- Email: [email protected]
Lateral decubitus and the nonaxillary roll
390
Regional Anesthesia Vol. 22 No. 4 July-August 1997
W h e n employing the nerve stimulator rather than eliciting paresthesias, w h e t h e r neuropathy can be avoided or its incidence reduced has yet to be proved by a major clinical study. From review of medicolegal cases (hospital charts, depositions, e t c . ) - - n o t h e a r s a y - - m y colleagues and I are aware of six p e r m a n e n t neuropathies that have resulted w h e n the nerve stimulator was being used while attempting peripheral nerve blocks. These occurred in semiconscious and unconscious patients, w h o did not respond w h e n the needle point, in all probability, pierced the nerve's epineurium and the therapeutic dose of local anesthetic was injected.
Technique of Gologorslff and Tenicella If Gologorsky and Tenicella expect their technique to be tried by others they need to provide (1) the age, height, and weight of the patients in w h o m they were able to obtain a satisfactory interscalene block with a 2cm (~-inch) needle, as well as the gauge and bevel configuration of the needle; (2) the length of time for establishment of operating anesthesia following completion of the injection of the local anesthetic; (3) the localanesthetic used; (4) its dosage (volume and concentration); (5) w h e t h e r it contained epinephrine, hyaluronidase, etc.; (6) the incidence of satisfactory anesthesia wi t h o u t the need for conscious or unconscious sedation with intravenous or inhalation agents or a combination of them; (7) w h e t h e r block of the ulnar nerve at the elbow is a necessary adjunct for satisfactory anesthesia; and (8) the incidence of occurrence of paresthesia, although they attempt to avoid them.
Conclusion There are no statistically significant clinical data to demonstrate that eliciting paresthesia results in neuropathy. Until a prospective blinded major clinical study provides such data, one should not draw conclusions relating to clinical practice that m a y have significant medicolegal connotations. Daniel C. Moore, M.D. Department of Anesthesiology Virginia Mason Medical Center, Seattle, Washington
References 1. Gologorsky E, Tenicella RA. Does the interscalene block require paresthesia? Reg Anesth 1997: 22: 337. 2. Moore DC. Regional anesthesia. Springfield IL, Charles C Thomas, 1953: 241. 3. Gentili ME, Wargnier JP. Peripheral nerve damage and regional anesthesia (letter). Br J Anaesth 1993: 70: 593-AR594. 4. Greenblan GM, Denson JA. Needle nerve stimulator-locatot: Nerve block with a new instrument for locating nerves. Anesth Analg 1962: 41: 599-602. 5. Moore DC, Mulroy MF, Thompson GE. Peripheral nerve damage and regional anesthesia. Br J Anaesth 1993: 73: 435-436. 6. Selander D. Catheter technique in axillary plexus block: Presentation of a new method. Acta Anaesthesiol Scand 1977: 21: 324-329.
7. Selander D, Edshage S, Wolff T. Paresthesiae or no paresthesiae?: Nerve lesion after axillary block. Acta Anaesthesiol Scand 1978: 23: 25-33. 8. Selander D, Dhuner KG, Lundborg G. Peripheral nerve injury due to injection needles used to regional block: An experimental study of the acute effects of needle point trauma. Acta Anaesthesiol Scand 1977: 21: 182-188. 9. Selander D, Sj6strand J. Longitudinal spread of intra-neurally injected local anaesthetics: An experimental study of the initial neural distribution following intraneural injections. Acta Anaesthesiol Scand 1978: 22: 622-634. 10. Selander D, Brattsand R, Lundborg G, Nordborg C, Olsson Y. Local anaesthetics: Importance of mode of application, concentration and adrenaline for the appearance of nerve lesions; an experimental study of axonal degeneration and barrier damage after intrafascicular injection or topical application of bupivacaine (Marcaine). Acta Anaesthesiol Scand 1978: 23: 127-136. 11. Se]ander D, MSnsson LG, Karlsson L, Svanvick J. Adrenergic vasoconstriction in peripheral nerves of the rabbit. Anesthesiology 1985: 62: 6-10. 12. Scott DB, Lee A, Fagan D, Bowler GMR, Bloomfield P, Lundh R: Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989: 69: 563-569. 13. Moore DC: An evaluation of hyaluronidase in local and nerve block analgesia: A review of 519 cases. Anesthesiology 1950:11: 470-484. 14. Moore DC. Complications following the use of Efocaine. Surgery 1954: 35:109-114. 15. Hadzic A, Voka JD. Peripheral nerve stimulator for unassisted nerve block. Anesthesiology 1996: 84: 1528-1529. 16. Phillips WJ. An argument against the use of the nerve stimulators for peripheral nerve block (letter). Reg Anesth 1992: 17: 309-310. Accepted for publication December 3, 1996.
Lateral Decubitus and the Nonaxillary Roll To the Editor: When placing a patient in the lateral position for an operation, it is recommended to place a padded roll beneath the dependent chest wall to relieve pressure on the brachial plexus and shoulder (I). Some, perhaps misled by the misnomer Uaxillary roll," erroneously place the roll too far cephalad, thus accentuating direct pressure on the axillary artery and brachial plexus. A rolled-up towel or an intravenous bag are frequently used for this purpose and while effective, are extraordinarily uncomfortable for the patient under regional anesthesia. Those who doubt this are urged to try it themselves. We have previously described the utilization of used intravenous (2) and irrigating solution (3) bags for positioning devices. Here we describe an easily constructed device to replace the traditional axillary roll. Two empty 3,000-mL irrigating solution bags are connected at their suspension holes. A 1,000 mL intravenous solution bag is connected at the lower edges of the irrigation solution bags to form a triangle. Wide-bore tubing is used to connect intravenous tubing connection of the three bags with injection ports from which the rubber nipple has been removed (Fig. 1). A length of wide-bore tubing with a roller clamp is attached to one of the ports
Letters to the Editor
of the 1,000-mL bag. The latter tubing m a y be attached to a standard bulb p u m p (Fig. 2) or to a fourth solution bag which serves as an air reservoir, or m a y be left open for temporary attachment to an external source of compressed gas, which is used to inflate the balloons. To use the device, the patient is first positioned in the lateral position with the deflated balloons under the chest wall. The balloons should be further covered by a sheet or towel. The position of the balloons is verified (the smaller balloon is most caudad and perpendicular to
Fig. 1. Construction of the device from materials available in all operating rooms.
the long axis of the body) and adjusted as necessary. The bags are then inflated (Fig. 3). At the end of surgery, the bags are readily deflated for moving the patient off tile operating table. The positioning device as described has several advantages: The device is e x t r e m e l y comfortable, a small but important detail for successful regional anesthesia.
irrigation
irrigation
bag
bag
IL 1o filling
device
roller clamp
Fig. 2. The nonaxillary roll, a triangle of interconnected, airfilled, discarded intravenous and irrigation solution bags.
391
intravenous bag
392
RegionalAnesthesia Vol. 22 No. 4 July-August 1997
Fig. 3. A patient positioned on the filled balloons. The device is surprisingly comfortable, vastly more so than the traditional axillary roll.
One is not required to strain to lift tile patient for placement of an axillary roll. The device spreads support of the patient's weight over a broad surface area and is thus less likely to cause pressure injury. Proper inflation elevates the chest enough to relieve pressure on the dependent shoulder, the axillary artery, and the brachial plexus. The device adds an element of postural stability. There is a heat insulation effect from the cushion of air u n d e r the patient. Alterations are readily made during the operation by inflating or deflating the device, with no need to reach u n d e r the drapes to make adjustments. The device costs essentially r/othing and can be put together from materials found in every operating room in a matter o'[ minutes. Bruce Ben-David, M.D. Konstantin Smirnof
Herzlia-Haifa (Horev) Medical Center Haifa, Israel
References
1. Cooper DE, Jenkins RS, Bready L, Rockwood CA. The prevention of injuries of the brachlal plexus secondary to malposition of the patient during surgery. Clin Orthop 1988: 228: 33-41. 2. Ben-David B, Smirnof K, Govrin-Yehudain J. Inexpensive positioning pads for surgery. Plast Reconstr Surg 1994: 94: 894-895. 3. Ben-David B, Smirnof K, Moscona R, Govrin-Yehudain J. A positioning system for reconstructive breast surgery. Plast Reconstr Surg 1995: 95:1131-1133. Accepted for publication November 14, 1996.
Regional Anesthesia Vol. 22 No. 4 July-August 1997
W h e n employing the nerve stimulator rather than eliciting paresthesias, w h e t h e r neuropathy can be avoided or its incidence reduced has yet to be proved by a major clinical study. From review of medicolegal cases (hospital charts, depositions, e t c . ) - - n o t h e a r s a y - - m y colleagues and I are aware of six p e r m a n e n t neuropathies that have resulted w h e n the nerve stimulator was being used while attempting peripheral nerve blocks. These occurred in semiconscious and unconscious patients, w h o did not respond w h e n the needle point, in all probability, pierced the nerve's epineurium and the therapeutic dose of local anesthetic was injected.
Technique of Gologorslff and Tenicella If Gologorsky and Tenicella expect their technique to be tried by others they need to provide (1) the age, height, and weight of the patients in w h o m they were able to obtain a satisfactory interscalene block with a 2cm (~-inch) needle, as well as the gauge and bevel configuration of the needle; (2) the length of time for establishment of operating anesthesia following completion of the injection of the local anesthetic; (3) the localanesthetic used; (4) its dosage (volume and concentration); (5) w h e t h e r it contained epinephrine, hyaluronidase, etc.; (6) the incidence of satisfactory anesthesia wi t h o u t the need for conscious or unconscious sedation with intravenous or inhalation agents or a combination of them; (7) w h e t h e r block of the ulnar nerve at the elbow is a necessary adjunct for satisfactory anesthesia; and (8) the incidence of occurrence of paresthesia, although they attempt to avoid them.
Conclusion There are no statistically significant clinical data to demonstrate that eliciting paresthesia results in neuropathy. Until a prospective blinded major clinical study provides such data, one should not draw conclusions relating to clinical practice that m a y have significant medicolegal connotations. Daniel C. Moore, M.D. Department of Anesthesiology Virginia Mason Medical Center, Seattle, Washington
References 1. Gologorsky E, Tenicella RA. Does the interscalene block require paresthesia? Reg Anesth 1997: 22: 337. 2. Moore DC. Regional anesthesia. Springfield IL, Charles C Thomas, 1953: 241. 3. Gentili ME, Wargnier JP. Peripheral nerve damage and regional anesthesia (letter). Br J Anaesth 1993: 70: 593-AR594. 4. Greenblan GM, Denson JA. Needle nerve stimulator-locatot: Nerve block with a new instrument for locating nerves. Anesth Analg 1962: 41: 599-602. 5. Moore DC, Mulroy MF, Thompson GE. Peripheral nerve damage and regional anesthesia. Br J Anaesth 1993: 73: 435-436. 6. Selander D. Catheter technique in axillary plexus block: Presentation of a new method. Acta Anaesthesiol Scand 1977: 21: 324-329.
7. Selander D, Edshage S, Wolff T. Paresthesiae or no paresthesiae?: Nerve lesion after axillary block. Acta Anaesthesiol Scand 1978: 23: 25-33. 8. Selander D, Dhuner KG, Lundborg G. Peripheral nerve injury due to injection needles used to regional block: An experimental study of the acute effects of needle point trauma. Acta Anaesthesiol Scand 1977: 21: 182-188. 9. Selander D, Sj6strand J. Longitudinal spread of intra-neurally injected local anaesthetics: An experimental study of the initial neural distribution following intraneural injections. Acta Anaesthesiol Scand 1978: 22: 622-634. 10. Selander D, Brattsand R, Lundborg G, Nordborg C, Olsson Y. Local anaesthetics: Importance of mode of application, concentration and adrenaline for the appearance of nerve lesions; an experimental study of axonal degeneration and barrier damage after intrafascicular injection or topical application of bupivacaine (Marcaine). Acta Anaesthesiol Scand 1978: 23: 127-136. 11. Se]ander D, MSnsson LG, Karlsson L, Svanvick J. Adrenergic vasoconstriction in peripheral nerves of the rabbit. Anesthesiology 1985: 62: 6-10. 12. Scott DB, Lee A, Fagan D, Bowler GMR, Bloomfield P, Lundh R: Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989: 69: 563-569. 13. Moore DC: An evaluation of hyaluronidase in local and nerve block analgesia: A review of 519 cases. Anesthesiology 1950:11: 470-484. 14. Moore DC. Complications following the use of Efocaine. Surgery 1954: 35:109-114. 15. Hadzic A, Voka JD. Peripheral nerve stimulator for unassisted nerve block. Anesthesiology 1996: 84: 1528-1529. 16. Phillips WJ. An argument against the use of the nerve stimulators for peripheral nerve block (letter). Reg Anesth 1992: 17: 309-310. Accepted for publication December 3, 1996.
Lateral Decubitus and the Nonaxillary Roll To the Editor: When placing a patient in the lateral position for an operation, it is recommended to place a padded roll beneath the dependent chest wall to relieve pressure on the brachial plexus and shoulder (I). Some, perhaps misled by the misnomer Uaxillary roll," erroneously place the roll too far cephalad, thus accentuating direct pressure on the axillary artery and brachial plexus. A rolled-up towel or an intravenous bag are frequently used for this purpose and while effective, are extraordinarily uncomfortable for the patient under regional anesthesia. Those who doubt this are urged to try it themselves. We have previously described the utilization of used intravenous (2) and irrigating solution (3) bags for positioning devices. Here we describe an easily constructed device to replace the traditional axillary roll. Two empty 3,000-mL irrigating solution bags are connected at their suspension holes. A 1,000 mL intravenous solution bag is connected at the lower edges of the irrigation solution bags to form a triangle. Wide-bore tubing is used to connect intravenous tubing connection of the three bags with injection ports from which the rubber nipple has been removed (Fig. 1). A length of wide-bore tubing with a roller clamp is attached to one of the ports
Letters to the Editor
of the 1,000-mL bag. The latter tubing m a y be attached to a standard bulb p u m p (Fig. 2) or to a fourth solution bag which serves as an air reservoir, or m a y be left open for temporary attachment to an external source of compressed gas, which is used to inflate the balloons. To use the device, the patient is first positioned in the lateral position with the deflated balloons under the chest wall. The balloons should be further covered by a sheet or towel. The position of the balloons is verified (the smaller balloon is most caudad and perpendicular to
Fig. 1. Construction of the device from materials available in all operating rooms.
the long axis of the body) and adjusted as necessary. The bags are then inflated (Fig. 3). At the end of surgery, the bags are readily deflated for moving the patient off tile operating table. The positioning device as described has several advantages: The device is e x t r e m e l y comfortable, a small but important detail for successful regional anesthesia.
irrigation
irrigation
bag
bag
IL 1o filling
device
roller clamp
Fig. 2. The nonaxillary roll, a triangle of interconnected, airfilled, discarded intravenous and irrigation solution bags.
391
intravenous bag
392
RegionalAnesthesia Vol. 22 No. 4 July-August 1997
Fig. 3. A patient positioned on the filled balloons. The device is surprisingly comfortable, vastly more so than the traditional axillary roll.
One is not required to strain to lift tile patient for placement of an axillary roll. The device spreads support of the patient's weight over a broad surface area and is thus less likely to cause pressure injury. Proper inflation elevates the chest enough to relieve pressure on the dependent shoulder, the axillary artery, and the brachial plexus. The device adds an element of postural stability. There is a heat insulation effect from the cushion of air u n d e r the patient. Alterations are readily made during the operation by inflating or deflating the device, with no need to reach u n d e r the drapes to make adjustments. The device costs essentially r/othing and can be put together from materials found in every operating room in a matter o'[ minutes. Bruce Ben-David, M.D. Konstantin Smirnof
Herzlia-Haifa (Horev) Medical Center Haifa, Israel
References
1. Cooper DE, Jenkins RS, Bready L, Rockwood CA. The prevention of injuries of the brachlal plexus secondary to malposition of the patient during surgery. Clin Orthop 1988: 228: 33-41. 2. Ben-David B, Smirnof K, Govrin-Yehudain J. Inexpensive positioning pads for surgery. Plast Reconstr Surg 1994: 94: 894-895. 3. Ben-David B, Smirnof K, Moscona R, Govrin-Yehudain J. A positioning system for reconstructive breast surgery. Plast Reconstr Surg 1995: 95:1131-1133. Accepted for publication November 14, 1996.