Brachial Plexus

A conduction block is a type of regional anesthesia produced by injection of a local anesthetic drug into or near a nerve trunk. Examples of a conduction block include an epidural block (injection of a local anesthetic into the space surrounding the dura of the spinal cord) a trails sacral (caudal) block (injection of a local anesthetic into the epidural space at the level of the sacrococcygeal notch) and brachial plexus block (injection of a local anesdietic into the brachial plexus). Epidural, especially, and trailssacral blocks are often used in obstetrics. A brachial plexus block may be used for surgery of the arm or hand. 

Central PN refers to the administration of PN via a large central vein, and the catheter tip must be positioned in the vena cava. Central PN allows the infusion of a highly concentrated, hypertonic nutrient admixture. The typical osmolarity of a central PN admixture is about 1500 to 2000 mOsm/L. Central veins have much higher blood flow, and the PN admixture is diluted rapidly on infusion, so phlebitis is usually not a concern. Patients who require PN administration for longer periods of time (greater than 7 days) should receive central PN. One limitation of central PN is the need for placement of a central venous catheter and an x-ray to confirm placement of the catheter tip. Central venous catheter placement may be associated with complications, including pneumothorax, arterial injury, air embolus, venous thrombosis, infection, chylothorax, and brachial plexus injury.1,20... 

Brachial plexus The collection of nerves that arises from the spine at the base of the neck from nerves that supply parts of the shoulder, arm, forearm, and hand. 

Regional block, a form of anesthesia that includes spinal and epidural anesthesia, involves injection near a nerve or nerve plexus proximal to the surgical site. It provides excellent anesthesia for a variety of procedures. Brachial plexus block is commonly used for the upper extremity. Individual blocks of the sciatic, femoral, and obturator nerves can be used for the lower extremity. An amount that is close to the maximally tolerated dose is required to produce blockade of a major extremity. 

Birch. Efficacy of two cannabis based medicinal extracts for relief of central neuropathic pain from brachial plexus avulsion results of a randomised controlled trial. Pain 2004 112(3) ... 

Intra-arterial injection of thiopentone is a serious complication as crystals of the thiobarbiturate can form in the arterioles and capillaries, causing intense pain, vasoconstriction, thrombosis, and even tissue necrosis. Accidental intra-arterial injections should be treated promptly with intra-arterial administration of a vasodilator (papaverine 20 mg) and lignocaine (lidocaine) Note leave the needle/cannula in the artery), as well as a regional anaesthesia-induced sympathectomy (stellate ganglion block, brachial plexus block) and anticoagulation with intravenous heparin. The risk of ischaemic damage is much higher with a 5% solution and the use of this concentration is not recommended. 

The variability can be accounted for largely by the diffusion barriers of the different fibre types and by Na+ channel density. For example, the presence of a Schwann cell and myelin sheath poses a considerable barrier to the diffusion of local anaesthetic to the interior of the cell. There is in vitro evidence to indicate that all desheathed nerves require a similar minimum concentration of local anaesthetic to induce block irrespective of fibre type. A consequence of the physical architecture of a mixed nerve is that access of the drug to the outer fibres is easier than access to fibres at the core. It is for this reason that the onset of proximal analgesia of the limb precedes distal analgesia with a brachial plexus block. 

When used for spinal anaesthesia, 0.75% ropivacaine produces less intense sensory and motor block than 0.5% bupivacaine. It is suitable for regional, spinal and epidural block but not for regional intravenous anaesthesia. The addition of adrenaline (epinephrine) does not prolong the duration of anaesthesia in brachial plexus or epidural block. Ropivacaine is indistinguishable from bupivacaine when used in obstetric anaesthesia. Its direct myocardial toxicity is somewhat less than that of bupivacaine. 

In 1997 Brose et al. published the result of a single case study. SNX-111, administered i.t. by continuous, constant-rate infusion, produced dose-dependent pain relief in a 43-year-old male patient with a 23-year history of intractable deafferentation and phantom limb pain secondary to brachial plexus avulsion and subsequent amputation. Dizziness, blurred vision, and lateral-gaze nystagmus... 

Brose, W.G., Gutlove, D.P., Luther, R.R., Bowersox, S.S., McGuire, D. Use of intrathecal SNX-111, a novel, N-type, voltage-sensitive, calcium channel blocker, in the management of intractable brachial plexus avulsion pain, Clin. J. Pain, 1997, 13, 256-259. 

Peripheral nerve block. The anesthetic is injected close to the nerve trunk so that transmission along the peripheral nerve is interrupted.61 This type of local anesthesia is common in dental procedures (restorations, tooth extractions, and so on) and can also be used to block other peripheral nerves to allow certain surgical procedures of the hand, foot, shoulder, and so forth. ii.56.65 xnjection near larger nerves (femoral, sciatic) or around a nerve plexus (brachial plexus)... 

Borgeat A, Ekatodramis G, Blumenthal S. Interscalene brachial plexus anesthesia with ropivacaine 5 mg/mL and bupivacaine 5 mg/mL effects on electrocardiogram. Reg Anesth Pain Med. 2004 29 557-563. 

Crews JC, Rothman TE. Seizure after levobupivacaine for interscalene brachial plexus block. Anesth Analg. 2003 96 1188-1190. 

Liisanantti O, Luukkonen J, Rosenberg PH. High-dose bupivacaine, levobupivacaine and ropivacaine in axillary brachial plexus block. Acta Anaesthesiol Scand. 2004 48 601-606. 

Singelyn FJ, Lhotel L, Fabre B. Pain relief after arthroscopic shoulder surgery a comparison of intraar-ticular analgesia, suprascapular nerve block, and inter-scalene brachial plexus block. Anesth Analg. 2004 99 589-592. 

Representative values are given in Table 3. Subject G died and the following arsenic concentrations found brachial plexus 0.99ppm (dry weight), heart 2.2 ppm, kidney 6.6 ppm and popliteal nerve 0.61 ppm. 

A healthy 17-year-old man received an interscalene brachial plexus block using mepivacaine 600 mg and bupivacaine 150 mg. He became disorientated and showed signs of local anesthetic toxicity, for which he was given midazolam 5 mg. Flumazenil 0.5 mg was given 23 minutes after the end of the procedure, causing opisthotonos. 

Dolerrc VV (1986) Corrtemporary deadnerrt of peripheral rrerve arrd brachial plexus lesiorrs. Neurosurg Rev 9 149—156. 

Dolenc W (1986) Contemporary treatment of peripheral nerve and brachial plexus lesions. Neurosurg Rev 9 149-156. 

Gu YD, Ma MK (1991) Nerve transfer for treatment of root avulsion of the brachial plexus Experimental studies in a rat model. J Reconstr Microsurg 7 15-22. 

A 36-year-old woman developed supraclavicular skin necrosis, followed by sloughing of subcutaneous tissue down to the first rib, including the dorsal roots of the brachial plexus, after receiving an interscalene block followed by an infusion 5 months later she still had complete sensory and motor paralysis of the C5 nerve root requiring nerve grafting. 

The addition of fentanyl 1 pg/ml to ropivacaine 7.5 mg/ml did not improve nerve blockade by axillary brachial plexus anesthesia in a double-blind, randomized study in 30 patients undergoing orthopedic procedures (31). In another double-blind, randomized study, 60 patients receiving axillary brachial plexus blockade were given 0.25% bupivacaine 40 mg, 0.25% bupivacaine 40 mg plus fentanyl 2.5 pg/ml, or 0.125% bnpivacaine 40 mg plus fentanyl 2.5 pg/ml (32). The addition of fentanyl 2.5 pg/ml prolonged sensory and motor blockade without any improvement in the onset of anesthesia and no significant increase in adverse effects. These two studies have reaffirmed the current position of conflicting results in studies of the benefits of adding fentanyl to local anesthetics for peripheral nerve blockade. 

FaneUi G, Casati A, Magistris L, Berti M, Albertin A, Scarioni M, Torri G. Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anaesthesia performed with ropivacaine. Acta Anaesthesiol Scand 2001 45(5) 590-4. 

Karakaya D, Buyukgoz F, Baris S, Guldogus F, Tur A. Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axUlaiy brachial plexus block. Reg Anesth Pain Med 2001 26(5) 434-8. 

By 1988 it was possible to summarize the adverse effects reported after the distribution of over 1.8 million doses of plasma-derived hepatitis B vaccine (Table 1) (2). From 1982 onwards, the Centers for Disease Control, the Food and Drug Administration, and the manufacturers, Merck Sharp Dohme, had supported a special surveillance system to monitor spontaneous reports of reactions to plasma-derived hepatitis vaccine. During the first 3 years, about 850 000 persons were immunized. In all, 41 reports were received for one of the following neurological adverse events convulsion (n = 5), Bell s palsy (n — 10), Guillain-Barre syndrome (n = 9), lumbar radiculopathy (n — 5), brachial plexus neuropathy (n = 3), optic neuritis (n — 5), and transverse myelitis (n = 4). Half of these events occurred after the first vaccine dose. However, no conclusive causal association could be made between any neurological adverse event and the vaccine (3). 

It is possible that the initial hypersensitivity reaction in this case determined focal neuronal involvement at the brachial plexus. 

A 60-year-old 70 kg woman with a fractured radius had an axillary brachial plexus block for postoperative analgesia after uneventful general anesthesia (5). A 50 mm insulated regional block needle attached to a nerve stimulator was used to locate the brachial plexus, and after negative aspiration, levobupivacaine 125 mg was injected with intermittent aspiration. Within 30 seconds the patient had a generalized tonic-clonic seizure which lasted about 30 seconds and self-terminated. She remained car-diovascularly stable and made an uneventful recovery. 

Pirotta D, Sprigge J. Couvulsious following axillary brachial plexus blockade with levobupivacaine. Anaesthesia 2002 57(12) 1187-9. 

Brachial plexus anesthesia Buccal anesthesia Caudal anesthesia Cervical plexus anesthesia Dental anesthesia Digital anesthesia Epidural anesthesia Intercostal nerve anesthesia Interpleural anesthesia Intra-articular anesthesia Intradermal anesthesia Intrathecal (spinal) anesthesia Intravenous regional anesthesia Laryngeal anesthesia Lumbar plexus anesthesia Nasal anesthesia Neck anesthesia Obstetric anesthesia Ocular anesthesia Oropharyngeal anesthesia Otic anesthesia Paravertebral anesthesia Perianal anesthesia Peritonsillar anesthesia Respiratory anesthesia Sciatic nerve anesthesia Stellate ganglion anesthesia... 

The systemic complications of brachial plexus anesthesia are similar to those seen with others if sufficient drug enters the circulation. Injections outside the axillary sheath result in higher plasma concentrations of local anesthetic than intrasheath injection (SEDA-22, 135). However, several other complications are specific to this route. Local complications include hematoma and infection. Horner s syndrome, temporary phrenic nerve blockade, and peripheral neuropathies have been reported (SEDA-18,142). 

The adverse effects of ropivacaine and bupivacaine have been compared in 104 patients who received 30 ml of either 0.75% ropivacaine or 0.5% bupivacaine for subclavian perivascular brachial plexus block (48). There were similar incidences of nausea (33 and 28%), vomiting (8 and 14%), and Horner s syndrome (8 and 6%), and one patient who received bupivacaine developed a tonic-clonic generalized seizure 8 minutes after injection, suggestive of systemic toxicity. 

Pulmonary embolism has been attributed to brachial plexus block. 

Two cases of respiratory compromise after infraclavi-cular brachial plexus blockade have been described (58). 

An 84-year-old woman weighing 74 kg had a past history of hypertension, emphysema, and ischemic heart disease. She had an infraclavicular brachial plexus block with 40 ml (400 mg) of prilocaine 1% and 10 ml (75 mg) of ropivacaine 0.75%, and 20 minutes later developed difficulty in breathing and became desaturated. She had received midazolam 2 mg before the block. 

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