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Skin-plexus depth of the brachial plexus performing a vertical infraclavicular block: A clinical observation
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Peripheral Nerve Blocks
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Peripheral Nerve Blocks 24. Skin-plexus depth of the brachial plexus performing a vertical infraclavicular block: a clinical observation Rettig HC, Gielen M, Boersma E Email: [email protected] Dept anesthesiology Ikazia hospital,montessoriweg 1, 3083 AN Rotterdam, The Netherlands The vertical infraclavicular approach of the brachial plexus carries the risk of vessel puncture and pneumothorax. The risk of a pneumothorax is considered to be 0.2-0.7% (1). We measured the distance from the puncture site on the skin to one of the cords of the brachial plexus. Method The vertical infraclavicular block (VIB) was done as described by Kilka (2). The puncture site is half way the midline of the jugular notch and ventral end of the acromion, directly under the clavicle. When good distal muscle contractions related to median nerve stimulation were observed, the local anesthetic was injected. The needle was marked at the entrance of the skin and after removal, the distance from the mark on the needle to the tip was measured. Results. In 30 patients with successful block the distance was measured: 13 male (mean age 51 yrs and weight 86,5 kg) and 17 female (mean age 60 yrs and weight 72,6 kg). The mean distance was 42,7 (range 33-50) mm in man and 41 (range 32-50) mm in woman. The plexus was always reached within 50 mm despite 3 patients weighing more than 100 kg. No pneumothorax occurred. There was no relation between weight and skin-plexus depth. Dscussion Our skin-plexus depth is different from the figures of Geiger, who described a mean depth of 33.6 mm (3). Greher, using ultrasound, measured a depth of only 23 mm (4). However, Geiger did the study in cadavers and Greher performed his study with volunteers without introducing a stimulating needle. Conclusion We can conclude that a 50 mm needle will always reach one of the cords of the plexus and most probably will not contact the pleura. By using a 50 mm stimulating needle the pleura can hardly be reached if one identifies the landmarks correctly.
References 1) Neuburger M, Landes H, Kaiser H. Vertical infraclavicular blockade. Case report of a infrequent complication. Anaesthesist 2000;49:901-904 2) Kilka H.G., Geiger P., Mehrkens H.H. Infraclavicualr vertical brachial plexus block. A new technique of regional anaesthesia. Anaesthesist 1995;44:339-344 3) Geiger P., Mehrkens H.H. Vertical infraclavicular brachial plexus blockade. Techniques in regional Anesthesia and Pain Management 2003;7:67-71 4) GreherM., Retzl G., Niel P., Kamolz L., Marhofer P., Kapral S. Ultrasound assessment of topographic anatomy in volunteers suggests a modification of the infraclavicualr vertical brachial plexus block. Br J Anaesth 2002;88:632636
26. The CUN-system (a proportional measurement system used in Chinese acupuncture) is superior to conventional cm-measurements to locate the femoral nerve in adults Schulz-Stu¨ bner S, Henszel A, Hata S Email: [email protected] University of Iowa Hospitals and Clinics 200 Hawkins Drive, 6JCP, Iowa City, Iowa 52242, USA The CUN-system (a proportional measurement system used in Chinese acupuncture) is superior to conventional cm-measurements to locate the femoral nerve in adults Background: Acupuncture plays a major role in the practice of Traditional Chinese Medicine for more than two millennia (1). Traditional Chinese Medicine recognizes the variance among individuals and uses a proportional system to describe the acupuncture-points that is based on the width of the thumb at the level of the distal interphalangeal joint. This distance is defined as one CUN (2). After a pilot-trial which showed good correlation between the CUN and weight and height in 500 Americans (3) we tested the hypothesis that the CUN-system is superior to the conventional measurement in cm lateral to femoral artery to localize the femoral nerve in a prospective, double-blinded randomized study. Material and Methods 40 patients were randomized to receive a femoral nerve block either using a needle entry point of 1 CUN or 2 cm lateral of the femoral artery. The time from needle entry to injection of local anesthetic was measured by an investigator blind to the technique, who also counted the incidence of needle repositioning, graded the ease of the block on a scale from 1-5 (1⫽ easy, 2⫽ minimal difficulties, 3⫽difficult, 4 extreme difficult, 5⫽impossible to perform). The success rate was also graded (1⫽ successful block, 2⫽patchy or incomplete block and 3⫽ unsuccessful block) and complications were registered. Results: Both groups were not significantly different for age, gender, weight and height showing a normal distribution. In the CUN-group the block was achieved significantly (p⬍0,05) faster with fewer attempts and easier. The success rate was the same and complications did not differ significantly between the groups.
CUN: CM.
Time (seconds)*
Number of attempts*
Ease of block*
Success rating
42,31 95,52
1,54 3.09
1.13 1,57
1.04 1.04
Numbers are given as mean value, n ⫽ 40, * significant (p⬍0,05)
Discussion: Using the CUN (⫽width of the thumb) of the patient as a proportional measurement system to localize the femoral nerve at a needle insertion point 1 CUN lateral of the femoral artery makes femoral nerve blocks faster and easier compared to the conventional approach using 2 cm.
References: 1.) Hsu DT. Acupuncture: A review. Reg Anesth 1996;21: 361-70 2.) Schulz-Stu¨ bner S. (ed.) Ko¨ rperakupunktur in der Ana¨ sthesiologie (Acupuncture in Anesthesia). Mainz-Wissenschaftsverlag, Aachen Germany 1999 3.) Schulz-Stu¨ bner S, Henszel A. CUN: a proportional measurement system used in acupuncture utilized for the description of anatomic landmarks in regional anesthesia - Preliminary results of a pilot trial. Abstract ESA, Glasgow 2003
•
Peripheral Nerve Blocks
17
Peripheral Nerve Blocks 24. Skin-plexus depth of the brachial plexus performing a vertical infraclavicular block: a clinical observation Rettig HC, Gielen M, Boersma E Email: [email protected] Dept anesthesiology Ikazia hospital,montessoriweg 1, 3083 AN Rotterdam, The Netherlands The vertical infraclavicular approach of the brachial plexus carries the risk of vessel puncture and pneumothorax. The risk of a pneumothorax is considered to be 0.2-0.7% (1). We measured the distance from the puncture site on the skin to one of the cords of the brachial plexus. Method The vertical infraclavicular block (VIB) was done as described by Kilka (2). The puncture site is half way the midline of the jugular notch and ventral end of the acromion, directly under the clavicle. When good distal muscle contractions related to median nerve stimulation were observed, the local anesthetic was injected. The needle was marked at the entrance of the skin and after removal, the distance from the mark on the needle to the tip was measured. Results. In 30 patients with successful block the distance was measured: 13 male (mean age 51 yrs and weight 86,5 kg) and 17 female (mean age 60 yrs and weight 72,6 kg). The mean distance was 42,7 (range 33-50) mm in man and 41 (range 32-50) mm in woman. The plexus was always reached within 50 mm despite 3 patients weighing more than 100 kg. No pneumothorax occurred. There was no relation between weight and skin-plexus depth. Dscussion Our skin-plexus depth is different from the figures of Geiger, who described a mean depth of 33.6 mm (3). Greher, using ultrasound, measured a depth of only 23 mm (4). However, Geiger did the study in cadavers and Greher performed his study with volunteers without introducing a stimulating needle. Conclusion We can conclude that a 50 mm needle will always reach one of the cords of the plexus and most probably will not contact the pleura. By using a 50 mm stimulating needle the pleura can hardly be reached if one identifies the landmarks correctly.
References 1) Neuburger M, Landes H, Kaiser H. Vertical infraclavicular blockade. Case report of a infrequent complication. Anaesthesist 2000;49:901-904 2) Kilka H.G., Geiger P., Mehrkens H.H. Infraclavicualr vertical brachial plexus block. A new technique of regional anaesthesia. Anaesthesist 1995;44:339-344 3) Geiger P., Mehrkens H.H. Vertical infraclavicular brachial plexus blockade. Techniques in regional Anesthesia and Pain Management 2003;7:67-71 4) GreherM., Retzl G., Niel P., Kamolz L., Marhofer P., Kapral S. Ultrasound assessment of topographic anatomy in volunteers suggests a modification of the infraclavicualr vertical brachial plexus block. Br J Anaesth 2002;88:632636
26. The CUN-system (a proportional measurement system used in Chinese acupuncture) is superior to conventional cm-measurements to locate the femoral nerve in adults Schulz-Stu¨ bner S, Henszel A, Hata S Email: [email protected] University of Iowa Hospitals and Clinics 200 Hawkins Drive, 6JCP, Iowa City, Iowa 52242, USA The CUN-system (a proportional measurement system used in Chinese acupuncture) is superior to conventional cm-measurements to locate the femoral nerve in adults Background: Acupuncture plays a major role in the practice of Traditional Chinese Medicine for more than two millennia (1). Traditional Chinese Medicine recognizes the variance among individuals and uses a proportional system to describe the acupuncture-points that is based on the width of the thumb at the level of the distal interphalangeal joint. This distance is defined as one CUN (2). After a pilot-trial which showed good correlation between the CUN and weight and height in 500 Americans (3) we tested the hypothesis that the CUN-system is superior to the conventional measurement in cm lateral to femoral artery to localize the femoral nerve in a prospective, double-blinded randomized study. Material and Methods 40 patients were randomized to receive a femoral nerve block either using a needle entry point of 1 CUN or 2 cm lateral of the femoral artery. The time from needle entry to injection of local anesthetic was measured by an investigator blind to the technique, who also counted the incidence of needle repositioning, graded the ease of the block on a scale from 1-5 (1⫽ easy, 2⫽ minimal difficulties, 3⫽difficult, 4 extreme difficult, 5⫽impossible to perform). The success rate was also graded (1⫽ successful block, 2⫽patchy or incomplete block and 3⫽ unsuccessful block) and complications were registered. Results: Both groups were not significantly different for age, gender, weight and height showing a normal distribution. In the CUN-group the block was achieved significantly (p⬍0,05) faster with fewer attempts and easier. The success rate was the same and complications did not differ significantly between the groups.
CUN: CM.
Time (seconds)*
Number of attempts*
Ease of block*
Success rating
42,31 95,52
1,54 3.09
1.13 1,57
1.04 1.04
Numbers are given as mean value, n ⫽ 40, * significant (p⬍0,05)
Discussion: Using the CUN (⫽width of the thumb) of the patient as a proportional measurement system to localize the femoral nerve at a needle insertion point 1 CUN lateral of the femoral artery makes femoral nerve blocks faster and easier compared to the conventional approach using 2 cm.
References: 1.) Hsu DT. Acupuncture: A review. Reg Anesth 1996;21: 361-70 2.) Schulz-Stu¨ bner S. (ed.) Ko¨ rperakupunktur in der Ana¨ sthesiologie (Acupuncture in Anesthesia). Mainz-Wissenschaftsverlag, Aachen Germany 1999 3.) Schulz-Stu¨ bner S, Henszel A. CUN: a proportional measurement system used in acupuncture utilized for the description of anatomic landmarks in regional anesthesia - Preliminary results of a pilot trial. Abstract ESA, Glasgow 2003