In the axillary fossa, the musculocutaneous nerve (MC) is generally distant from the axillary artery and from the other brachial plexus nerves. In that way, MC requires a specific block. We observed that the location of MC is influenced by the position of the patient's arm and shoulder. Abduction of the shoulder significantly reduced the distance between the MC and the axillary artery. This change in the location of the MC is probably due to the moving of the nerve because of muscle rearrangements and the ability to achieve better proximity of the probe in the axillary fossae.

A 29-year-old patient was scheduled for bilateral halllux valgus surgery and a lateral sciatic popliteal nerve block was performed on each side using ropivacaine and lidocaine using nerve stimulation. Although the sensory and motor block had usual duration on the left side, the block lasted more than 48 hours on the right side with both sensory and motor impairment. An MRI performed on day 2 on the blocked side showed extra- and intraneural fluid accumulation with cephalad and distal spread. Sensory and motor function progressively recovered within the next day and was complete on the fourth day. We postulate that this case of extremely long duration of a peripheral nerve block can be ascribed to subepineural trapping of the local anaesthetic. Part of the variability in the duration of the sensory and motor block after peripheral nerve blocks might be explained by the variable amount of drug injected intraneurally.Un bloc sciatique poplité latéral bilatéral a été réalisé chez une patiente de 29 ans sans antécédents pour permettre la cure d’un hallux valgus bilatéral. Un mélange de ropivacaïne et lidocaïne a été utilisé de chaque côté après détection par neurostimulation. Bien que le bloc sensitif et moteur ait eu une durée usuelle du côté gauche, le bloc a perduré plus de 48 heures du côté droit. Une imagerie par IRM réalisée au second jour montrait la persistance péri- et intraneurale de liquide qui diffusait en direction céphalique et caudale sur plusieurs centimètres. La fonction sensitive-motrice revenait progressivement à la normale au troisième jour et était complète au quatrième jour. Nous proposons l’hypothèse que la durée extrêmement prolongée d’un bloc nerveux périphérique peut être la conséquence d’un piégeage subépineural (intraneural et extrafasciculaire) de l’anesthésique local avec diffusion le long du nerf. Une partie de la variabilité de la durée des blocs nerveux périphériques pourrait ainsi être expliquée par le degré variable d’injection intraneurale.

OBJECTIVES:Ultrasound-guided regional anesthesia is commonly used for block placement. At present, the risk of cross contamination from probes is not well documented. To avoid transmission of infectious agents, several methods have been used for probe disinfection and protection. The aim of this study was to evaluate the antibacterial efficacy of a new high-level disinfection method based on ultraviolet C (UV-C) light under routine conditions after block placement with an unprotected probe. METHODS:The study was after approval by the local Ethics Committee. In the first part of the study, 15 ultrasound probes were exposed to a large inoculum of 3 bacteria. Ultraviolet C disinfection consisted of cleaning the probe with dry and disinfectant-impregnated paper followed by a 90-second UV-C disinfection cycle in a decontamination chamber. A protocol was established to retrieve the probe with sterile gloves after opening the door of the chamber. In the second part, 50 blocks were placed with ultrasound-guided regional anesthesia. The skin was first prepared with an antiseptic solution, and sterile gel was applied; no covers were used to protect the probes. The blocks were then disinfected with UV-C light. Bacteriologic samples were collected before and after the UV-C method and inoculated on chocolate agar plates. RESULTS:During the first part of the study, all probes were infected after inoculation (>150 colony-forming units) but were considered sterile (<10 colony-forming units) after disinfection. During the second part of the study, all probes were considered sterile before and after disinfection. CONCLUSIONS:Ultraviolet C disinfection seems relevant for ultrasound-guided regional anesthesia just before block placement. It offers simple, fast, and effective high-level disinfection. Moreover, this method should obviate the use of sterile probe covers, which can improve echogenicity.

Background Axillary brachial plexus block under neurostimulation is commonly used for upper limb surgery, but it is sometimes recognized as an uncomfortable technique, with most patients identifying electrical stimulation as an unpleasant moment. Ultrasound-guided regional anaesthesia, which becomes an increasingly popular technique, does not require electrical stimulation and then should theoretically improve axillary block placement comfort. The aim of this study was to compare the comfort of the patients during axillary block placement with neurostimulation and ultrasound guidance using either the out-of-plane or the in-plane approach. Methods Consecutive patients were prospectively enrolled in three equal groups: neurostimulation, ultrasound out-of-plane and ultrasound in-plane approaches. A score was used to measure the comfort of the patients during axillary blocks placement. This score included three criteria: maximum pain intensity perceived during block placement measured using a visual analogue scale (0, no pain and 100, maximal or worse imaginable pain), the number of unpleasant events declared by the patients and the satisfaction of the patient (unsatisfied, acceptable, satisfied, very satisfied). The comfort score was calculated as the sum of each criterion, which was attributed a value of 0 or 1: visual analogue scale (≤30/100, 1; >30/100, 0), number of unpleasant events (0, 1; ≥1, 0) and satisfaction (satisfied or very satisfied, 1; acceptable or unsatisfied, 0). Procedures of axillary blocks placement resulting in a comfort score of 3 and 2 were arbitrary considered as very comfortable and comfortable, respectively. Success rate of axillary blocks, time to perform block and complications related to procedures were noted. Results One hundred and twenty patients were included. In the ultrasound out-of-plane group, 55% (22/40) and 25% (10/40) of the procedures were very comfortable and comfortable as compared with 32% (13/40, P < 0.05) and 20% (8/40, P < 0.01) in the ultrasound in-plane group and 25% (10/40, P < 0.01) and 8% (3/40, P < 0.01) in the neurostimulation group, respectively. Duration of axillary placement was significantly smaller in the ultrasound out-of-plane group as compared with that of in-plane approaches (P < 0.05) and neurostimulation (P < 0.01). Conclusion The present study showed that the ultrasound approaches were less painful and more comfortable than neurostimulation to place axillary blocks. We also showed that, although pain intensity resulting from blocks placement was similar with the ultrasound approaches, very comfortable procedures were more frequent with the out-of-plane than with the in-plane approach.

Objective. - The monitoring in the postanaesthesia care unit (PACU) improves the safety, the comfort and the analgesia of patients. At present, studies suggest the possibility to bypass the PACU according to the principle of fast-tracking (FT). The aim of this study was to evaluate the feasibility and the safety of a simulated protocol of FT after a regional anaesthesia.Patients and methods. - Seven hundred patients were prospectively included in this study over a period of 6 months.Methods. - The Withes' scoring system was used for determining when patients could be safely discharged from PACU. We added a variable concerning the monitoring of surgical site. A minimum score of 14 was required on arrival to the PACU to consider a FT. The success rate of blocks, the use of sedation or general anaesthesia were noted. Adverse events were recorded.Results. - The success rate of blocks was 93%. The score was higher than 14 in 98% of case on arrival to the PACU. Thirteen adverse events were reported before surgery and/or operating room. No adverse events were reported during the stay in the PACU.Conclusion. - Regional anaesthesia seems to be an appropriate principle to fast-track the PACU. It could be a way to reduce health care costs, and can offer solution for the PACU congestion problem. In France, the fast-tracking is a marginal concept without any support regulatory. An evolution to such a practice could be considered. (C) 2010 Elsevier Masson SAS. All rights reserved.

Background: Because poor echogenicity of the needle remains a safety issue, we decided to analyze the learning process of the hydrolocalization technique (Hloc) performed to continuously identify needle‐tip anatomical position during many ultrasound‐guided regional anesthesia procedures.Methods: Ten senior anesthesiologists naïve to the Hloc agreed to participate in the study. They were requested to perform 40 out‐of‐plane (OOP) approach ultrasound‐guided axillary blocks (AB) each using the Hloc. The Hloc, which is a needle‐tip localization principle, was performed by means of repetitive injections of a small amount of a local anesthetic solution (0.5–1 ml) under an ultrasound beam. Details of the learning process and skill acquisition of the Hloc were derived from the following parameters: the duration of block placement, a measure of the perceived difficulty of needle‐tip visualization, a measure of block placement difficulty, and the amount of local anesthetics solution required for the technique.Results: Four hundred ABs were performed. The success rate of an ultrasound‐guided AB was 98%. The Hloc was successful in all patients. Skill acquisition over time of the Hloc was associated with a significant reduction of both the duration and the perceived difficulty of ABs placement. Apprenticeship data revealed that 20 blocks were required to successfully place AB within 5 min in most cases using the Hloc.Conclusion: The Hloc performed during the OOP approach of ultrasound‐guided regional anesthesia is a simple technique with a relatively short learning process feasible for efficient placement of ABs.

ackground and Aims: Peripheral nerves may be visualised using wo-dimensional ultrasound in either their short (cross-sectional) or ong axis (longitudinal) views. Three-dimensional, multiplanar ultraound displays both views simultaneously, together with a plane arallel to the probe surface which effectively looks down on the egion of interest and thus can be called a ’plan view’ (as in architecural nomenclature). The plan view is unobtainable with conventional ltrasound. To date, experience of three-dimensional, multiplanar, ltrasound in regional anaesthesia is limited. [1]

OBJECTIVES:The objective of this study was to determine if the ultrasound probe can act as a vector for cross-infection and to compare two cleaning methods for ultrasound probes in order to limit or control the transmission risk.STUDY DESIGN:Prospective study.PATIENTS AND METHODS:The first part of the study (P1) was conducted to evaluate the possibility of the ultrasound probe to serve as a source of cross-contamination. Thirty blocks were placed under ultrasound guidance in elective outpatients. After each procedure (Proc), the ultrasound probe was decontaminated/cleaned using either an antiseptic solution spray (AS: n=15) or just wiped with two dry paper sheets (DP: n=15), in a randomly assigned order. Bacteriological samples were collected before and after each decontamination/cleaning methods and inoculated on a chocolate agar plates. The second part of the study (P2) was conducted to compare the effectiveness of two cleaning methods for ultrasound probes. The ultrasound probes were exposed to a large inoculum of three bacteria (Inoc). They were then cleaned/decontaminated using either DP (n=10) or AS (n=10), in a randomly assigned order. Bacteriological samples were collected before and after each cleaning/decontamination methods and inoculated on a chocolate agar plates.RESULTS:During P1, after Pro, all probes were found to be sterile before and after both AS and DP. During P2, after Inoc, all probes were found infected (CFU>150) but were considered sterile (CFU<10) after both DP and AS.CONCLUSION:The results of this study suggest that the risk of cross-infection during ultrasound guidance in locoregional anaesthesia is really low. Our data suggest that wiping ultrasound probe with two dry paper sheets is an adequate cleaning method to prevent cross-contamination risk.

ethods: In the first part of the study (P1) we evaluated the ossibility of the ultrasound probe to serve as a source of crossontamination. Thirty upper and lower limbs blocks were placed nder ultrasound guidance in elective out-patients. After each lock, the USP was decontaminated/cleaned using either an antieptic solution spray (AS: n 15) or just wiped with two dry paper heets (DP: n 15), in a randomly assigned order. Bacteriological amples were collected before and after each decontamination/ leaning methods and inoculated on a chocolate agar plates.In the econd part of the study (P2) we compared the effectiveness of 2 leaning methods for USP exposed to a large inoculum of 3 bacteia. USP were cleaned/decontaminated using either DP (n 15) or S (n 15), in a randomly assigned order. Bacteriological samples ere collected before and after each cleaning/decontamination ethods and inoculated on a chocolate agar plates.

Objectives. - To assess the feasibility of neurostimulation and ultrasound guidance combination for infraclavicular brachial plexus block (ICB) technique.Study design. - Prospective study.Patients and methods. - Fifty consecutive patients scheduled for hand, forearm or elbow surgery were included.Methods. - A single stimulation lateral approach technique of ICB was performed. During the procedure, neurostimulation and ultrasound guidance were combined. The feasibility of ICB was assessed using a visual analogue scale. (VAS, 0: impossible, 100: very simple) for ultrasound anatomical structures identification (VAS(Anat)) and for block placement (VAS (Block)). The success rate of ICB block was noted.Results. - No patient required general anaesthesia conversion. Median VAS +/- SD of YAS(Anat) and VAS(Block) were of 84 +/- 15 and 96 +/- 7, respectively. Success rate of ICB was 96%. No specific complication of ICB technique was noted.Conclusion. - Combination of neurostimulation and ultrasound guidance is feasible. Combination of neurostimulation and ultrasound guidance secured ICB. Ultrasound-evidenced spread of local anaesthetics increased the success rate of ICB. (c) 2007 Elsevier Masson SAS. Tous droits reservos.

BACKGROUND AND OBJECTIVES:We have compared ultrasound characteristics of spread during infraclavicular brachial-plexus blocks by use of electrically evoked radial-nerve- or median-nerve-type distal motor responses to guide the injection of 30 mL of 1.5% mepivacaine.METHODS:Consecutive patients who required surgery distal to the upper arm were prospectively included in this study. With radial- or median-evoked distal motor response at a stimulating current intensity of less than 0.5 mA, patients were distributed into 2 equal groups. An independent investigator blinded to the evoked response described ultrasound characteristics of the spread of local anesthetic and assessed block quality 30 minutes after placement. A quality diffusion score proportional to the extent and intensity of spread around the axillary artery was used, and dynamic movements during injection were noted.RESULTS:Thirty-two patients were included. With radial-nerve-type motor response, the success rate of infraclavicular plexus block was 100%, but 3 supplemental axillary blocks were requested with median-nerve-type motor response. Quality diffusion scores were significantly higher with radial-nerve-type as compared with median-nerve-type motor response (P = .03). Injection after radial-nerve-type motor response resulted in a typical and reproducible ultrasound feature of posterior local-anesthetic spread associated with medial and upper movement of the axillary artery. With median-nerve-type motor response, failed blocks were associated with a specific posterior displacement of the axillary artery that resulted from superficial spread.CONCLUSION:We have demonstrated that as compared with median-nerve-type motor response, injection performed after a radial-nerve-type motor response promoted reproducible and remarkable ultrasound spread characteristics associated with complete sensory block of the 3 cords at 30 minutes.

OBJECTIVES:To assess the feasibility of neurostimulation and ultrasound guidance combination for infraclavicular brachial plexus block (ICB) technique.STUDY DESIGN:Prospective study.PATIENTS AND METHODS:Fifty consecutive patients scheduled for hand, forearm or elbow surgery were included.METHODS:A single stimulation lateral approach technique of ICB was performed. During the procedure, neurostimulation and ultrasound guidance were combined. The feasibility of ICB was assessed using a visual analogue scale (VAS, 0: impossible, 100: very simple) for ultrasound anatomical structures identification (VAS(Anat)) and for block placement (VAS (Block)). The success rate of ICB block was noted.RESULTS:No patient required general anaesthesia conversion. Median VAS+/-SD of VAS(Anat) and VAS(Block) were of 84+/-15 and 96+/-7, respectively. Success rate of ICB was 96%. No specific complication of ICB technique was noted.CONCLUSION:Combination of neurostimulation and ultrasound guidance is feasible. Combination of neurostimulation and ultrasound guidance secured ICB. Ultrasound-evidenced spread of local anaesthetics increased the success rate of ICB.

BACKGROUND AND OBJECTIVES:We compared the success rate of single-injection infraclavicular plexus block by using electrically evoked radial, ulnar, or median nerve-type distal motor response to guide the injection of local anesthetic.METHODS:Consecutive patients requiring surgery distal to the upper arm were prospectively included in this study over a 6-month period. No search for predetermined distal motor responses was performed. The first qualifying distal motor response evoked for a stimulating current intensity of <0.5 mA distributed patients into 3 groups of patients. The study was continued until 3 groups of 60 patients were fulfilled. Twenty to 25 minutes after the injection of 30 mL of 1.5% mepivacaine, blinded evaluation of block quality was performed. A successful block was defined by the presence of a complete sensory block of the 5 major nerve distal distributions of the arm.RESULTS:Five hundred patients were included. The first evoked distal motor response was of radial, median, and ulnar nerve type in 46% (n = 230), 42% (n = 210), and 12% (n = 60) cases, respectively. The success rate of the infraclavicular plexus block was significantly higher when the injection was performed on a radial nerve-type response (90%) as compared with the median (74%) or ulnar (68%) nerve distal motor response. Intraoperative sedation and general anesthesia were not needed. None of the patients experienced specific complications.CONCLUSION:We showed that evoked distal motor response influenced the success rate of single-injection infraclavicular plexus block. The highest success rate was obtained when injection was performed after radial nerve-type motor response.

OBJECTIVES:To assess the efficiency of a posterior secondary trunk single stimulation, low volume (30 ml 1.5% mepivacaine) infraclavicular brachial plexus block (ICB) technique. STUDY DESIGN:Prospective study. PATIENTS AND METHODS:One hundred consecutive patients scheduled for hand, forearm or elbow surgery were included. ICB was placed using a single stimulation technique. 30 ml 1.5% mepivacaine was injected when an evoked distal radial motor type response was elicited for 0.3-0.6 mA intensity current. Based upon both sensory and motor distribution ICB, characteristics and performance were assessed. RESULTS:No patient required general anesthesia conversion. Success rate was 92%. 8 patients required a total amount of 10 complementary distal troncular blocks. No specific complication of ICB technique was accoutered. All patients completed full neurological recovery from ICB 24 hours after surgery. CONCLUSION:30 ml mepivacaine 1.5% ICB is suitable for upper limb surgery.

Objectives. - To assess the efficiency of a posterior secondary trunk single stimulation, low volume (30 ml 1.5% mepivacaine) infraclavicular brachial plexus block (ICB) technique.Study design. - Prospective study.Patients and methods. - One hundred consecutive patients scheduled for hand, forearm or elbow surgery were included. ICB was placed using a single stimulation technique. 30 ml 1.5% mepivacaine was injected when an evoked distal radial motor type response was elicited for 0.3-0.6 mA intensity current. Based upon both sensory and motor distribution ICB, characteristics and performance were assessed.Results. - No patient required general anesthesia conversion. Success rate was 92%. 8 patients required a total amount of 10 complementary distal troncular blocks. No specific complication of ICB technique was accoutered. All patients completed full neurological recovery from ICB 24 hours after surgery.Conclusion. - 30 ml mepivacaine 1.5% ICB is suitable for upper limb surgery. (c) 2005 Elsevier SAS. Tous droits reserves.