WHAT ARE THE CHARACTERISTICS OF THE IDEAL BRACHIAL PLEXUS BLOCK?
by Colin McCartney
Since the advent of ultrasound much has been investigated and written about blocks of the brachial plexus. Yet we are no closer to the day when every anaesthetist can perform a satisfactory brachial plexus block. In order to achieve that aim I believe that some standardization is necessary, and in order to standardize we have to decide on what approach is best. I therefore offer the following criteria for the ideal brachial plexus block and subsequent consideration of which technique comes closest.
In my opinion the ideal brachial plexus block has to have the following features:
1. Easy to perform: every anaesthetist should learn this technique in training and it should require minimal effort to maintain competence.
2. Fast onset: the technique should have an onset time less than 30 minutes from block performance.
3. Prolonged analgesia: ideally the technique allows methods to maintain prolonged analgesia after surgery.
4. No side effects: there should be no inadvertent blocks of other structures such as phrenic, recurrent laryngeal nerves or sympathetic chain.
5. No complications: major complications such as systemic injection or pneumothorax should be absent.
6. Easy to teach: ties into 1)
7. Painless to perform: patients should not have memories of multiple needle insertions.
8. Suitable for all types of surgery distal to shoulder: the block needs to be adaptable to all types of upper limb surgery with no risk of missed dermatomes.
So what technique, in my opinion, is closest to the ideal?
In my opinion the ultrasound-guided axillary perivascular technique described by Sites et al in 2006 is the block to learn. This technique is easy to perform-it is essentially an ultrasound version of the original transarterial axillary block. It has an onset within 30 minutes of block performance. It produces no unintended side effects common to supraclavicular or interscalene block. It has low risk of major intravascular injection provided normal precautions are taken and no risk of pneumothorax. Although no studies have examined how easy it is to teach this technique the anatomy is very straightforward and involves basic skills of needle and probe alignment. It should involve few major needle remanipulations that often cause patient discomfort. Finally, it should cover all surgical procedures distal to the elbow and has minimal risk of missing the inferior trunk (like supraclavicular and interscalene block). The one limitation is that continuous catheters are somewhat technically difficult to perform in the axilla.
What we need now are further studies examining the ability to learn and maintain skills in this basic brachial plexus block.
If we can teach the next generation of trainees so that all consultants of the future have ability to perform a consistent, high quality brachial plexus block I believe that this will be a major step forward for anesthesia and for patient care. I would greatly like to hear your comments about my thoughts and opinions and look forward to some active debate as we try to advance the science and practice of ultrasound-guided brachial plexus block.
In my opinion the ideal brachial plexus block has to have the following features:
1. Easy to perform: every anaesthetist should learn this technique in training and it should require minimal effort to maintain competence.
2. Fast onset: the technique should have an onset time less than 30 minutes from block performance.
3. Prolonged analgesia: ideally the technique allows methods to maintain prolonged analgesia after surgery.
4. No side effects: there should be no inadvertent blocks of other structures such as phrenic, recurrent laryngeal nerves or sympathetic chain.
5. No complications: major complications such as systemic injection or pneumothorax should be absent.
6. Easy to teach: ties into 1)
7. Painless to perform: patients should not have memories of multiple needle insertions.
8. Suitable for all types of surgery distal to shoulder: the block needs to be adaptable to all types of upper limb surgery with no risk of missed dermatomes.
So what technique, in my opinion, is closest to the ideal?
In my opinion the ultrasound-guided axillary perivascular technique described by Sites et al in 2006 is the block to learn. This technique is easy to perform-it is essentially an ultrasound version of the original transarterial axillary block. It has an onset within 30 minutes of block performance. It produces no unintended side effects common to supraclavicular or interscalene block. It has low risk of major intravascular injection provided normal precautions are taken and no risk of pneumothorax. Although no studies have examined how easy it is to teach this technique the anatomy is very straightforward and involves basic skills of needle and probe alignment. It should involve few major needle remanipulations that often cause patient discomfort. Finally, it should cover all surgical procedures distal to the elbow and has minimal risk of missing the inferior trunk (like supraclavicular and interscalene block). The one limitation is that continuous catheters are somewhat technically difficult to perform in the axilla.
What we need now are further studies examining the ability to learn and maintain skills in this basic brachial plexus block.
If we can teach the next generation of trainees so that all consultants of the future have ability to perform a consistent, high quality brachial plexus block I believe that this will be a major step forward for anesthesia and for patient care. I would greatly like to hear your comments about my thoughts and opinions and look forward to some active debate as we try to advance the science and practice of ultrasound-guided brachial plexus block.