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2021 KoreAnesthesia_Updates of BPB
- 1. Recent updates of BPB Boohwi Hong koho0127@gmail.com
- 3. •Above clavicle – Intertruncal approach •Below clavicle – Costoclavicular approach
- 7. Intracluster High risk of intraneural injection Sub-epineural (extra-perineural) Sub-perineural Intra-fascicular (9/10) 0.2 ml ink 44% 24%
- 8. Sequential ultrasound imaging technique
- 9. Sequential ultrasound imaging technique Refinements of traditional BPB techniques Superior trunk block Selective trunk block Intertruncal block
- 10. Intertruncal approach Dense motor and sensory block of the entire brachial plexus, including the lower trunk and related ulnar nerve territory, within 15 min of injection.
- 12. Subfascial Injection Spread deep to the brachial plexus sheath within the connective tissue matrix NO any obvious swelling of the individual trunks or division of the brachial plexus
- 13. SUIT • Suprascapular nerve 빠져나오는 동영상 • 7월 30일 찍은 영상들중
- 15. Corner 만들기 어려운 케이스 ? • 비디오
- 18. Intertruncal approach More complete block of ulnar nerve at 15 minutes after BPB
- 19. Intracluster No significant association between sonographic hypoechoic structure expansion and sub-perineural ink
- 22. Introduction
- 23. Introduction
- 24. Introduction 20 mL of 0.5% ropivacaine Rapid sensory and motor onset time (5 [5–15] and 5 [5–10] minutes)
- 25. Block Character 25 ml of 0.5% ropivacaine Faster onset of sensory blockade and earlier readiness for surgery
- 26. Block Character 35 mL of mixture of 1% lidocaine – 0.25% bupivacaine
- 27. Septum Linear septum within the CCS in 92.5% of patients.
- 28. Septum Piercing the septum evoked motor responses from the medial or posterior cord.
- 31. Volume MEV90: 34 mL LA injection in the middle of the 3 cords Lidocaine 1.5% with epinephrine 5 μg/mL
- 32. Volume 19-ml dose of 0.5% ropivacaine is likely to produce an effective ultrasound-guided costoclavicular block for providing adequate surgical anesthesia to 95% of the patients. MEV90 of 0.5% ropivacaine for ultrasound- guided CC-BPB is 20.92 (95% CI, 20.65 to 21.80) ml.
- 34. Continuity with Supraclavicular space
- 35. Continuity with Supraclavicular space 20 ml
- 36. Continuity with Supraclavicular space
- 37. Supraclavicular spreading •Shoulder analgesia ? •Avoiding hemi-diaphragmatic palsy ?
- 38. Hemidiaphragm paralysis The incidence of ipsilateral PNP was lower (p=0.008) in the costoclavicular group (5%) than in the supraclavicular group (45%). Definition: Decreased by at least 50% during deep breathing at 30 min after the BPB.
- 39. Hemidiaphragm paralysis 2.5% (n = 3) in CCB 39.8% (n = 47) in SCB
- 40. Hemidiaphragm paralysis 25 mL of local anesthetics
- 41. Shoulder Surgery
- 42. Method Our Data CCB vs STB (unpublished) Sufficient analgesia & Hemidiaphragmatic paralysis (HDP) Diaphragm Sparing block for Shoulder surgery
- 43. Results; Primary outcome The pain score at 1 h postoperatively was higher in group CCB than group STB (2 [0 to 3] vs 0 [0 to 0], median difference, 2; 95% CI, 1 to 3; non-inferiority was not demonstrated). Our Data Abstract no. 2021-0249
- 44. Opioid consumption First analgesic time Our Data Abstract no. 2021-0249
- 45. Results; US diaphragm exam data Our Data Abstract no. 2021-0249
- 46. Pre Our Data Post Suprascapular nerve Suprascapular nerve Abstract no. 2021-0282
- 47. ksra.kr
- 48. Thank you ! 감사합니다 ! Boohwi Hong koho0127@gmail.com
Editor's Notes
- I’m Boohwi Hong from Chungnam national university hospital. I’m more nervous than usual to be in charge of this session with Prof. Karmarkar.
- I admire his valuable research in the field of regional anesthesia and learn so much from his textbooks and lectures. I’m especially a big fan of his thoracic paravertebral block and costoclavicular block. I take this opportunity as an honor, and will try best to guide this session.
- Well, today I will be talking about two techniques of brachial plexus block. One of them is the intertruncal approach of supraclavicular block. And the other technique is the costoclavicular block
- The supraclavicular block is a popular approach to the brachial plexus. This approach targets the plexus at the level of the trunks and divisions at the base of the neck that are tightly clustered lateral to the subclavian artery, which is an easily recognizable anatomical landmark. The most common ultrasound-guided approaches are: (1) a single injection in the ‘corner pocket’ between the subclavian artery and the lower trunk, (2) an ‘intracluster’ injection in the center of the plexus and (3) a combination of the two approaches. However, the two techniques have been associated with a few problems.
- First, although there are some technical issues about inside or outside sheath, corner pocket approach does not avoid ulnar nerve sparing. In this comparative study with infraclavicular block, of the 11 failures in group supraclavicular, nine were due to incomplete ulnar nerve territory anesthesia.
- An alternative technique has been the so-called ‘intracluster’ approach whereby local anesthetic is injected into the main and all satellite ‘neural clusters’. TII (targeted intracluster injection) SCB (supraclavicular block) provides a quicker onset and a shorter total anesthesia-related time than other techniques do. However, the safety of this approach has recently been questioned.
- By placing the needle within clusters of hypoechoic structures, corresponding to neural tissue, this technique may increase needle trauma and the incidence of nerve injury. Indeed, in a cadaveric study of ‘intracluster’ injections found nearly 25% incidence of subepineural injections, 90% of which were intrafascicular injection. Thus the targeted intracluster injection supraclavicular block cannot be recommended for an only modest improvement in onset time.
- The advancement in ultrasound guidance allowed for a fundamental understanding of the underlying anatomy and a resurgence of interest in the supraclavicular brachial plexus. We can consistently identify the majority of the main components of the BP above the clavicle, Root to trunk formation, three trunks (superior, middle, and inferior), origin of the suprascapular nerve from the superior trunk, divisions of the superior trunk with SPA arrangement, and formation of the inferior trunk. Prof. Karmakar recommends that it should become an integral part of the pre-block routine before any BPB.
- SUIT showed High inter-rater agreement for proximal components: Thses results may have implications for ST block, selective trunk block and intertruncal supraclavicular brachial plexus block (BPB), that are refinements of traditional BPB techniques
- In extension to such advancement of ultrasonography, intertruncal approach was introduced in RAPM. The goal of this approach is to provide comprehensive and complete blockade of the entire brachial plexus while avoiding intraneural injection and pleural puncture. They performed over 200 intertruncal supraclavicular blocks. It consistently resulted in dense motor and sensory block of the entire brachial plexus, including the lower trunk and related ulnar nerve territory, within 15 min of injection.
- Specifically, they described the role of the intertruncal adipose tissue plane. This is a microscopic anatomy of the brachial plexus. The yellow arrows indicate two intertruncal planes with adipose tissues. If you look more closely, there is an inner epineurium that connects between the fascicles, and an outer epineurium that covers the entire trunk. You can see the adipose tissue plane between the middle and superior trunk. The needle tip is placed outside the outer epineurium surrounding each trunk. Adipose tissue has low resistance channels for the local anesthetic to spread Local anesthetic diffuses across the nerve epineurium driven by a concentration gradient, by specifically targeting the thin adipose layers between the trunks.
- In my opinion, this is not a completely new technique, but more of an evolved form of subfacial injection. Through the development of ultrasound imaging and the research of several pioneers, we have been able to identify each brachial plexus component in more detail, so we can perform a more precise BPB. This is a posterior division and an anterior division of the superior trunk. Importantly, during this procedure, there should be no obvious swelling or expansion of the individual trunks or divisions of the brachial plexus to prevent intraneural injection.
- This is an image scanning from interscalene to the supraclavicular fossa. Cervical 5,6 to the superior trunk, cervical 7 to the middle trunk, and cervical 8 and Thoracic 1 to the lower trunk. Suprascapular nerve is located here. You can also see the SPA arrangement. We can distinguish between the trunk and the hyperechoic epineurium that surrounds it.
- The needle traverses the prevertebral fascia to enter the lateral aspect of the plexus compartment. Once in the plexus compartment, the local anesthetic is injected in small aliquots using ‘hydrodissection’ while securing a safe needle path. And then the needle is slowly advanced in the two intertruncal planes. Similarly, we inject between the middle and the superior trunks, and personally I sometimes do additional injections over the superior trunk.
- If you observe after the block, you can see the boundary of the trunk more clearly. The main advantage of the intertruncal approach over the ‘intracluster’ approach is that the external boundaries of each trunk are identified so that accidental intraneural injection can be avoided, thus preserving nerve integrity. Also, in a case where it is difficult to secure a corner pocket, it has the advantage of being able to safely access above the inferior trunk.
- In this case, the DSA crosses beneath the T1 of inferior trunk, it lies directly in the path of the needle when performing the corner pocket approach. The DSA often crosses the brachial plexus compartment, mostly between the lower and middle trunk or between the middle and superior trunk. Rarely, DSA passes under IT as in this case. We perform intertruncal approach in this case to avoid risk of vascular puncture.
- This is our study of intertruncal approach. We hypothesized that the IT approach (injection between lower and middle trunk) would result in more complete blockade rate of UN compared to the CP approach at 15 minutes after blockade.
- The rates of complete sensory blockade (75.9% [22/29] vs 43.3% [13/30]; P = 0.023) and complete motor blockade (82.8% [24/29] vs 50.0% [15/30]; P = 0.017) of the UN after 15 minutes were significantly higher in the IT than in the CP group. The progression of sensory and motor blockade of the UN territory is more rapid in intertruncal approach. None of the patients reported transient or persistent neurological signs or symptoms after 24 hours or at the 1-week follow-up after surgery.
- However, additional studies are required to ascertain the safety of the IT approach, especially in terms of neural damage. Again, this study found that no significant association exists between sonographic hypoechoic structure expansion and sub-perineural ink deposits. We need more histological evidence in intertruncal approach.
- Next is the costoclavicular block.
- Traditionally, infraclavicular block has been performed at the lateral infraclavicular fossa. Ultrasound transducer is placed in a sagittal plane. As you can see here, the three cords of the brachial plexus surround the axillary artery. Each cord is separated from one another,
- Costoclavicualr approach was introduced in 2015 by short technical letter. Prof. Karmakar proposed that the anatomy of the brachial plexus at the “costoclavicular space” is better suited than that at the LIF for the ICBPB.
- In the following year, this cadaver anatomic study/ defined the anatomy of the cords of the brachial plexus at the CCS/ and thereby established the anatomic basis for ultrasound-guided infraclavicular brachial plexus block/ at this proximal site. The cords of the brachial plexus are clustered together lateral to the axillary artery/ and share a consistent relation relative to one another/ and to the axillary artery/ at the CCS.
- single injection of local anesthetic at the center of the nerve cluster at the costoclavicular space/ produces rapid onset of sensory-motor blockade of the 4 major nerves of the brachial plexus
- Compared to the lateral sagittal approach, it showed faster onset and surgical readiness, showing superior clinical results.
- In this similar research, mean onset times were comparable between the costoclavicular and paracoracoid groups. Furthermore, no intergroup differences were found in terms of performance time (P = 0.09), total anesthesia-related time (P = 0.90), surgical anesthesia (P[0.99), and hemidiaphragmatic paralysis (P[0.99). But, they used larger volumes of local anesthetics.
- Like other regions of the BP, the brachial plexus of the costoclavicular space is surrounded by fascia of its connective tissues. Such composition forms a septal formation between compartments and cords/ resulting in an incomplete spread of LA to block all three cords/ in case of a single injection. Monzo and Hadzic observed by ultrasound/ the existence of a linear septum within the CCS in 92.5% of their patients.
- Motor responses from the medial or posterior cord observed when septum was pierced. Additionally, Intraplexus fascial septae that separate the bundle of the medial and posterior cords from the lateral cord / were confirmed by microscopic study.
- Actually, this septum is not visualized well before blockade. However, after or during block, we can identify the septum and pierce the septum to inject into the posterior compartment. We can also identify the paraneural sheath and epimysium of the subclavian and serratus anterior muscle. Needle tip should be located at the exact point for successful block.
- The double-injection technique showed shorter onset time and total anesthesia-related time compared with single-injection costoclavicular block.
- Early study of costoclavicular showed that the minimal effective volume of 90 was 34 ml in single injection in the middle of the 3 cords.
- In the two studies that had recently been published, they found that about 20 ml of ropivacaine is the effective volume. These discrepancies may be due to different standards of a successful block, injection speed and whatnot. In my practice, 20~25 ml was sufficient.
- Costoclavicular space is contiguous with the supraclavicular fossa. Thus, continuity was reported in several papers.
- In this short report, catheter was inserted at the costoclavicular space and advanced to the supraclavicular area. Advantage of this technique would be: more stable placement of the catheter than in the case of the supraclavicular approach.
- In this cadaver study, 20 ml was injected in the costoclavicular space. Injected solution reached the interscalene region in the CT image.
- Recently, supraclavicular spreading was more clearly demonstrated in this cadaver study in which 20 ml of dye was injected in the costoclavicular space in 5 objects. The dyes spread cephalad to the brachial plexus in the supraclavicular space, consistently reaching the suprascapular nerve and all trunks of brachial plexus, while sparing the phrenic nerve.
- So, If supraclavicular spreading specifically (?) to suprascapular nerve is sufficient for nerve block, we expected shoulder analgesia was feasible with costoclavicular block. And it is necessary to investigate whether the phrenic nerve sparing effect is also clinically similar.
- First, let's talk about HDP. In this RCT using diaphragm excursion for diagnosis of HDP, the incidence of ipsilateral PNP was lower (p=0.008) in the costoclavicular group (5%) than in the supraclavicular group.
- This is a retrospective study of our group: we measured the elevation of diaphragm before and after surgery. Costoclavicualr block reduced HDP, yet, in some cases, HDP had occurred.
- We also conducted RCT, using the diaphragm thickness fraction for diagnosis of HDP. HDP was significantly reduced in the costoclavicular group, but HDP occurred in a higher proportion of costoclavicular group than expected. As you can see, costoclavicular block cannot completely avoid HDP.
- Then how about shoulder surgeries? In this RCT, CCB, in comparison to ISB, results in equivalent postoperative analgesia. Also, surprisingly in this study, incidence of HDP was zero in the costoclavicular group.
- So, we also conducted a study about costoclavicular block for shoulder arthroscopic surgeries. This study has not been published yet. We compared the costoclavicular block with the superior trunk block. And DE and DTF were both used for diagnosis of HDP. We hypothesized that CCB would provide non-inferior analgesia to STB 1 hour after surgery and also avoid the risk of HDP.
- The primary outcome, 1 hour postoperative pain score, was 2 in CCB and 0 in STB, the median difference was 2, upper CI was 3, and non-inferiority was not established.
- However, there was no difference in the postoperative opioid consumption and the time of first analgesic use between the two groups.
- In addition, although the incidence of complete HDP was significantly reduced in the CCB group, HDP still occurred in some cases as shown in previous studies.
- We are currently trying to observe the supraclavicular spreading after ccb with the ultrasound, but so far the spreading is not so consistent, and this seems to affect the patient's pain after shoulder surgery. Hence, we may need further research about CCB regarding shoulder surgery.
- You can check the mini lecture and the practice videos about CCB on the ksra homepage after November 15. Other contents will be updated monthly.
- Thank you for your attention. Please, connect with KSRA.