interscalene brachial plexus block

Method

quantitative, prospective, longitudinal, observational and descriptive study was carried out in the Anesthesiology Service of the Celia Sánchez Manduley Hospital in Manzanillo, Granma province, from August 2019 to January 2023. The un iverso It consisted of 35 patients, the sample was made up of 23 patients operated on for upper limbs under brachial plexus block via interscalene route at the Celia Sánchez Manduley Hospital during the study period.

Inclusion criteria:

Patients with an indication for elective surgical interventions of the upper limbs in the region from the shoulder to the forearm, aged 18 years or older and 70 years or younger, and physical status I and II according to the American Society of Anesthesiology (ASA) classification.

Exclusion criteria

Patients who expressed their desire not to participate in the study.

Study variables:

Age: biological age measured in years of life completed.

Sex: chromosomal sex (female or male).

Physical condition: It was classified according to the categorization designed in 1940 by the American Society of Anesthesiologists (ASA).

Surgical pathology: diagnosis made in the patient for which it is decided to perform the surgical intervention.

Comorbidities: presence of other conditions (chronic non-communicable diseases).

Anesthetic agent: local anesthetics used to perform the anesthetic technique (lidocaine, bupivacaine or mepivacaine ).

Variables related to the evaluated bioparameters: systolic blood pressure (SBP) and diastolic blood pressure (DBP) in millimeters of mercury ( mmHg ), heart rate (HR) in beats per minute ( lt × min ), pulsatile oxygen saturation (SpO2). The study recorded the average of the measurements taken at each stage of the perioperative period.

Complications: complications associated with both the anesthetic technique and the drug. Complications resulting from changes in bioparameter values were also recorded.

Scientific methods:

Theoretical methods:

Analytic-synthetic: It enabled the mental decomposition of the phenomenon studied into its main elements or parts, determining its particularities, while also allowing the integration of said elements, discovering new relationships and links between the anesthetic method used and the behavior of the vital signs.

Empirical methods:

Document review : Medical records and anesthesia records were reviewed to obtain information about the biopsychosocial, clinical, and anesthesia-related characteristics of the patients who participated in the study.

Statistical-mathematical methods:

Descriptive statistics and frequency distribution tables were used to determine the significant elements of each variable to be controlled and, within it, the percentage calculation.

Techniques and procedures

The research information was obtained through an updated bibliographic review, using data from patients' medical records, as well as archived data and historical records from the statistics department of the Celia Sánchez Manduley Hospital.

It consisted of the examination and recording of vital parameters including: heart rate, systolic blood pressure, diastolic blood pressure and pulsatile oxygen saturation (SpO2) which were correlated with other study variables (sex, age, physical condition, comorbidities, surgical pathology, complications and anesthetic agent); in patients who underwent elective upper limb surgery for conditions involving anatomical structures from the shoulder to the forearm, who underwent interscalene brachial plexus block with a single injection as an anesthetic method.

The following scale was developed as a tool for the final evaluation of the behavior of the bioparameters :

Results: Evaluation of bioparameter behavior during the perioperative period, i.e., possible deviations from normal values. The assignment of values according to the scale (Normal Values, Mild Alterations, Moderate Alterations, and Severe Alterations) was based on the magnitude of the alterations and the number of parameters affected.

No alterations: absence of alterations in the values of the bioparameters evaluated, arising from the application of the anesthetic method.

Mild alterations: patients who presented alterations in only one of the bioparameters evaluated (two when the alterations included simultaneous measurements of SBP and DBP).

Moderate alterations: patients who presented alterations in at least two of the measured parameters, except for simultaneous alterations in SBP and DBP when these were unique, which were assigned to the previous category.

Severe abnormalities: patients who presented abnormalities that could constitute an imminent danger to life, including extreme bradyarrhythmias or extreme tachyarrhythmias (less than 40 L/min and more than 160 L/min respectively), hypertensive crisis (BP ≥ 180∕110 mmHg ) or arterial hypotension in the degree of shock and SpO2 levels less than 90%; which were recorded as such in the section on complications.

Ethical aspects of research:

The research was carried out taking into account the ethical principles and guidelines developed on biomedical research involving human beings at the international level, such as the Nuremberg Code of 1947, the Declaration of Helsinki and other documents that regulate international guidelines for research involving human beings, proposed in 1982 by the Council for International Organizations of Medical Sciences (COICM) and the World Health Organization . [8]

Results

Patients aged 41 to 50 years predominated, representing 26% of cases, and males accounted for 60.8%. ( TABLE 1 )

Table 1: Distribution according to age and sex.

Wilfredo Enrique Romero Aguirre; https://orcid.org/0009-0006-8663-3045

Smoking and high blood pressure (HBP) were the main comorbidities, accounting for 30.4% and 26.1% of cases, respectively. ( TABLE 2 )

Table 2: Comorbidities by sex.

Variable	Scale	Female		Masculine		Total
Variable	Scale	Node	%	Node	%	Node	%
Age	18 – 30	-	-	3	13	3	13
	31 – 40	2	8.6	3	13	5	21.7
	41 – 50	2	8.6	4	17.3	6	26
	51 – 60	3	13	2	8.6	5	21.7
	61 – 70	2	8.6	2	8.6	4	17.3
TOTAL		9	39.1	14	60.8	23	100

Physical condition predominated of ASA II representing 73.9% of cases. ( TABLE 3 )

Table 3: Physical condition according to the ASA scale by sex .

Variable	Scale	Female		Male		Total
Variable	Scale	No	%	No	%	No	%
Comorbidities	Smoking	2	8.6	5	21.7	7	30.4
	HBP	3	13	3	13	6	26.1
	Bronchial Asthma	-	-	3	13	3	13
	Diabetes Mellitus	2	8.6	2	8.6	4	17.3
	Chronic Gastritis	1	4.3	2	8.6	3	13
	Hypothyroidism	1	4.3	1	4.3	2	8.6
	Glaucoma	-	-	1	4.3	1	4.3

The perioperative heart rate stage was 70 to 90 lt/min (52.1%) preoperatively; 91 to 100 lt/min (39.1%) intraoperatively ; and 70 to 90 lt/min and 91 to 100 lt/min (34.7%) postoperatively . ( TABLE 4 )

Table 4: Distribution according to heart rate by stages in the perioperative period.

Variable	Scale	Female		Male		Total
Variable	Scale	No	%	No	%	No	%
Physical condition	Yo	3	13	3	13	6	26
Physical condition	II	6	26	11	47.8	17	73.9
TOTAL		9	39.1	14	60.8	23	100

Partial oxygen saturation (SpO2) values were maintained between 95 and 100 preoperatively in all patients; between 95 and 100 intraoperatively in 86.9% of patients; and between 95 and 100 postoperatively in 95.6% of patients ( TABLE 5 ).

Table 5: Distribution according to SpO2 by stages in the perioperative period .

Variable	Scale	PERIOPERATIVE
Heart Rate lt×min		Preoperative		Transoperative		Postoperative
		No	%	No	%	No	%
	Less than 60	2	8.6	1	4.3	3	13
	60-69	2	8.6	4	17.3	-	-
	70-90	12	52.1	7	30.4	8	34.7
	91-100	4	17.3	9	39.1	8	34.7
	More than 100	2	8.6	1	4.3	3	13

Preoperative systolic blood pressure was 105–139 mm Hg in 73.9% of patients, and diastolic blood pressure was 60–89 mm Hg in 95.6%. Intraoperative systolic blood pressure was 105–139 mm Hg in 73.9%, and diastolic blood pressure was 60–89 mm Hg in 69.5%. Postoperative systolic blood pressure was 105–139 mm Hg in 69.5%, and diastolic blood pressure was 60–89 mm Hg in 69.5%. ( TABLE 6 ).

Table 6: Distribution according to systolic and diastolic blood pressure by stages in the perioperative period .

Variable	Scale	PERIOPERATIVE
SpO2 (%)		Preoperative		Transoperative		Postoperative
		No	%	No	%	No	%
	Less than 90	-	-	-	-	-	-
	90 and 94	-	-	3	13	1	4.3
	95 and 100	23	100	20	86.9	22	95.6
	Total	23	100	23	100	23	100

The main complications dependent on the behavior of bioparameters in females were mild systolic -diastolic hypertension (17.3%) and, dependent on the technique and anesthetic agent, recurrent laryngeal nerve block (8.9%) of patients; while in males mild sinus tachycardia (26%) and Horner's syndrome (8.9%) were the most common complications .

According to the use of lidocaine as an anesthetic agent, the results of the bioparameters remained unchanged and mildly altered in 13% of patients, respectively, and moderate alterations were present in 21.7%. Mepivacaine showed normal values and moderate alterations in 4.3% of patients, respectively. Bupivacaine showed no alterations in 17.3%. Overall, lidocaine was the most common use, at 52.2%, and the results of the bioparameters behaved with normal values in 34.7% of patients ( TABLE 7 ).

Table 7: Results of the bioparameters according to the anesthetic agent used.

Variable	Scale	PERIOPERATIVE
TAS ( mmHg )		Preoperative		Transoperative		Postoperative
		No	%	No	%	No	%
	Less than 105	2	8.6	2	8.6	2	8.6
	105 to 139	17	73.9	17	73.9	16	69.5
	140 and over	4	17.3	4	17.3	5	21.7
	Total	23	100	23	100	23	100
TAD ( mmHg )	Less than 60	-	-	2	8.6	2	8.6
	60 and 89	22	95.6	16	69.5	16	69.5
	90 and over	1	4.3	5	21.7	5	21.7
	Total	23	100	23	100	23	100

Discussion

Brachial plexus block is used as a regional anesthetic strategy to provide analgesia and sympathetic blockade, thereby improving blood flow in the upper extremity. There are multiple local anesthetics used; however, to date, there is no evidence that any of them shows superiority during brachial plexus blockade in patients undergoing upper extremity surgical procedures. [9]

In the present study there is a predominance of patients between 41 and 50 years old and males. Tijerino-Rodríguez E [1] in the sociodemographic characterization of his study found ages between 35 and 45 years and 65% corresponding to the male sex. Ponce-González L [9] also reports the age of his population from 35 to 38 years, with a minimum age of 17 and maximum of 59 years and 56% of the male sex, Lenis-Chacón F et al [10] , in a similar study carried out at the Hermanos Ameijeiras Clinical Surgical Hospital in Havana, Cuba, determined that the average age of the patients treated ranges between 44 and 45 years; data similar to those of the current study.

In the authors' opinion, the similarity found between this research and the cited studies may be due to the fact that, historically, men have been associated with dangerous and physically demanding jobs. In many countries, especially underdeveloped or developing ones, men lack tools to facilitate their work or adequate protective equipment, which makes them more prone to accidents resulting in musculoskeletal disorders (MOAS), with a high percentage of upper limb injuries.

The current study also found that 73.9% of patients had physical status II. Ponce-González L [9] found a predominance of patients with ASA I, while 55% of the patients treated by Cunha-Ferraro L, et al. [11] were classified as ASA II, which agrees with what was proposed in the present article; these results may be due to the fact that the surgical intervention used carries a low anesthetic risk in the perioperative period. In this case, the classification of patients into the ASA I and ASA II groups is encouraging since they are the categories that show the lowest risk.

On the other hand, arterial hypertension was the comorbidity that most affected patients in the current study. These data coincide with those provided by Tijerino-Rodríguez E [1] , Peña-Malo C, et al [3] and Núñez-Mendoza J, et al. [9] , these results could be explained because cardiovascular diseases are the most frequent diseases in Cuba and in the first world countries, and within these arterial hypertension is the disease that shows the highest prevalence rate.

Specialists from the World Health Organization (WHO) [12] explain that smoking decreases the amount of oxygen that reaches the cells in the surgical wound. Consequently, the wound may heal more slowly and is more prone to infection. All smokers have an increased risk of heart and lung disease. Both tobacco smoke and nicotine itself have severe adverse effects on recovery after surgery.

As expressed by Mille -Loera J, et al. [13] hypertension is a high risk factor for coronary artery disease, congestive heart failure, kidney failure, dementia, presence of a cerebrovascular event, in addition to increasing blood loss during surgery; in many cases it is associated with diabetes mellitus, dyslipidemia and obesity.

Humerus fracture, shoulder instability and humerus bone tumor are the main surgical pathologies for which patients in the current study are operated on, results that do not coincide with those of Ponce-González L [9] in which the main pre-surgical diagnoses are fracture of the radius and wrist.

The type of injury requiring surgical intervention influences the choice of anesthetic technique to be used, as it depends on the structure(s) injured, the complexity of the condition itself, the estimated duration of the surgery, among other factors. In general, most researchers consulted agree that the brachial plexus block technique, whether via the axillary or interscalene route , for upper limb injuries is most effective in patients with simple injuries such as trauma or inflammation.

In the current study, the heart rate by stages behaves in the preoperative period between 70 and 90 lt×min with 52.1%; in the transoperative period between 91 and 100 lt×min and in the postoperative period between 70 and 90 lt×min and 91 and 100 lt×min , with 34.7%, respectively. Normal and similar heart rate values were found by Núñez-Mendoza J, et al [6] and Lenis-Chacón F, et al [10] in a study carried out with patients under brachial plexus block via the axillary and supraclavicular routes, changes in heart rate during the perioperative period may be due to the fact that it is common to add adrenaline and phenylephrine to local anesthetics.

During surgical procedures on the upper extremity, events such as stress, anxiety, and fear, among others, occur; these can be associated with an intense cardiovascular response, often harmless in healthy patients but potentially harmful in individuals with heart conditions. Through proper diagnosis and treatment planning for each patient, it is important to assess blood pressure, temperature, and heart rate. It is known that an increased heart rate during the perioperative period is associated with a higher risk of heart disease.

According to the preoperative SpO2, it was maintained between 95 and 100 in all patients in the current study; intraoperatively, it was between 95 and 100 in 86.9% of patients, and postoperatively, it was between 95 and 100 in 95.6% of patients, all normal values. Acute hypoxemia with an SpO2 below 80% may be suspected by the presence of cyanosis; however, it may manifest through nonspecific signs such as tachycardia, tachypnea, and central nervous system abnormalities.

Pulse oximetry is currently an indispensable monitoring tool, adapted and required by the world's leading anesthesiology societies, such as the ASA.

According to the systolic blood pressure of the patients in the study, preoperatively it was maintained between 105 and 139 mm Hg in 73.9%, diastolic between 60 and 89 mm Hg , intraoperatively systolic blood pressure was 105 to 139 mm Hg and diastolic between 60 and 89 mm Hg , postoperatively systolic blood pressure was 105 to 139 mm Hg and diastolic between 60 and 89 mm Hg . Stressful events can elevate the levels of circulating catecholamines and produce a rise in blood pressure to levels that are harmful to the body.

A hypertensive crisis due to elevated blood pressure can cause a cerebral stroke or an acute myocardial infarction. In the present study, blood pressure changes occurred in the form of isolated peaks, allowing for easy monitoring and ensuring hemodynamic stability in most patients; although not without risk, isolated variations in blood pressure are much less likely to cause fatal events. This parameter, like heart rate, can be influenced during the perioperative period by factors such as anxiety, stress, and fear.

systolic -diastolic hypertension and, depending on the technique and anesthetic agent, recurrent laryngeal nerve block. In men, mild sinus tachycardia and Horner's syndrome were observed.

Interscalene block affects virtually the entire brachial plexus, including the circumflex and musculocutaneous nerves that differentiate further down, allowing for the anesthesia of virtually the entire upper limb, including the scapulohumeral joint. Quoting Sánchez S [14] , interscalene block presents numerous complications and adverse effects related to the technique, the injection site, and the volume of local anesthetic administered, including recurrent laryngeal nerve block (3-21%), stellate ganglion block (5-75%) (Horner's syndrome), and seizures (0.2-3%); at standard volumes of 20-30 ml.

Other researchers such as Solís-de la Paz D, et al [15] report a predominance of systemic complications such as nausea and vomiting, which does not agree with what is proposed in the present study. However, they disagree with what is proposed by Lenis-Chacón F, et al [10] and Tijerino-Rodríguez E [1] who do not report any patients with systemic complications.

The authors report that patients who presented hypertensive episodes were diagnosed with chronic arterial hypertension, which in some cases may have been associated with insufficient treatment. Furthermore, technique-related complications were more frequent in cases where a larger volume of anesthetic was used, thus blocking a greater number of nerve roots with greater impact on the autonomic nervous system.

According to the use of lidocaine as an anesthetic agent, the current study found that the result of the bioparameters remained with moderate alterations in 21.7%, as well as without alterations and with mild alterations in 13% of the patients, respectively. In mepivacaine without alterations and with moderate alterations in 4.3% of patients, respectively. By bupivacaine without alterations in 17.3%. Overall, lidocaine use predominated at 52.2%, and the bioparameter results were unchanged in 34.7% of patients . The study considered minimal alterations in the values of the evaluated bioparameters arising from the application of the anesthetic method.

When identifying the relationship between the anesthetics used and possible favorable results, the authors emphasize that no superiority of one agent over another was evident, with 8 patients included in the best evaluation categories (Normal Values and Minimal Alterations) for the use of lidocaine or bupivacaine , which were the most representative agents in the study.

Conclusions

The study group comprised predominantly male patients aged 41 to 50 years, with a physical status of II. The main comorbidities were smoking and high blood pressure, and surgical pathologies included humeral fracture, shoulder instability, and humeral bone tumor. Complications included high blood pressure, mild sinus tachycardia, recurrent laryngeal nerve block, and Horner's syndrome.

AUTHORSHIP CONTRIBUTION

GLT: Conceptualization, Data curation, Formal analysis, Research, Methodology, Resources, Validation, Writing – review and editing

RJAP: Conceptualization, Data Curation, Research, Methodology, Validation, Visualization, Writing – original draft

IICM: Data Curation, Research, Methodology, Validation, Visualization

YTC: Research, Methodology, Validation, Visualization

SRC: Research, Methodology, Validation, Visualization

LRCG: Research, Methodology, Validation, Visualization

CONFLICTS OF INTEREST

The authors declare that there are no conflicts of interest.

FINANCING

The authors did not receive funding for the development of this article.

BIBLIOGRAPHIC REFERENCES

Tijerino Rodríguez EM. Effectiveness of ultrasound- guided supraclavicular brachial plexus block vs. neurostimulator in upper limb orthopedic surgery. Carlos Roberto Huembes Teaching Hospital [Internet]. Managua, Nicaragua: National Autonomous University of Nicaragua; 2019 [cited 08 Oct 2024]. Available from: https://repositorio.unan.edu.ni/id/eprint/12165/1/100598.pdf
Peña Malo CM, Gómez Ayala A. Plexus blocks in anesthesia and analgesia for Nursing. Rev. One hundred Med OCRONOS [Internet]. 2021 [cited 08 Oct 2024];IV(5):145-54. Available at: https://revistamedica.com/bloqueos-plexos-enfermeria/
Villar T, Pacreu S, Chavero E, Torrens C, Montes A. Prolonged brachial plexopathy after interscalene block in shoulder surgery. Colomb J Anesthesiol [Internet]. 2019 [citado 08 Oct 2024];47(1):71-5. Disponible en: https://www.revcolanest.com.co/index.php/rca/article/view/223/338
Galván Talamantes Y, Álvarez Reséndiz GE, Cisneros García J, López Hernández MN, Fernández Soto JR, Fajardo Pérez M. Postoperative analgesic management with ultrasound-guided regional blocks in shoulder surgery. An Med (Mex) [Internet]. 2020 [cited 08 Oct 2024];65(2):114-21. Available at: https://www.medigraphic.com/pdfs/abc/bc-2020/bc202e.pdf
Kwon W, Lee SM, Bang S. Costoclavicular block for shoulder surgery in a patient with tracheobronchopathia osteochondroplastica and COPD. J Clin Anesth [Internet]. 2019 [citado 08 Oct 2024];55:13-4. Disponible en: https://www.sciencedirect.com/science/article/abs/pii/S0952818018313515?via%3Dihub
Núñez Mendoza JR, Monroy Álvarez CJ, Torres Maldonado AS, Isais Millán RP. Ultrasound-guided intervention for upper extremity postoperative pain. Rev. mex anestesiol [Internet]. 2019 [cited 08 Oct 2024];42(3):235-44. Available at: https://www.scielo.org.mx/pdf/rma/v42n3/0484-7903-rma-42-03-235.pdf
Albrecht E, Chin KJ. Advances in regional anaesthesia and acute pain management: a narrative review. Anaesthesia [Internet]. 2020 [citado 08 Oct 2024];75(Supl.1):101-10 . Disponible en: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.14868
World Medical Association (WMA). WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects [Internet]. Geneva, Switzerland: WMA; c. 1947–2024 [updated 23 May 2024; cited 07 Oct 2024]. Available at: https://www.wma.net/policies-post/wma-helsinki-declaration-ethical-principles-for-medical-research-involving-human-subjects/
Ponce González L. Ultrasound-guided supraclavicular block : contrasting postoperative analgesia with the use of ropivacaine vs. ropivacaine associated with clonidine in upper extremity surgeries, performed at the José Vicente Villada Hospital, period June to October 2021 [Internet]. Toluca de Lerdo, Mexico: Autonomous University of the State of Mexico. Faculty of Medicine. Coordination of Research and Advanced Studies in Health Sciences. Department of Advanced Studies. Coordination of the Anesthesiology Specialty. Department of Professional Evaluation; 2022 [cited 08 Oct 2024]. Available at: http://ri.uaemex.mx/bitstream/handle/20.500.11799/137070/PONCE%20GONZALEZ%20LEONEL-TESIS.pdf?sequence=1&isAllowed=y
Lenis Chacón FJ, Rodríguez Castro NI, Cordoví de Armas L, Cordero Escobar I, Díaz Mora I. Ultrasound-guided brachial plexus block via the supraclavicular and axillary routes. Rev Cuba Anestesiol Reanim [Internet] 2017 [cited 08 Oct 2024];16(1):[ approx. 13 p.]. Available at: https://revanestesia.sld.cu/index.php/anestRean/article/view/180/537
Cunha Ferraro L, Takeda A, Barreto CN, Faria B, Assunção NA. Randomized prospective study of three different techniques for ultrasound-guided axillary brachial plexus block. Rev Braz Anestesiol [Internet]. 2018 [cited 08 Oct 2024];68(1):62-8. Available at: https://www.scielo.br/j/rba/a/pTsyQFztR5gCZkZQcdy68yJ/?format=pdf&lang=en
World Health Organization (WHO). Tobacco and postoperative complications: WHO tobacco knowledge summaries [Internet]. Geneva, Switzerland: WHO; 2020 [cited 08 Oct 2024]. Available from: https://iris.who.int/bitstream/handle/10665/344916/9789240015951-spa.pdf?sequence=1&isAllowed=y
Mille Loera JE, Ortiz Martínez JJ, Rocha Machado JF. Perioperative arterial hypertension as a risk factor. Rev. Mex Anestesiol [Internet]. 2017 [cited 08 Oct 2024];40(Suppl.1):100-2. Available at: https://www.medigraphic.com/pdfs/rma/cma-2017/cmas171ad.pdf
Sánchez S. Interscalene block in the era of ultrasound-guided regional anesthesia. Rev. Chil Anest [Internet]. 2019 [cited 08 Oct 2024];48(4):298-307. Available at: https://revistachilenadeanestesia.cl/PII/revchilanestv48n04.04.pdf
Solís de la Paz D, Vera Díaz I, García García GL, González Álvarez Y, Ricardo Morel IM. Usefulness and use of mepivacaine - fentanyl in axillary brachial plexus block for postoperative analgesia. Rev. Med Electrón [Internet]. 2018 [cited 08 Oct 2024];40(3):638-47. Available from: https://revmedicaelectronica.sld.cu/index.php/rme/article/view/2350/pdf_431

Este es un artículo publicado bajo una licencia del Creative Commons

Bioparameters in patients undergoing upper limb surgery under intercalenic brachial plexus block

Abstract

Keywords

Introduction