Regional anaesthesia for bilateral upper limb surgery can be challenging, yet surgeons are becoming increasingly interested in performing bilateral procedures at the same operation. Anaesthetists have traditionally avoided bilateral brachial plexus block due to concerns about local anaesthetic toxicity, phrenic nerve block and pneumothorax. We discuss these three concerns and review whether advances in ultrasound guidance and nerve catheter techniques should make us reconsider our options. A search of Medline and EMBASE from 1966 to January 2009 was conducted using multiple search terms to identify techniques of providing anaesthesia or analgesia for bilateral upper limb surgery and potential side-effects. Ultrasound imaging and nerve catheter techniques have led to a reduction in dose requirements for effective blocks without side-effects. Effective regional anaesthesia can be performed for bilateral surgery while remaining within recommended safe dose limits. Spacing blocks apart in time can further reduce potential toxicity issues, such that peak absorption rates for each block do not coincide. Since phrenic nerve block remains an issue even with low doses of local anaesthesia, bilateral interscalene blocks are still not recommended. Peripheral nerve blocks have excellent safety profiles and are ideal for ultrasound guidance. Regional anaesthesia can be a suitable option for bilateral upper limb surgery.
CasatiA., BaciarelloM., Di CianniS., DanelliG., De MarcoG., LeoneS.Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve.Br J Anaesth2007; 98: 823–827.
2.
SandhuN.S., MaharloueiB., PatelB., ErkulwaterE., MedabalmiP.Simultaneous bilateral infraclavicular brachial plexus blocks with low-dose lidocaine using ultrasound guidance.Anesthesiology2006; 104: 199–201.
3.
RiaziS., CarmichaelN., AwadI., HoltbyR.M., McCartneyC.J.L.Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block.Br J Anaesth2008; 101: 549–556.
4.
ErrandoC.L., PallardoM.A., HerranzA., PeiroC.M., de AndresJ.A.Bilateral axillary brachial plexus block guided by multiple nerve stimulation and ultrasound in a multiple trauma patient.Rev Esp Anestesiol Reanim2006; 53: 383–386.
5.
BrownD.L., RansomD.M., HallJ.A., LeichtC.H., SchroederD.R., OffordK.P.Regional anesthesia and local anesthetic-induced systemic toxicity: seizure frequency and accompanying cardiovascular changes.Anesth Analg1995; 81: 321–328.
6.
AuroyY., BenhamouD., BarguesL., EcoffeyC., FalissardB., MercierF.J.Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service.Anesthesiology2002; 97: 1274–1280.
7.
CoxB., DurieuxM.E., MarcusM.A.E.Toxicity of local anaesthetics.Best Pract Res Clin Anaesthesiol2003; 17: 111–136.
8.
RaederJ.C., DrosdahlS., KlaastadO., KvalsvikO., IsaksenB., StromskagK.E.Axillary brachial plexus block with ropivacaine 7.5 mg/ml. A comparative study with bupivacaine 5 mg/ml.Acta Anaesthesiol Scand1999; 43: 794–798.
9.
WankW., ButtnerJ., MaierK.R., EmanuelsonB.M., SelanderD.Pharmacokinetics and efficacy of 40 ml ropivacaine 7.5 mg/ml (300 mg), for axillary brachial plexus block – an open pilot study.Eur J Drug Metab Pharmacokinet2002; 27: 53–59.
10.
CasatiA., DanelliG., BaciarelloM., CorradiM., LeoneS., Di CianniS.A prospective, randomized comparison between ultrasound and nerve stimulation guidance for multiple injection axillary brachial plexus block.Anesthesiology2007; 106: 992–996.
11.
ZhaoX., WangY.W., ChenH., ZhangZ., YouX.M., LuoK.Efficacy of low dose levobupivacaine (0.1%) for axillary plexus block using multiple nerve stimulation.Anaesth intensive Care2008; 36: 850–854.
12.
RosenbergP.H., VeeringB.T., UrmeyW.F.Maximum recommended doses of local anesthetics: a multifactorial concept.Reg Anesth Pain Med2004; 29: 564–575.
13.
KnudsenK., Beckman SuurkulaM., BlombergS., SjovallJ., EdvardssonN.Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers.Br J Anaesth1997; 78: 507–514.
14.
KleinS.M., BenvenisteH.Anxiety, vocalization, and agitation following peripheral nerve block with ropivacaine.Reg Anesth Pain Med1999; 24: 175–178.
15.
GristwoodR.W.Cardiac and CNS toxicity of levobupivacaine: strengths of evidence for advantage over bupivacaine.Drug Saf2002; 25: 153–163.
16.
RoyseC.F., RoyseA.G.The myocardial and vascular effects of bupivacaine, levobupivacaine, and ropivacaine using pressure volume loops.Anesth Analg2005; 101: 679–687.
17.
CopelandS.E., LaddL.A., GuX.Q., MatherL.E.The effects of general anesthesia on whole body and regional pharmacokinetics of local anesthetics at toxic doses.Anesth Analg2008; 106: 1440–1449.
18.
CopelandS.E., LaddL.A., GuX.Q., MatherL.E.The effects of general anesthesia on the central nervous and cardiovascular system toxicity of local anesthetics.Anesth Analg2008; 106: 1429–1439.
19.
BernardsC.M., HadzicA., SureshS., NealJ.M.Regional anesthesia in anesthetized or heavily sedated patients.Reg Anesth Pain Med2008; 33: 449–460.
20.
HickeyR., BlanchardJ., HoffmanJ., SjovallJ., RamamurthyS.Plasma concentrations of ropivacaine given with or without epinephrine for brachial plexus block.Can J Anaesth1990; 37: 878–882.
21.
VainionpaaV.A., HaavistoE.T., HuhaT.M., KorpiK., NuutinenL.S., HollmenA.I.A clinical and pharmacokinetic comparison of ropivacaine and bupivacaine in axillary plexus block.Anesth Analg1995; 81: 534–538.
22.
SalonenM.H., HaasioJ., BachmannM., XuM., RosenbergP.H.Evaluation of efficacy and plasma concentrations of ropivacaine in continuous axillary brachial plexus block: high dose for surgical anesthesia and low dose for postoperative analgesia.Reg Anesth Pain Med2000; 25: 47–51.
23.
RettigH.C., LerouJ.G.C., GielenM.J.M., BoersmaE., BurmA.G.L.The pharmacokinetics of ropivacaine after four different techniques of brachial plexus blockade.Anaesthesia2007; 62: 1008–1014.
24.
MardirosoffC., DumontL.Convulsions after the administration of high dose ropivacaine following an interscalenic block.Can J Anaesth2000; 47: 1263.
25.
Ala-KokkoT.I., LopponenA., AlahuhtaS.Two instances of central nervous system toxicity in the same patient following repeated ropivacaine-induced brachial plexus block.Acta Anaesthesiol Scand2000; 44: 623–626.
26.
SatsumaeT., TanakaM., SaitoS., InomataS.Convulsions after ropivacaine 300 mg for brachial plexus block.Br J Anaesth2008; 101: 860–862.
27.
DhirS., GanapathyS., LindsayP., AthwalG.S.Case report: ropivacaine neurotoxicity at clinical doses in interscalene brachial plexus block.Can J Anaesth2007; 54: 912–916.
28.
ScottD.B.Evaluation of the toxicity of local anaesthetic agents in man.Br J Anaesth1975; 47: 56–61.
29.
MulroyM.F.Systemic toxicity and cardiotoxicity from local anesthetics: incidence and preventive measures.Reg Anesth Pain Med2002; 27: 556–561.
30.
MulroyM.F., NorrisM.C., LiuS.S.Safety steps for epidural injection of local anesthetics: review of the literature and recommendations.Anesth Analg1997; 85: 1346–1356.
31.
DhirS., SinghS., ParkinJ., HannoucheF., RichardsR.S.Multiple finger joint replacement and continuous physiotherapy using ultrasound guided, bilateral infraclavicular catheters for continuous bilateral upper extremity analgesia.Can J Anaesth2008; 55: 880–881.
32.
CabellosO.M., ClarosL.E., PuenteC.E., IngelmoI.I.Bloqueo bilateral del plexo braquial por via axilar para ligamentotaxis de fractura bilateral conminuta de extremidad distal del radio en paciente cardiopata con politraumatismo.Act Anest Reanim2008; 18: 46–54.
33.
NeuburgerM., ButtnerJ., LangD.Case report: bilateral block of the brachial plexus – approaches, dosage and effectiveness.Anasthesiol Intensivmed Notfallmed Schmerzther2007; 42: 770–773.
RettigH.C., GielenM.J.M., BoersmaE., KleinJ., GroenG.J.Vertical infraclavicular block of the brachial plexus: effects on hemidiaphragmatic movement and ventilatory function.Reg Anesth Pain Med2005; 30: 529–535.
46.
MaurerK., EkatodramisG., RentschK., BorgeatA.Interscalene and infraclavicular block for bilateral distal radius fracture.Anesth Analg2002; 94: 450–452.
47.
WilliamsS.R., ChouinardP., ArcandG., HarrisP., RuelM., BoudreaultD.Ultrasound guidance speeds execution and improves the quality of supraclavicular block.Anesth Analg2003; 97: 1518–1523.
48.
Koscielniak-NielsenZ.J.Ultrasound-guided peripheral nerve blocks: what are the benefits?Acta Anaesthesiol Scand2008; 52: 727–737.
49.
DesrochesJ.The infraclavicular brachial plexus block by the coracoid approach is clinically effective: an observational study of 150 patients.Can J Anaesth2003; 50: 253–257.
MarhoferP., SitzwohlC., GreherM., KapralS.Ultrasound guidance for infraclavicular brachial plexus anaesthesia in children.Anaesthesia2004; 59: 642–646.
55.
MarhoferP., SchrogendorferK., KoinigH., KapralS., WeinstablC., MayerN.Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks.Anesth Analg1997; 85: 854–857.
56.
MarhoferP., SchrogendorferK., WallnerT., KoinigH., MayerN., KapralS.Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks.Reg Anesth Pain Med1998; 23: 584–588.
57.
SitesB.D., BeachM.L., SpenceB.C., WileyC.W., ShiffrinJ., HartmanG.S.Ultrasound guidance improves the success rate of a perivascular axillary plexus block.Acta Anaesthesiol Scand2006; 50: 678–684.
58.
LiuF.C., LiouJ.T., TsaiY.F., Li AllenH., DayY.Y., HuiY.L.Efficacy of ultrasound-guided axillary brachial plexus block: a comparative study with nerve stimulator-guided method.Chang Gung Med J2005; 28: 396–402.
