Year : 2023 | Volume
| Issue : 1 | Page : 113-116
Peri-humeral block for postoperative analgesia in patients with distal humerus surgery: A case series
Sandeep Diwan1, Himaunshu V Dongre1, Abhijit S Nair2, Suhrud Panchwagh3
1 Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India
2 Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
3 Medical Student, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
Abhijit S Nair
Department of Anesthesiology, Ibra Hospital, Ibra - 414
Source of Support: None, Conflict of Interest: None
|Date of Submission||04-Aug-2022|
|Date of Decision||04-Aug-2022|
|Date of Acceptance||05-Aug-2022|
|Date of Web Publication||02-Jan-2023|
The brachial plexus blocks (BPBs) are routinely performed for all surgeries in the vicinity of the elbow joint. Phrenic nerve paresis is a major problem with above-clavicle blocks especially the interscalene approach. The primary aim of this pilot study was to assess feasibility and to evaluate if perioperative pain management with the articular and cutaneous nerve block, the peri-humeral block (PHB) resulted in decreased use of opioid consumption in the intraoperative and postoperative period for the first 24 hours. Twenty-four patients with distal humerus fracture received ultrasound (US)-guided PHB as part of their perioperative anesthetic management. The primary aim was to evaluate block efficacy in terms of time to first analgesia and opioid consumption in first 24 hours. US in real time revealed that in all patients the local anesthetic was optimally deposited. Due to a stable intraoperative hemodynamics, none of the patients required additional opioid doses. The median pain scores over 24 hours were 2.4 with IQR (0-3.8). The mean time to first analgesic was 425.417 ± 229.005 min. There were no adverse effects reported at the time of hospital discharge. Though the US-guided PHB would not replace the BPB, in some special circumstances, it would be desirable to implement the former block which has opioid and motor sparing features and incorporate with multimodal analgesia.
Keywords: Acute pain, anesthesia, bone fracture, brachial plexus, humerus, nerve block, regional anesthesia, ultrasonography
|How to cite this article:|
Diwan S, Dongre HV, Nair AS, Panchwagh S. Peri-humeral block for postoperative analgesia in patients with distal humerus surgery: A case series. Saudi J Anaesth 2023;17:113-6
|How to cite this URL:|
Diwan S, Dongre HV, Nair AS, Panchwagh S. Peri-humeral block for postoperative analgesia in patients with distal humerus surgery: A case series. Saudi J Anaesth [serial online] 2023 [cited 2023 Feb 1];17:113-6. Available from: https://www.saudija.org/text.asp?2023/17/1/113/364876
| Introduction|| |
Brachial plexus blocks (BPBs) are routinely performed for all surgeries in the vicinity of the elbow joint. Phrenic nerve paresis and a redundant motor blockade of the axillary nerve and the musculocutaneous nerve accompanies a BPB. Thus, it would be prudent to accomplish blockade of the distal nerves innervating the skin and the periosteum, to have a definitive block of a particular segment. Though BPBs are implemented for postoperative analgesia, debate continues regarding the application of US-guided BPB in patients with coagulopathy and on anticoagulants. An articular–cutaneous nerve block for elbow surgery has been described earlier. The primary aim of this case series was to assess block efficacy in terms of time to first analgesia and number of doses rescue analgesic based on pain scores (NRS) monitored postoperatively at various time points. Secondary aim included assessment of additional doses of intraoperative intravenous (IV) fentanyl based on response of hemodynamics to skin incision and fracture manipulation, distal motor movements, total opioid during the first 24 hours, and adverse effects.
| Case Series|| |
Ethical approval for this study was provided by Institutional Ethics Committee. Twenty-four American Society of Anesthesiologists'-physical status (ASA-PS) I and II patients, 15 male and 9 female patients, age between 18 and 55 years, with distal humerus fractures were recruited in this study starting from April 2020 to April 2021. All patients with fractures of distal humerus classified under the Association of the Study of Internal Fixation (AO-ASIF), 1-3- C1/C2/C3 for fractures of distal humerus who were to undergo open reduction and internal fixation through the posterior approach (ulnar osteotomy and triceps retraction) were included in this pilot study. Patients with pre-existing brachial plexus injuries, nerve entrapment injuries secondary to fractures, coagulopathy, on anticoagulants, history of uncontrolled diabetes mellitus, a revision surgery, ASA-PS III and IV were excluded from the study. Prior to block, all patients were evaluated for major nerve (musculocutaneous median, radial, and ulnar) functions and sensory functions (medial antebrachial and posterior antebrachial nerves).
Patients were administered general anesthesia (GA) with a standard protocol followed by the block. GA was induced with 1.5 μg/kg fentanyl intravenously (IV), 2 mg/kg propofol, 0.15 mg/kg cisatracurium, and nitrous-oxide in oxygen with sevoflurane. Blocks were performed under ultrasound (US) guidance [Sonosite M-Turbo (SonoSite Inc., Bothell, WA, USA)] with a 13–6 MHz linear array transducer. A 50 mm needle (Pajunk® Geisingen, Germany) was used to deliver LA (freshly prepared 40 ml 0.2% ropivacaine with 1 μg/kg clonidine) of 3–5 ml of solution injected in designated areas. Pain scores were assessed using the visual analog scale (VAS score) at 0 hours (after emergence) in recovery room, 4, 8, 12, and 24th hours. IV diclofenac sodium 50 mg was infused 30 min prior to skin closure and thereafter every 8th hourly. Rescue analgesia (IV tramadol 50 mg infusion) was initiated on patient demand or a VAS score of more than 4, in the first 24 hours. Wrist and finger movements and sensory distribution were assessed in postoperative ward at 0th hours postoperatively.
Block efficacy was defined based on following criteria: No more than 20% increase in the hemodynamics [at surgical incision, during fracture manipulation, bone drilling, and implantation], a mean VAS less than 4 in 24-hour postoperative period and all movements at the wrist and finger joints. In the supine position, the linear array US probe was deployed on the ventral arm 6 cm proximal [Figure 1]a to the line joining the medial and lateral epicondyle (intercondylar line). The biceps, brachialis, proximal brachioradialis in the anterior compartment, and triceps in the posterior compartment were visualized [[Figure 1]b-schematic]. An echogenic needle was inserted from lateral to medial, through the biceps brachii muscle and the tip was positioned at the anteromedial [Figure 1]c and anterolateral [Figure 1]d aspect of humerus, 0.5 cm away from the bone. Three ml of 0.2% ropivacaine was injected in real time as the local anesthetic (LA) spread from the ventral to dorsal aspect at both sites [Figure 1]c and [Figure 1]d. An extra 1 ml was injected if spread was inadequate. In the supine position, with the arm rested on the chest in adduction and internal rotation, the probe was deployed on the dorsal arm 6 cm proximal to the line joining the medial and lateral epicondyle. With the posterior surface of the humerus in vision, the needle was inserted from lateral to medial, through the triceps muscle and 0.2% ropivacaine 5 ml was injected 0.5 cm away from the bone as the needle withdrawn [Figure 1]e. The medial brachial cutaneous and posterior brachial cutaneous nerves [Figure 1]e were blocked separately in the subcutaneous tissues. Immediately before the incision skin, infiltration was performed by the surgeon with 0.2% ropivacaine 10 ml along the proposed surgical incision to avoid sparing of the areas innervated by posterior cutaneous nerve of arm.
|Figure 1: Right distal humerus fracture undergoing PHB. Ans showing probe placements and needle insertions in supine position (a) Probe on the ventral surface of arm 6 cm [blue dotted line] proximal to the elbow crease, with needle inserted from lateral to medial; (b) Schematic explains the compartment, relation of nerve to inter-muscular space; (c) Ultrasound image illustrating the needle tip placement [broad white arrows] and spread of local anesthetic [light blue] on anteromedial surface. (LA − local anesthetic); (d) Ultrasound image illustrating the needle tip placement [broad white arrows] and spread of local anesthetic [light blue] on anterolateral surface. LA − local anesthetic; (e) Probe placement, needle trajectory and LA spread with injections and LA spread posterior to humerus [light blue] and posterior brachial cutaneous nerve [PBCN] in the subcutaneous tissue. Yellow arrow depicts the site on injection. (LA − local anesthetic); (f) Average VAS [0-24th hour]; (g) Time to first analgesic for tramadol. McN – musculocutaneous nerve; RN – radial nerve; AM-NP − anteromedial needle positioning; AL-NP − anterolateral needle positioning; NP – needle positioning|
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Continuous data were expressed as mean ± standard deviation or median/interquartile range whichever appropriate. Categorical data were expressed as numbers or percentages. Demographic data is depicted in [Table 1]. Median of VAS after 24 hours was 3 (IQR-O to 4) [Figure 1]f and the mean time to first analgesia (TTFA) was 425.417 ± 229.005 min [Figure 1]g.
| Discussion|| |
To our knowledge, this is the first report of a prospective case series of the PHB around the distal humerus affecting the articular and cutaneous nerves. Open reduction and fixation (ulnar osteotomy and triceps retraction) require extensive soft tissue dissection and manipulation of bony fragments leading to severe postoperative pain. Though BPBs are implemented for postoperative analgesia, debate continues regarding the application of US-guided BPB in patients with coagulopathy and on anticoagulants. Moreover, an insensate limb results in patient dissatisfaction and apprehension. With major peripheral nerves (radial, ulnar, and median) around the elbow, surgeon often demands preservation of distal motor function in the immediate postoperative period for neurological assessment. Thus, it would be justified to administer a highly specific block targeting the articular and cutaneous nerves to the distal humerus (proximal elbow joint) in the form of a PHB.
There are several limitations of this study. The recurrent branches of the nerves below the elbow joint, if any were not blocked. Though hand movement were not affected, no efforts were taken to quantify patient satisfaction. Pain scores monitored for 24 hours could have been extended for 48 hours. The strength of the study lies in its anatomic basis and the possibility to provide a motor and opioid sparing block for the elbow surgeries.
To conclude, US-guided PHB appears to be a safe, effective, and opioid-sparing intervention for managing perioperative pain following fracture of distal humerus surgery. Though PHB will not replace the BPBs, it is a good alternative for perioperative analgesia in certain circumstances as a part of multimodal analgesic protocol.
We acknowledge Dr. Parag Sancheti, Chairman and Managing Director of Sancheti hospital, Pune, India, for his technical and intellectual support during this study and the encouraging words which made this study possible.
Ethical approval for this study was provided by Institutional Ethics Committee, Sancheti Institute for Orthopedics and Rehabilitation, Pune – 411005, India (Chairperson Dr. Prahlad Patki) on November 7, 2019. The study was prospectively registered with Clinical Trials Registry, India (CTRI/2020/03/024094).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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