Jandard C, Gentili M E, Girard F, Ecoffey C, Heck M, Laxenaire M C, Bouaziz H
Service d'Anesthésie-Réanimation, Hôpital Central, Nancy, Cedex, France.
Reg Anesth Pain Med. 2002 Jan-Feb;27(1):37-42. doi: 10.1053/rapm.2002.29123.
The infraclavicular approach to the brachial plexus is little used despite theoretical advantages of the technique. Using a vertical paracoracoid approach, we assessed the extent of the sensory block and the incidence of adverse effects.
After obtaining informed consent, 100 patients undergoing surgical procedures distal to the elbow were evaluated. The block was performed using a peripheral nerve stimulator. The puncture site was located in the infraclavicular fossa; the direction of the insulated needle was perpendicular to the skin. Motor response was sought in the hand or wrist at < or = 0.6 mA. A total of 40 mL of 1.5% mepivacaine was administered as a single injection. The sensory block was evaluated every 5 minutes for 30 minutes before surgery in the cutaneous distribution of terminal branches of the brachial plexus.
When one considers the cutaneous distributions of the median, ulnar, radial, and musculocutaneous nerves, the success rate was 89% for surgery without need for additional peripheral nerve blocks or general anesthesia. In contrast, cutaneous areas innervated by the axillary and medial cutaneous nerves were rarely anesthetized. We were unable to demonstrate a correlation between the intensity of the stimulation and the success of the block. On the other hand, a correlation was found between tourniquet sensation and the absence of anesthesia of the medial cutaneous nerve of the arm. Local anesthetic toxicity, Horner's syndrome, and vascular puncture were respectively observed in 1%, 4%, and 5% of cases. The depth of the needle introduction was correlated with the body mass index (P <.001; r =.63).
Single injection infraclavicular block, using a vertical paracoracoid approach, appears suitable for surgery distal to the elbow. Selective anesthesia of the medial cutaneous nerve is useful in improving tolerance of the tourniquet.
尽管锁骨下臂丛神经阻滞技术具有理论上的优势，但该技术很少被使用。我们采用垂直喙突旁入路，评估了感觉阻滞范围及不良反应发生率。
在获得患者知情同意后，对100例肘部以下手术患者进行评估。使用外周神经刺激器进行阻滞。穿刺部位位于锁骨下窝；绝缘针的方向与皮肤垂直。在电流≤0.6 mA时，寻找手部或腕部的运动反应。单次注射40 mL 1.5%甲哌卡因。在手术前30分钟内，每隔5分钟在臂丛神经终末支的皮肤分布区域评估感觉阻滞情况。
从中、尺、桡及肌皮神经的皮肤分布来看，89%的患者手术时无需额外的外周神经阻滞或全身麻醉。相比之下，腋神经和臂内侧皮神经支配的皮肤区域很少被麻醉。我们未能证实刺激强度与阻滞成功之间存在相关性。另一方面，发现止血带感觉与臂内侧皮神经未麻醉之间存在相关性。局部麻醉药毒性、霍纳综合征和血管穿刺的发生率分别为1%、4%和5%。进针深度与体重指数相关（P<.001；r =.63）。
采用垂直喙突旁入路的单次注射锁骨下阻滞似乎适用于肘部以下手术。臂内侧皮神经的选择性麻醉有助于提高对止血带的耐受性。
