RU2825704C1 - Method of prolonged radial nerve block from axillary approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to anaesthesiology and intensive care. Ultrasound imaging of anatomical structures is performed in the axillary fossa on the side of the locked extremity, searching for axillary artery, axillary vein, radial nerve, biceps and triceps muscles of shoulder, coracohumeral muscle of shoulder and humerus. Local anesthesia of skin and subcutaneous fat is performed with lidocaine 5 mg/ml in amount of 5.0 ml at the point of access to the radial nerve. Skin and subcutaneous fat are incised 3 mm, in which a guide needle for spinal needles with an outer diameter of 0.9 mm is inserted in the area of an axillary fossa along an anterior axillary line. Wound is widened with a mosquito-type surgical forceps. Under ultrasound control Tuohy guide needle with outer diameter of 1.3 mm and size of 80 mm from this wound is delivered through biceps and coracohumeral muscles. Distal end of the needle is brought to a point between the radial nerve and the fascia of the triceps muscle. Sodium chloride solution 9 mg/ml—10.0 ml is introduced into the space between the radial nerve and the fascia of the triceps muscle, thus, the perineural space of the radial nerve is hydraulically dissected. Through the lumen of the Tuohy guide needle into the space located between the radial nerve and the fascia of the triceps muscle, catheter for prolonged radial nerve block with an outer diameter of 0.85 mm and an inner diameter of 0.45 mm at distance of 15 mm from the distal end of the Tuohy guide needle. Tuohy guide needle is removed. This needle is delivered through the lateral edge of the skin wound, having previously displaced the catheter for the prolonged radial nerve block to the medial edge of the skin wound, under the skin of the subclavian region towards the sternoclavicular joint at distance of 70 mm to the exit of the distal end of the guide needle on the skin surface, thereby forming a subcutaneous canal. Spinal needle with a pencil sharpening of the distal end with an outer diameter of 0.5 mm and length of 103 mm is delivered through the lumen of the Tuohy guide needle from its distal end to the proximal end. Tuohy guide needle is removed from the subclavian skin. Proximal end of the catheter for prolonged radial nerve block is connected to a distal end of a spinal needle located in the subclavian canal, by passing the distal end of the spinal needle into the lumen of the proximal end of the catheter for prolonged radial nerve block at distance of 3 mm, holding the distal end of the spinal needle with a "mosquito" clamp. Spinal needle with a catheter for prolonged radial nerve block is removed from under the skin of the subclavian region, by placing the catheter for the prolonged radial nerve block in the subcutaneous canal. Proximal end of catheter is connected by means of connector with antibacterial filter, which by means of an antibacterial filter retainer is attached to the subclavian skin on the side opposite the locked extremity. Catheter loop measuring 15 mm in diameter is formed at the catheter exit point on the skin of the subclavian region, which is attached to the skin with a fixing device "Perifix". Catheter for prolonged radial nerve block and an antibacterial filter fixed on the skin, connected to a catheter for prolonged radial nerve block, are covered with an aseptic plaster. Under ultrasound control solution of local anesthetic is introduced through lumen of catheter into perineural space located between radial nerve and fascia of triceps muscle.

EFFECT: method enables to perform prolonged analgesia in the treatment of acute and chronic pain syndromes in the area of innervation of the radial nerve from the axillary approach, provide anesthetic management of upper extremity surgeries, perform reliable catheter fixation for prolonged radial nerve block.

1 cl, 14 dwg, 1 ex

Description

The invention relates to the field of medicine, namely to anesthesiology and intensive care, and can be used to perform a prolonged block of the radial nerve from an axillary approach for the purpose of pain relief during surgical interventions on the upper limb, postoperative analgesia and in the treatment of acute and chronic pain syndromes in the innervation zone of the radial nerve.

The peculiarity of this method is that the catheter is inserted to the radial nerve using a Tuohy guiding needle. After the catheter is inserted to the radial nerve, it is fixed under the skin of the subclavian region using a Tuohy guiding needle, which is also used to insert the catheter to the radial nerve and a spinal needle with a pencil sharpening of the distal end, and the catheter exit site is located on the skin of the subclavian region. The location of the catheter under the skin of the subclavian region allows for reliable fixation of the catheter for prolonged blockade of the radial nerve and long-term and high-quality analgesia of the operated upper limb in the area of innervation of the radial nerve.

Existing methods of regional anesthesia, such as brachial plexus block from the axillary approach, do not provide for prolonged anesthesia, since the brachial plexus in the axillary region is located superficially around the axillary artery in the form of individual nerves: radial, median and brachial. The superficial location of the nerves of the brachial plexus in the axillary region and the axillary region itself, which is an anatomical fossa limited by the latissimus dorsi muscle, the pectoralis major and minor muscles, does not allow for a high degree of reliability in installing and fixing a catheter for prolonged blockade of the nerves of the brachial plexus from the axillary approach. There are descriptions of methods of brachial plexus blockade from the axillary approach in the literature, but in the form of a single injection of local anesthetic (Yamshchikov O.N., Marchenko A.P., Emelianov S.A., Ivanova O.D., Ignatova S.A., Marchenko N.A. Brachial plexus blockade by the axillary approach. Literature review. Far East Healthcare. No. 1. 2024 DOI: 10.33454/1728-1261-2024-1-51-58; Terenin M.A., Yalonetsky I.Z., Kaganovich B.M. Experience in using ultrasound imaging when performing axillary brachial plexus block. Med. zhurnal. 2019. No. 3. pp. 102-106).

There are methods of prolonged brachial plexus blockade from the interscalene, supraclavicular and subclavian approaches. Prolonged blockade is not performed from the axillary approach due to the anatomical features described above (Zagrekov V.I. Choice of brachial plexus block technique in operations on the upper limbs. Regional anesthesia and treatment of acute pain. 2008. 2(3):49-57; Yamshchikov O.N. et al. Prolonged plexus blockade in surgical interventions on the upper limbs. Avicenna Bulletin. 2023. No. 4 doi: 10.25005/2074-0581-2023-25-4-562-570).

The use of catheter tunneling technology for extended brachial plexus blockade allows increasing the internal part of the catheter to 140 mm or more, which contributes to its reliable fixation even from such anatomically inconvenient approaches as the supraclavicular one (Yamshchikov O.N., Marchenko A.P., Emelianov S.A., Ivanova O.D., Pavlova K.A. Demonstration of an extended brachial plexus blockade with an original method of catheter fixation: a clinical case. Regional anesthesia and treatment of acute pain. 2023. Vol. 17, No. 2. Pp. 135-144. DOI: https://doi.org/10.17816/RA321559; Russian Federation Patent RU2806484C1 “Method of fixing a catheter under the skin of the subclavian region during extended brachial plexus blockade”. IPC: A61M 19/00, A61 B 17/34. Priority date: 09.03.2023).

There are no descriptions of methods for prolonged blockade of the brachial plexus nerves and separately the radial nerve from the axillary approach in literary sources. The closest analogues to the claimed invention in the field of technology have not been identified.

The technical result of the claimed method is that the method allows for reliable fixation of a catheter for prolonged blockade of the radial nerve and for anesthetic support during surgical interventions on the upper limb, and for prolonged analgesia in the treatment of acute and chronic pain syndromes in the innervation zone of the radial nerve.

The specified technical result is achieved by sequentially performing the stages of the proposed method described below.

To install the catheter to the radial nerve and fix the catheter under the skin of the subclavian region, a Tuohy G 18 guiding needle from B/Braun (Germany) with an outer diameter of 1.3 mm and a length of 80 mm and a catheter for extended radial nerve block with an outer diameter of 0.85 mm and an inner diameter of 0.45 mm and a Pencan G 25 spinal needle from B/Braun (Germany) with a pencil sharpening of the distal end with an outer diameter of 0.5 mm and a length of 103 mm are used.

1. At the first stage, an ultrasound examination of the anatomical structures in the area of the axillary fossa of the limb to be blocked is performed. For this purpose, an ultrasound linear sensor is installed on the skin surface in the area of the axillary fossa so that one edge of the sensor, related to the right side (R), is located at the level of the anterior axillary line, while the patient's arm is abducted relative to the body by 90°. Using ultrasound visualization, a search is performed for such anatomical structures as: axillary vein, axillary artery, median, ulnar and radial nerves, biceps and triceps brachii muscles, coracobrachialis muscle of the shoulder and humerus (Fig. 1).

2. At the second stage, after the ultrasound visualization of the anatomical structures of the axillary fossa, the access site to the radial nerve is determined, which is located in the axillary fossa along the anterior axillary line. At this site, local anesthesia of the skin and subcutaneous fat is performed with a lidocaine solution of 5 mg/ml - 5 ml, after which a 3 mm incision is made in the skin and subcutaneous fat at this site, into which a guide needle for spinal needles with an outer diameter of 0.9 mm is inserted (Fig. 2).

3. At the third stage, the wound is widened using a mosquito-type surgical clamp (Fig. 3).

4. At the fourth stage, under ultrasound control, a Tuohy guide needle with an outer diameter of 1.3 mm and a size of 80 mm is passed from the wound at the access site to the radial nerve through the biceps and coracobrachialis muscles, bringing the distal end of the needle to a point located between the radial nerve and the fascia of the triceps muscle. Next, a sodium chloride solution of 9 mg/ml - 10.0 ml is injected into the space located between the radial nerve and the fascia of the triceps muscle under ultrasound control, thereby performing hydropreparation of the perineural space of the radial nerve (Fig. 4, 5).

5. At the fifth stage, a catheter for extended radial nerve block with an outer diameter of 0.85 mm and an inner diameter of 0.45 mm is inserted through the lumen of the Tuohy guiding needle into the space located between the radial nerve and the fascia of the triceps muscle at a distance of 15 mm from the distal end of the Tuohy guiding needle, after which the Tuohy guiding needle is removed (Fig. 6, 7).

6. At the sixth stage, this needle is passed through the lateral edge of the skin wound, having first moved the catheter for extended blockade of the radial nerve to the medial edge of the skin wound, under the skin of the subclavian region in the direction of the sternoclavicular joint at a distance of 70 mm until the distal end of the needle emerges on the surface of the skin, thereby forming a subcutaneous channel (Fig. 8).

7. At the seventh stage, a spinal needle with a pencil sharpening of the distal end with an outer diameter of 0.5 mm and a length of 103 mm is passed through the lumen of the Tuohy guiding needle from its distal end to the proximal end, after which the Tuohy guiding needle is removed from under the skin of the subclavian region (Fig. 9).

8. At the eighth stage, the proximal end of the catheter for extended radial nerve block is connected to the distal end of the spinal needle located in the subcutaneous canal of the subclavian region by inserting the distal end of the spinal needle into the lumen of the catheter for extended radial nerve block at a distance of 3 mm, holding the distal end of the spinal needle with a mosquito clamp (Fig. 10).

9. At the ninth stage, the spinal needle with the catheter fixed to it for extended radial nerve block is removed from under the skin of the subclavian region, placing the catheter for extended radial nerve block in the subcutaneous canal of the subclavian region (Fig. 11).

10. At the tenth stage, the proximal end of the catheter is connected with a connector to an antibacterial filter, which is attached to the skin of the subclavian region on the side opposite the blocked limb using an antibacterial filter retainer, after which a catheter loop measuring 15 mm in diameter is formed at the point where the catheter exits the skin of the subclavian region, which is attached to the skin using a Perifix fixing device, then the catheter itself for extended radial nerve blockade and the antibacterial filter attached to the skin, connected to the catheter for extended radial nerve blockade are covered with an aseptic adhesive tape (Fig. 12, 13).

11. At the eleventh stage, under ultrasound control, a local anesthetic solution is injected through the lumen of the catheter into the perineural space located between the radial nerve and the fascia of the triceps muscle (Fig. 14).

Fig. 1 shows an ultrasound image of the axillary artery (1), axillary vein (2), median nerve (3), ulnar nerve (4), radial nerve (5), biceps muscle (6), coracobrachialis muscle (7), triceps muscle (8), humerus (9) from the axillary approach.

Fig. 2 shows the making of an incision in the skin and subcutaneous fat with a guide needle for spinal needles in the area of the axillary fossa along the anterior axillary line.

Fig. 3 shows the widening of a skin wound using a mosquito clamp.

Fig. 4 shows the insertion of a Tuohy guiding needle using ultrasound navigation to the radial nerve.

Fig. 5 shows an ultrasound image of the insertion of the Tuohy guiding needle (10) to the radial nerve (5), also shown are the axillary artery (1), the median nerve (3), and the fascia of the triceps muscle (11).

Fig. 6 shows the insertion of a catheter for prolonged radial nerve block through a Tuohy guide needle into the perineural space of the radial nerve.

Fig. 7 shows the removal of the Tuohy guide needle from the axillary tissue.

Fig. 8 shows the passage of a Tuohy guiding needle under the skin of the subclavian region from a skin wound at the site of access to the radial nerve in the direction of the sternoclavicular joint and the formation of a subcutaneous canal of the subclavian region.

Fig. 9 shows a spinal needle with a pencil-sharpened distal end positioned in the subcutaneous canal of the subclavian region after removal of the Tuohy guiding needle from the subcutaneous canal of the subclavian region.

Fig. 10 shows the fixation of the proximal end of the catheter for extended radial nerve block to the distal end of the spinal needle located in the subcutaneous canal.

Fig. 11 shows the removal of a spinal needle with a catheter fixed to it from the subcutaneous canal of the subclavian region.

Fig. 12 shows the fixation of a catheter for extended radial nerve blockade on the skin of the subclavian region at the site of its exit onto the skin using the Perifix fixation device and the connection of the proximal end of the catheter for extended radial nerve blockade through a connector with an antibacterial filter, fixed on the skin of the subclavian region, on the side opposite the blocked limb.

Fig. 13 shows the final view of the attachment of the catheter for prolonged radial nerve block to the skin of the subclavian regions.

Fig. 14 shows an ultrasound image of the introduction of a local anesthetic solution (12) through the lumen of a catheter for prolonged radial nerve block (13) into the perineural space of the radial nerve (5), located between the radial nerve (5) and the fascia of the triceps muscle (11).

As an embodiment of the invention, a clinical example is given:

Patient N., 69 years old, was hospitalized in the traumatology department. After a comprehensive examination, the main diagnosis was: "Closed comminuted unstable fracture of the radius in a typical place with displacement of fragments of the right upper limb." Concomitant diagnosis: "HB 2 AG 2 CCO Risk 3 CHF2a (FC2). Overweight (BMI - 26.27 kg / m2). Carriage of the hepatitis C virus." The patient's physical status according to ASA is class 2. On October 19, 2023, the following surgery was performed: "Open reposition of the radius, osteosynthesis of the radius fracture with a titanium plate and screws." Anesthesiology support for the surgery: "Brachial plexus blockade through axillary access, extended radial nerve blockade from axillary access with fixation of the catheter under the skin of the subclavian region." A solution of ropivacaine 5 mg/ml in the amount of 30 ml (150 mg) was injected into the brachial plexus area. The median, ulnar and radial nerves were blocked. The time for the brachial plexus block and catheter insertion to the radial nerve from the axillary access was 15 minutes. The catheter was secured at the site of exit to the skin of the subclavian region with a Perifix fixing device. The onset of sensory and motor blockade of the right forearm and hand was 25 minutes. The duration of the surgical intervention was 80 minutes. The patient tolerated the surgical intervention satisfactorily. Postoperative pain relief was performed in the form of an extended radial nerve block for four days by introducing a solution of ropivacaine 2 mg/ml - 3 ml/hour (6 mg/hour) through the lumen of the catheter installed to the radial nerve. The fixing sticker on the Perifix device was changed on the next day after the surgery. Four days after the surgery, before the catheter was removed, the adhesive properties of the fixation device were not impaired, the catheter dislocation was 0 mm, which indicates the absence of dislocation. During postoperative analgesia, the pain level was assessed using the visual analog scale (VAS) of pain. The pain level according to VAS was from 0 cm to 2 cm, which is assessed as mild pain. The quality of postoperative analgesia was good. The patient did not receive any further analgesia. The patient was verticalized 2 hours after the surgery. The postoperative period was uneventful. On the 6th day, the patient was discharged for outpatient treatment by a traumatologist.

Claims (1)

A method for performing an extended radial nerve block from an axillary approach, including performing ultrasound visualization of the anatomical structures in the axillary fossa on the side of the limb to be blocked, searching for the axillary artery, axillary vein, radial nerve, biceps and triceps brachii, coracobrachialis and humerus, performing local anesthesia of the skin and subcutaneous fat with 5 mg/ml lidocaine solution in an amount of 5.0 ml at the site of access to the radial nerve, then making a 3 mm incision in the skin and subcutaneous fat, into which a guiding needle for spinal needles with an outer diameter of 0.9 mm is inserted in the axillary fossa along the anterior axillary line, then expanding this wound with a mosquito-type surgical clamp, after which, under ultrasound control, a guiding Tuohy needle with an outer diameter of 1.3 mm and a size of 80 mm is passed from this wound through biceps and coracobrachialis muscles, bringing the distal end of the needle to a point located between the radial nerve and the fascia of the triceps muscle, then a sodium chloride solution of 9 mg / ml - 10.0 ml is introduced into the space located between the radial nerve and the fascia of the triceps muscle under ultrasound control, thereby performing hydropreparation of the perineural space of the radial nerve, then through the lumen of the Tuohy guide needle, a catheter for extended radial nerve blockade with an outer diameter of 0.85 mm and an inner diameter of 0.45 mm is inserted into the space located between the radial nerve and the fascia of the triceps muscle at a distance of 15 mm from the distal end of the Tuohy guide needle, after which the Tuohy guide needle is removed and this needle is passed through the lateral edge of the skin wound, having previously shifted the catheter for extended radial nerve blockade to the medial edge of the skin wound, under the skin of the subclavian region in the direction to sternoclavicular joint to a distance of 70 mm until the distal end of the guiding needle exits the skin surface, thereby forming a subcutaneous canal, then a spinal needle with a pencil sharpening of the distal end with an outer diameter of 0.5 mm and a length of 103 mm is passed through the lumen of the guiding Tuohy needle from the side of its distal end to the proximal end, after which the guiding Tuohy needle is removed from under the skin of the subclavian region, the proximal end of the catheter for extended radial nerve block is connected to the distal end of the spinal needle located in the subcutaneous canal of the subclavian region by passing the distal end of the spinal needle into the lumen of the proximal end of the catheter for extended radial nerve block at a distance of 3 mm, holding the distal end of the spinal needle with a mosquito clamp, the spinal needle with the catheter fixed to it for extended radial nerve block is removed from under the skin of the subclavian region, placing the catheter for prolonged radial nerve block in the subcutaneous canal of the subclavian region, then the proximal end of the catheter is connected using a connector to an antibacterial filter, which is attached to the skin of the subclavian region on the side opposite the blocked limb using an antibacterial filter retainer, after which a catheter loop measuring 15 mm in diameter is formed at the point where the catheter exits onto the skin of the subclavian region, which is attached to the skin using the Perifix fixing device, then the catheter itself for prolonged radial nerve block and the antibacterial filter fixed to the skin, connected to the catheter for prolonged radial nerve block, are covered with an aseptic adhesive tape, then, under ultrasound control, a local anesthetic solution is injected through the lumen of the catheter into the perineural space located between the radial nerve and the fascia of the triceps muscle.