3, G. Krishnamurthy4 1Specialist Registrar Anaesthetics, Good Hope Hospital, West Midlands, UK, Sutton Coldfield, UK, 2Staff Grade Anaesthetist, Good Hope Hospital, Sutton Coldfield, UK, 3Senior House officer Orthopaedics, Good Hope Hospital, Sutton Coldfield, UK, 4Consultant Orthoapedic Surgeon, Good Hope Hospital, Sutton Coldfield, UK Background & Aims: It is a widely-held belief that using wrist block anaesthesia for Dupuytren’s fasciectomy is unacceptable due to the use of an upper arm tourniquet. However, this is common practice in our institution and we have reviewed 85 patients in order to demonstrate our experience. Methods: A retrospective analysis of 85 consecutive patients undergoing Dupuytren’s fasciectomy using Brunner’s zigzag incision was performed. A standardised technique was used: ● ●
● ● ●
Single anaesthetist; single surgeon. Peripheral nerve block administered using 23G hypodermic needle (landmark technique), to block median and ulnar nerves at the wrist. A total 3-5 ml 2% lidocaine and 3-5ml 0.5% bupivicaine for each nerve. Elevation of arm during skin preparation, followed by draping. Tourniquet inflated immediately prior to incision. Deflation of tourniquet immediately after excision of abnormal tissue and correction of deformity. Haemostasis under direct vision after tourniquet release.
Data collected included demographics, finger(s) involved, tourniquet time and additional drugs used. Follow-up was complete for at least 2 months in order to identify anaesthetic or surgical complications. Results: Data collection was complete for 70 patients. Wrist block was effective in a 69 patients. One patient had an inadequate block and was converted to general anaesthesia. Four patients required additional local anaesthetic infiltration (⬍ 5ml). Seven out of 70 (10%) patients required additional sedation because of tourniquet pain (2mg midazolam in 6 cases, 4mg morphine in 1case). In these 7 cases, the tourniquet was inflated for more than 30 minutes. Mean tourniquet time was 22.5 minutes (SD 6.03, range 12 – 40 minutes). No anaesthetic complications were recorded. Conclusion: Wrist block anaesthesia is an acceptable technique for Dupuytren’s fasciectomy using an upper arm tourniquet, provided tourniquet time is minimised. It has advantages over more proximal techniques/general anaesthesia and we have demonstrated no anaesthetic complications.
104. Comparison of single, transarterial and multiple injection techniques, for axillary brachial plexus block for distal upper extremity surgery A. Makris1, L. Palialexi1, A. Tsirogianni1, V. Zisopoulou1, Th. Mania2 1Anaesthesiology, General Hospital of Lamia, Lamia, Greece, 2Anaesthesiology, General Hospital of Veroia, Veroia, Greece Background & Aims: The axillary block is the most commonly performed variety of brachial plexus block. The aim of our study was to compare the effects of 3 techniques using single, transarterial and multiple injections. Methods: After institutional approval and informed consent, 48 patients scheduled for hand, wrist or forearm surgery, were randomly divided into 3 groups of 16 (A, B and C). All patients received axillary brachial plexus anesthesia, using 40ml ropivacaine 0,5 % solution. In group A, a single injection technique was used, inserting the needle in the plexus sheath, felt as a click or with the patient mentioning paresthesia. In group B, transarterial approach was used, injecting 20 ml deep to and 20 ml superficial to the axillary artery. In group C, multiple injection technique was used, involving 2, 3 or 4 separate terminal nerves identification with a nerve stimulator and injection of an amount of local anesthetic around each. We recorded onset time of anesthesia, success rate of the block, need for additional medication and patient satisfaction. All incomplete blocks were successfully supplemented by electrolocating the unblocked nerves. Results: Onset time and need for additional medication (fentanyl 100 g or nerve block supplementation) were less in group C (14-20 min, 12% respectively) than in groups A( 25-35min, 31%) and B(20-30 min, 25%).In group C, the more nerves detected by the nerve stimulator before injection of local anaesthetic, the higher the success rate of the block. Conclusions: The multiple injection technique produces faster and more extensive block than the transarterial technique and the latter, faster and more extensive block than the single injection technique. The single injection block is rapidly performed, is better tolerable by the patient, but gives unpredictable results. Block by multiple nerve stimulation technique gives better results, but takes longer to perform.
•
Peripheral Nerve Blocks
101
122. Dupuytren’s fasciectomy under wrist block anaesthesia— our experience S. Quasim1, M. Kyi2, S. Giri3, G. Krishnamurthy4 1Specialist Registrar Anaesthetics, Good Hope Hospital, West Midlands, UK, Sutton Coldfield, UK, 2Staff Grade Anaesthetist, Good Hope Hospital, Sutton Coldfield, UK, 3Senior House officer Orthopaedics, Good Hope Hospital, Sutton Coldfield, UK, 4Consultant Orthoapedic Surgeon, Good Hope Hospital, Sutton Coldfield, UK Background & Aims: It is a widely-held belief that using wrist block anaesthesia for Dupuytren’s fasciectomy is unacceptable due to the use of an upper arm tourniquet. However, this is common practice in our institution and we have reviewed 85 patients in order to demonstrate our experience. Methods: A retrospective analysis of 85 consecutive patients undergoing Dupuytren’s fasciectomy using Brunner’s zigzag incision was performed. A standardised technique was used: ● ●
● ● ●
Single anaesthetist; single surgeon. Peripheral nerve block administered using 23G hypodermic needle (landmark technique), to block median and ulnar nerves at the wrist. A total 3-5 ml 2% lidocaine and 3-5ml 0.5% bupivicaine for each nerve. Elevation of arm during skin preparation, followed by draping. Tourniquet inflated immediately prior to incision. Deflation of tourniquet immediately after excision of abnormal tissue and correction of deformity. Haemostasis under direct vision after tourniquet release.
Data collected included demographics, finger(s) involved, tourniquet time and additional drugs used. Follow-up was complete for at least 2 months in order to identify anaesthetic or surgical complications. Results: Data collection was complete for 70 patients. Wrist block was effective in a 69 patients. One patient had an inadequate block and was converted to general anaesthesia. Four patients required additional local anaesthetic infiltration (⬍ 5ml). Seven out of 70 (10%) patients required additional sedation because of tourniquet pain (2mg midazolam in 6 cases, 4mg morphine in 1case). In these 7 cases, the tourniquet was inflated for more than 30 minutes. Mean tourniquet time was 22.5 minutes (SD 6.03, range 12 – 40 minutes). No anaesthetic complications were recorded. Conclusion: Wrist block anaesthesia is an acceptable technique for Dupuytren’s fasciectomy using an upper arm tourniquet, provided tourniquet time is minimised. It has advantages over more proximal techniques/general anaesthesia and we have demonstrated no anaesthetic complications.