Randomized comparative study between two different techniques of intercostobrachial nerve block together with brachial plexus block during superficialization of arteriovenous fistula

Comparison between ultrasound-guided subpectoral intercostal plane approach and pectoserratus plane approach for intercostobrachial nerve block in surgeries involving posterior and medial aspects of the arm - A randomised comparative trial

Background and Aims

The intercostobrachial nerve (ICBN), along with the brachial plexus, supplies the medial and posterior aspects of the upper arm. This study hypothesised that ultrasound blockade of ICBN by subpectoral intercostal plane block may provide faster and complete blockade compared to the pectoserratus plane block.

Methods

Sixty patients were randomised into two groups, and initially, an ultrasound-guided supraclavicular brachial plexus block was performed. After 10 min, Group A received a subpectoral intercostal plane block at the second rib. Group B received a pectoserratus plane block at the fourth rib. Anaesthesia over the posterior and medial aspects of the upper arm was assessed. The primary outcome was the time of onset of the blockade. The secondary outcome was the time taken to perform the block and the block failure rate. Student's t-test was used to compare the means. The categorical variables were compared using the Chi-squared test. Significance was defined by a P value of <0.05.

Results

The time of onset of the block over the medial and posterior sides of the arm was significantly faster in Group A. Time taken for administering block in Group B was more than twice that of Group A (P < 0.001). The block was 100% successful in Group A, while in Group B, only 70% was successful.

Conclusion

The subpectoral intercostal plane block at the second rib produces a faster and more complete blockade of ICBN in all patients compared to the pectoserratus plane block at the fourth rib.

Randomized comparison between ultrasound-guided proximal and distal approaches of intercostobrachial nerve block as an adjunct to supraclavicular brachial plexus block for upper arm arteriovenous access procedures

BACKGROUNDS

Ultrasound-guided proximal and distal approaches of the intercostobrachial nerve (ICBN) blocks facilitate analgesia for upper arm and axillary surgery, though success rates vary and lack clinical comparison. This study compared their anesthetic and analgesic efficacy as an adjunct to the supraclavicular brachial plexus block for upper arm arteriovenous access surgery.

METHODS

60 end-stage renal disease patients undergoing upper arm arteriovenous access were randomly assigned to receive either proximal or distal ICBN block using 10 mL of a mixture of levobupivacaine and lidocaine with epinephrine. The primary outcome was a successful ICBN block, defined as a cutaneous sensory blockade at both the medial upper arm and axilla 30 min after the block. Secondary outcomes included block performance, block-related complications, rate of surgical anesthesia, and postoperative analgesia.

RESULTS

The proximal approach had a higher percentage of sensory blockade at the axilla (96.7% vs 73.3%, p=0.03), but comparable rates at the medial upper arm (96.7% vs 96.7%, p=1.00). Consequently, the proximal approach had a higher overall success rate (96.7% vs 73.3%, difference: 23.3%; 95% CI: 6.3%, 40.4%; p=0.03). Both groups had similar surgical anesthesia rates of 93.3%. No significant differences were found in performance time, procedural pain, or postoperative pain intensity.

CONCLUSIONS

Proximal ICBN block consistently reduced sensation in the medial upper arm and axilla, while one-quarter of distal blocks spared the axilla. Both approaches, in combination with a supraclavicular brachial plexus block, were effective for upper arm arteriovenous access procedures. However, the proximal approach may be preferable for axillary surgery.

TRIAL REGISTRATION NUMBER

TCTR20200730006.

Advancing pain management for extremity trauma: the evolution of ultrasound-guided nerve blocks for patients in the supine position in trauma centers

PURPOSE

Trauma, particularly extremity trauma, poses a considerable challenge in healthcare, especially among young adults. Given the severity of patient pain and the risks associated with excessive opioid use, managing acute pain in trauma centers is inherently complex. This study aims to investigate the application and benefits of ultrasound-guided nerve blocks for early pain management in patients with extremity trauma positioned supine.

METHODS

A comprehensive literature review was conducted to assess the effectiveness and advantages of ultrasound-guided peripheral nerve blocks in the acute pain management of extremity trauma patients in the supine position. Special emphasis was placed on evaluating the selection criteria, indications, contraindications, adverse reactions, and potential complications associated with these nerve block techniques.

RESULTS

Ultrasound-guided nerve blocks represent a safer and more precise option for managing pain in extremity trauma patients placed in the supine position. These techniques offer significant advantages in terms of reducing healthcare expenses, diminishing reliance on opioid medications, and mitigating opioid-related complications. Nonetheless, challenges may arise due to the necessity for patient cooperation during specific nerve block procedures.

CONCLUSION

Ultrasound-guided nerve blocks present a promising avenue for early pain management in extremity trauma patients positioned supinely. Their implementation can lead to improved patient outcomes by alleviating pain severity, reducing opioid consumption, and cutting down healthcare costs. Further research and clinical integration of these techniques is imperative to enhance pain management protocols in trauma centers.

Clinically Important Pharmacologic Considerations for Wide-Awake Local Anesthesia No Tourniquet Hand Surgery

SUMMARY

Understanding the clinically important pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) of medications used in surgery will help surgeons use them more safely and effectively. The goal of this article is to provide an overview of these considerations for the 2 medications used in wide-awake local anesthesia with no tourniquet upper extremity surgery (ie, lidocaine and epinephrine) to establish a better understanding of lidocaine and epinephrine in tumescent local anesthesia, as well as adverse reactions and how to manage them.

Blockade of intercostobrachial nerve by an erector spinae plane block at T2 level: a case report

BACKGROUND

The intercostobrachial nerve blockade is required, in addition to brachial plexus block, to anesthetize the entire upper arm. No studies have described the use of erector spinae plane (ESP) block for an intercostobrachial nerve block.

CASE PRESENTATION

A 72-year-old man was scheduled to undergo left brachial vein transposition-arteriovenous fistula creation for hemodialysis access. An ultrasound-guided infraclavicular brachial plexus block was performed using a mixture of 0.5% levobupivacaine (12.5 ml) and 2% lidocaine (12.5 ml). An ESP block was implemented using 10 ml of the same local anesthetic at the T2 level. A pinprick test showed that the entire upper arm and lateral aspect of the left upper chest wall were anesthetized 20 min after the blocks. Surgery was successfully performed without the need for general anesthesia.

CONCLUSIONS

In the present case, an ESP block performed at the T2 level provided sensory loss of the area innervated by the intercostobrachial nerve.

Beyond the Brachial Plexus: Reapplication of the Thoracic Paravertebral Block for Upper Arm Fistula Surgery

Patients requiring complex upper arm arteriovenous fistulas or grafts may not be suitable candidates for a single regional anesthesia technique and monitored anesthesia care because the necessary thoracic (T2) dermatomal area of the medial, upper arm remains spared by any solitary brachial plexus (C5-T1) technique. An infiltrative intercostobrachial nerve block can often be used in conjunction with a brachial plexus block; however, coverage may still be incomplete. This case report describes the use of a high thoracic paravertebral block in conjunction with a brachial plexus block to achieve adequate anesthetic coverage for an upper arm arteriovenous fistula creation procedure extending into the axilla. The result of this technique showed adequate coverage of the upper arm and demonstrates that paravertebral blocks are a reasonable adjunct for proximal upper arm arteriovenous fistula procedures.

Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group

The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was - 10 mg (95% credible interval [CrI] - 15.0 to - 5.6 mg) with PECS II block and - 5.7 mg (95% CrI - 11.0 to - 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block.

Ultrasound to the Rescue: Axillary Clearance under Complete Regional Blockade

No single regional anaesthetic technique is capable of complete anaesthesia of the axillary region. Regional or interfascial nerve blockade could be an effective alternative where administering general anaesthesia is not feasible, with superior analgesia, favourable haemodynamics, and reduced opiate related adverse effects. Ultrasound guidance improves effectiveness and safety profile. We report a case of a successful axillary clearance conducted under combined regional blocks for an axillary nodal recurrence following mastectomy for a breast carcinoma, in a patient who was not fit for general anaesthesia due to a persistent lobar pneumonia and recurrent asthma exacerbations. Our experience and current evidence supersede the initial conceptions of difficult ultrasonic intercostobrachial nerve (ICBN) visualization.

Surgical anesthesia for proximal arm surgery in the awake patient

This education article discusses a combination of brachial plexus and peripheral nerve blocks aimed at providing complete surgical anesthesia to the proximal arm, while consistently avoiding diaphragmatic paresis. This type of approach may be warranted in patients with respiratory compromise of any etiology. In these settings awake surgery is recommended to preserve respiratory function and at the same time minimize the risk of infection of the healthcare team by avoiding the aerosol-generating medical procedures associated with general anesthesia.

Cadaveric study identifying clinical sonoanatomy for proximal and distal approaches of ultrasound-guided intercostobrachial nerve block

Background and objectives

The intercostobrachial nerve (ICBN) has significant anatomical variation. Localization of the ICBN requires an operator’s skill. This cadaveric study aims to describe two simple ultrasound-guided plane blocks of the ICBN when it emerges at the chest wall (proximal approach) and passes through the axillary fossa (distal approach).

Methods

The anatomical relation of the ICBN and adjacent structures was investigated in six fresh cadavers. Thereafter, we described two potential techniques of the ICBN block. The proximal approach was an injection medial to the medial border of the serratus anterior muscle at the inferior border of the second rib. The distal approach was an injection on the surface of the latissimus dorsi muscle at 3–4 cm caudal to the axillary artery. The ultrasound-guided proximal and distal ICBN blocks were performed in seven hemithoraxes and axillary fossae. We recorded dye staining on the ICBN, its branches and clinically correlated structures.

Results

All ICBNs originated from the second intercostal nerve and 34.6% received a contribution from the first or third intercostal nerve. All ICBNs gave off axillary branches in the axillary fossa and ran towards the posteromedial aspect of the arm. Following the proximal ICBN block, dye stained on 90% of all ICBN’s origins. After the distal ICBN block, all terminal branches and 43% of the axillary branches of the ICBN were stained.

Conclusions

The proximal and distal ICBN blocks, using easily recognized sonoanatomical landmarks, provided consistent dye spread to the ICBN. We encourage further validation of these two techniques in clinical studies.

Addition of serratus-intercostal plane block/BRILMA for arteriovenous access surgery

ARTERIOVENOUS: access creation is mandatory in patients with end stage renal disease for hemodialysis treatment. It frequently involves upper arm or axillary dissection and general anesthesia is predominantly used as axillary compartment innervation is complex. Avoiding general anesthesia may be beneficial in these risk patients. We present two cases where serratus-intercostal plane block (SIPB/BRILMA) was used, along with ultrasound guided supraclavicular block and multimodal analgesia for proximal arm and axillary AV access surgery. Regional anesthesia combination of supraclavicular and serratus-intercostal/BRILMA block in arteriovenous fistula surgery was successful and should be considered by anesthesiologist in order to avoid general anesthesia.