RU2848375C1 - Method for prolonged blockade of the internal cutaneous nerve and musculocutaneous nerve from the axillary approach - Google Patents

Abstract

FIELD: medicine; anaesthesiology; intensive care.

SUBSTANCE: invention can be used to perform prolonged blockade of the internal cutaneous nerve and musculocutaneous nerve from the axillary access. A catheter is inserted into the internal cutaneous nerve using the first Tuohy G 18 guide wire with an outer diameter of 1.3 mm and a length of 80 mm. A catheter is inserted into the musculocutaneous nerve using a Tuohy G 18 guide wire with an outer diameter of 1.3 mm and a length of 80 mm. Fix the catheters under the skin of the axillary region and under the skin of the subclavian region using the second Tuohy guide wire G 18 with an outer diameter of 1.3 mm and a length of 120 mm, a third Tuohy G 18 guide needle with an outer diameter of 1.3 mm and a length of 80 mm, and a Pencan G 25 spinal needle with a pencil-point distal end, an outer diameter of 0.5 mm, and a length of 120 mm. Both catheters, starting from the point of access to the musculocutaneous nerve, are located in a single subcutaneous channel in the axillary and subclavian regions. The inner part of the catheter for prolonged blockade of the musculocutaneous nerve is 140 mm, and the inner part of the catheter for prolonged blockade of the internal cutaneous nerve is 160 mm; the exit point of the catheters is located on the skin of the subclavian region.

EFFECT: method allows for the installation and reliable fixation of catheters for prolonged blockade of the internal cutaneous and musculocutaneous nerves from the axillary access and provides anaesthesiological support during surgical interventions on the upper limb in the elbow joint area, in the lower third of the shoulder and upper third of the forearm on the outer, inner and posterior surfaces, to provide prolonged analgesia in the treatment of acute and chronic pain syndromes in the innervation zone of the internal cutaneous and musculocutaneous nerves by placing catheters under the skin of the axillary region and under the skin of the subclavian region, with the catheters exiting onto the skin of the subclavian region, increasing the internal part of the catheters to 140 mm and 160 mm.

1 cl, 28 dwg, 1 ex

Description

The invention relates to the field of medicine, specifically anesthesiology and intensive care, and can be used to perform prolonged blockades of the internal cutaneous nerve and musculocutaneous nerve via an axillary approach. This method of prolonged blockade of the internal cutaneous nerve and musculocutaneous nerve is used for anesthetic management during upper limb surgery in the lower third of the shoulder and elbow joint, for postoperative analgesia, and for the treatment of acute and chronic pain syndromes in the distribution of the internal cutaneous nerve and musculocutaneous nerve.

Existing regional anesthesia techniques, such as axillary brachial plexus blocks, do not utilize catheter-based techniques or prolonged analgesia. The brachial plexus nerves in the axillary region are located superficially around the axillary artery as individual nerves: the radial, median, and brachial, as well as the separately located internal cutaneous and musculocutaneous nerves. Continuous blocks of the radial, median, and ulnar nerves fail to provide prolonged, high-quality analgesia to the distribution area of the internal cutaneous and musculocutaneous nerves, as they are located at a distance from the main nerves of the brachial plexus. Therefore, during surgeries in the distribution area of these nerves—the elbow joint, the lower third of the arm, and the upper third of the forearm—it is necessary to perform continuous blocks of the internal cutaneous and musculocutaneous nerves on the outer, inner, and posterior surfaces. The superficial location of these nerves of the brachial plexus in the axillary region and the axillary region itself, which is an anatomically pit limited by the latissimus dorsi muscle, the pectoralis major and minor muscles, does not allow for the reliable installation and fixation of catheters for prolonged blockade of the internal cutaneous and musculocutaneous nerves from the axillary approach. There are descriptions of methods of brachial plexus block 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 block by the axillary approach. Literature review. Far East Healthcare. No. 1. 2024 DOI: 10.33454/1728-12612024-1-51-58; 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 block from the interscalene, supraclavicular and infraclavicular approaches. From the axillary approach, prolonged block of separately located nerves of the brachial plexus, such as the internal cutaneous and musculocutaneous, is not performed 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 block 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 prolonged 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 prolonged brachial plexus blockade with an original method of catheter fixation: a clinical case. Regional anesthesia and acute pain treatment. 2023. Vol. 17, No. 2. Pp. 135-144. https://doi.org/10.17816/RA321559; Yamshchikov O.N. et al. Russian Federation Patent RU 2806484 "Method for fixing a catheter under the skin of the subclavian region during prolonged brachial plexus blockade." Priority date 09.03.2023. Date of registration: 01.11.20213), as well as an axillary approach to the brachial plexus (Yamshchikov O.N. et al. Russian Federation Patent RU 2822814 "Method for extended blockade of the radial nerve, median nerve and ulnar nerve from an axillary approach". Priority date: 11.03.2024. Date of registration: 15.07.2024). This method does not allow for an extended blockade of the internal cutaneous nerve and musculocutaneous nerve due to the remote location of these nerves from the main nerves of the brachial plexus (radial, median and ulnar nerves). There are no descriptions in the literature of methods for an extended blockade of separately located nerves of the brachial plexus: the internal cutaneous and musculocutaneous nerves. The closest analogues to the claimed invention in the field of technology have not been identified. Therefore, there is a need to create a method for simultaneous prolonged blockade of the internal cutaneous and musculocutaneous nerves when prolonged anesthesia of the innervation zone of these nerves is required.

For installation of catheters to the internal cutaneous nerve and musculocutaneous nerve from the axillary approach and fixation of catheters under the skin of the subclavian region, the first guiding needle Tuohy G 18 by B/Braun (Germany) with an outer diameter of 1.3 mm and a length of 80 mm, the second guiding needle Tuohy G 18 by B/Braun (Germany) with an outer diameter of 1.3 mm and a length of 120 mm, the third guiding needle Tuohy G 18 by B/Braun (Germany) with an outer diameter of 1.3 mm and a length of 80 mm, catheters for prolonged nerve block G 20 by B/Braun (Germany) with an outer diameter of 0.85 mm, an inner diameter of 0.45 mm and a length of 1000 mm and a spinal needle Pencan G 25 by B/Braun (Germany) with pencil sharpening of the distal end with an outer diameter of 0.5 mm and a length of 120 mm.

A preliminary ultrasound examination of the anatomical structures in the axillary fossa of the limb being blocked is performed. For this, a linear ultrasound transducer is placed on the skin surface in the axillary fossa so that one edge of the transducer, corresponding to the right side (R), is positioned at the level of the anterior axillary line, with the patient's arm abducted at 90° relative to the torso. Using ultrasound imaging, anatomical structures such as the axillary artery, axillary vein, musculocutaneous nerve, internal cutaneous nerve, biceps brachii, triceps brachii, and coracobrachialis muscles are identified.

The technical result of the claimed method is that the method allows for the installation and reliable fixation of catheters for prolonged blockade of the internal cutaneous and musculocutaneous nerves from an axillary approach and for anesthetic support during surgical interventions on the upper limb in the area of the elbow joint, in the area of the lower third of the shoulder and the upper third of the forearm along the outer, inner and posterior surfaces, and for prolonged analgesia in the treatment of acute and chronic pain syndromes in the innervation zone of the internal cutaneous and musculocutaneous nerves.

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

1. At the first stage, local anesthesia of the skin and subcutaneous fat tissue is performed in the axillary region along the midaxillary line with a 5 mg/ml lidocaine solution in an amount of 5.0 ml, after which, using ultrasound imaging and neuromuscular stimulation with a neurostimulation needle, the internal cutaneous nerve is identified and the access site to the internal cutaneous nerve is determined (Fig. 1).

2. At the second stage, at the site of access to the internal cutaneous nerve, a 3 mm incision is made in the skin and subcutaneous fat using a sharp scalpel, forming the first skin wound (Fig. 2).

3. At the third stage, in the axillary region 10 mm below the anterior axillary line, local anesthesia of the skin and subcutaneous fat is performed with a 5.0 ml lidocaine solution of 5 mg/ml and, using ultrasound imaging and neuromuscular stimulation with a neurostimulation needle, the musculocutaneous nerve is identified and the access site to the musculocutaneous nerve is determined (Fig. 3).

4. At the fourth stage, at the site of access to the musculocutaneous nerve, a 3 mm incision is made in the skin and subcutaneous fat with a sharp scalpel, forming a second skin wound (Fig. 2).

5. At the fifth stage, the first Tuohy needle, 80 mm long, is inserted through the first skin wound under ultrasound control to the internal cutaneous nerve (Fig. 4, 5).

6. At the sixth stage, a catheter for prolonged blockade of the internal cutaneous nerve is inserted through the lumen of the first 80 mm long Tuohy needle into the perineural space of the internal cutaneous nerve (Fig. 6).

7. At the seventh stage, the first 80 mm long Tuohy needle is removed from the axillary region, leaving a catheter inserted into the internal cutaneous nerve for an extended blockade of the internal cutaneous nerve in the lumen of the first skin wound (Fig. 7).

8. At the eighth stage, the first Tuohy needle, 80 mm long, is inserted through the second skin wound under ultrasound control to the musculocutaneous nerve (Fig. 8, 9).

9. At the ninth stage, a catheter for prolonged blockade of the musculocutaneous nerve is inserted through the lumen of the first 80 mm long Tuohy needle into the perineural space of the musculocutaneous nerve (Fig. 10).

10. At the tenth stage, through the first skin wound under the skin of the axillary region to the location of the first Tuohy needle 80 mm long in the lumen of the second skin wound, a second Tuohy needle 120 mm long is inserted so that the distal end of the second Tuohy needle 120 mm long is located outside the second skin wound (Fig. 11).

11. In the eleventh step, a 120 mm long Pencan spinal needle is inserted through the lumen of the second 120 mm long Tuohy needle in the direction from its distal end to its proximal end (Fig. 12).

12. At the twelfth stage, the second 120 mm long Tuohy needle is removed from under the skin of the axillary region, while the 120 mm long Pencan spinal needle is positioned in the subcutaneous canal of the axillary region between the first skin wound and the second skin wound so that the distal end of the needle protrudes 20 mm from the edge of the first skin wound (Fig. 13).

13. At the thirteenth stage, the distal end of the 120 mm long Pencan spinal needle, held with a surgical clamp, is inserted into the lumen of the catheter for an extended block of the internal cutaneous nerve to a distance of 4 mm (Fig. 14).

14. At the fourteenth stage, the 120 mm long Pencan spinal needle with a catheter for extended block of the internal cutaneous nerve fixed at its distal end is removed from the subcutaneous canal of the axillary region, placing the catheter for extended block of the internal cutaneous nerve in the subcutaneous canal of the axillary region between the first and second skin wounds (Fig. 15).

15. At the fifteenth stage, the third Tuohy needle, 80 mm long, is inserted through the lumen of the second skin wound at the location of the first Tuohy needle, 80 mm long, and the catheter for extended blockade of the internal cutaneous nerve under the skin of the subclavian region at a distance of 70 mm with the distal end of the third Tuohy needle, 80 mm long, exiting onto the skin at a location 10 mm below the clavicle along the midclavicular line (Fig. 16).

16. At the sixteenth stage, the second Tuohy needle, 120 mm long, is inserted through the lumen of the second skin wound at the location of the first Tuohy needle, 80 mm long, the third Tuohy needle, 80 mm long, and the catheter for extended blockade of the internal cutaneous nerve under the skin of the subclavian region at a distance of 70 mm so that the distal end of the second Tuohy needle, 120 mm long, comes out onto the skin at the location of the third Tuohy needle, 80 mm long, which comes out onto the skin, located 10 mm below the clavicle along the midclavicular line, while the second Tuohy needle, 120 mm long, and the third Tuohy needle, 80 mm long, are located in the same subcutaneous channel in the subclavian region (Fig. 17).

17. At the seventeenth stage, a 120 mm long Pencan spinal needle is passed through the lumen of a second 120 mm long Tuohy needle located in the subcutaneous canal of the subclavian region in the direction from its distal end to its proximal end (Fig. 18).

18. At the eighteenth stage, the distal end of the 120 mm long Pencan spinal needle, held with a surgical clamp, is inserted into the lumen of the catheter for an extended block of the internal cutaneous nerve to a distance of 4 mm (Fig. 19).

19. At the nineteenth stage, the 120 mm long Pencan spinal needle with a catheter for extended block of the internal cutaneous nerve fixed at its distal end is removed from the subcutaneous canal of the subclavian region, placing the catheter for extended block of the internal cutaneous nerve in the subcutaneous canal of the subclavian region together with the third 80 mm long Tuohy needle (Fig. 20).

20. At the twentieth stage, a 120 mm long Pencan spinal needle is inserted through the lumen of a third 80 mm long Tuohy needle located in the subcutaneous canal of the subclavian region in the direction from its distal end to the proximal end (Fig. 21).

21. At the twenty-first stage, after removing the third 80 mm long Tuohy needle from under the skin of the subclavian region, the distal end of the 120 mm long Pencan spinal needle is held with a surgical clamp (Fig. 22).

22. At the twenty-second stage, the first 80 mm Tuohy needle is removed from under the skin of the axillary region, while the catheter for the prolonged musculocutaneous nerve block is located in the perineural space of the musculocutaneous nerve, then the 120 mm Pencan spinal needle is inserted into the lumen of the catheter for the prolonged musculocutaneous nerve block to a distance of 4 mm. The 120 mm Pencan spinal needle and the catheter for the prolonged internal cutaneous nerve block are located in the same subcutaneous channel of the subclavian region (Fig. 23).

23. At the twenty-third stage, the 120 mm long Pencan spinal needle with a catheter for prolonged blockade of the musculocutaneous nerve fixed at its distal end is removed from the subcutaneous canal of the subclavian region, placing the catheter for prolonged blockade of the musculocutaneous nerve in the subcutaneous canal of the subclavian region together with the catheter for prolonged blockade of the internal cutaneous nerve (Fig. 24).

24. At the twenty-fourth stage, the catheter for the prolonged block of the internal cutaneous nerve and the catheter for the prolonged block of the musculocutaneous nerve are fixed on the skin at the site of the catheters’ exit onto the skin of the subclavian region, located 10 mm below the clavicle along the midclavicular line on the side of the blocked limb with a Perifix fixing sticker and the proximal end of the catheter for the prolonged block of the internal cutaneous nerve and the proximal end of the catheter for the prolonged block of the musculocutaneous nerve with installed antibacterial filters are fixed on the skin of the subclavian region on the side opposite the blocked limb with an aseptic adhesive tape (Fig. 25, 26).

25. At the twenty-fifth stage, ultrasound control of the position of the catheter for prolonged blockade of the musculocutaneous nerve (Fig. 27) and the catheter for prolonged blockade of the internal cutaneous nerve (Fig. 28) is performed.

Fig. 1 shows an ultrasound image of visualization and neurostimulation identification of the internal cutaneous nerve (1), axillary vein (2), neurostimulation needle (3).

Fig. 2 shows the first skin wound at the site of access to the internal cutaneous nerve, located along the mid-axillary line, and the second skin wound at the site of access to the musculocutaneous nerve, located 10 mm below the anterior axillary line in the axillary region.

Fig. 3 shows an ultrasound image of visualization and neurostimulation identification of the musculocutaneous nerve (4), neurostimulation needle (3).

Fig. 4 shows the insertion of the first 80 mm long Tuohy needle through the first skin wound to the internal cutaneous nerve in the axillary region using ultrasound guidance.

Fig. 5 shows an ultrasound image of the passage of the first 80 mm long Tuohy needle (5) through the first skin wound to the internal cutaneous nerve (1).

Fig. 6 shows the passage of a catheter for prolonged blockade of the internal cutaneous nerve through the lumen of the first 80 mm Tuohy needle into the perineural space of the internal cutaneous nerve.

Fig. 7 shows a catheter for prolonged block of the internal cutaneous nerve placed to the internal cutaneous nerve through the first skin wound in the axillary region.

Fig. 8 shows the insertion of the first 80 mm long Tuohy needle to the musculocutaneous nerve through the second skin wound in the axillary region under ultrasound guidance.

Fig. 9 shows an ultrasound image of the passage of the first 80 mm long Tuohy needle (5) through the second skin wound to the musculocutaneous nerve (4) in the axillary region.

Fig. 10 shows the insertion of a catheter for prolonged blockade of the musculocutaneous nerve through the lumen of the first 80 mm Tuohy needle into the perineural space of the musculocutaneous nerve and shows a catheter installed through the first skin wound for prolonged blockade of the internal cutaneous nerve in the axillary region.

Fig. 11 shows the insertion of a second Tuohy needle, 120 mm long, through the first skin wound under the skin of the axillary region to the location of the first Tuohy needle, 80 mm long, in the lumen of the second skin wound, with the distal end of the second Tuohy needle, 120 mm long, being brought out beyond the second skin wound.

Fig. 12 shows the passage of a 120 mm Pencan spinal needle through the lumen of a second 120 mm Tuohy needle, from its distal end to its proximal end. The second 120 mm Tuohy needle is positioned in the subcutaneous canal of the axillary region between the first skin wound and the second skin wound.

Fig. 13 shows a 120 mm long Pencan spinal needle positioned in the subcutaneous canal of the axillary region between the first skin wound and the second skin wound so that the distal end of the needle protrudes 20 mm from the edge of the first skin wound.

Fig. 14 shows the passage of the distal end of a 120 mm Pencan spinal needle, held by a surgical clamp, into the lumen of the catheter for an extended block of the internal cutaneous nerve at a distance of 4 mm. The 120 mm Pencan spinal needle is positioned in the subcutaneous canal of the axillary region between the first skin wound and the second skin wound.

Fig. 15 shows the insertion of a catheter into the subcutaneous canal of the axillary region for a prolonged block of the internal cutaneous nerve. The catheter for a prolonged block of the internal cutaneous nerve is positioned in the subcutaneous canal of the axillary region between the first skin wound and the second skin wound.

Fig. 16 shows the passage of a third Tuohy needle, 80 mm long, through the lumen of the second skin wound at the location of the first Tuohy needle, 80 mm long, and a catheter for an extended block of the internal cutaneous nerve under the skin of the subclavian region at a distance of 70 mm with the exit of the distal end of the third Tuohy needle, 80 mm long, onto the skin at a location located 10 mm below the clavicle along the midclavicular line.

Fig. 17 shows the insertion of a second 120 mm long Tuohy needle through the lumen of the second skin wound at the site of the first 80 mm long Tuohy needle, the third 80 mm long Tuohy needle, and the catheter for the extended block of the internal cutaneous nerve under the skin of the subclavian region for a distance of 70 mm with the exit of the distal end of the second 120 mm long Tuohy needle onto the skin at the exit site of the third 80 mm long Tuohy needle onto the skin, located 10 mm below the clavicle along the midclavicular line. The second 120 mm long Tuohy needle and the third 80 mm long Tuohy needle are located in the same subcutaneous channel in the subclavian region.

Fig. 18 shows the passage of a 120 mm Pencan spinal needle through the lumen of a second 120 mm Tuohy needle positioned in the subcutaneous canal of the subclavian region in the direction from its distal end to its proximal end. The second 120 mm Tuohy needle and the third 80 mm Tuohy needle are positioned in the same subcutaneous canal of the subclavian region.

Fig. 19 shows the distal end of a 120 mm Pencan spinal needle being advanced into the lumen of a catheter for an extended block of the internal cutaneous nerve to a distance of 4 mm. The distal end of the 120 mm Pencan spinal needle is held with a surgical clamp. The 120 mm Pencan spinal needle and a third 80 mm Tuohy needle are positioned in the same subcutaneous canal in the subclavian region.

Fig. 20 shows the insertion of a catheter for an extended block of the internal cutaneous nerve, connected to the distal end of a 120 mm long Pencan spinal needle, into the subcutaneous canal of the subclavian region. The catheter for an extended block of the internal cutaneous nerve and a third 80 mm long Tuohy needle are located in the same subcutaneous canal of the subclavian region.

Fig. 21 shows the passage of a 120 mm Pencan spinal needle through the lumen of a third 80 mm Tuohy needle from its distal end to its proximal end. The third 80 mm Tuohy needle and the catheter for the extended internal cutaneous nerve block are located in the same subcutaneous canal in the subclavian region.

Fig. 22 shows the distal end of a 120 mm Pencan spinal needle being held with a surgical clamp. The 120 mm Pencan spinal needle and the catheter for an extended internal cutaneous nerve block are positioned in the same subcutaneous canal in the subclavian region.

Fig. 23 shows the passage of the distal end of a 120 mm Pencan spinal needle into the lumen of a catheter for an extended musculocutaneous nerve block to a distance of 4 mm. The 120 mm Pencan spinal needle and the catheter for an extended internal cutaneous nerve block are located in the same subcutaneous canal in the subclavian region.

Fig. 24 shows the insertion of a catheter for continuous musculocutaneous nerve block, attached to the distal end of a 120 mm Pencan spinal needle, into the subcutaneous canal of the subclavian region. The catheter for continuous internal cutaneous nerve block and the catheter for continuous musculocutaneous nerve block are located in the same subcutaneous canal of the subclavian region.

Fig. 25 shows the fastening of a catheter for prolonged blockade of the internal cutaneous nerve and a catheter for prolonged blockade of the musculocutaneous nerve with a Perifix fixing sticker at the site of catheter exit onto the skin of the subclavian region, located 10 mm below the clavicle along the midclavicular line on the side of the blocked limb and fixation of the proximal end of the catheter for prolonged blockade of the internal cutaneous nerve and the proximal end of the catheter for prolonged blockade of the musculocutaneous nerve with installed antibacterial filters on the skin of the subclavian region on the side opposite the blocked limb.

Fig. 26 shows the final view of fixation of the catheter for prolonged blockade of the internal cutaneous nerve and the catheter for prolonged blockade of the musculocutaneous nerve with a Perifix fixing sticker at the site of exit of the catheters onto the skin of the subclavian region, located 10 mm below the clavicle along the midclavicular line on the side of the blocked limb and fixation of the proximal end of the catheter for prolonged blockade of the internal cutaneous nerve and the proximal end of the catheter for prolonged blockade of the musculocutaneous nerve with installed antibacterial filters on the skin of the subclavian region on the side opposite to the blocked limb and fixation of the catheters with an adhesive sticker.

Fig. 27 shows an ultrasound image of the visualization of the catheter for prolonged blockade of the musculocutaneous nerve (6) and the musculocutaneous nerve (4).

Fig. 28 shows an ultrasound image of the visualization of the catheter for prolonged block of the internal cutaneous nerve (7) and the internal cutaneous nerve (1).

Clinical example of the invention

Patient M., 78 years old, was admitted to the traumatology department. After a comprehensive examination, the primary diagnosis was: "Closed comminuted intercondylar fracture of the ulna of the left upper limb with displacement of fragments." Concomitant diagnoses: "IHD. ABS. Hypertension 3. Arterial hypertension 2. CVD risk 4 CHF 2a (FC 2). COPD. Chronic obstructive bronchitis, moderate course. Tobacco smoking for 52 years." The patient's physical status according to ASA is class 3. On September 26, 2024, surgery was performed: "Open reduction of the intercondylar fracture of the ulna of the left upper limb, osteosynthesis with titanium plates and screws." Anesthetic management of the surgical procedure: "Brachial plexus block via axillary access with placement of a catheter for prolonged block of the internal cutaneous nerve and a catheter for prolonged block of the musculocutaneous nerve from the axillary access with fixation of the catheters under the skin of the subclavian region." Placement of a catheter for prolonged block of the internal cutaneous nerve was performed under local anesthesia of the skin and subcutaneous fat with a lidocaine solution of 5 mg/ml in an amount of 5.0 ml (25 mg). Placement of a catheter for prolonged block of the musculocutaneous nerve was performed under local anesthesia of the skin and subcutaneous fat with a lidocaine solution of 5 mg/ml in an amount of 5.0 ml (25 mg). After placement of catheters for prolonged blockade from the axillary approach into the perineural space of the radial, median, ulnar, musculocutaneous, and internal cutaneous nerves, 30 ml (150 mg) of ropivacaine 5 mg/ml solution was injected. The brachial plexus nerve block and the insertion of catheters for prolonged blockade of the musculocutaneous and internal cutaneous nerves from the axillary approach with their fixation under the skin of the subclavian region took 25 minutes. The catheters were secured at the site of exiting the skin of the subclavian region with a Perifix fixation device. The onset of sensory and motor blockade of the left upper extremity was 30 minutes. The duration of the surgical intervention was 125 minutes. The patient tolerated the surgery satisfactorily. Postoperative analgesia was performed in the form of prolonged blockade of the musculocutaneous and internal cutaneous nerves for three days by administering ropivacaine solution 2 mg / ml at a total dose of 2 ml / hour (8 mg / hour) as a bolus injection at a daily dose of 192 mg (96 ml) through the lumen of catheters for prolonged blockade of the musculocutaneous and internal cutaneous nerves (bolus in each catheter ropivacaine solution 2 mg / ml - 16 ml (32 mg) three times). The fixing sticker on the Perifix device was changed on the next day after the surgery. Three days after the surgery, before removing the catheters, the adhesive properties of the fixing device were not affected, the dislocation of the catheters was 4 mm, which indicates the absence of dislocation. During postoperative analgesia, the pain level was assessed using a visual analog scale (VAS). The pain level on the VAS scale ranged from 0 cm to 2 cm, which is considered mild pain. Postoperative pain relief was good. Subsequently, the patient received paracetamol solution at a daily dose of 2000 mg intravenously, divided into two doses over two days. The patient was restored to a standing position 5 hours after surgery. The postoperative period was uneventful. On the eighth day, the patient was discharged for outpatient treatment by a traumatologist.

Claims (1)

A method for performing an extended block of the internal cutaneous nerve and musculocutaneous nerve from an axillary approach, including ultrasound imaging of the anatomical structures in the axillary fossa on the side of the limb being blocked, searching for the axillary artery, axillary vein, musculocutaneous nerve, internal cutaneous nerve, biceps and triceps brachii, coracobrachialis, after which local anesthesia of the skin and subcutaneous fat is performed in the axillary region along the midaxillary line with a 5.0 ml solution of lidocaine and using ultrasound imaging and neuromuscular stimulation with a neurostimulation needle, identify the internal cutaneous nerve, determine the access site to the internal cutaneous nerve, after which, at the access site to the internal cutaneous nerve, a 3 mm incision is made in the skin and subcutaneous fat with a sharp scalpel, form the first skin wound, then in the axillary region 10 mm below the anterior axillary line, local anesthesia of the skin and subcutaneous fat is performed with a 5.0 ml solution of lidocaine 5 mg / ml and, using ultrasound imaging and neuromuscular stimulation with a neurostimulation needle, the musculocutaneous nerve is identified, the access site to the musculocutaneous nerve is determined, after which, at the access site to the musculocutaneous nerve, a 3 mm incision is made with a sharp scalpel in the skin and subcutaneous fat, forming a second skin wound, then the first Tuohy needle, 80 mm long, is inserted through the first skin wound under ultrasound control to the internal cutaneous nerve, after which a catheter for an extended block of the internal cutaneous nerve is inserted through the lumen of the first Tuohy needle, 80 mm long, into the perineural space of the internal cutaneous nerve, then the first Tuohy needle, 80 mm long, is removed from the axillary region, leaving the catheter advanced to the internal cutaneous nerve for extended blockade of the internal cutaneous nerve in the lumen of the first skin wound, after which the first Tuohy needle, 80 mm long, is inserted through the second skin wound under ultrasound control to the musculocutaneous nerve, then a catheter for extended blockade of the musculocutaneous nerve is inserted through the lumen of the first Tuohy needle, 80 mm long, into the perineural space of the musculocutaneous nerve, after which a second Tuohy needle, 120 mm long, is inserted through the first skin wound under the skin of the axillary region to the location of the first Tuohy needle, 80 mm long, in the lumen of the second skin wound so that the distal end of the second Tuohy needle, 120 mm long, is located outside the second skin wound, then a Pencan spinal needle, 120 mm long, is inserted through the lumen of the second Tuohy needle, 120 mm long, in the direction from its distal end to the proximal end, after which the second Tuohy needle, 120 mm long, is removed from under the skin of the axillary region, wherein the Pencan spinal needle, 120 mm long, is positioned in the subcutaneous canal of the axillary region between the first skin wound and the second skin wound so that the distal end of the needle protrudes 20 mm from the edge of the first skin wound, then the distal end of the Pencan spinal needle, 120 mm long, held with a surgical clamp, is inserted into the lumen of the catheter for an extended block of the internal cutaneous nerve at a distance of 4 mm, after which the Pencan spinal needle, 120 mm long, with a catheter for an extended block of the internal cutaneous nerve fixed to its distal end, is removed from the subcutaneous canal of the axillary region, placing the catheter for an extended block of the internal cutaneous nerve in the subcutaneous canal of the axillary region between the first and second skin wounds, then the third Tuohy needle, 80 mm long, is inserted through the lumen of the second skin wound at the location of the first Tuohy needle, 80 mm long, and a catheter for an extended block of the internal cutaneous nerve under the skin of the subclavian region to a distance of 70 mm with the exit of the distal end of the third Tuohy needle, 80 mm long, onto the skin at a location located 10 mm below the clavicle along the midclavicular line, after which the second Tuohy needle, 120 mm long, is inserted through the lumen of the second skin wound at the location of the first Tuohy needle, 80 mm long, the third Tuohy needle, 80 mm long, and a catheter for an extended block of the internal cutaneous nerve under the skin of the subclavian region to a distance of 70 mm so that the distal end of the second Tuohy needle, 120 mm long, comes out onto the skin at the exit of the third Tuohy needle, 80 mm long, onto the skin, located 10 mm below the clavicle along the midclavicular line, while the second Tuohy needle, 120 mm long, and the third Tuohy needle, 80 mm long, are located in one subcutaneous channel in the subclavian region, then a 120 mm long Pencan spinal needle is inserted through the lumen of a second 120 mm long Tuohy needle located in the subcutaneous channel of the subclavian region in the direction from its distal end to the proximal end, after which the distal end of the 120 mm long Pencan spinal needle, held with a surgical clamp, is inserted into the lumen of a catheter for an extended block of the internal cutaneous nerve at a distance of 4 mm, then the 120 mm long Pencan spinal needle with a catheter for an extended block of the internal cutaneous nerve fixed to its distal end is removed from the subcutaneous channel of the subclavian region, placing the catheter for an extended block of the internal cutaneous nerve in the subcutaneous channel of the subclavian region together with a third 80 mm long Tuohy needle, after which the 120 mm long Pencan spinal needle is inserted through the lumen of the third 80 mm long Tuohy needle located in the subcutaneous channel subclavian region in the direction from its distal end to the proximal end, then after removing the third 80 mm long Tuohy needle from under the skin of the subclavian region, the distal end of the 120 mm long Pencan spinal needle is held with a surgical clamp, after which the first 80 mm long Tuohy needle is removed from under the skin of the axillary region, while the catheter for an extended musculocutaneous nerve block is in the perineural space of the musculocutaneous nerve, then the 120 mm long Pencan spinal needle is inserted into the lumen of the catheter for an extended musculocutaneous nerve block at a distance of 4 mm, after which the 120 mm long Pencan spinal needle with the catheter for an extended musculocutaneous nerve block fixed at its distal end is removed from the subcutaneous canal of the subclavian region, placing the catheter for an extended musculocutaneous nerve block in the subcutaneous canal of the subclavian region together with catheter for prolonged block of internal cutaneous nerve, then the catheter for prolonged block of internal cutaneous nerve and the catheter for prolonged block of musculocutaneous nerve are fixed on the skin at the site of catheter exit onto the skin of the subclavian region, located 10 mm below the clavicle along the midclavicular line on the side of the blocked limb with a Perifix fixing sticker and the proximal end of the catheter for prolonged block of internal cutaneous nerve and the proximal end of the catheter for prolonged block of musculocutaneous nerve with installed antibacterial filters are fixed on the skin of the subclavian region on the side opposite to the blocked limb with an aseptic adhesive sticker, after which ultrasound control of the position of the catheter for prolonged block of musculocutaneous nerve and prolonged block of internal cutaneous nerve is performed.