D. COŞKUN, A. MAHLİ Turk J Med Sci 2011; 41 (4): 623-631 © TÜBİTAK Original Article E-mail: [email protected] doi:10.3906/sag-1008-1091 Th e extent of blockade following axillary, supraclavicular, and interscalene approaches of brachial plexus block Demet COŞKUN, Ahmet MAHLİ Aim: To investigate the onset, quality, and extent of the sensory and motor blocks in brachial plexus blocks performed through axillary, supraclavicular, or interscalene approaches. Materials and methods: Th is study involved 75 patients scheduled for orthopedic surgery of the upper extremity. Brachial plexus block was performed in patients through axillary (group AX, n = 25), supraclavicular (group SC, n = 25), or interscalene (group IS, n = 25) approaches. Results: Excluding intercostobrachial nerve, the adequate sensory and motor block rates in group AX on the nerves of brachial plexus were found to be 100% and 92%-100%, respectively. Sensory and motor block rates were both found to be 96%-100% in group SC and also 80%-100%, and 88% in group IS, respectively. In terms of sensory and motor block evaluation of all the nerves, there were statistically signifi cant diff erences among the 3 groups at all measurement times (P < 0.05). Conclusion: Th e onset, quality, and extent of the sensory and motor block in brachial plexus blocks changed depending on the axillary, supraclavicular, or interscalene approaches. Key words: Brachial plexus block, axillary, supraclavicular, interscalene Aksiller, supraklavikular ve interskalen yaklaşımlar ile uygulanan brakiyal pleksus bloğunun yayılımı Amaç: Bu çalışmanın amacı, aksiller, supraklaviküler veya interskalen yaklaşım yoluyla gerçekleştirilen brakiyal pleksus bloklarında duyusal ve motor bloğun başlangıcı, kalitesi ve yayılımını araştırmaktır. Yöntem ve gereç: Çalışma, ortopedik üst ekstremite cerrahisi planlanmış 75 hastayı içermektedir. Hastalarda aksiler (grup AX, n = 25), supraklaviküler (grup SC, n = 25) veya interskalen yaklaşım (grup İS, n = 25) yoluyla brakiyal pleksus bloğu gerçekleştirilmiştir. Bulgular: Grup AX’de interkostobrakiyal sinir hariç olmak üzere brakiyal pleksusa ait sinirlere ilişkin yeterli duyusal blok oranı % 100, yeterli motor blok oranı ise % 92-100 olarak bulunmuştur. Grup SC’de duyusal ve motor blok oranlarının her ikisi de % 96-100, grup İS’de ise bu oranlar sırasıyla % 80-% 100 ve % 88 olarak bulunmuştur. Duyusal ve motor blok yönünden, değerlendirilen tüm sinirlerde, ölçüm yapılan tüm zaman dilimlerinde, üç grup arasında anlamlı fark vardır (P < 0,05). Sonuç: Brakiyal pleksus bloğunda duyusal ve motor bloğun başlangıcı, kalitesi ve yayılımı uygulanan aksiller, supraklavikular veya interskalen yaklaşıma bağlı olarak değişmektedir. Anahtar sözcükler: Brakiyal pleksus bloğu, aksiller, supraklaviküler, interskalen Received: 02.09.2010 – Accepted: 01.10.2010 Department of Anesthesiology and Reanimation, Faculty of Medicine, Gazi University, Ankara - TURKEY Correspondence: Demet COŞKUN, Department of Anesthesiology and Reanimation, Faculty of Medicine, Gazi University, Ankara - TURKEY E-mail: [email protected] 623 Th e extent of axillary, supraclavicular, and interscalene blockade Introduction Supplemental oxygen (via nasal cannula at 4 L/min) Brachial plexus block is a multifunctional and was applied throughout the procedure. reliable regional anesthesia that is performed All blocks were performed according to previously through various blocks for upper extremity surgery. described techniques (3-5) by the fi rst author and In planning brachial plexus block, the operation were supervised by the second author, who possesses should be diagnostic or therapeutic, and several experience with all the 3 approaches. Th e blocks in factors, such as the duration and site of the operation, all groups were performed via a peripheral nerve postoperative analgesia, general condition of the stimulator (Stimuplex HNS® 11; B. Braun, Melsungen, patient, absence of accompanying diseases, and Germany) and a short-beveled stimulating needle overnight hospitalization, should also be considered (Stimuplex® Kanüle A, 50 mm; B. Braun, Melsungen, (1,2). Germany). Th is study was aimed to investigate the onset, Th e per ivascular axillary approach was performed quality, and extend of sensory and motor blocks in in a supine patient with the upper arm abducted 90°, brachial plexus blocks, and partially, cervical plexus and fl exed 90° cranially at the elbow with a supin ated through axillary, supraclavicular, and interscalene forearm. Aft er identifi cation of the axillary artery, the approaches by the use of local anesthetics containing needle was inserted as high as possible in the axilla a mixture of lidocaine and bupivacaine in equal superior and tangential to the axillary artery (3). amounts. Supraclavicular approach was performed in a supine patient with a needle inserted above the subcl avian artery directing the tip of the needle dorsolaterally Materials and methods (4). Interscalene approach was performed with Th is study was approved by the Institutional the patient in the supine position. Th e needle was Ethics Committee, and informed consent was inserted at the level of the crico id cartilage, in the obtained from each patient. Th is study included interscalene groove and directed in a slightly caudal, patients of ASA physical status I-II, aged between medial, and dorsal direction (5). 18 and 65 years, scheduled for elective orthopedic For all approaches, the volume of the local surgical procedures involving only soft tissue of the anesthetics (approximately 30-35 mL) was calculated upper arm, lower arm, or hand. Brachial plexus block based on the height of each patient according to was performed in patients through axillary (group the following formula: volume (mL) = height (cm) AX, n = 25), supraclavicular (group SC, n = 25), or / 5 (6), and the volume determined was prepared interscalene (group IS, n = 25) approaches according by mixing 2% lidocaine and 0.5% bupivacaine in to the site on which surgery will be conducted. Patients equal proportions. In all patients undergoing the were excluded if they had a history of neurological, procedure, the plexus was identifi ed with a short- neuromuscular, or psychiatric disorders or hepatic, beveled electric stimulation needle connected to a renal, respiratory, or cardiac disease. Patients with nerve stimulator using a low current (<1.0 mA). a history of drug or alcohol abuse, coagulation For axillary approach, the media n, radial, ulnar, disorders, uncontrolled seizures, and pregnant or and musculocutaneous nerves were selectively lactating women were excluded as well. localized by elicited characteristic muscle group No premedication was given to the patients, movements secondary to each nerve stimulation. whose routine laboratory examinations were made Aft er obtaining an appropriate peripheral motor preoperatively, since full cooperation during block response with a current near or below 0.5 mA assessment was required. On arrival in the anesthetic with respect to the stimulation of each nerve, room, an intravenous catheter was placed in the predetermined volumes of local anesthetics in upper limb contralateral to the surgical site and accordance with the formula was selectively injected saline solution was given at a rate of 2 mL/kg per in each nerve through multiple injections in the AX hour. Monitoring included electrocardiography, group, with intermittent aspiration. Firm digital non-invasive blood pressure and pulse oximetry. pressure was maintained during the injection and 3 624 D. COŞKUN, A. MAHLİ min thereaft er immediately distal to the injection site were monitored in the postanesthesia care unit to prevent distal fl ow of the local anesthetic solution. (PACU) and were discharged from the hospital aft er Th e arm was then brought to rest at the patient’s side. recovery from sensory and motor block. For supraclavicular approach, the current was Statistical analysis reduced until appropriate twitching of the hand, SPSS version 14 (SPSS, Chicago, IL, USA) was and also for interscalene approach the current was used to perform statistical analysis. Kolmogorov- reduced until appropriate fl exion of the shoulder, Smirnov test was used fi rst to assess the normality of arm, or hand was achieved near or below 0.5 mA the continuous data. One-way variance analysis was and then predetermined volumes of local anesthetic then used to analyze the continuous data. For multiple accordance with the formula was injected over 1 comparisons, post hoc testing was performed using min, with repeat aspirations every 5 mL. Verbal the Tukey tests. Kruskal-Wallis test was used for contact with the patients was maintained throughout categorical data, and Mann-Whitney U test was used the injection, and before the injections were made, for post hoc analysis. For the adjustment of multiple the patients were informed about the signs of local comparisons, Holm’s sequential Bonferroni method anesthetic toxicity, such as numbness of the lips and was used. Continuous variables are presented as tongue, and lightheadedness. mean (SD); categorical data are presented as numbers or percentages. Th e hypotheses that were tested Sensory and motor blocks of all upper extremity were 2-tailed. P < 0.05 was considered statistically nerves were evaluated at the 3rd, 6th, 9th, 12th, 15th, signifi cant. 18th, and 30th min aft er injection and recorded on a chart. Th e patients were followed up for 24 h including both intraoperative and postoperative periods. Results During that period,