Hale UYSAL YARKAN, H. Volkan ACAR, Esma TEZER, Ayşegül CEYHAN, Bayazıt DİKMEN

ULtrasonografi (us) rehberliğinde infraklaviküler blok: Us ile us + sinir stimülasyonu'nun prospektif, randomize çalışmayla karşılaştırılması

Amaç: Bu çalığmada yalnız ultrasonografi (US) eğliğinde infraklaviküler blok ile US ve sinir stimülasyonu (USSS) kullanılarak uygulanan infraklaviküler bloğun, uygulama süreleri ile duyusal ve motor blok kalitesinin karğılağtırılması amaçlanmığtır. Yöntem: Çalığmaya el, el bileği ve dirsek cerrahisi geçirecek 40 hasta dahil edildi. Hastalar operasyon öncesi randomize olarak US veya USSS olmak üzere 2 gruba ayrıldı. LA solüsyonu 20 mL bupivakain + 10 mL prilokain olacak ğekilde hazırlandı. US grubunda 30 mL lokal anestezik aksiller arter çevresinde U ğeklinde dağılımı gözlenerek mümkün olan en az sayıda enjeksiyon uygulanarak enjekte edildi. USSS grubunda ise 30 mL lokal anestezik 0,6 - 0,4 mAde elin ince motor hareketi (median veya radial veya ulnar) gözlendiğinde tek bir enjeksiyon ğeklinde uygulandı. Her iki grupta bloğun uygulama süreleri kaydedilerek, giriğim sürecinde duyulan rahatsızlık hissi Vizüel Analog Skala (VAS), (0-10) ile değerlendirildi. Duyusal ve motor bloğun derecesi LA enjeksiyonunun bitiminden itibaren 10 dakika arayla ölçüldü. Bulgular: Hastaların özellikleri her iki grupta benzer bulundu. Blok bağarı oranları US grubunda %90,5, USSS grubunda ise %89,5 olup iki grup arasında anlamlı fark saptanmadı. Blok uygulama süresi her iki grupta benzer bulundu [185 sn (96-565) vs 170,5 sn (84-639), p= 0,754]. Giriğim sürecinde iğne yönlendirme sayısı US grubunda USSS grubuna göre anlamlı derecede fazlaydı [ 3 (1-4) vs 1(1-1), p=

Ultrasonography (us) guidance in infraclavicular block: Comparison of us vs. us + neurostimulation in a prospective, randomised study

Objective: This study aims to compare the block performance time, sensory and motor block qualities of ultrasound guided infraclavicular block with ultrasound guided infraclavicular block with neurostimulation. Method: Forty patients undergoing hand, wrist and elbow surgery were included in the study. Patients were divided randomly into 2 groups as US and USNS before the surgery. Local anesthetic solution was composed of 20 mL bupivacaine + 10 mL prilocaine. In the US group, 30 mL of local anesthetic was injected by minimum possible number of injections around the axillery artery in a U shaped pattern. In the USNS group, the injection was performed by single injection of 30 mL of local anesthetic, after observation of fine motor movements of the hand (of median, ulnar or radial nerve) by the stimulation with 0,6 - 0,4 mA. The block performance times were noted and patient discomfort was evaluated by VAS(0-10). Sensory and motor block levels were assessed 10 minutes after the LA injection. Results: Patient characteristics were similar in both groups. Block success rates were 90,5 % in US group and 89,5% in USNS group with no significant difference. Block performance times were found to be similar in both groups [185 sn (96-565) vs 170,5 sn (84-639), p= 0,754]. Number of needle guidance during the procedure was significantly higher in the US group, compared to the USNS group [ 3(1-4) vs 1(1-1), p=<0,001]. Sensory and motor block quality were similar in both groups at durations of 10th, 20th ve 30th minutes. Conclusion: In this study, similar results were obtained by infraclavicular block observing the spread of LA around axillary artery with US-only, compared to the utility of neurostimulation with US guidance, with regard to block performance times, sensory and motor block qualities.

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1.Rodríguez J, Taboada-Muñiz M, Bárcena M, Alvarez J. Median versus musculocutaneous nerve response with single-injection infraclavicular coracoid block. Reg Anesth Pain Med 2004; 29: 534-538.
2.Rodríguez J, Bárcena M, Taboada-Muñiz M, Lagunilla J, Alvarez J. A comparison of single versus multiple injections on the extent of anesthesia with coracoid infraclavicular brachial plexus block. Anesth Analg 2004; 99: 1225-1230.
3.Rodríguez J, Bárcena M, Lagunilla J, Alvarez J. Increased success rate with infraclavicular brachial plexus block using a dual-injection technique. J Clin Anesth 2004; 16: 251-256.
4.Ting PL, Sivagnanaratnam V. Ultrasonographic study of the spread of local anaesthetic during axillary brachial plexus block. Br J Anaesth 1989; 63: 326-329.
5.Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-guided sup-raclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg 1994; 78: 507-513.
6.Kapral S, Krafft P, Gosch M, Fleischmann D, We-instabl C. Ultrasound imaging for stellate gang-lion block: Direct visualization of puncture site and local anesthetic spread: A pilot study. Reg Anesth 1995; 20: 323-328.
7.Marhofer P, Schrogendorfer K, Wallner T, Koi-nig H, Mayer N, Kapral S. Ultrasonographic gu-idance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998; 23: 584-588.
8.Arcand G, Williams SR, Chouinard P, et al. Ultrasound-guided infraclavicular versus supraclavicular block. Anesth Analg 2005; 101: 886-890.
9.Casati A, Baciarello M, Di Cianni S, et al. Effects of ultrasound guidance on the minimum effec-tive anaesthetic volume required to block the femoral nerve. Br J Anaesth 2007; 98: 823-827.
10. Marhofer P, Schrögendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 1997; 85: 854-857.
11. Sandhu NS, Manne JS, Medabalmi PK, Capan LM. Sonographically guided infraclavicular brachial plexus block in adults: a retrospective analysis of 1146 cases. J Ultrasound Med 2006; 25: 1555-1561.
12. Kapral S, Greher M, Huber G, et al. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Reg Anesth Pain Med 2008; 33: 253-258.
13. Weintraud M, Lundblad M, Kettner SC, et al. Ultrasound versus landmark-based technique for ilioinguinal-iliohypogastric nerve blockade in children: the implications on plasma levels of ropivacaine. Anesth Analg 2009; 108: 1488-1492.
14. Eichenberger U, Stöckli S, Marhofer P, et al. Minimal local anesthetic volume for peripheral nerve block: a new ultrasound-guided, nerve dimension-based method. Reg Anesth Pain Med 2009; 34: 242-246.
15. Marhofer P, Eichenberger U, Stöckli S, et al. Ultrasonographic guided axillary plexus blocks with low volumes of local anaesthetics: a crossover volunteer study. Anaesthesia 2010; 65: 266-271.
16. Latzke D, Marhofer P, Zeitlinger M, et al. Minimal local anaesthetic volumes for sciatic nerve block: evaluation of ED 99 in volunteers. Br J Anaesth 2010; 104: 239-244.
17. Tammam TF. Ultrasound-guided infragluteal sciatic nerve block: a comparison between four different techniques. Acta Anaesthesiol Scand 2013; 57: 243-248.
18. Borgeat A, Ekatodramis G, Dumont C. An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001; 93: 436-441.
19. Desroches J. The infraclavicular brachial plexus block by the coracoid approach is clinically effective: an observational study of 150 patients. Can J Anaesth 2003; 50: 253-257.
20. Gürkan Y, Tekin M, Acar S, Solak M, Toker K. Is nerve stimulation needed during an ultrasound-guided lateral sagittal infraclavicular block? Acta Anaesthesiol Scand 2010; 54: 403-407.
21. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad Ø. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observer- blinded, comparative study. Anesth Analg 2008; 106: 1910-1915.
22. Gürkan Y, Ozdamar D, Solak M, Toker K. Lateral sagittal infraclavicular block is a clinically effective block in children, Eur J Anaesthesiol 2008; 25: 949-951.
23. Gürkan Y, Hoflten T, Solak M, Toker K. Lateral sagittal infraclavicular block: clinical experience in 380 patients. Acta Anaesthesiol Scand 2008; 52: 262-266.
24. Brull R, Lupu M, Perlas A, Chan VW, McCartney CJ. Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance. Can J Anaesth 2009; 56: 812-818.
25. Taboada M, Rodríguez J, Amor M, et al. Is ultrasound guidance superior to conventional nerve stimulation for coracoid infraclavicular brachial plexus block? Reg Anesth Pain Med 2009; 34: 357-360.
26. Dingemans E, Williams SR, Arcand G, et al. Neurostimulation in ultrasound-guided infraclavicular block: a prospective randomized trial. Anesth Analg 2007; 104: 1275-1280.
27. Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002; 89: 254-259.
28. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad Ø. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observer- blinded, comparative study. Anesth Analg 2008; 106: 1910-1915.
29. Sauter AR, Smith HJ, Stubhaug A, Dodgson MS, Klaastad Ø. Use of magnetic resonance imaging to define the anatomical location closest to all three cords of the infraclavicular brachial plexus. Anesth Analg 2006; 103: 1574-1576.
30. Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance for infraclavicular brachi-al plexus anaesthesia in children. Anaesthesia 2004; 59: 642-646.
31. Frederiksen BS, Koscielniak-Nielsen ZJ, Jacobsen RB, Rasmussen H, Hesselbjerg L. Procedural pain of an ultrasound-guided brachial plexus block: a comparison of axillary and infraclavicular approaches. Acta Anaesthesiol Scand 2010; 54: 408-413.
32. Lecamwasam H, Mayfield J, Rosow L, Chang Y, Carter C, Rosow C. Stimulation of the posterior cord predicts successful infraclavicular block. Anesth Analg 2006; 102: 1564-1568.
33. Bloc S, Garnier T, Komly B, et al. Single-stimulation, low-volume infraclavicular plexus block: influence of the evoked distal motor response on success rate. Reg Anesth Pain Med 2006; 31: 433-437.
34. Minville V, Fourcade O, Bourdet B, et al. The optimal motor response for infraclavicular brachial plexus block. Anesth Analg 2007; 104: 448-451.
35. Yıldırım M: Temel İnsan Anatomisi, Nobel Kitabevi, üçüncü baskı, İstanbul, 72-5, 1997.