RU2355434C2 - Methods of brachial plexus blockade in people of brachimorphic body type - Google Patents

Abstract

FIELD: medicine; anesthesiology.

SUBSTANCE: in order to perform branchial plexus blockade from supraclavicular access in patients with branchimorphic body type puncture of fascial compartment of branchial plexus is made directly behind upper clavicle edge. Point of needle sticking is placed 1.5 cm medialward than middle of clavicle length. Needle is inserted at angle 90° to skin surface in direction of clavicle-rib space on maximal depth 3.5 cm with further injection of anesthetic.

EFFECT: complete blockade of branchial plexus, preventing possibility to damage cervical pleura, due to increasing accuracy of needle hit into plexus region.

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Description

The invention relates to medicine, namely to anesthesiology, and can be used to perform brachial plexus blockade from supraclavicular access in adults of a brachymorphic body type.

An anesthesiologist performing a blockade of the brachial plexus from the supraclavicular access constantly meets with patients with a brachymorphic physique. For them, unlike people of the dolichomorphic and mesomorphic body types, the structure and topography of the brachial plexus are characteristic: the frontipetal arrangement of the clavicle, the loose structure of the nerve trunks, the location of the subclavian artery in the lower parts of the supraclavicular fossa, and the location of the subclavian vein in front of the subclavian artery , lower standing of the pleura dome relative to the clavicle, smaller width of the brachial plexus, greater depth of the location of nerve trunks from the surface of the skin, more than projection of the brachial plexus, diagonal with respect to the middle length of the clavicle (Fursaev V.A. Conduction anesthesia of the upper extremity. Author. Thesis. Candidate of Medical Sciences. - Saratov, 1966. - 12 pp .; Individual anatomical variability of organs of systems and body shape person / Under the editorship of DB Bekov. - K .: Health, 1988. - 224 p .; Zanin V.Yu. Morphometric differences of the brachial plexus as the basis for the individualization of its blockade // Anatomical and physiological aspects of modern surgical technologies. Materials of the All-Russian Scientific Conference dedicated to the centenary of the birth of A.N.Maksimenkov / Ed. prof. N.F. Fomina. - SPb, 2006. - S.92-93).

For the implementation of the blockade of the brachial plexus in patients with a brachymorphic body type, various methods are used, the essence of which is the introduction of an anesthetic into the fascial case of the brachial plexus by puncture it over the clavicle. These methods provide a universal approach for all types of physique (dolichomorphic, mesomorphic and brachymorphic) to the choice of the point of injection of the needle, its direction and depth of insertion.

There is a method of blocking the brachial plexus from supraclavicular access according to Kulenkampff, which involves the introduction of a needle 1 cm above the middle of the clavicle to a depth of 1-3 cm to the 1st rib in the direction of the spinous processes of the II-III thoracic vertebrae (Svetlov V.A., Kozlov S .P., Gnezdilov A.V., Vashchinskaya T.V. Blockade of the brachial plexus - ways of improvement in modern anesthesiology // Anesthesiology and intensive care. - 1984. - No. 4. - S.50-56).

The disadvantages of this method are:

- difficulties in finding the brachial plexus due to the mismatch of the reference point of the needle point of the projection of the brachial plexus on the skin in individuals of a brachymorphic body type;

- the difficulty of controlling the direction of the needle with a brachymorphic body type;

- High probability of damage to the pleura dome, since the needle is inserted in the medial direction.

There is also a method of supraclavicular blockade of the brachial plexus according to A.Yu. Pashchuk, in which the point of needle injection is outside the palpable subclavian artery 1 cm above the posterior medial edge of the clavicle. The needle is held in the direction of the 1st rib at an angle of 80 ° to the skin (Pashchuk A.Yu. Regional anesthesia. - M .: Medicine, 1987. - P.75-82).

The disadvantages of this method are:

- difficulty palpation of the subclavian artery in people with a brachymorphic body type;

- the difficulty of introducing the needle at the estimated angle;

- the risk of puncture of the pleura is not excluded, since there is a medial deviation in the direction of the needle.

A common drawback of these methods, in our opinion, is that they do not take into account the projection of the brachial plexus onto the skin, depending on the type of person’s physique. This leads to the fact that to achieve the blockade of the brachial plexus, it is necessary to repeat the puncture many times, changing the angle and depth of the needle. Such repeated manipulations contribute to significant injury to the tissues surrounding the brachial plexus.

Closest to the claimed invention is a method of blocking the brachial plexus from the supraclavicular access, described by M. Malroy and providing a point of injection of the needle immediately behind the middle of the clavicle and introducing it in the sagittal plane to the 1st rib (Malroy M. Local anesthesia: Illustrated practical guide: Per from English / Edited by Prof. S.I. Emelyanov. - M .: BINOM. Laboratory of Knowledge, 2005. - P.152-172).

As a prototype, this method has disadvantages when performing brachial plexus blockade in people of a brachymorphic body type:

- does not provide a complete blockade of the brachial plexus due to the mismatch of the point of injection of the needle of the projection of the nerve trunks of the brachial plexus on the surface of the skin, as a result of which the needle does not fall into the fascial case of the brachial plexus;

- there is no quantitative characteristic of the direction and depth of advancement of the needle;

- there is a risk of damage to the pleura dome due to the manipulation to detect the brachial plexus on the surface of the 1st rib.

Anatomical studies conducted by us on corpses showed that the method chosen as a prototype is acceptable for people with dolichomorphic and mesomorphic body types, since their brachial plexus was projected to the middle of the clavicle or 0.5-0.7 cm medial to this point. To get the needle into the projection of the brachial plexus in people of the brachymorphic type of physique, it was necessary to introduce it 1.5 cm medial to the middle of the length of the clavicle, since the nerve trunks were projected at this point. In this case, the maximum depth of the brachial plexus location from the skin surface was 3.5 cm. It was established experimentally on the corpses that introducing a needle from the projection point of the brachial plexus perpendicular to the skin surface ensures that it is brought to the fascial case of the brachial plexus in the shortest possible way. In addition, the direction of the needle perpendicular to the skin contributes to its advance mainly in the clavicular-rib space, and not to the I-th rib.

The novelty of the present invention is the ability to perform the brachial plexus blockade in humans of a brachymorphic body type by introducing an anesthetic into the fascial brachial plexus case by puncturing it directly behind the upper edge of the clavicle due to the use of quantitative characteristics of the needle point of injection, its direction and depth of introduction, which are individualized by the type of physique, which ensures the accuracy of the needle getting into the fascial case of the brachial plexus. This minimizes the risk of damage to the pleura dome, since the introduction of the needle according to the proposed characteristics is carried out to a greater extent in the clavicular-rib gap, and not in the direction of the I-th rib.

The essence of the claimed invention lies in the fact that the needle is injected 1.5 cm medial to the middle of the length of the clavicle at an angle of 90 ° to the skin surface in the direction of the clavicular-rib gap to a maximum depth of 3.5 cm.

The implementation of the proposed method of blockade of the brachial plexus

Instrumentation: standard single-use needles for subcutaneous and intramuscular injection, single-use Luer syringes with a capacity of 20 ml.

Local anesthetic: 1.5% lidocaine solution (6 mg / kg) with the addition of fentanyl 0.05 mg.

Blockade Technique:

1. The patient is placed on his back. The hand on the side of the blockade is placed along the body. The head is turned in the direction opposite to the place of the manipulation.

2. Determine the upper edge of the clavicle and the middle of the length of the clavicle. Directly behind the upper edge of the clavicle, 1.5 cm medial to the middle of its length mark the point of injection of the needle.

3. Disinfectant treats the skin in the area of the blockade. At the intended point, a subcutaneous needle connected to the syringe performs intracutaneous anesthesia.

4. The hypodermic needle is changed to intramuscular, which is injected at an angle of 90 ° to the surface of the skin and is moved deeper into the tissues in the clavicular-rib space until the patient has paresthesias in the fingers of the upper limb. The maximum depth of needle injection is limited and is 3.5 cm.

5. After the brachial plexus is detected by the appearance of paresthesias, the needle is fixed between the index finger and thumb, an aspiration test is performed, and then a slow (within 2-3 minutes) administration of the calculated dose of the anesthetic is carried out. An aspiration test is repeated after every 10 ml of solution has been administered.

The drawing shows a diagram of the implementation of the method of blocking the brachial plexus in people of the brachymorphic type of physique. The letters in the drawing indicate:

A) front view;

B) side view;

B) top view.

The numbers in the drawing indicate:

1) the acromial end of the clavicle;

2) the sternal end of the clavicle;

3) the middle of the length of the clavicle;

4) the upper edge of the clavicle;

5) the point of injection of the needle;

6) a needle inserted at an angle of 90 ° to the surface of the skin.

The method of blocking the brachial plexus in people of a brachymorphic body type was tested in an experiment on fixed human corpses (40).

Clinical Example

Patient S., 38 years old, medical record inpatient No. 1209. He entered the Department of Traumatology and Orthopedics of the State Health Institution “Orenburg Regional Clinical Hospital” on January 24, 2007 with a diagnosis of False joint of the lower third of the right radial bone. A patient with a brachymorphic body type.

01/24/07, the operation was performed: osteosynthesis of the right radial articulation with screws. Surgery was performed in conditions of blockade of the brachial plexus according to the proposed method. The blockade execution time (from the beginning of the manipulation to the registration of anesthesia) was 15 minutes. Anesthesia was adequate and did not require intravenous administration of components of general anesthesia. Hemodynamics was stable. There were no complications during the blockade during the operation and in the immediate postoperative period.

The method of blocking the brachial plexus in people of a brachymorphic type of physique improves the accuracy of getting the needle into the fascial case of the brachial plexus and eliminates the need for multiple punctures when searching for it, since the needle injection point is located at the site of the projection of nerve trunks on the skin. This ensures a complete blockade of the brachial plexus and, therefore, increases its effectiveness with the least degree of trauma of the tissues surrounding the brachial plexus. The inventive method makes it easy to control the direction and depth of insertion of the needle. At the same time, the risk of damage to the pleura dome is minimized, since the needle is more directed not to the 1st rib, but to the clavicular-rib gap.

Thus, the proposed method for blocking the brachial plexus in people of the brachymorphic type of physique is simple, effective, and can be used in wide clinical practice.

Claims (1)

A method for blocking the brachial plexus in people of a brachymorphic type of physique, including introducing an anesthetic into the fascial brachial plexus case by puncturing it directly behind the upper edge of the clavicle, characterized in that the needle injection point is 1.5 cm medial to the middle of the clavicle length and the needle is inserted under 90 ° to the skin surface in the direction of the clavicular-rib gap to a maximum depth of 3.5 cm.