Clinical Research Of Ultrasound Guided Brachial Plexus Block

Part One: The Study of Diaphragmatic Movement after Ultrasound-guidedInterscalene and Traditional BlockObjective：The purpose of this study was to set an effective method to assessdiaphragmatic kinetics by ultrasound and then confirm its validity. Basing on these, wecompared the anesthetic effect and right hemidiaphragm motion between interscaleneand supraclavicular brachial plexus block had the same dose and interscalene brachialplexus block had different dose, to study how to reduce the incidence of Diaphragmaticparalysis.Methods：Part one.12healthy volunteers were submitted to a B-and M-modeultrasound examination to study the right hemidiaphragm motion at three times (oh,1h,2h), to set an effective method to assess the right diaphragmatic kinetics. Part two.60Patients need Surgery on right Upper limb,1%Lidocaine+0.33%Ropivacaine,randomly divided into three groups: Traditional20ml group (T), Ultrasound guide20ml group (U20), Ultrasound guide12ml group (U12). After ultrasound-guidedbrachial plexus block, we measured the effects of sensory block and motor block,complication and the effect of anesthesia, then using the method set in part one tomeasure the right Diaphragmatic paralysis before brachial plexus block,5min,30minafter brachial plexus block.Results: Part one: there was no statistics difference in the right hemidiaphragmmotion about12healthy volunteers at three times using ultrasound examination(P>0.05). Part two: there was no statistics difference in the effect of sensory blockamong the three groups (P>0.05). Between group T and group I20, between group I20and group I12there was no statistics difference in the effect of motor block (P>0.05).Between group T and group I20, between group I20and group I12there was no statistics difference in the effect of anesthesia, All patients can Bear the Pressure ofTourniquet (P>0.05). The quiet breathing of5min after brachial plexus block, groupU12had lower diaphragmatic paralysis than group U20(P<0.05), between group U20and group T there was no statistics difference on diaphragmatic paralysis (P>0.05). Thequiet breathing of30min after brachial plexus block, group U12had lowerdiaphragmatic paralysis than group U20(P<0.05), between group U20and group Tthere was no statistics difference on diaphragmatic paralysis (P>0.05). ComparedDiaphragmatic paralysis of quiet breathing between5min and30min, there was nostatistics difference in group U12(P>0.05), group U20and group T were deeper thanbefore (P<0.05). The deep breathing of5min after brachial plexus block, group U12had lower diaphragmatic paralysis than group U20(P<0.05), between group U20andgroup T there was no statistics difference on diaphragmatic paralysis (P>0.05). Thedeep breathing of30min after brachial plexus block, group U12had lowerdiaphragmatic paralysis than group U20(P<0.05), between group U20and group Tthere was no statistics difference on diaphragmatic paralysis (P>0.05). Compareddiaphragmatic paralysis of quiet breathing between5min and30min, there was nostatistics difference in group U12(P>0.05), group U20and group T were deeper thanbefore (P<0.05).5min after brachial plexus block the positive rate of diaphragmaticparalysis group U12was lower than group U20(P<0.05); between group U20andgroup T there was no statistics difference on diaphragmatic paralysis (P>0.05).30minafter brachial plexus block the positive rate of diaphragmatic paralysis group U12waslower than group U20(P<0.05); between group U20and group T there was no statisticsdifference on diaphragmatic paralysis (P>0.05). There was no complication occurexcept one patient felt chest tightness.Conclusions: Part one: using a B-and M-mode ultrasound examination to study theright hemidiaphragm motion is easy to operate, non-invasive, reproducible, it can be amethod to measure diaphragmatic paralysis after brachial plexus block. Part two:between the same dose of traditional and ultrasound guide block. The former had agreater impact on the diaphragm movement. In the ultrasound guide block,12ml localanesthetic reduces the incidence of diaphragmatic paralysis compare to20ml. Part Two: Anatomical Relationship of Supraclavicular Brachial byultrasoundObjective: With the development of ultrasonic technique, the method of locationand block of nerve has great change. The clinical application of ultrasonic technique insupraclavicuar brachial plexus block has a unique advantage, the technology currentlyjust started in China. The purpose of this study was to lean more about of anatomy ofadult supraclavicuar brachial plexus and its adjacent relationships. Then we comparedthe clinical effects of ultrasound-guided supraclavicular brachial block with the mixtureof0.3%ropivacaine and1%lidocaine10ml20ml or30ml in order to provide somereferences for clinical application of ultrasound-guided Supraclavicular brachial plexusblock.Methods: Part one: one hundred subjects scheduled for surgery. With traditionmethods, supraclavicuar brachial plexus above clavicular midpoint1~1.5cm waslocated. A portable ultrasound system with a linear6to13MHz transducer was used.The transducer was parallel the clavicle and close to the midpoint of clavicle and wasperpendicular to the skin. The best cross-sectional ultrasonogram of subclavian artery,brachial plexus and first rib were found. The radius of supraclavicuar brachial plexus,the distance of skin to supraclavicuar brachial plexus, first rib, pleur and the horizontaldistance beween the midpoint of supraclavicuar brachial plexus and the midpoint ofsubclavian artery were measured. The actual surface position of supraclavicuar brachialplexus was located by ultrasonography. The relationship beween supraclavicuar brachialplexus and subclavian artery and the relationship beween supraclavicuar brachial plexusand external jugular vein.and the relationship beween the location of supraclavicuarbrachial plexus by tradition methods and the actual surface position of supraclavicuarbrachial plexus by ultrasonography were observed. The multi-factor correlationsbetween the distance of the skin to supraclavicular brachial plexus, the fist rib, pleur andweight, height, age, neck length, neck circumference was analysed. Part two: Part two:60patients scheduled for distal upper limb surgery were enrolled for this prospective,randomized controlled clinical trail. All patients were randomly assigned to receiveultrasound-guided supraclavicular brachial block with the mixture of0.3%ropivacaineand1%lidocaine10ml,20ml or30ml (n=40). Sensory block of axillary nerve,musculocutaneous nerve, radial nerve, median nerve, ulnar nerve, medial brachial cutaneous nerve and medial antebrachial cutaneous nerves was assessed at5min,10min,15min,20min,25min,30min after administration of the local anesthetic. Motor block ofaxillary nerve, musculocutaneous nerve, radial nerve, median nerve, ulnar nerve, wasevaluated at30min after administration of the local anesthetic. The operation time ofblock, the onset time of anaesthesia, the surgical success rate, the duration of analgesiaand complications were recorded.Results: Part one: The radius of the supraclavicular brachial plexus was0.38cm(0.33~0.45). The distance of skin to supraclavicular brachial plexus, the first rib thepleur was0.72cm (0.59~0.91),1.68cm (1.66~1.94), and2.01cm (1.74~2.25). Thehorizontal distance beween the midpoint o supraclavicular brachial plexus and themidpoint of subclavian artery was0.59cm (0.45~0.72). Subclavian artery as a reference,supraclavicular brachial plexus in its lateral was25%, in its top-outside was59%, in itsabove was15%and divided into about two stocks was1%. The actual surface locationof supraclavicular brachial with ultrasound as a reference, the external jugular veinoverlaped with its was27%, in its lateral horizontal distance0~1cm was28%, in itslateral horizontal distance>1cm was9%, in its medial horizontal distance0~1cm was13%,17%, in its medial horizontal distance>1cm was6%, and without in a ultrasoundplane was17%. The actual surface location of supraclavicular brachial with ultrasoundas a reference, the location of supraclavicular brachial plexus by traditional methodsoverlaped with its was35%, in its lateral was64%, in its medial was1%. The locationof supraclavicular brachial plexus by traditional methods was0.65cm (0.00~1.00)lateral of actual surface location of supraclavicular brachial with ultrasound. There wasa multi-factor correlation between the distance of skin to supraclavicular brachial plexus,the first rib, the pleur, and weight, height, neck circumference, neck length, but withoutage.Conclusions: There is a multi-factor correlation between the distance of skin tosupraclavicular brachial plexus, the first rib, the pleur, and weight, height, neckcircumference, neck length, but without age; Subclavian artery as a reference,supraclavicular brachial plexus in its top-outsider is most. The actual surface location ofsupraclavicular brachial with ultrasound as a reference, the location of supraclavicularbrachial plexus by traditional methods in its lateral is most. The location of externaljugular vein in the horizontal distance0~1cm of the position of supraclavicular brachialis most. Part Three: The study of ultrasound-guided infraclavicular brachial plexusblockObjective: The infraclavicular brachial block techinique has become increasinglypopular for the provision of anaesthesia in upper limb surgery. The infraclavicularvertical brachial plexus block (VIB) offers a precisely defined simple approach: thepuncture site lies exactly in the center of an infraclavicular line between the jugularfossa and the ventral process of the acromion,where the neddle is advanced verticallyusing a nerve stmulatior. The first part of our study is initiated to assess the accuracyand safety of the approach.Methods: Part one.100patients scheduled for elective surgery were randomlyenrolled and received non-invasive bilateral infraclavicular ultrasound examination. Themidpoint of jugular fossa and the ventral process of the acromion was designated theVIB point. Thereafter, high-resolution US imaging was performed with a portableultrasound systems. The ultrasound device was placed under the clavicle at the VIBpoint in a strictly vertical position to the ground. By slight rotational movement of thescanning head we looked for the typical US cross-sectional view of the infraclavicularregion which included the axillary artery and vein, the pleura, the cephalic vein andinfraclavicular brachial plexus. The distance between the center of infraclavicularbrachial plexus and the skin, the distance between the center of axillary artery and theskin, the distance between the center of infraclavicular brachial plexus and the center ofaxillary artery was measured. The US-modified point was the center of infraclavicularbrachial plexus. The deviation of the US-modified point and VIB point was recorded.Part two. Part two: sixty subjects scheduled for upper extremity surgery. We useportable ultrasound systems. The transducer was parallel the clavicle and close to themidpoint of clavicle. The transducer is perpendicular to the skin. The best cross-sectional ultrasonogram of the right subclavian artery, brachial plexus were found.Puncture point far away from the transducer1.5cm. The sleeve of trocar was fastenedand the stylet of trocar was exited. Epidural catheter through the sleeve of trocar wasinserted adjacent to the brachial in region of the first rib, subclavian artery and brachialplexus. With20G needles, brachial plexus was block by multi-target injection with0.4%ropivacaine+1%lidocaine20ml by ultrasound-guided in plane technology.2mlsaline was injected via the epidural catheter to observe and to adjust the loaction of epidural catheter after surgery. If the catheter deviated from and could’t be adjusted toadjacent to the target nerves around, according to the method of the previous torepeatedly place the catheter and the times of repeatedly placed catheter was beenrecord. According to different concentrations of ropivacaine by epidural catheter, thepatients were randomly divided into two groups,0.2%ropivacaine group,0.3%ropivacaine group The basis dose of electronic infusion pump: was5ml/h, patient-controlled doses was5ml, lockout time30min.in two groups. The standard of auxiliaryanalgesic: VAS≤4, given no painkillers, VAS4~7, given dynastat injection40mg (dailytotal does not exceed80mg), VAS≥7given pethidine hydrochloride injection100mg(daily dosage of not more than600mg, the time interval should not be less than4hours).The surgery time, the VAS score values of postoperative8h,12h,16h,20h,24h,32h,40h,48h, the highest VAS score values of postoperative1,2d, the total dosage ofdynastat injection and pethidine hydrochloride injection, the times of PCA andcomplications2days after surgery was recorded in two groups Postoperative analgesiasatisfaction of patients.was evaluated.Results: Part one. The distance between the center of infraclavicular brachialplexus and the skin was2.53±0.41cm on the left and2.54±0.45cm on the righ. Thedistance between the center of axillary artery and the skin was2.78±0.48cm on the leftand2.77±0.56cm on the right. The distance between the center of infraclavicularbrachial plexus and the center of axillary artery was0.76±0.15cm on the leftand0.76±0.14cm on the right. The deviation of the US-modified point and VIB pointwas0.73±0.54cm on the left and0.74±0.51cm on the right. The deviation d of bothsides differed significantly from zero. Part two. VAS score of the two groups was nosignificant difference in8~12h and after24h after surgery (P>0.05). The VAS score of0.3%ropivacaine group was significantly lower than0.2%ropivacaine group in16~20hafter surgery (P<0.05). The highest VAS score of0.3%ropivacaine group wassignificantly lower than0.2%ropivacaine group in1d after surgery (P<0.05). Thehighest VAS score of two groups in8~12h after surgery was no significant difference(P>0.05). The total dosage of dynastat injection of0.3%ropivacaine group wassignificantly less than0.2%ropivacaine group in2d after surgery (P<0.05). The totaldosage of pethidine hydrochloride injection of two groups was no significant differencein2d after surgery. The patient satisfaction of0.3%ropivacaine group was higher than0.2%ropivacaine group (P<0.05). The number of PAC of0.3%ropivacaine group was significantly less than0.2%ropivacaine group in2d after surgery (P<0.05). There wereno punctured subclavian artery, local anesthetic toxicity, Horner syndrome, hoarseness,difficulty in breathing in two groups of subjects. There were two subjects with puncturesite redness, heat, pain, but no systemic reactions. There are ten subjects with liquidexudation. There were twelve subjects with catheter off. There are twelve subjects withparesthesia, dysesthesia.Conclusion: Part one. The VIB technique is not accurate enough to predict theoptimal puncture site. There are probabilities that the needle may reach the pleura orvessel. The US-modified point was lateral to the VIB point. Part two: As result of theVAS score, under the conditions of the basis dose of electronic infusion pump is5ml/h,patient-controlled doses is5ml, lockout time30min, both0.2%ropivacaine and0.3%ropivacaine groups have some analgesic effect, but0.3%ropivacaine group better thanthe0.2%ropivacaine group in16~20h after surgery. The patient satisfaction of0.3%ropivacaine group is higher than0.2%ropivacaine group. The total dosage of dynastatinjection of0.3%ropivacaine group is significantly less than0.2%ropivacaine group.The number of PAC of0.3%ropivacaine group is significantly less than0.2%ropivacaine group.Part Four: The Study of Ultrasound-Guided Axillary Brachial Plexus BlockObjective In this prospective, randomized, double-blind study, we compared theanesthetic effects of axillary brachial plexus block guided by ultrasound technique (withtwo different concentrations of local anesthetic) with that guided by anatomicallandmarks.Methods Sixty patients undergoing hand or forearm or elbow surgery wererandomized to three groups: Group UA (0.3%ropivacaine, ultrasound-guided group),Group UB (0.5%ropivacaine, ultrasound-guided group), and Group T (0.5%ropivacaine, anatomical landmarks group). Local anesthetic of each group was20ml.Ultrasound-guided group was used1skin puncture and4separate injections to themusculocutaneous, median, radial, and ulnar nerves with the in-plane technique.Anatomical landmarks group was used transarterial technique. The operation time ofblock, the duration of analgesia and the complications were recorded, the time of paindeprivation of radial nerve, median nerve, ulnar nerve, lateral antebrachial cutaneous measured, and the extent of pain sensory block, motor block, the effects of anesthesiaduring operation were assessed.Results There was no statistics difference in opertation time of block in threegroups (P>0.05). The time of pain deprivation of radial nerve, ulnar nerve, medialantebrachial cutaneous nerve, medial brachial cutaneous nerve in Group UB was shorterthan those in Group UA(P<0.05)，and the time of pain deprivation of ulnar nerve inGroup UB was shorter than that in Group T(P<0.05). There was no statistics differencein effects of pain sensory block in three groups(P>0.05). The effect of motion block ofmusculocutaneous nerve in Group UB was more complete than that in Group T(P<0.05).There was no statistics difference in effects of motor block in Group UA and Group UB(P>0.05). The excellent anesthesia rate in Group UB was higher than that in GroupT(P<0.05), and there was no statistics difference in the excellent anesthesia rate inGroup UA and Group UB (P>0.05). The duration of analgesia in Group UB and GroupT was longer than that in Group UA(P<0.05). There was1case in Group UA and theother case in Group UB occurred tourniquet intolerance. There was1case in Group UBoccurred postoperation partial nerve disfunction.Conclusion Compare with that guided by anatomical landmarks, the effect ofanesthesia during operation is significantly better in groups guided by ultrasound. Theduration of analgesia was longer in groups guided by ultrasound. There was nostatistical difference in the excellent anesthesia rate in0.3%ropivacaine or0.5%ropivacaine for axillary brachial plexus block with ultrasound-guided, but0.5%wasmore time efficient and longer duration of analgesia than0.3%. Athough there issmaller dose of local anesthetic for axillary brachial plexus block using ultrasoundguidance, we should consider patients’ comfort besides the safety and choose the onewhich has quicker onset and longer duration of analgesia. So,0.5%ropivacaine shouldbe used to perform axillary brachial plexus blocks.Part Five: A retrospective study of ultrasound-guided brachial plexus block in956patientsObjective As we know, brachial plexus block anesthesia is one of the mostfrequently used methods of the upper extremity surgery, but thetraditional way ofbrachial plexus block as a “blind probe” type depends on many factors such as accurate anatomic localization, the operator`s experience based on certain anatomicallocalization. Thus, the blind wayis easy to damage the nerves and cause toxic reactionsof the local anesthetic. Theoretically,operations in visual conditions can improveaxillary brachial plexus block effects. This study shows a retrospective analysis of theinformation of956cases patients with upper extremity surgery which includedtheanesthetic effect, operator`s experience, anesthetic drugs and puncture approachtoprovide a reference for clinical application.Methods We studied956cases of adult patients who would be undergoing electiveupper extremity surgery during2009to2012, each complete record included gender,age, height, weight, surgery area anesthesia effect and the operator. Anesthetic effectassessed by whether the patient could endure skin incision pain, supplemental analgesiadrugs and change anesthesia ways or not. Dateswere grouped by years, drugs, bodymessindex(BMI), approaches and operatorsto show whether the effects influencedbythese factors. Measurement data using t-test rate compared using chi-square test, P<0.05statistically significant difference.Result The technique of Ultrasound—guided brachial plexus blockfor theupperextremity surgery showed a bettereffect whichdid not influenced by anestheticdrugs,patient`s BMI, operator`s experience and puncture approach.The anesthesia effectin2010was as good as2009, but stepped a foreward in both2011and2012.Conclusions From this study we can deduce that Ultrasound-guided brachialplexus block as a visualization technique can be applied to the upper extremitysurgery.This technique is worthy popularizing as it demands no higher requirements forboth the operators and patients, provides more puncturing approaches and shorten thetraining cycle whileresults afaster, safer and better effect.