Journal of the Louisiana State Medical Society
The use of ultrasound allows the clinician to determine the size, depth, and precise location of the brachial plexus and its neighboring structures under direct visualization. 11 Pre-block anatomical examination can define the optimal site and depth of needle insertion, help avoid vascular and pleu- ral puncture, and impart confidence to the anesthesiologist performing the block. 9,12 In a recent study, Cornish et al. dem- onstrated that it is possible to avoid phrenic nerve paralysis using a bent needle technique, further demonstrating how a combination of clinician technique and ultrasound guidance may reduce the risk of complications. 13 However, though ultrasound-guided supraclavicular block placement has been demonstrated to be a safe alternative to the electrical nerve stimulator-guided supraclavicular block, there is little evidence as yet to support the superiority of one technique over the other. 14 As such, the choice of technique should be determined by a combination of physician preference (typically determined by familiarity and comfort level) and specific indications for a particular approach, as in our case. The performance of bilateral supraclavicular blocks is certainly controversial, given the potential consequences of bilateral phrenic nerve paralysis and/or pneumothorax. The unusual circumstances specific to our case necessitated a bilateral approach, despite the high risk of complications, with every possible precaution taken to mitigate these risks. The blocks were performed sequentially rather than simul- taneously, with a window of observation between blocks to assess for immediate complications. The procedure was conducted in the intensive care unit under constant moni- toring, with emergency resuscitation equipment, including endotracheal tubes and thoracostomy tubes, available at the bedside. CONCLUSION This unique case highlights the need for acute pain control in patients with electrocution injuries and some of the clinical challenges that may be encountered. In ad- dition, it highlights the utility of brachial plexus blockade for painful upper extremity injuries and defines a group of patients for whom nerve-stimulator guidance may not be possible. Finally, it stresses the potential complications of bilateral brachial plexus blockade and the need for intensive patient monitoring. REFERENCES 1. Hussmann J, Kucan JO, Russell RC, et al. Electrical injuries-- morbidity, outcome and treatment rationale. Burns 1995;21(7):530- 535. 2. Lee J, Sinno H, Perkins A, et al. 14,000 volt electrical injury to bilateral upper extremities: a case report. Mcgill J Med 2011;13(1):18. 3. Singerman J, GomezM, Fish JS. Long-term sequelae of low-voltage electrical injury. J Burn Care Res 2008;29(5):773-777. 4. Searle RD, Simpson KH. Chronic Post Surgical Pain. Contin Educ Anaesth Crit Care Pain 2010;10(1):12-14. 5. Mak PH, Irwin MG, Ooi CG, et al. Incidence of diaphragmatic paralysis following supraclavicular brachial plexus block and its
effect on pulmonary function. Anaesthesia 2001;56(4):352-356. 6. Yang CW, Kwon HU, Cho CK, et al . A comparison of infraclavicular and supraclavicular approaches to the brachial plexus using neurostimulation. Korean J Anesthesiol 2010;58(3):260- 266. 7. Plunkett AR, Brown DS, Rogers JM, et al. Supraclavicular continuous peripheral nerve block in a wounded soldier: when ultrasound is the only option. Br J Anaesth 2006;97(5):715-717. 8. UrmeyWF, Talts KH, SharrockNE. One hundredpercent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991;72(4):498-503. 9. Perlas A, Lobo G, Lo N, et al. Ultrasound-guided supraclavicular block: outcome of 510 consecutive cases. Reg Anesth Pain Med 2009;34(2):171-176. 10. De Tran QH, Clemente A, Doan J, et al. Brachial plexus blocks: a reviewof approaches and techniques. Can J Anaesth 2007;54(8):662- 674. 11. Mirza F, Brown AR. Ultrasound-guided regional anesthesia for procedures of the upper extremity. Anesthesiol Res Pract 2011;2011:579824. 12. Chan VW, Perlas A, Rawson R, et al. Ultrasound-guided supraclavicular brachial plexus block. AnesthAnalg 2003;97(5):1514- 1517. 13. Cornish PB, Leaper CJ, NelsonG, et al. Avoidance of phrenic nerve paresis during continuous supraclavicular regional anaesthesia. Anaesthesia 2007;62(4):354-358. 14. Abrahams MS, Aziz MF, Fu RF, et al. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth 2009;102(3):408-417. Dr. Gelpi is a final-year Resident with the Department of Anesthesiology at Louisiana State University Health Sciences Center in Shreveport. Dr. Telang is a Pain Management Specialist with Alabama Spine and Pain and a former Pain Medicine Fellow with the Department of Anesthesiology at LSUHSC-Shreveport. Dr. Samuelson is a Resident with the Department of Anesthesiology at LSUHSC-Shreveport. Dr. Hamilton is a Clinical Research Associate at LSUHSC-Shreveport. Dr. Billiodeaux is a Pain Management Specialist with Lake Charles Memorial Health System and a former member of Faculty in the Department of Anesthesiology at LSUHSC-Shreveport.
62 J La State Med Soc VOL 166 March/April 2014
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