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Anesth Analg 2006;102:610-614 © 2006 International Anesthesia Research Society doi: 10.1213/01.ane.0000195228.65280.b4
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Abstract |
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We prospectively evaluated the feasibility and efficacy of a simple method for inserting 5.1-cm brachial plexus catheters using a fascial click technique. In 120 patients, after inserting an axillary catheter by a resident and verifying adequate position using a nerve stimulator, 0.7 mL/kg 1% mepivacaine was injected. Success of blockade (analgesia at 40 min in the 4 terminal nerves), analgesia efficacy, and resident autonomy were recorded. The primary success rate was 87%. Reinjections were performed preoperatively and perioperatively in 40% and 50% of patients, respectively. The resident completed the technique in 91% of cases. We conclude that this technique is easily performed by residents in training and is associated with frequent success for anesthesia and postoperative analgesia.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Many regional anesthesia procedures are useful in the emergency setting (1). For upper limb trauma surgery, placement of an axillary brachial plexus catheter has many advantages. First, effective analgesia is established quickly and maintained during the preoperative period until surgery. Second, prolonged anesthesia is possible in the case of surgery of long duration (2,3). Third, postoperative analgesia is possible (4–6).
In this prospective and descriptive study, we evaluated a simple method of axillary catheter insertion using a nerve stimulator, in an emergency setting.
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Methods |
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After institutional approval and written informed patient consent, patients undergoing upper limb (hand, forearm, elbow) emergency surgery were prospectively evaluated over a 6-mo period. Patients with contraindications to axillary brachial plexus anesthesia, those in a coma, and those who were unconscious or had sustained major injuries were excluded. In all patients, an IV line and standard ASA monitors were placed. There was no minimum fasting period required.
All blocks were performed by one of three residents under continuous supervision by an experienced anesthesiologist. Midazolam 0.03 mg/kg was given IV 5 min before the block. We used a short-bevel catheter 18-gauge and 5.1 cm (Tactilong Pajunk TM, Melsungen, Germany) (Figure 1).
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The patients were placed supine with the arm abducted 120° and the forearm flexed and supinated. The insertion site was 6 cm distal to the lateral border of the pectoralis major muscle. After local anesthesia of the skin, the catheter was inserted cephalad at 40° to 60° to the skin just above the axillary artery. The characteristic "fascial click" indicated the penetration of the neurovascular sheath.
The stylet was connected to a nerve stimulator (HNS11, B Braun, Germany) and the position of the catheter was judged adequate if output 
0.5 mA (2 Hz, 100 µs) still elicited a median, radial, or ulnar motor response. A test dose of 2 mL 1% mepivacaine with 1:200,000 epinephrine was injected to detect intravascular injection. In case of tachycardia, blood vessel puncture, or absence of muscular response during nerve stimulation, the catheter was removed and a new insertion was attempted.
After the stylet was withdrawn, a flexible extension tubing (Figure 2) was interposed between the catheter and a syringe to facilitate injection performed with the arm adducted (7). The catheter was fixed in position. To standardize the volume among patients, 0.7 mL/kg 1% mepivacaine (with a maximum of 60 mL) was injected in 5 mL increments, after careful aspiration. At the end of surgery, a further injection of 20 mL of 1% mepivacaine was performed through the catheter (with a minimal 90-min interval) in any patient reporting pain. In the recovery room, postoperative analgesia was commenced with 20 mL 0.125% bupivacaine through the catheter. Nalbuphine (20 mg IV) was allowed as rescue analgesia.
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All blocks were assessed by a blinded investigator. The time to perform the block (catheter insertion) was defined as the time between the skin infiltration and test dose injection. Sensory (0 = normal sensation; 1 = analgesia; 2 = anesthesia) and motor (0 = normal muscular function; 1 = paresis; 2 = complete paralysis) blocks were tested every 10 min. The primary block was defined as successful when sensory score 
1 (pinprick test) was observed at 40 min in the 4 terminal nerves (musculocutaneous, median, radial, and ulnar). After 40 min, in case of incomplete block, the unblocked nerve(s) implicated in the surgical site was blocked at elbow level. In the event of failure of the distal blocks, general anesthesia was performed. Motor block was considered complete if only weak muscular function was present in all four terminal nerves. Resident autonomy during the procedure was analyzed: block performed without physical or verbal intervention by senior; block performed with verbal direction by senior; block performed entirely by the senior. The incidence of adverse effects was noted. Patient satisfaction was evaluated and scored (0, dissatisfied; 1, moderately satisfied; 2, totally satisfied). Data are expressed as mean ± sd for quantitative variables and as percentage for qualitative variables.
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Results |
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None of the 120 patients included refused the regional anesthesia technique. Patient demographics and details of trauma are listed in Table 1. Details of axillary catheter insertion and surgery are presented in Table 2. The surgery lasted more than 1 h in 42 patients.
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The time to perform the block was <10 min in 81% of patients. In all but one patient, after detection of a fascial click, muscle twitches were elicited on the first attempt.
The primary success rate was 87%. At 40 min, a sensory score 1 was noted on the radial, median, ulnar, and musculocutaneous nerves in 93%, 98%, 98%, and 97% of patients, respectively. Fifteen patients (13%) underwent supplementary blocks. In 92% of cases, surgery was achieved with no sedation or with light sedation. In the remaining 9 patients (8%), general anesthesia was performed because of failure of regional anesthesia. The onset time of motor blocks is shown Figure 3.
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Blocks were performed by the residents alone, in 74% of cases, on average after 1 ± 0.5 (range, 1–3) attempts. Verbal assistance was provided by the senior anesthesiologist in 17% of cases. In the remaining 9% of cases, the senior anesthesiologist performed the block. Assistance was necessary only during the first 20 cases.
Difficulty in palpating the axillary pulse and introducing the catheter was encountered in 13 and 2 patients, respectively. Paresthesia or vascular puncture was not reported in any case. Signs of systemic local anesthetic toxicity (one seizure and one subtle behavioral change) occurred in two patients during the initial dosing. No sequelae were noted afterward.
In 107 patients, the axillary catheter was used for postoperative analgesia from 24 h (45%) to 72 h (9%). During this period, opioid supplementation was necessary in only 4 patients. The axillary catheter was successfully used for subsequent surgery in 4 cases.
Patient satisfaction was scored 1 in 97% of cases. Ninety percent of patients would choose to have the same anesthetic technique in the future.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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In upper limb traumatic surgery, placement of a short axillary catheter is a simple and reliable technique with frequent success rate for anesthesia and for preoperative and postoperative analgesia.
We chose this specific catheter because the solid stylet causes a distinctly perceivable resistance before the neurovascular sheath is penetrated. A clear click during the puncture indicates that the cannula is positioned correctly. Electric stimulation is not mandatory with this approach, which may be another advantage of the technique (decreased pain in case of fracture). On the other hand, a click felt could lead to an incorrect position (penetration of the coracobrachialis muscle). In such conditions, nerve stimulation may be helpful to confirm the adequate position of the cannula within the sheath. Moreover, from an educational point of view, nerve stimulation facilitates the training of the residents.
The axillary catheter technique permitted good analgesia preoperatively. This is particularly useful in the emergency setting during presurgical transport and evaluation.
The technique described is frequently successful for anesthesia. The 15 partial failures might have been secondary to our use of a single injection technique (8) or the variable spread of local anesthetic when injected through a catheter (9). We reported frequent of unsuccessful radial nerve block, as described elsewhere in the literature (10,11). Our success rate is in accordance with that previously reported by Rawal et al. (12), using axillary brachial plexus catheterization. It was better than the 50% success rate found in other studies with single-shot axillary brachial plexus injection (8,13,14). One explanation might be that the site of injection of local anesthetic was more cephalad.
As compared with elective surgery, many procedures performed for trauma may require a second procedure shortly after the first. During the first week, 7 patients (5.8%) underwent an additional surgery in our study, with the same axillary catheter used to provide successful anesthesia in 4 cases. One limitation of the technique is the requirement for arm abduction during catheter insertion. In such conditions, other approaches to the brachial plexus, such as infraclavicular, present a good alternative (15).
The technique described seems simple for the anesthesiologist in training (81% of success alone or with only verbal intervention). Physical assistance by the senior was required during the 20 first blocks attempted by the resident. This is in accordance with data previously reported (16,17). However, only three residents participated in this study, thus limiting the strength of our conclusions.
Incidences of side effects are comparable with those observed by Bergman et al. (18). No other complications were noted, specifically localized infection, or new neurological deficits, although this series included prolonged catheter use.
In conclusion, a short axillary brachial plexus catheter can be inserted by junior anesthesiology residents (with attending supervision) and with frequent success for preoperative, perioperative, and postoperative analgesia.
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Footnotes |
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Accepted for publication September 21, 2005.
Presented, in part, at the 2000 World Congress of Anesthesiologists, Montreal, Quebec.
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References |
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- Fuzier R, Tissot B, Mercier-Fuzier V, et al. Evaluation of regional anesthesia procedure in an emergency department. Ann Fr Anesth Reanim 2002;21:193–7.[Web of Science][Medline]
- Sada T, Kobayashi T, Murakami S. Continuous axillary brachial plexus block. Can Anaesth Soc J 1983;30:201–5.[Web of Science][Medline]
- Selander D. Catheter technique in axillary plexus block: presentation of a new method. Acta Anaesth Scand 1977;21:324–9.[Web of Science][Medline]
- Neal JM, Hebl JR, Gerancher JC, Hogan QH. Brachial plexus anesthesia: essentials of our current understanding. Reg Anesth Pain Med 2002;27:402–28.[Web of Science][Medline]
- Rosenblatt R, Pepitone-Rockwell F, McKillop MJ. Continuous axillary analgesia for traumatic hand surgery. Anesthesiology 1979;51:565–6.[Web of Science][Medline]
- Gaumann DM, Lennon RL, Wedel DJ. Continuous axillary block for postoperative pain management. Reg Anesth 1988;13:77–82.[Web of Science]
- Yamamoto K, Tsubokawa T, Ohmura S, Kobayashi T. The effects of arm position on central spread of local anesthetics and on quality of the block with axillary brachial plexus block. Reg Anesth Pain Med 1999;24:36–42.[Web of Science][Medline]
- Lavoie J, Martin R, Tetrault JP, Côte DJ. Axillary plexus block using a peripheral nerve stimulator: single or multiple injections. Can J Anaesth 1992;39:583–6.[Web of Science][Medline]
- Klaastad O, Smebdy O, Thompson GE, et al. Distribution of local anesthetic in axillary brachial plexus block: a clinical and magnetic resonance imaging study. Anesthesiology 2002;96:1315–24.[Web of Science][Medline]
- Brockway MS, Wildsmith JAW. Axillary brachial plexus block: method of choice? Br J Anaesth 1990;64:224–31.
[Free Full Text] - Lanz E, Theiss D, Jankovic D. The extent of blockade following various techniques of brachial plexus block. Anesth Analg 1983;62:55–8.
[Abstract/Free Full Text] - Rawal N, Allvin R, Axelsson K, et al. Patient-controlled regional analgesia (PCRA) at home: controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia. Anesthesiology 2002;96:1290–6.[Web of Science][Medline]
- Goldberg ME, Gregg C, Larijani GE, et al. A comparison of three methods of axillary approach to brachial plexus blockade for upper extremity surgery. Anesthesiology 1987;66:814–6.[Web of Science][Medline]
- Baranowski AP, Pither CE. A comparison of three methods of axillary brachial plexus anaesthesia. Anaesthesia 1990;45:362–5.[Web of Science][Medline]
- Fuzier R, Fuzier V, Albert N, et al. The infraclavicular block is a useful technique for emergency upper extremity analgesia. Can J Anaesth 2004;51:191–2.[Web of Science][Medline]
- Kopacz D. QA in regional anesthesia training: quantity or quality? Reg Anesth 1997;22:209–11.[Web of Science][Medline]
- Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998;86:635–9.[Abstract]
- Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive continuous axillary catheters. Anesth Analg 2003;96:247–52.
[Abstract/Free Full Text]
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