Diaphragm-sparing brachial plexus blocks: a focused review of current evidence and their role during the COVID-19 pandemic

Cubillos, Javier; Girón-Arango, Laura; Muñoz-Leyva, Felipe

doi:10.1097/aco.0000000000000911

Cited by 10 publications

(17 citation statements)

References 43 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Combined interscalene and intermediate cervical plexus block would seem the most effective technique [1]. However, this approach can be associated with undesirable effects and may be contraindicated in patients with impaired pulmonary function [2].…”

Section: Dear Editormentioning

confidence: 99%

See 1 more Smart Citation

Novel use of ultrasound guidance in wide awake local anesthesia technique for clavicle surgery

Azizi¹,

Benhamza

Motiaa

2021

Korean J Anesthesiol

View full text Add to dashboard Cite

Section: Dear Editormentioning

confidence: 99%

Section: Dear Editormentioning

confidence: 99%

Novel use of ultrasound guidance in wide awake local anesthesia technique for clavicle surgery

Azizi¹,

Benhamza

Motiaa

2021

Korean J Anesthesiol

View full text Add to dashboard Cite

“…Combined interscalene and intermediate cervical plexus block seems to be the most effective technique [1]. However, this approach can be associated with undesirable effects and may be contraindicated in patients pulmonary function [2].The wide awake local anesthesia with no tourniquet (WALANT) technique was recently reported as an alternative landmark-based technique for clavicle fractures [3]. This technique involves injecting diluted and buffered local anesthesia with epinephrine under the clavicular periosteum.…”

mentioning

confidence: 99%

mentioning

confidence: 99%

“…In addition to its technical simplicity, WALANT might reduce the risk of nerve damage and phrenic nerve palsy associated with regional techniques commonly used for awake clavicle repair [ 2 ]. Although WALANT is performed anatomically distant from the phrenic nerve, theoretically precluding its involvement, we did not assess diaphragmatic function by ultrasound to validate this.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Novel use of ultrasound guidance in wide-awake local anesthesia technique for clavicle surgery

Azizi¹,

Benhamza

Motiaa

2022

Korean J Anesthesiol

View full text Add to dashboard Cite

Clavicle fixation is becoming more common but only a few comparative studies have been conducted to determine the optimal approach in regional anesthesia as the sole modality for such surgery. Combined interscalene and intermediate cervical plexus block seems to be the most effective technique [1]. However, this approach can be associated with undesirable effects and may be contraindicated in patients pulmonary function [2].The wide awake local anesthesia with no tourniquet (WALANT) technique was recently reported as an alternative landmark-based technique for clavicle fractures [3]. This technique involves injecting diluted and buffered local anesthesia with epinephrine under the clavicular periosteum. We describe the use of ultrasound guidance to perform this technique in two patients undergoing clavicle surgery. This study was approved by the local Institutional Review Board committee (approval number: 2020-09). Written informed consent was obtained from the patients.A 17-year-old patient was admitted for a displaced segmental fracture of the midshaft clavicle. The patient was placed in a semi-fowler position with the head turned away from the operative side. The anesthetic solution prepared was a mixture of 0.5% lidocaine containing 0.05% bupivacaine, epinephrine 1/200000, and 8.4% sodium bicarbonate (1 ml per 10 ml of lidocaine). We used a linear ultrasound probe (13-6 MHz, SonoSite Edge II, USA) to scan above and below the clavicle to identify relevant nearby structures particularly the pleura, brachial plexus, and subclavian vessels. After subcutaneous injection of 10 ml over the incision line, ultrasound-guided WALANT was performed by administering 40 ml of the prepared solution at four intervals along the clavicle. The probe was placed perpendicular to the long axis of the clavicle to view the bone in cross section (Fig. 1A). A conventional needle (21 gauge × 38 mm) was inserted vertically out-of-plane until the needle tip contacted the clavicle. Local anesthetic was injected, then the needle was withdrawn to the skin level and redirected cranially and caudally until bone contact to anesthetize the borders of the clavicle. Ultrasound guidance allowed visualization of adequate spread around the cortical line of the clavicle. Thickening of the hyperechoic and thin cortical line with subsequent lower echogenicity and fuzzy edges was also observed (Fig. 1B), confirming spread of the anesthetic solution under the periosteum (Supplemental Video 1). Additionally, 5 ml of anesthetic mixture was injected into the fracture site under ultrasound guidance using an in-plane technique. Surgical incision was begun after 30 min to allow maximal vasoconstriction and optimal sensory anesthesia of the clavicular area. There was no motor or sensory block of the upper limb, indicating ab-

show abstract

Statistical fragility of reporting hemidiaphragmatic paralysis after brachial plexus blocks in randomized controlled trials: a systematic review

Luo

Liu

Zhu

et al. 2023

APS

View full text Add to dashboard Cite

To characterize the fragility index (FI) of statistically significant results reported in randomized controlled trials (RCTs) investigating the incidence of hemidiaphragmatic paralysis (HDP) after brachial plexus blocks. A systematic review of RCTs retrieved from the PubMed-Medline, Embase, and Web of Science electronic databases was conducted. All alternative RCTs published between January 2012 and October 2022 were identified. Only RCTs with two parallel arms designs, and reporting HDP as the primary outcome, statistical significance, and superiority results were selected. The FI was calculated according to Fisher’s exact test using previously described methods. In addition, the risk of bias was evaluated using the Cochrane Risk-of-Bias tool for randomized trials. The 23 RCTs that fulfilled the inclusion criteria had a median FI of 4 (interquartile range [IQR]2–8) and a median Fragility Quotient of 0.077 (IQR 0.038- 0.129). However, in 13 (56.5%) trials, the calculated FI value was ≤ 4. In 3/23 (13.0%) trials, the number of patients who dropped-out exceeded the FI value. Most trials (91.3%) had an overall low risk of bias. This systematic review revealed that the statistical results of RCTs investing HDP after brachial plexus blocks have tended to be fragile in the past decade. The FI should be an important aid in the interpretation of clinical results in combination with the P-value, particularly when statistically significant results are dependent on a small number of events. Future RCTs with larger sample sizes are needed to obtain more robust results in this field.

show abstract

Diaphragm-sparing brachial plexus blocks: a focused review of current evidence and their role during the COVID-19 pandemic

Cited by 10 publications

References 43 publications

Novel use of ultrasound guidance in wide awake local anesthesia technique for clavicle surgery

Novel use of ultrasound guidance in wide awake local anesthesia technique for clavicle surgery

Novel use of ultrasound guidance in wide-awake local anesthesia technique for clavicle surgery

Statistical fragility of reporting hemidiaphragmatic paralysis after brachial plexus blocks in randomized controlled trials: a systematic review

Contact Info

Product

Resources

About