Continuous supraclavicular brachial plexus anesthesia

Continuous Supraclavicular Brachial Plexus Anesthesia Juhani

Haasio, MD, PhD and Per H. Rosenberg,

Continuous supraclavicular brachial plexus blocks are useful for long surgical operations on the shoulder and upper extremity. Their usefulness can be increased with continuous infusions of local anesthetics through the same catheter for postoperative analgesia. Our technique includes the use of a commercial set (Contiplex; B. Braun Medical Inc, Melsungen, Germany and Bethlehem, PA). For shoulder surgery the most superficial trunk of the plexus is identified by using a nerve stimulator with a low current (0.2-0.3 mA) and motor response distal to the shoulder. The initial surgical anesthetic dose of 1% mepivacaine, 0.75% bupivacaine or 0.75% ropivacaine, with 5 pg/mL epinephrine, is injected. Then the catheter is threaded as far as it can be advanced without obstruction (usually less than 1 cm past the tip of the cannula). To have a functional catheter for 24 to 48 hours, it must be tightly fixed to the skin with tape or sutures. For postoperative analgesia, an infusion of either 0.25% bupivacaine or 0.2% ropivacaine solution can be used. Complications from catheter use are rare but occasional intraarterial catheterizations and epidural blocks have been observed. A phrenic nerve block will always accompany a successful supraclavicular brachial plexus block and hemidiaphragmatic dysfunction can occur as long as the infusion continues. Copyright 9 1997 by W.B. Saunders Company

ontinuous catheter techniques are useful in lengthy sur-

C gery of the upper extremity and for postoperative analgesia. Before the introduction of modern designated brachial plexus catheter sets, intravenous plastic cannulas and epidural catheters were often used as "brachial plexus catheters." Before the plastic era, immobilized metal needles or cannulas were used for various continuous intermittent regional anesthesia blocks. In the first published continuous brachial plexus block technique a metal needle was in fact left in situ in the axilla for the duration of surgery. The practicality of being able to supplement an inadequate brachial plexus block before surgery commences is another factor contributing to the popularity of using brachial plexus catheters in some centers. Both patients and surgeons have learned to appreciate the value of continuous brachial plexus techniques. The supraclavicular region of the brachial plexus can be entered using different approaches (Table 1). An interesting approach to the supraclavicular brachia] plexus was reported by Ilias et al s who, while using the Seldinger technique were From the Departmentof Anesthesiology,T6616Hospital, Helsinki University Central Hospital, Finland. Address reprint requests to Juhani Haasio, MD, PhD, Department of Anesthesiology, ]'6616 Hospital, Helsinki University Central Hospital, FIN00260 Helsinki, Finland. Copyright 9 1997 by W.B. Saunders Company 1084-208X/97/0102-000855.00/0

MD, PhD

able to pass an epidura] catheter all the way from the axilla to the supraclavicular region of the plexus. Although it is anatomically feasible, we have only rarely been successful in threading a guide wire unobstructed past the clavicular level. Therefore, this approach has not been routinely adopted in our clinical practice. Anecdotally, and according to textbooks on regional anesthesia, catheter techniques have been applied in all areas of the supraclavicular brachial plexus block. However, published studies are very rare. The first study on the use of continuous interscalene brachial plexus block for postoperative pain was published by Tuominen et al in i987. 9 Subsequent studies from this department have focused on the efficacy of the continuous block, bupivacaine pharmacokinetics, and side effects of the block.I0-15

Continuous Supraclavicular Brachial Plexus Block Use in Regional Anesthesia Gaertner et a116 used continuous supraclavicular brachial plexus anesthesia for nonarthroscopic shoulder surgery. One hundred patients received an initial dose of 0.5% bupivacaine plus etidocaine 1% with epinephrine, 0.5 mL/kg through a plexus block catheter. A success rate of only 16% was achieved and 65% of the patients received general anesthesia. Rung et a117 used the modified Seldinger technique for continuous supraclavicular brachial plexus anesthesia while performing a single injection technique with a short bevel 21 gauge (G) needle. A "J" tipped guide wire was passed through the needle. Then the needle was removed and a 3 French catheter was inserted over the guide wire. Ashley et al 7 performed an initial supraclavicular block with the aid of a nerve stimulator. The patients received 20 mL of 0.5% bupivacaine and 10 mL of 2% lidocaine with epinephrine 1:200,000. Half the patients then received a plexus catheter (Contiplex; B. Braun Medical Inc, Melsungen, Germany and Bethlehem, PA). The catheter was placed through the same puncture site b y using the loss-of-resistance technique with saline, and correct placement was confirmed with contrast medium. Catheters were injected postoperatively with local anesthetic as the occasion required and removed within 72 hours.

Use in Pain Management Continuous supraclavicular blocks have been sporadically used by ourselves and others for chronic pain. Sato et al ta used continuous supraclavicular brachial plexus analgesia for cancer pain for two weeks, and Abram and Haddox 19 have used this method in some patients in the treatment of causalgia.

Techniques in Regional Anesthesia and Pain Management, Vol 1, No 4 (October), 1997: pp 157-162

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TABLE 1. Modifications of the Supraclavicular Brachial Plexus Block Year and Physician

Technique

Modification

1911, Kulenkampff2

Supraclavicular

Percutaneous infiltration of the brachial plexus and search for multiple paresthesias and multiple injections. 1964, Winnie and Collins 3 Subclavian perivascular The presence of the subclavian artery in the neurovascular bundle is used as landmark and needle is directed caudad to the lower one-third of the interscalene space. 1970, Winnie 4 Interscalene Injection at the level of the interscalene groove (between anterior and middle scalene muscles). 1991, Moorthy et al5 Supraclavicular lateral paravascular Needle is inserted above and parallel to the subclavian artery with the direction caudally, posteriorly, and laterally toward the axilla. 1993, Rucci et al6 Posterior interscalene block 1995, Ashley et al7 Plumb and bob

Pharmacokinetic Aspects An interscalene brachial plexus block with 0.75% bupivacaine (150-210 rag) followed by a continuous infusion of 0.25% bupivacaine at a rate of 0.25 mg/kg/hour (ie, 17.5 rag/hour in the case of a 70-kg patient) does not seem to result in systemic toxicity.9,12 Plasma concentrations of bupivacaine have been highest soon after the initial brachial plexus block (approximately 3/xg/mL in individual cases). In patients with a 24-hour continuous infusion plasma concentrations have remained in tile vicinity of 1/~g/mL, whereas in the time period between 24 and 48 hours, a small but statistically significant increase in bupivacaine concentrations has been observed (Fig 1). 13 The concentration of two major metabolites of bupivacaine, desbutylbupivacaine (pipecolyl xylidide, or PPX) and 4-hydroxybupivacaine, increased slowly during the 24- and 48-hour continuous infusions.13 Even so, the maximum concentrations reached by these metabolites within an hour of discontinuing the infusions were so low that any pharmacological effect of the metabolites would be unlikely, a~ One of the reasons for lack of systemic toxicity of bupivacaine despite the use of larger than recommended dosages (500-800 mg/24 hour) is the fact that there does not appear to be any accumulation of unbound bupivacaine in the plasma (blood), ie, the fraction that is responsible for its immediate

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Fig 1. Plasma concentrations (mean +- SD) of bupivacaine (El), and two of its major metabolites, desbutylbupivacaine (1~) and 4-OH-bupivacaine (11), after an initial surgical interscalene brachial plexus block with 0.75% bupivacaine followed by a 48-hour continuous infusion of 0.25% bupivacaine 6 to 10 mlJkg/hour. Note the significant rise in bupivacaine concentration between 24 and 48 hours. (Reprinted with permission, la)

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action. This is the result of trauma-induced stimulation of synthesis of al acid glycoprotein, the acute phase protein that binds bupivacaine in plasma. 9m The capacity of % acid glycoprotein to bind bupivacaine in normal nontoxic situations is great, and even relatively minor surgery of the shoulder region causes an increase in the mean concentration of this protein by 38%. 12 The concentration of % acid glycoprotein may continue to increase for up to five days after surgery. 21 Another reason for the low incidence of systemic toxicity during continuous brachial plexus blocks is that the speed at which the local anesthetic concentration rises in blood is more important for acute systemic toxicity than the actual concentration. 22,23 When a brachial plexus catheter is correctly placed, the systemic absorption of local anesthetic is high only after the initial surgical anesthetic dose of local anesthetic, but during the continuous infusion of local anesthetic of an analgesic dose there are no rapid changes in plasma concentration. In the case of bupivacaine infusion for pain treatment it is estimated that the unbound concentration of bupivacaine in plasma should rise above 0.24 p~g/mL before central nervous system toxicity symptoms may appear. 24 This is about three times higher than the maximum unbound bupivacaine concentration observed during interscalene brachial plexus block with bupivacaine doses mentioned previously (150-210 rag).12 So far there are no published studies about plasma concentrations during continuous infusion brachial plexus blocks with the newest amide local anesthetic, ropivacaine. In continuous intravenous infusion in volunteers, mild central nervous system (CNS) toxic symptoms occur at doses about 25% greater in milligrams than those of bupivacaine. 25 The disposition is more efficient than that of bupivacaine 26 and, therefore, accumulation of ropivacaine during continuous regional nerve blocks can hardly be expected. PPX is also one of the major metabolites of ropivacaine, but, as in the case of bupivacaine, PPX or hydroxylated (para- and meta-hydroxy [OHI) metabolites probably would not pose any toxicity problems even during prolonged continuous brachial plexus blocks.

The Technique of the Authors Continuous supraclavicular brachial plexus anesthesia is systematically used in our institution especially for shoulder surgery. A Contiplex catheter set is used and the brachial plexus is identified with the aid of a nerve stimulator (Fig 2). The supraclavicular technique used by the authors is quite similar to that described by Winnie and Collins 3,2r for the subclavian perivascular approach except that a nerve stimulator is used instead of paresthesias. The patient is asked to turn his/her head about 30 degrees away from the side to be blocked HAASIO AND ROSENBERG

Fig 2. The Contiplex catheter set (B. Braun Medical Inc) and nerve stimulator used in our institution. and the interscalene groove is identified at C-6 level (Fig 3). During this time it is often beneficial to tell the patient to take a deep breath to make identification of the interscalene groove easier. 28 The skin is infiltrated with a small amount (0.5 m L) of local anesthetic at the injection site and then a short beveled needle (30 degrees. 1.3 mm outer diameter) is advanced in a caudad direction to seek a motor response with the current set

at 1.0 mA and a frequency of i Hz. A motor response is sought in the arm (distal to the shoulder) or hand with low current (0.2-0.3 mA) if possible, but sometimes a clear motor response with a current greater than 0.5 mA is sufficient to produce reliable anesthesia of the shoulder region. If a response from the phrenic nerve is observed, the needle is directed dorsally; and if a response from the back or scapular region (the suprascapular nerve) is observed; the needle is directed ventrally The cannula is slowly advanced over the needle as far as it goes easily without resistance. Then the needle is removed and 30 to 40 mL of local anesthetic is injected in 3 to 5 mL increments. The catheter is then threaded through the cannula and the cannula is removed. The catheter is fixed and covered with a sterile occlusive transparent dressing (Opsite; Smith & Nephew Medical Ltd, Hull, UK). At the end of the procedure the catheter is connected to an infusion pump for postanesthetic use. The subclavian perivascular method is used mainly for shoulder operations because by seeking motor response in the C-4-C-5 region, anesthesia of the upper trunk of the plexus is easily achieved and its block will provide analgesia and anesthesia sufficient for the shoulder operations. 29 The catheter placement is also easier compared to that in a "classic" interscalene technique such as the one described by Winnie. 27 If the planned surgery is on the elbow or clearly below the shoulder, however, we direct the needle as W-innie indicates for

Fig3, Supraclavicular technique of the authors. (A) The interscalene groove between the anterior and median scalene muscles is palpated. In patients with thin necks, the Chassaignac tubercle on the transverse process of C-6 can be easily palpated. In the nerve stimulator technique such a thorough, and sometimes painful, landmark identification procedure is not necessary. (B) The catheter set stimulator needle is directed almost directly caudad from the upper edge of the interscalene triangle. (C) A positive motor response in the shoulder region and/or the elbow region will be achieved at a distance of 2 to 4 cm, depending on tissue layer thickness. The catheter will be introduced after the fractional injection of the initial surgical anesthetic dose of the local anesthetic. CONTINUOUS SUPRACLAVlCULARBRACHIAL PLEXUS ANESTHESIA

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the interscalene approach, but we use the axillary brachial plexus method for operations on the elbow, forearm, and hand. Patients may be lightly sedated while performing this technique. Heavy sedation and general anesthesia should be avoided because intraneural injections may not be detected. It is obvious that in experienced hands, the success of the block is equally good with either the nerve stimulator technique or the paresthesia method, but for a beginning anesthesiologist it may be easier and safer to use the nerve stimulator technique. 3~

Indications T h e continuous supraclavicular brachial plexus anesthesia technique is suitable particularly for shoulder operations and associated postoperative pain treatment. It can be used also for hand operations although it is mandatory to achieve total anesthesia of the whole plexus, ie, from C-5 to T-1 (Fig 4). This is more difficult than to produce anesthesia of the shoulder region, which gets its neural innervation from the more superficially situated upper trunk of the plexus. Postoperative

pain management as well as rehabilitation and physiotherapy of the shoulder (eg, frozen shoulder) or the whole extremity is satisfactory when a catheter technique is used. We have also used catheters that are placed by the surgeon for pain relief after large and invasive cancer operations of the arm and shoulder region. A continuous interscalene brachial plexus block may be useful for the treatment of complex regional pain syndrome (reflex sympathetic dystrophy) of the arm because it can provide both plexus block analgesia and sympathetic block. For this purpose it suffices to place the catheter superficially adjacent to the most cephalad trunks of the plexus. Continuous supradavicular plexus blocks may be also be used m other chronic pain indications affecting the shoulder region.

Local Anesthetic Solutions The drugs of choice in the past have been mepivacaine 1% with 5 Ixg/mL of epinephrine, or bupivacaine 0.5% with 5 txg/mL of epinephrine for the initial surgical block of 30 to 40 mL. Nowadays, ropivacaine 0.75% is more and more frequently

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Fig 4. Anatomy of the brachial plexus. Note the layered trunks of the plexus when viewed from above. Key: 1, superior trunk; 2, median trunk; 3, inferior trunk; 4, phrenic nerve; 5, median nerve; 6, radial nerve; 7, ulnar nerve; and 8, musculocutaneous nerve. 160

HAASIO AND R O S E N B E R G

used for surgical anesthesia and the initial experience (1 year) is quite favorable. Immediately before injection epinephrine is added to achieve a concentration of 5 txg/mL to detect an intravascular injection, but vasopressors probably have no effect on the duration of the ropivacaine block. 31 For postoperative continuous infusion bupivacaine 0.25% or ropivacaine 0.2% is used dosages of 1 mL/10 kg/hour, ie, usually 5 to 8 mL per hour for 24 or 48 hours. There seems to be no benefit in adding fentanyl to the continuous infusion solution. 32

Acknowledgment We are grateful to Dr. Neal T. Sakima, Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, at the Johns Hopkins Hospital in Baltimore, MD, USA, and to Dr. William E Urmey, Department of Anesthesiology, The Hospital for Special Surgery, in New York, NY, USA for consultations regarding their use and views of continuous supraclavicular brachial plexus block.

References Complications, Problems, and Side Effects The use of large gauge needles to facilitate the passage of a catheter may cause problems and complications. Large gauge needles may cause pain, particularly when the deeper trunks of the plexus are sought. Bleeding and hematoma formation can sometimes occur. The anatomical proximity of the large vessels to the nerve plexus has to be kept in mind. and it is easy to avoid puncture of the external jugular vein just by noting its passage superficially to the interscalene groove. Catheters have occasionally fallen out of mobile patients. therefore special attention should be paid to the primary fixation of the catheter to the skin. Adhesive tape or a suture can prevent this problem. Occasional intravenous cannulation and. rarely, vertebral artery cannulation can occur while placing an interscalene catheter. 33 The injection of a small quantity of 0.75% bupivacaine resulted in loss of consciousness within a minute. without further signs of toxicity, There were no cardiac dysrhythmias and the patient recovered unharmed. In the subsequent radiograph the catheter tip was observed to be in the vertebral arte W. No blood was obtained in the initial aspiration test because the catheter was kinked. It is also possible to introduce the catheter into the epiduraP 4 or even subarachnoid space. Phrenic nerve block and hemidiaphragmatic paralysis occur always during a supraclavicular brachial plexus block. 14,32,35 The hemidiaphragmatic dysfunction continues partially during continuous interscalene blocks even when a dilute bupivacaine (0.125%) solution is used. 32 The constantly occurring paralysis of the diaphragm during a supraclavicular plexus block often passes unnoticed in healthy resting patients. However, in patients with chronic respiratory diseases a supraclavicular plexus block is considered contraindicated. Stellate ganglion block with the development of Homer's syndrome is a common side effect that has been seen in 15% to 30% of the patients in our studies. 14,32 Hoarseness may occur occasionally. There is always the risk of pneumothorax when a needle is directed caudad towards the cupula of the lung. Transient hearing loss may occur on the ipsilateral side ~5and this is probably caused by the sympathetic blockade and swelling of the mucosa in the ear and the eustachian tube. The amide-type local anesthetics may cause local toxic damage to skeletal muscle tissue. 36,37 Therefore, prolonged postoperative infusions of local anesthetics into the "muscular" supraclavicular region may be disadvantageous. In the past ten years, our practice of discontinuing the postoperative supraclavicular (interscalene) brachial plexus block infusion within 48 hours has been found to be safe also in this respect. CONTINUOUS SUPRACLAVICULAR BRACHIAL PLEXUS ANESTHESIA

1. Ansbro FB: A method of continuous brachial plexus block. Am J Surg 71:7i 6-722, 1946 2. Kulenkampff D: Die Anfisthesie des Plexus Brachialis. Zentralbl Chir 38:1337-1340, 1911 3. Winnie AP, Collins VJ: The subclavian perivascular technique of bracNai plexus aneSthesia. AneStheSiology 25:353-363, 1964 4. Winnie AP: The interscalene brachial plexus block. Anesth Analg 49:455-466, 1970 5. Moorthy SS, Schmidt SI, Dierdorf SF, et al: A supraclavicular lateral approach for brachial plexus regional anesthesia. Anesth Analg 72:241-244, 1991 6. Rucci FS, Pippa P, Barbagli R, et al: How many interscalenic blocks are there? A comparison between the lateral and posterior approach. Eur J Anaesth 10:303-307, 1993 7, Ashley S, Wood L, Louis-Jackues MA, et al: A comparison of single shot versus continuous supraclavicular nerve block using the "plumb bob" approach. Reg Anesth 20:133, 1995 (abstr) 8, Ilias W, Fitzal S, Mutz N, et al: Die kontinuierliche perivasculare axillare Plexus-Blockade bei Replantationen an der Hand. Anaesthesist 27:79-82, 1978 9, Tuominen M, Pitk&nen M, Rosenberg PH: Postoperative pain relief and bupivacaine plasma levels during continuous interscalene brachial plexus block. Acta Anaesthesiol Scand 31:276-278, 1987 10. Tuominen M, Haasio J, Hekali R, et al: Continuous interscalene brachiat plexus block: Clinical efficacy, technical problems and bupivacaine plasma concentrations. Acta Anaesthesiol Scand 33:84-88, 1989 11. Haasio J, Tuominen M, Rosenberg PH: Continuous interscalene brachial plexus block during and after shoulder surgery. Ann Chir Gynaeco179:103-107,1990 12. Rosenberg PH, Pere P, Hekali R, et al: Plasma concentrations of bupivacaine and two of its metabolites during continuous interscalene brachial plexus block. Br J Anaesth 66:25-30, 1991 13. Pere P, Tuominen M, Rosenberg PH: Cumulation of bupivacaine, desbutylbupivacaine and 4-hydroxybupivacaineduring and after continuous interscalene brachial plexus block. Acta Anaesthesiol Scand 35:647-650, 1991 14. Pere P, Pitk&nen M, Rosenberg PH, et al: Effect of continuous interscalene brachial plexus block on diaphragm motion and on ventilatory function. Acta Anaesthesiol Scand 36:53-57, 1992 15. Rosenberg PH, Lamberg TS, Tarkkila P, et al: Auditory disturbance associated with interscalene brachial plexus block. Br J Anaesth 74:89-91,1995 16. Gaertner E, Cuche H, Ocquidant S, et al: Role of interscalene brachial plexus catheter in shoulder surgery. Presented at the XVth Annual European Society of Regional Anaesthesia Congress, September 18-21,1996, Nice, France (abstr) 17. Rung GW, McQuillan PM: A modified Seldinger technique for continuous interscalene brachial plexus block. Reg Anesth 20:101, 1995 (abstr) 18. Sato S, Yamashita S, Iwai M, et al: Continuous interscalene block for cancer pain. Reg Anesth 19:73-75, 1994 (letter) 19. Abram SE, Haddox JD: Chronic pain management, in Barash PG, Cullen BF, Stoelting RK (eds): Clinical Anesthesia. Philadelphia, PA, Lippincott, 1992, pp 1579-1607 20. Rosenberg PH, Heavner JE: Acute cardiovascular and central nervous system toxicity of bupivacaine and desbutylbupivacaine in the rat. Acta Anaesthesiol Scand 36:138-141, 1992 /

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21. Aronsen KF, Ekelund G, Kindmark C-O, et al: Sequential changes of plasma proteins after surgical trauma. Scand J Clin Lab Invest 29:127-136, 1972 (suppl) 22. Scott DB: Toxicity caused by local anaesthetic drugs. Br J Anaesth 53:553-554, 1981 23. Tucker GT: Pharmacokinetics of local anaesthetic agents. Br J Anaesth 58:717-731, 1986 24. Denson DD, Myers JA, Hartrick CT, et al: The relationship between free bupivacaine concentration and central nervous system toxicity. Anesthesiology 61 :A211,1984 (abstr) 25. Scott DB, Lee A, Fagan D, et al: Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 69:563-569, 1989 26. Lee A, Fagan D, Lamont M, et al: Disposition kinetics of ropivacaine in humans. Anesth Analg 69:736-738, 1989 27. Winnie AP: Plexus anesthesia: Pedvascular techniques of brachial plexus block. Fribourg, Switzerland, Mediglobe SA, 1993 28. Sharrock NE: Shoulder surgery under regional anesthesia. Highlights, in Pain Therapy and Regional Anaesthesia. XV Annual European Society of Regional Anesthesia Congress, Nice, France, September 18-21, 1996, pp 338-342 29. Hickey R, Garland TA, Ramamurthy S: Subclavian perivascular block: Influence of location of paresthesia. Anesth Analg 68:767-771, 1989

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30. Selander D: Axillary plexus block: paresthetic or perivascular. Anesthesiology 66:726-728, 1987 (editorial) 31. Hickey R, Candido KD, Ramamurthy S, et al: Brachial plexus block with a new local anaesthetic: 0.5 per cent ropivacaine. Can J Anaesth 37:732-738, 1990 32. Pere P: The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine plus fentanyl on diaphragmatic motility and ventilatory function. Reg Anesth 18:93-97, 1993 33. Tuominen MK, Pere P, Rosenberg PH: Unintentional arterial catheterization and bupivacaine toxicity associated with continuous interscalene brachial plexus block. Anesthesiology 75:356-358, 1991 34. Cook LB: Unsuspected extradural catheterization in an interscalene block. Br J Anaesth 67:473-475, 1991 35. Urmey WF, Talts KH, Sharrock NE: One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 72:498-503,1991 36. Foster AH, Carlson BM: Myotoxicity of local anesthetics and regeneration of damaged muscle fibers. Anesth Analg 59:727-736, 1980 37. Pere P, Watanabe H, PitkAnen M, et al: Local myotoxicity of bupivacaine in rabbits after continuous supraclavicutar brachial plexus block. Reg Anesth 18:304-307, 1993

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