Interscalene brachial plexus block anesthesia for upper extremity surgery

A life-threatening complication of the arterial tourniquet in Timothy syndrome

An infant with Timothy syndrome, a congenital syndrome resulting in a long QT interval and high risk of death in childhood, is presented along with his perioperative management. Characteristic life-threatening arrhythmias thought to be caused by excess sympathetic stimulation secondary to an arterial tourniquet are described.

The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence

Interscalene brachial plexus block is a commonly used anesthetic. However, substantial complications can be associated with its use. Our study included 15 years of data from a local medical center and 3 decades of records from the national American Society of Anesthesiology Closed Claims Project. The hospital had 27 peripheral neurologic injuries, 3 central nervous system complications, 6 respiratory complications, and 5 cardiovascular complications. Of these complications, 14 were still present at the most recent follow-up, some causing major compromise of the patient's comfort and function. All central blocks, local toxicities, and respiratory complications resolved. In the hospital series, more experienced anesthesiologists tended to have lower complication rates. The American Society of Anesthesiology Closed Claims database had 20 peripheral neurologic injuries, 10 respiratory complications, 5 central nervous system complications, 4 deaths, 2 emotional disturbances, and 1 other unknown event. Of the complications, 19 were described as permanent. Interscalene brachial plexus block can be accompanied by substantial and disabling complications, especially when administered by less experienced anesthesiologists.

Increased body mass index and ASA physical status IV are risk factors for block failure in ambulatory surgery — an analysis of 9,342 blocks

PURPOSE

Regional anesthesia can be the technique of choice for selected ambulatory surgery procedures, but in spite of its benefits, it has an inherent failure rate even in experienced hands. We examine the efficacy and factors associated with failure of ambulatory regional anesthesia techniques.

METHODS

This study included 9,342 blocks performed on 7,160 patients at the Duke University Ambulatory Surgery Center. Blocks were classified as interscalene, supraclavicular, axillary, lumbar plexus, femoral, sciatic, ankle, paravertebral, spinal, and other (frequency less than 100). A block was considered surgical if a single attempt at placing the block resulted in a complete sensory, motor, and sympathetic nerve block. Multiple logistic regression analyses were used to assess the risk-adjusted association between patient characteristics and block failure.

RESULTS

Paravertebral blocks and those considered in the "other" category had significantly higher failure rates (P < 0.001), while spinal and lumbar plexus blocks had lower than average rates of failure (P < 0.001 and P = 0.03, respectively). In multiple logistic regression analyses excluding paravertebral blocks, body mass index (BMI) scores greater than 25 (P values: BMI 25-29: < 0.001; BMI 30-34: P < 0.001; BMI 35: P < 0.001) and ASA physical status IV (P < 0.001) were significantly associated with higher block failure rates.

CONCLUSION

High BMI and ASA IV are independent risk factors for block failure in ambulatory surgery patients.

The "mini-Bier's block": a new technique for prevention of tourniquet pain during axillary brachial plexus anaesthesia

Tourniquet cuff pain is a significant cause of morbidity following regional anaesthesia of the upper limb. We describe a simple new technique for effectively anaesthetizing the area under a pneumatic tourniquet (the "mini-Bier's block"), which permits comfortable surgery under axillary block anaesthesia even if the local block is incomplete. We report a controlled study of 40 patients in whom statistically significant tourniquet cuff pain relief was obtained in patients receiving an additional low-dose intravenous injection of local anaesthetic localized beneath the cuff. This technique ensures that the safe axillary approach to the brachial plexus can always be used with avoidance of pain from the pressure of the tourniquet cuff.

Interscalene brachial plexus blocks in the management of shoulder dislocations

Interscalene brachial plexus block is a simple and effective alternative to intravenous benzodiazepines or general anaesthesia for manipulation of the dislocated shoulder. Thirty interscalene brachial plexus blocks were performed on 29 patients with dislocations of the shoulder to provide regional anaesthesia for reduction. Pain was abolished by 14 out of the 30 blocks performed, improved by 13 and unchanged by three. Muscle relaxation (MRC grade 3 or less) occurred in 21 patients. In 26 cases the block allowed reduction of the dislocation without additional analgesia or sedative. Reduction was not possible in four cases. There were no significant complications.

Brachial Plexus Anaesthesia for Upper Limb Surgery: A Review of Eight Years’ Experience

1248 supraclavicular brachial plexus blocks and 665 axillary plexus blocks were administered to 1913 patients undergoing upper limb surgery. Plexus block alone was successful in 83.5%. In a further 11.4% of cases, adequate anaesthesia was obtained following augmentation by other regional or local techniques. This resulted in an overall success rate of 94.9% and general anaesthesia was required in only 5.1%. The two percutaneous approaches to the brachial plexus did not differ in their success-rates but clinically apparent pneumothorax occurred in 0.8% of supraclavicular blocks.

Brachial plexus block anaesthesia is recommended as a safe and satisfactory alternative to general anaesthesia for upper limb surgery.