Journal of Anaesthesia and Pain. 2022. Vol.3(1):10-12 10
Axillary Block Ultrasound Guiding in Patient with Pseudoaneurysm Regio Brachii Sinistra pro Repair Pseudoaneurysm
Heri Dwi Purnomo
1, Emmanuel Nera Kurnia Kasmantino
11Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Sebelas Maret University, Dr. Moewardi Regional General Hospital, Surakarta
INTRODUCTION
An aneurysm may be a true aneurysm or a pseudoaneurysm. A true aneurysm occurs when all layers of an arterial wall are dilated. On the other hand, a pseudoaneurysm affects only one or more arterial wall layers and or neointima, fibrous tissue, and thrombus. Pseudoaneurysm is defined as a defect in the arterial wall, connecting the lumen and the extraluminal space. Thus, blood can flow from the artery and then be blocked by the soft tissue around it and the compressed thrombus forms a sac. A narrow passage that is usually formed from the arterial wall to this sac is named the "neck".1 Pseudoaneurysms in brachial arteries generally develop after a trauma (0.5%) or an iatrogenic injury (3–7%).2
The main etiology of brachial artery pseudoaneurysm is incidental arterial puncture during venous cannulation for hemodialysis, which is considered a rare complication of the procedure. The risk factors of this phenomenon are the usage of large-diameter needles, poor puncture technique, and early puncture of the fistula after surgery.3 Furthermore, other risk factors include penetrating trauma, blunt trauma,
catheterization, substance abuse, and arterial gas sampling, which usually induce brachial artery pseudoaneurysms in weeks to months.2
Upper extremity surgeries can be done under several types of anesthesia, whether general, regional, or even combined.4 The main advantage of regional anesthesia for upper extremity surgeries is that nerve blocks can prolong the postoperative analgesia.4
The brachial plexus originates from the anterior branches of C5-C7. Block of this plexus is a great anesthetic choice for upper extremity surgery.5 The most familiar approach of brachial plexus block is the axillary approach, as it is easy to perform. This approach may also result in lower complications than the interscalene region approach, which can lead to the spinal cord or vertebral artery puncture, and the supraclavicular approach, which can cause pneumothorax.6 Other advantages are prolonged analgesia, lower incidence of postoperative nausea and vomiting, and shorter in-hospital days. However, this procedure also has several risks, such as nerve injury and accidental vascular puncture.7
Case Report
ABSTRACT
Background
:
An aneurysm may be a true aneurysm or a pseudoaneurysm. Pseudoaneurysm is defined as a defect in the arterial wall, making a connection between the lumen and the extraluminal space. The main etiology of brachial artery pseudoaneurysm is incidental arterial puncture during venous cannulation for hemodialysis.Case:: Anesthetic management was performed on a 56 years old female patient, body weight 45 kg, height 150 cm. The patient had other comorbidities such as hypertension, diabetes mellitus, chronic renal kidney with a diagnosis of left brachial pseudoanuerysm. Pro Pseudoanurysm repair surgery.
The anesthetic technique uses axillary peripheral nerve block with ultrasound guiding. The duration of surgery is ± 120 minutes. After the operation, the patient was treated in the hospital ward.
Conclusion: Choosing the most appropriate anesthetic technique for patients with renal impairment is necessary to maintain normovolemia and normotension in order to avoid unexpected complications. Using regional anesthetic technique for sympathetic nerve block may be favorable in these patients. With ultrasound guiding, the incidence of failure is lower, the time required is shorter, the latency is shorter, the blockade is longer, and the risk of accidental vascular puncture is lower so that vascular lesions are less likely.
Keywords: pseudoaneurysm, hemodialysis, axillary block, ultrasound guiding Correspondence:
Heri Dwi Purnomo, MD*
Sebelas Maret University Faculty of Medicine Sebelas Maret University
e-mail:
Received: August 2021, Revised: October 2021, Published: January 2022
How to cite this article: Purnomo, HD, ENK Kasmantino. Axilary Block Ultrasound Guiding in Patient with Pseudoaneurysm Regio Brachii Sinistra pro Repair Pseudoaneurysm. Journal of Anaesthesia and Pain. 2022:3(1):10-13. doi: 10.21776/ub.jap.2022.003.01.03
Journal of Anaesthesia and Pain, 2022, Volume: 3, No.1: 10-12 P-ISSN : 2722-3167
https://jap.ub.ac.id E-ISSN : 2722-3205
Journal of Anaesthesia and Pain. 2022. Vol.3(1):10-12 11
Prior to the era of ultrasonography, the possibility of exposure to the spinal cord, lungs, and major blood vessels, namely the subclavian and vertebral arteries with more proximal approaches (interscalene and supraclavicular), was of particular attention. For the last decade, ultrasound has been utilized to guide nerve localization in brachial plexus blockade procedures.7 Ultrasonography minimalizes risks during needle puncture while visualizing the spread of local anesthetic during the block.4 This case study presents a pseudoaneurysm repair surgery using the anesthesia technique of axillary peripheral nerve block with ultrasound guidance.
CASE
A 56-year-old woman weighing 45 kg, with a height of 150 cm, came to the RSUD Dr. Moewardi complaining that her left hand was getting bigger, starting two days after the last hemodialysis. The patient had other comorbidities such as hypertension, diabetes mellitus, chronic kidney failure, and a history of shunting arteriovenous. History of hemodialysis since one year ago for twice a week with the last procedure on February 24, 2021, at 12.30, and cardiomegaly with pulmonary edema.
Physical examination showed that the patient was in a conscious state of Glasgow coma scale (GCS) E4V5M6, with blood pressure 168/96 mmHg, pulse rate 85 bpm, strong lifting, respiratory rate of 22 breaths/minute. Examination of the heart showed a widening of the heart border in the mediocaudolateral direction with normal heart sounds I and II, without murmur.
Examination of lungs revealed vesicular basal voice with pulmonary rales on the basal of the right lung. The extremities were warm, not pale with capillary refill time (CRT) <2 seconds.
A routine hematological laboratory (Table 1) showed moderate anemia, low hematocrit, azotemia, and hyperglycemia.
X-ray examination of the thorax showed cardiomegaly with a cardiac-thoracic ratio of 70% with left ventricular hypertrophy and right atrial hypertrophy configuration with pulmonary edema. A caudal hemodialysis catheter was attached with a tip
projecting at the right thoracic vertebral bones level. ECG examination revealed rhythmic synchrony, 80 beats/minute, hypertrophy without ischemia.
The patient with the American Society of Anesthesiology (ASA) physical status III was then planned for pseudoaneurysm repair under ultrasound-guided axillary block regional anesthesia. Education was given to the patient and her family regarding the surgery under regional anesthesia.
Preparation was done with two intravenous access lines using IV cath number 18. The patient was then fasted and given premedication of intravenous metoclopramide 10 mg and ranitidine 50 mg. Arriving at the operating room, the patient's anesthesia team installed the monitor and sterilized the patient's skin. Then, the transducer was positioned in a short axis orientation in order to reveal the axillary artery, about 1-3 cm from the skin surface. The patient's arm was abducted to 90 degrees, and the transducer was placed. We avoided abducting the patient's arm excessively, as this could cause patient discomfort and traction on the brachial plexus, increasing the risk of needle injury. The transducer was placed distal to the insertion of pectoralis major muscle on the humerus bone. The transducer moves proximally to locate the axillary artery, conjoint tendons, and terminal branches of the brachial plexus.
The anesthesia technique began with levobupivacaine injection 0.375% 20 ml and Lidocaine 1.5% 10 ml (total 30 ml).
One-third of the total dose (10 ml) was constantly injected to block the ulnar, median, radial, and musculocutaneous nerves.
The anesthetic agent was injected posteriorly to the artery first, as starting with an injection of the median or ulnar nerves might displace the aimed structure deeper and cloud the nerve. The needle was then pulled just under the skin, directed to the median and ulnar nerves. Lastly, the injection was completed with spread around the median nerve.
The last step was to withdraw the needle and direct it back to the musculocutaneous nerve to make the final injection.
The musculocutaneous nerve sometimes is located near the median nerve. In this case, double injection is not necessary. Ten minutes after the injection, the patient felt hypesthesia in the surgery area. Prior to the operation, each nerve's sensory and motor functions were reassessed, then surgery was started after confirming that the nerve block was successful. The operation lasted approximately for 2 hours.
Postoperatively, the patient did not state any complaints of pain. The visual analogue scale (VAS) was assessed in 2, 8, 12, and 24 hours postoperatively and range from 1-2.
DISCUSSION
Patients with chronic renal failure require routine hemodialysis. However, the site of the hemodialysis puncture can be a risk for the formation of brachial artery pseudoaneurysms.2 Patients with renal dysfunction usually have accompanying comorbidities, namely hypertension, diabetes, and cardiovascular diseases. Due to reduced erythropoietin production in the kidneys, anemia is also commonly found in these patients. Patients with renal failure also have a higher risk of bleeding due to impaired thrombocyte function and von Willebrand factor. Another problem is altered homeostasis, such as electrolyte imbalance and it affecting many organ systems.
Thus, the intraoperative management of these patients can be challenging for anesthesiologists.8
As a requirement for elective surgery, patients with chronic kidney disease should undergo hemodialysis a day in advance to improve electrolyte, metabolic, and volume status.
Administration of intravenous fluid should be limited in such Table 1. Laboratory preoperation examination result
Laboratory Examination Result
Hemoglobin (g/dl) 6.1
Hematocrit (%) 19
Leukocytes (/mcl) 4.5
Trombocytes (/mcl) 171
Erythrocytes 2
Blood type A
Protrombin Time (second) 13.2
Activated Partial
Thromboplastin Time (second) 29.1 International Normalized Ratio 0.970 Non-fasting glucose testing ( mg/dl) 159*
Albumin ( g/dl) 3.7
Creatinine ( mg/dl) 5
Ureum ( mg/dl) 116
Sodium ( mmol/l) 138
Potassium ( mmol/l) 3.6
Cloride ( mmol/l) 106
Hepatitis B surface antigen Non-reactive
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patients for minor surgery, and euvolemia state should be controlled to maintain adequate preload to avoid hypotension and hypoperfusion to organs. Volume overload can cause pulmonary edema and hypoxia. Another crucial thing is maintaining normovolemia and normotension, preventing reduced renal perfusion. Volatile anesthetics can reduce renal perfusion pressure by decreasing systemic vascular resistance (e.g., isoflurane or sevoflurane) or cardiac output (e.g., halothane), thus lowering the glomerular filtration rate (GFR).
Several factors can exacerbate this phenomenon, such as pain which may induce responses like hypovolemia and release of catecholamines and vasopressin hormone during surgery.9 Administration of general anesthesia can lower the renal blood flow, affecting the excretion of nephrotoxic agents.10
The use of regional anesthetic techniques for sympathetic nerve block attenuates catecholamine-induced renal vasoconstriction and suppresses the release of cortisol and epinephrine release. Thus, this block may be helpful for patients with renal failure or patients with a higher risk for postoperative acute kidney injury.12
Advantages of brachial plexus block include prolonged analgesia, lower incidence of postoperative nausea and vomiting, and shorter in-hospital days.7 However, it holds the risk for procedure-related complications such as accidental nerve injury and vascular puncture.
With ultrasound guiding, the incidence of failure is lower, the time required is shorter, the latency is shorter, the blockade is longer, and the risk of accidental vascular puncture is lower, resulting in less chance of vascular lesions. superior for guiding peripheral nerve blocks. A meta-analysis compared ultrasound-guided peripheral nerve blocks and conventional techniques (paresthesia and neurostimulation) showed a lower risk of accidental vascular puncture when ultrasound was used.12 CONCLUSION
Patients with renal impairment usually have accompanying comorbidities, namely hypertension, diabetes, and cardiovascular diseases. Another obstacle is altered homeostasis, such as electrolyte imbalance, affecting many organ systems. Thus, the intraoperative management of these patients can be challenging for anesthesiologists. Choosing the most appropriate anesthetic technique and the agent is necessary to maintain normovolemia and normotension to avoid unexpected complications. Regional anesthetic techniques for sympathetic nerve block may be favorable for such patients. With the help of ultrasound, the incidence of failure is lower, the time required is shorter, the latency is shorter, the blockade is longer, and the risk of accidental vascular puncture is lower, resulting in less chance of vascular lesions.
ACKNOWLEDGMENT -
CONFLICT OF INTEREST None
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