A comparison of the lateral and posterior approach for brachial plexus block.

Contains fulltext : 51106.pdf (publisher's version ) (Closed access)BACKGROUND: Brachial plexus block by the posterior approach described by Pippa is not widely used in contrast to the lateral approach of Winnie. We compared the clinical efficacy of both approaches in a randomized prospective study. METHODS: Eighty patients, American Society of Anesthesiologists physical status I or II, scheduled for surgery of the shoulder or upper arm were randomized in 2 groups: lateral (Winnie, n = 40) or posterior approach (Pippa, n = 40). A single injection of ropivacaine 7.5 mg/mL, 0.5 mL/kg, was made after obtaining a motor response in the distribution of the axillary nerve at a current below 0.5 mA (2 Hz, 0.1 millisecond). Onset and distribution of analgesia and motor block were assessed at 5, 10, 15, 20, 30, and 60 minutes after the local anesthetic injection. Complete block was defined as anesthesia in all dermatomes C3-C6 at 60 minutes after injection. RESULTS: The posterior approach provided complete block in 36 patients (90%) and the lateral approach in 33 patients (83%). Corresponding motor block was similar in both approaches, but the block procedure time was faster in the posterior approach (6.2 [5.2-7.2] minutes v 8.4 [7.1-10.2] minutes; P < .001). Surgical success rate (posterior 95% v lateral 93%) and side effects were similar in both approaches. One complication (thoracic epidural block) was seen using the lateral approach, whereas none occurred in the posterior approach. There was no difference in patient satisfaction scores of the 2 approaches, which were equally high in both groups (posterior 98% v lateral 95%). CONCLUSION: Both approaches are comparable regarding clinical efficacy for anesthesia of the shoulder and upper arm

Ultrasound-guided continuous phrenic nerve block for persistent hiccups.

Contains fulltext : 87560.pdf (publisher's version ) (Closed access)BACKGROUND: Phrenic nerve block can be performed and repeated if necessary for persistent hiccups, when conservative and pharmacological treatment is unsuccessful. We report the first description of an in-plane ultrasound (US)-guided phrenic nerve block (PhNB) with a catheter, after US investigation of the bilateral diaphragm, to treat hiccups while avoiding repeated PhNBs. CASE: A 36-year-old man had persistent postoperative hiccups not responding to conservative and pharmacological treatment. Bilateral diaphragmatic US evaluation showed abnormal right-sided movement. A right-sided in-plane US-guided PhNB with catheter was performed. Injection of local anesthetic stopped the hiccups, and a continuous infusion of local anesthetic was started for 24 hrs. After discontinuation of the infusion, the hiccups recurred. Restart of the continuous infusion of the local anesthetic through the catheter was performed, and after discontinuation 24 hrs later, no further hiccups occurred. No adverse effect occurred. CONCLUSIONS: An US-guided in-plane PhNB with catheter is feasible and avoids repeated PhNB when hiccups reoccur. Ultrasound investigation of the bilateral diaphragm should be performed before performing the nerve block

Hemidiaphragmatic paresis can be avoided in ultrasound-guided supraclavicular brachial plexus block.

Contains fulltext : 80558.pdf (publisher's version ) (Closed access)BACKGROUND AND OBJECTIVES: Supraclavicular brachial plexus block is associated with 50% to 67% incidence of hemidiaphragmatic paresis as a result of phrenic nerve block. We examined whether ultrasound-guided compared with nerve stimulation supraclavicular brachial plexus block using 0.75% ropivacaine results in a lower incidence of hemidiaphragmatic paresis. METHODS: In a prospective randomized observer-blinded controlled trial, 60 patients scheduled for elective elbow, forearm, wrist, or hand surgery under supraclavicular brachial plexus block without sedation were included. Supraclavicular brachial plexus block was performed with 20 mL of 0.75% ropivacaine using either ultrasound or nerve stimulation guidance. Ventilatory function was assessed by ultrasound examination of hemidiaphragmatic movement and spirometry. RESULTS: None of the 30 patients in the ultrasound group showed complete or partial paresis of the hemidiaphragm (95% confidence interval, 0.00-0.14), whereas in the nerve stimulation group, 15 patients showed complete paresis of the hemidiaphragm and 1 patient showed partial paresis of the hemidiaphragm (0% versus 53%, respectively; P < 0.0001). Ventilatory function (forced expiratory volume 1, forced vital capacity, peak expiratory flow) was significantly reduced in the nerve stimulation group compared with the ultrasound-guided group (P < 0.05). Two block failures occurred in the nerve stimulation group compared with none in the ultrasound group (P = 0.49). No adverse effects occurred in either group. Conclusions: Ultrasound-guided supraclavicular brachial plexus block, using 20 mL of 0.75% ropivacaine with the described technique, is not associated with hemidiaphragmatic paresis

Minimum effective volume of local anesthetic for shoulder analgesia by ultrasound-guided block at root C7 with assessment of pulmonary function.

Contains fulltext : 88926.pdf (publisher's version ) (Closed access)BACKGROUND AND OBJECTIVES: This study was performed to determine the minimum effective volume of ropivacaine 0.75% required to produce effective shoulder analgesia for an ultrasound (US)-guided block at the C7 root level with assessment of pulmonary function. METHODS: Using the Dixon and Massey up-and-down method study design, 20 patients scheduled for elective open shoulder surgery under combined general anesthesia and continuous interscalene brachial plexus block were included. Initial volume of ropivacaine 0.75% was 6 mL; block success or failure determined a 1-mL decrease or increase for the subsequent patient, respectively. General anesthesia was standardized. A continuous infusion of ropivacaine 0.2% was started at a rate of 6 mL/hr at 2 hrs after completion of surgery. Ventilatory function was assessed using spirometry, and movement of the hemidiaphragm was assessed by US. RESULTS: The minimum effective volume of local anesthetic in 50% and 95% of the patients was 2.9 mL (95% confidence interval, 2.4-3.5 mL) and 3.6 mL (95% confidence interval, 3.3-6.2 mL), respectively. Ventilatory function and hemidiaphragmatic movement was not reduced up to and including 2 hrs after completion of surgery, but 22 hrs after start of the continuous infusion of ropivacaine 0.2%, ventilatory function and hemidiaphragmatic movement were significantly reduced (P < 0.001). CONCLUSIONS: The minimum effective volume of local anesthetic for shoulder analgesia for a US-guided block at the C7 root level in 50% and 95% of the patients was 2.9 and 3.6 mL, respectively. Pulmonary function was unchanged until 2 hrs after completion surgery, but reduced 22 hrs after start of a continuous infusion of ropivacaine 0.2%.1 november 201

Reply to Dr. Cornish.

Contains fulltext : 89396.pdf (publisher's version ) (Closed access

Ultrasound-guided training in the performance of brachial plexus block by the posterior approach: an observational study.

Contains fulltext : 52689.pdf (publisher's version ) (Closed access)The application of ultrasonography in guiding and controlling the path of the stimulating needle to the brachial plexus via the posterior approach (Pippa technique) was studied. In 21 ASA physical status 1 and 2 patients, scheduled for surgery of the shoulder or upper arm, needle insertion was monitored by ultrasonography and the interaction between needle, surrounding structures and brachial plexus was followed. During injection, the spread of local anaesthetic was visualised and a prediction of block success was made. One failure was predicted. Complete block was achieved in 20 (95%) patients. One potential complication, puncture of the carotid artery, was prevented using ultrasound. Ultrasound is a useful tool in the training and performance of a neurostimulation-guided brachial plexus block by the posterior approach. Ultrasonographic guidance may prevent serious complications associated with this approach to the brachial plexus

De axillaire plexus brachialis blokkade anno 2014 cht en toekomstperspectief

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High serum thyrotropin levels are associated with current but not with incident hypertension

Background: Recent data from a population-based study in children and adolescents suggest that serum thyrotropin (TSH) levels are associated with arterial blood pressure and hypertension. These results are in agreement with some but not all population-based studies in adults. Discrepancies in results might be explained by drug intake, different iodine supplies, and sizes of populations investigated. In addition, it is not clear whether an association between TSH and hypertension exists longitudinally or only cross-sectionally. Thus, our aim was to investigate cross-sectional and longitudinal associations between thyroid function and arterial blood pressure in a large consortium of cohort studies in adults. Methods: Data from five population-based studies were pooled resulting in 17,023 individuals being available for cross-sectional and 10,048 individuals for longitudinal analyses. Associations of baseline TSH with baseline blood pressure or hypertension were analyzed by multivariable median or logistic regression models. Multivariable median or Poisson regression models were used to investigate associations of baseline TSH with five-year change in arterial blood pressure or incident hypertension. Results: There was a cross-sectional positive association of TSH with arterial blood pressure (p&lt;0.001) and hypertension (odds ratio [OR]=1.76 [confidence interval (CI) 1.24-2.50], p=0.002). Likewise, hypothyroidism was associated with systolic (&beta;=1.1 [CI 0.1-2.1], p=0.040) and diastolic blood pressure (&beta;=1.4 [CI 0.7-2.0], p&lt;0.001). TSH, however, was not consistently associated with a five-year change in blood pressure or incident hypertension. Conclusions: High serum TSH levels were associated with current hypertension and blood pressure but not with a five-year change in blood pressure and incident hypertension. This argues for only a short-term effect of thyroid hormone levels on arterial blood pressure or a spurious association that needs further evaluation in population-based studies