Skip to main content
SpringerLink
Log in

To what extent can local anesthetics be reduced for infraclavicular block with ultrasound guidance?

Bis zu welcher Menge können Lokalanästhetika bei ultraschallgesteuerter infraklavikulärer Plexusblockade reduziert werden?

  • Originalien
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Abstract

Objectives

To assess the adequacy of different amounts of local anesthetics (LA) in infraclavicular blockade (ICB) under ultrasonographic (US) guidance and neurostimulation and compare them to the conventional doses under neurostimulation (NS).

Material and methods

In this study 100 patients scheduled for upper limb surgery and suitable for ICB were randomly allocated to 1 of 5 groups: group NS (NS alone group 0.5 ml/kg LA), group FD (full-dose US group 0.5 ml/kg LA), group 30 (30 % reduced dose LA 0.35 ml/kg), group 50 (0.25 ml/kg LA) and group 70 (0.15 ml/kg LA). The ICB was performed under US in conjunction with NS in all groups except group NS in which neurostimulation was used alone. When necessary local anesthetic supplementation to the operation site was administered during surgery and propofol infusion for sedation ensued. Evaluation of sensory and motor block was performed for each terminal nerve (i.e. radial, ulnar, median and musculocutaneous nerves). Block quality (assessing the need for rescue LA and propofol sedation) and duration of the block were documented.

Results

None of the patients in the FD and 30 groups required any supplementation or sedation, whereas LA supplementation rates were 5 % in group 50 and 10 % in groups 70 and NS. The propofol sedation rates were 20 % in group NS, 25 % in group 50 and 40 % in group 70. Sensory block was significantly better in groups FD, 30 and NS at 30 min. A complete block was achieved more rapidly in all nerve territories in the full-dose group (p = 0.0001). Block duration was longest in group FD and was significantly longer in group 30 than in the other two groups (p = 0.0001).

Conclusion

The results show that US guidance is more effective in maintenance of successful ICB than neurostimulation guidance alone and a reduction of LA doses even to 70 % of conventionally used doses seems possible with US guidance.

This article is published in English.

Zusammenfassung

Ziele

Es sollten die Effekte unterschiedlicher Mengen an Lokalanästhetika während ultraschall- und nervenstimulationsgestützter infraklavikulärer Plexusblockade (ICB) im Vergleich zu den konventionellen Dosen unter alleiniger nervenstimulationsgestützter Blockade evaluiert werden.

Material und Methoden

Es wurden 100 Patienten in die Studie aufgenommen, die sich einem Eingriff an der oberen Extremität in peripherer Anästhesie des Plexus brachialis unterzogen. Die Patienten wurden in 5 Untersuchungsgruppen randomisiert: Gruppe NS [allein Nervenstimulator, 0,5 ml/kgKG Lokalanästhetika (LA)], Gruppe VD (Volle-Dosis-Ultraschall-Gruppe, 0,5 ml/kgKG LA), Gruppe 30 (um 30 % reduzierte LA-Dosis, 0,35 ml/kgKG), Gruppe 50 (0,25 ml/kgKG LA) und Gruppe 70 (0,15 ml/kgKG LA). In allen Gruppen, bis auf Gruppe NS, wurden eine ultraschallgesteuerte ICB und eine Nervenstimulation durchgeführt. In der Gruppe NS wurde eine ICB unter Nervenstimulation allein vorgenommen. Um die sensorischen und motorischen Blockaden zu beurteilen, wurden die 4 Hauptnerven (Nn. radialis, medianus, ulnaris und musculocutaneus) des Arms untersucht. Bei Bedarf wurden dem Patienten während des chirurgischen Eingriffs ergänzend LA oder Propofol zur Sedierung verabreicht. Die Blockqualität (unter Berücksichtigung des zusätzlichen Bedarfes an LA und Propofol Sedierung) und Wirkdauer wurden dokumentiert.

Ergebnisse

In den Gruppen VD und 30 wurde bei keinem Patienten ein Bedarf an ergänzendem LA oder Sedierung durch Propofol beobachtet. In Gruppe 50 konnte ein Bedarf an einer LA-Ergänzung bei 5 % sowie in den Gruppen 70 und NS bei 10 % der Patienten beobachtet werden. Der Bedarf an Sedierung durch Propofol betrug in der NS-Gruppe 20 %, in der 50-Gruppe 25 % und in der 70-Gruppe 40 %. Die sensorische Blockade in den Gruppen VD, 30 und NS war in der 30. Minute signifikant besser. Eine komplette Blockade aller Nervengebiete wurde in der VD-Gruppe am schnellsten erreicht (p = 0,0001). Die Blockadedauer war in der VD-Gruppe am längsten. In der Gruppe 30 ließ sich eine signifikant längere Blockadedauer als in den anderen beiden Gruppen ermitteln (p = 0,0001).

Schlussfolgerungen

Bei der erfolgreichen ICB-Durchführung ist die Steuerung durch Ultraschall im Vergleich zur Nervenstimulation effektiver und kann den Bedarf der LA-Menge bis zu 70 % der konventionellen Dosis reduzieren.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Koscielniak-Nielsen ZJ, Frederiksen BS, Rasmussen H, Hesselbjerg L (2009) A comparison of ultrasound-guided supraclavicular and infraclavicular blocks for upper extremity surgery. Acta Anaesthesiol Scand 53(5):620–626

    Article  PubMed  CAS  Google Scholar 

  2. Gurkan Y, Hosten T, Tekin M et al (2012) Comparison of ultrasound-guided supraclavicular and infraclavicular approaches for brachial plexus blockade. Agri 24(4):159–164

    Article  PubMed  Google Scholar 

  3. Sandhu NS, Capan LM (2002) Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 89:254–259

    Article  PubMed  CAS  Google Scholar 

  4. Desroches J (2003) The infraclavicular brachial plexus block by the coracoid approach is clinically effective: an observational study of 150 patients. Can J Anaesth 50:253–257

    Article  PubMed  Google Scholar 

  5. Jandard C, Gentili ME, Girard F et al (2002) Infraclavicular block with lateral approach and nerve stimulation: extent of anesthesia and adverse effects. Reg Anesth Pain Med 27:37–42

    PubMed  CAS  Google Scholar 

  6. Liu SS, Ngeow J, John RS (2010) Evidence basis for ultrasound-guided block characteristics: onset, quality, and duration. Reg Anesth Pain Med 35(2):S26–S35. DOI 10.1097/AAP.0b013e3181d266f0

    Article  PubMed  Google Scholar 

  7. Dingemans E, Williams SR, Arcand G et al (2007) Neurostimulation in ultrasound-guided infraclavicular block: a prospective randomized trial. Anesth Analg 104(5):1275–1280

    Article  PubMed  Google Scholar 

  8. Borgeat A, Ekatodramis G, Dumont C (2001) An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 93:436–441

    PubMed  CAS  Google Scholar 

  9. Ootaki C, Hayashi H, Amano M (2000) Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to anatomical landmark-guided approaches. Reg Anesth Pain Med 25:600–604

    PubMed  CAS  Google Scholar 

  10. Marhofer P, Schrögendorfer K, Koinig H et al (1997) Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 85:854–857

    PubMed  CAS  Google Scholar 

  11. Williams SR, Chouinard P, Arcand G et al (2003) Ultrasound guidance speeds execution and improves the quality of supraclavicular block. Anesth Analg 97:1518–1523

    Article  PubMed  Google Scholar 

  12. Marhofer P, Schrogendorfer K, Wallner T et al (1998) Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 23:584–588

    PubMed  CAS  Google Scholar 

  13. Casati A, Baciarello M, Di Cianni S et al (2007) Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth 98:823–827

    Article  PubMed  CAS  Google Scholar 

  14. Valery P, Aliaksei M (2013) A comparison of the onset time of complete blockade of the sciatic nerve in the application of ropivacaine and its equal volumes mixture with lidocaine: a double-blind randomized study. Korean J Anesthesiol 65(1):42–47

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  15. Laur JJ, Bayman EO, Foldes PJ, Rosenquist RW (2012) Triple-blind randomized clinical trial of time until sensory change using 1.5 % mepivacaine with epinephrine, 0.5 % bupivacaine, or an equal mixture of both for infraclavicular block. Reg Anesth Pain Med 37(1):28–33

    Article  PubMed  CAS  Google Scholar 

  16. Keckeis A, Hofmockel R (1994) Mixtures of different local anesthetics for subaxillary plexus anesthesia. Anaesthesiol Reanim 19(2):32–36

    PubMed  CAS  Google Scholar 

  17. Tryba M, Börner P (1988) Clinical effectiveness and systemic toxicity of various mixtures of prilocaine and bupivacaine in axillary plexus block. Reg Anaesth 11(2):40–49

    PubMed  CAS  Google Scholar 

  18. Chan VW, Perlas A, Rawson R, Odukoya O (2003) Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 97:1514–1517

    Article  PubMed  Google Scholar 

  19. Marhofer P, Sitzwohl C, Greher M, Kapral S (2004) Ultrasound guidance for infraclavicular brachial plexus anaesthesia in children. Anaesthesia 59:642–646

    Article  PubMed  CAS  Google Scholar 

  20. Tran De QH, Charghi R, Finlayson RJ (2006) The “double bubble” sign for successful infraclavicular brachial plexus blockade. Anesth Analg 103(4):1048–1049. DOI 10.1213/01.ane.0000239077.49794.a5

    Article  Google Scholar 

  21. Tran De QH, Bertini P, Zaouter C et al (2010) A prospective, randomized comparison between single- and double-injection ultrasound-guided infraclavicular brachial plexus block. Reg Anesth Pain Med 35:16–21

    Article  PubMed  Google Scholar 

  22. Desgagnés MC, Lévesque S, Dion N et al (2009) A comparison of a single or triple injection technique for ultrasound-guided infraclavicular block: a prospective randomized controlled study. Anesth Analg 09:668–672

    Article  Google Scholar 

  23. Retzl G, Kapral S, Greher M, Mauritz W (2001) Ultrasonographic findings of the axillary part of the brachial plexus. Anesth Analg 92:1271–1275

    Article  PubMed  CAS  Google Scholar 

  24. Becker DE, Reed KL (2006) Essentials of local anesthetic pharmacology. Anesth Prog 53:98–108

    Article  PubMed  PubMed Central  Google Scholar 

  25. Mather LE, Copeland SE, Ladd LA (2005) Acute toxicity of local anesthetics: underlying pharmacokinetic and pharmacodynamic concepts. Reg Anesth Pain Med 30:553–566

    PubMed  CAS  Google Scholar 

  26. Ponrouch M, Bouic N, Bringuier S et al (2010) Estimation and pharmacodynamic consequences of the minimum effective anesthetic volumes for median and ulnar nerve blocks: a randomized, double-blind, controlled comparison between ultrasound and nerve stimulation guidance. Anesth Analg 111:1059–1064

    PubMed  CAS  Google Scholar 

  27. Sandhu NS, Bahniwal CS, Capan LM (2006) Feasibility of an infraclavicular block with a reduced volume of lidocaine with sonographic guidance. J Ultrasound Med 25:51–56

    PubMed  Google Scholar 

  28. Tran De QH, Dugani S, Dyachenko A et al (2011) Minimum effective volume of lidocaine for ultrasound-guided infraclavicular block. Reg Anesth Pain Med 36:190–194

    Article  CAS  Google Scholar 

  29. Fredrickson MJ, Smith KR, Wong AC (2010) Importance of volume and concentration for ropivacaine interscalene block in preventing recovery room pain and minimizing motor block after shoulder surgery. Anesthesiology 112:1374–1381

    Article  PubMed  CAS  Google Scholar 

  30. Duggan E, El Beheiry H, Perlas A et al (2009) Minimum effective volume of local anesthetic for ultrasound-guided supraclavicular brachial plexus block. Reg Anesth Pain Med 34:215–218

    Article  PubMed  CAS  Google Scholar 

  31. Flohr-Madsen S, Ytrebø LM, Kregnes S et al (2013) Minimum effective volume of ropivacaine 7.5 mg/ml for an ultrasound-guided infraclavicular brachial plexus block. Acta Anaesthesiol Scand 57(4):495–501. DOI 10.1111/aas.12078

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We would like to acknowledge Konyalioglu R. (Bakirkoy Dr Sadi Konuk Training Hospital, Biostatistics) for consultation on the statistical analyses used in this study.

Compliance with ethical guidelines

Conflict of interest. G. Eren, E. Altun, Y. Pektas, Y. Polat, H. Cetingok, G. Demir, D. Bilgi, Y. Tekdos und M. Dogan state that there are no conflicts of interest. All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.

Author information

Authors and Affiliations

  1. Department of Anesthesiology and Intensive Care, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Tevfik Sağlam Cad. No:11, 34147, Zuhuratbaba/Istanbul, Turkey

    G. Eren M.D., E. Altun, Y. Pektas, Y. Polat, H. Cetingok, G. Demir, D. Bilgi, Y. Tekdos & M. Dogan

Authors
  1. G. Eren M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. Altun
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Y. Pektas
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Y. Polat
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. H. Cetingok
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. G. Demir
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. D. Bilgi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Y. Tekdos
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. M. Dogan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to G. Eren M.D..

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Eren, G., Altun, E., Pektas, Y. et al. To what extent can local anesthetics be reduced for infraclavicular block with ultrasound guidance?. Anaesthesist 63, 760–765 (2014). https://doi.org/10.1007/s00101-014-2361-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-014-2361-4

Keywords

Schlüsselwörter

Search

Navigation