Bloqueo del plexo braquial por vía supraclavicular: estudio clínico comparativo entre bupivacaína y levobupivacaína. José Ricardo Pinotti Pedro, TSA, M.D.I;. La vía infraclavicular para bloqueo de plexo braquial es frecuentemente utilizada . can be avoided in ultrasound-guided supraclavicular brachial plexus block. Supraclavicular Brachial Plexus Block: A Comparative Clinical Study between Bupivacaine and LevobupivacaineBloqueio do Plexo Braquial por Via.
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Supraclavicular brachial plexus block: Brachial plexus block is used in surgical procedures of the upper limbs. The brachial plexus is a potential territory brawuial absorption of local anesthetics.
Studies on bupivacaine isomers have shown reduced cardiovascular toxicity of its levorotatory form levobupivacaine. However, the anesthetic efficacy sensorial and motor blockades of levobupivacaine in neuroaxis blocks has been debated. The objective of this brqquial was to demonstrate the anesthetic efficacy of levobupivacaine in brachial plexus block, using the perivascular subclavian approach, by comparing it to racemic bupivacaine.
Fifty adult patients of both genders, ASA I and II, underwent subclavian perivascular brachial plexus block, with the aid of a peripheral neurostimulator, for orthopedic surgeries of the upper limbs.
Patients were randomly divided into two groups: Sensorial blockade was evaluated by pinprick stimulation from C 5 to C 8 metameres; and the motor blockade was assessed 1, 2, 5, 10, 15, 20, 25, and 30 minutes after the administration of the local anesthetic or until blockade of fingers, hand, forearm, and arm movements was observed.
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Statistical differences in latency, failure rate, and degree of the motor blockade, and failure of the sensorial blockade between both groups were not observed, but the latency of the sensorial blockade in all metameres analyzed showed statistically significant differences. Adverse events inherent to the administration of local anesthetics were not observed.
The anesthetic efficacy of levobupivacaine in brachial plexus block was similar to that of the racemic solution commonly used. Se dividieron de modo aleatorio, en dos grupos: Scientific confirmation of the cardiac toxicity of bupivacaine in the s stimulated experimental studies with its enantiomers, which indicated lower cardiodepressor activity of S – bupivacaine levobupivacaine Several clinical studies on neuroaxis block have shown that the efficacy and the duration of the motor blockade of levobupivacaine are similar to that of racemic bupivacainewhile others observed that the duration of its motor blockade is shorter than that of racemic bupivacaine Subclavian perivascular block is widely used in several upper limb procedures.
One can choose several approaches whose common denominator is the larger volume of local anesthetics required, comparing with neuroaxis blocks, and making the choice of the local anesthetic crucial. The use of levobupivacaine in brachial plexus block seems promising considering the lower toxicity and the need of large volumes. However, the possibility of unsatisfactory motor blockade, both in neuroaxis and brachial plexus blocks, has yet to be discarded This lack of consensus was the basis for this study, i.
The primary objectives of the present study included comparing the latency and prevalence of failure of the motor blockade of racemic bupivacaine and levobupivacaine in subclavian perivascular brachial plexus block.
Secondary objectives included the evaluation of the effectivity of the motor and sensorial blockades, the degree of the motor blockade, and the presence of adverse events. Inclusion criteria were as follows: Patients with coagulation disorders, severe cardiopathies, liver disease, and kidney diseases, neurologic disorders or deficit, associated peripheral nerve lesions, skin lesion at the site of the blockade, or associated lesions in other areas of the body requiring general anesthesia, as well as pregnant women or those suspected brasuial being pregnant, were excluded from the study.
Supraclaivcular were assigned according to an increasing numeric sequence that classified the local anesthetic provided by the laboratory.
The local anesthetic 0. The numeric sequence was generated by a random list created by the laboratory that provided the local anesthetic for the study. According to this method, two groups of patient were created: On the day before the surgery, patients were informed about the study and signed an informed consent.
Patients did not receive any pre-medication. In the operating room, venoclysis was performed in the contralateral upper limb, Ringer’s lactate 10 mL. The site that triggered muscular response to a stimulus equal to or lower than 0.
Sensorial blockade was evaluated by pinprick stimulation of C 5C 6C 7and C 8 metameres 1, 2, 5, 10, 15, 20, 25, and 30 minutes after the administration of the local anesthetic and every five minutes until the effectivity or failure of the blockade was identified. Failure of blockade was diagnosed if sensorial or motor change was not observed up to 45 minutes after the administration of the local anesthetic.
Motor blockade was evaluated by flexion of the 5 th finger, thumb adduction, extension, abduction, and flexion of the wrist, pronation of the forearm, and rotation and abduction of the humerus. The time between the administration of the local anesthetic and the onset of the blockade for each of the movements mentioned was recorded. To assess the degree of the motor blockade, the following classification was used: In case of failure, the patient underwent general anesthesia and the procedure was carried out.
Those cases were maintained in the study and analyzed as blockade failures. After establishment of the blockade, sedation was supplemented with sequential intravenous boluses of 1 mg of midazolam, and patients remained in horizontal dorsal decubitus with oxygen via nasal catheter. At the end of the procedure, patients were transferred to the post-anesthetic care unit.
The primary outcome of the study included the latency and prevalence of motor blockade failures. Anthropometric data underwent descriptive analysis and, according to the parameter, the following tests were used: Significant differences in anthropometric data and physical status were not observed between both groups Table Idemonstrating that the study groups were comparable.
The duration of the surgery median was The latency and incidence of failures were not statistically different between both groups Table II.
The latency of the sensorial blockade in C 5C 6C 7and C 8 metameres did not show normal distribution; therefore, median and 25 th and 75 th percentiles were used in the respective statistical analyses. Comparing the latency of the sensorial blockade, statistical differences were observed between both groups in C 5C 6C 7and C 8with shorter latency in G LEVO.
Bloqueo continuo del plexo braquial vía supraclavicular – Gerardo Luis García García – Google Books
However, statistical differences in the incidence of failures in the four metameres analyzed were not observed Table IV. Significant hemodynamic changes were not observed.
As for adverse events, one case of tinnitus, without deleterious consequences, was observed in each group. The present study demonstrated that the anesthetic qualities of pure levorotatory bupivacaine in brachial plexus block are similar to that of the racemic mixture.
Brachial plexus block has long been considered a safe method when proper technique is observed, which includes blqueo and patient selection. However, brachial plexus blockade can set a potential place for absorption of local plfxo and the development of systemic toxicity A considerable sulraclavicular of studies on the use of levobupivacaine in ee blocks and, especially, in epidural blocks can be found in the literature. But the same is not true for levobupivacaine in brachial plexus blocks 17,19, Only two studies compared racemic bupivacaine and levobupivacaine 17,21 while the other studies in the literature compared levobupivacaine and ropivacaine 19,20 or evaluated different volumes, doses, concentrations, and routes of administration of levobupivacaine 18, In the present study, shorter latency of the sensorial blockade was observed in the levobupivacaine group in all metameres evaluated, but both groups had similar incidence of failures.
However, Cox et al. In the study of Liisanatti et suprac,avicular. In the present study, statistically significant differences in motor blockade latency, degree of the blockade, and failure rates were not observed between both groups, corroborating the results of Cox et al.
The motor blockade in the hand did not show statistically significant differences.
Since the present study used the supraclavicular technique while the axillary approach was used by Liisanantti et al. The clinical results of levobupivacaine in brachial plexus blocks, both in the present study and in the literature, indicate that latency, duration, and quality of the blockade is similar to that of racemic bupivacaine. Considering the greater toxicity blooqueo and the cardiovascular effects of the racemic mixture, levobupivacaine seems a good indication for brachial plexus blocks.
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A double-blind, randomised controlled trial. J Bone Joint Surg Br, ; Anaesth Intensive Care, ; All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License.
Services on Demand Journal. RESULTS Significant differences in anthropometric data and physical status were not observed between both groups Table Idemonstrating that the study groups were comparable. How to cite this article.