A 45-year-old, 60 kgs, ASA II [E]female patient of road side accident, sustained multiple

injuries including open fracture bilateral humerus with right sided haemothorax (ICD in situ)

along with fracture ramus of mandible. The patient was brought to the emergency theatre for

bilateral humerus fracture repair in one sitting .

On examination patient was well oriented to time, place and person and her vitals included

pulse rate 106 bpm, respiratory rate 20-24 breaths/ min, non invasive blood pressure

121/74mmHg in right leg and Sp02 94-96% on room air. The right sided ICD was in place

with column moving. The baseline ABG revealed pH 7.36, Pao2=68 on room air and Paco2

of 36mmHg. Rest of the investigations were unremarkable. The head injury component was

excluded by NCCT head.

On airway examination mouth opening was 2 fingers width approximately, neck movements

were within normal range. The patient was informed the option of bilateral brachial plexus

block to be performed sequentially utilizing ultrasonography. The plan was to institute USG

guided sequential brachial block [axillary block on right side] for distal humerus fracture and

right supraclvicular block for midshaft humerus fracture, using a lower volume of local

anesthetic on each side to decrease the total dose. She was explained the risk of general

anaesthesia and postoperative morbidity, however with the understanding that the probability

of general anesthesia could not be completely excluded. Patient gave her consent for the

procedure.

The patient had a functional IV line on the left foot and had been started on systemic

antibiotics in the emergency room. Standard ASA monitors were applied, and supplemental

oxygen by nasal cannula @4l/min was started. As the excessive blood loss and hemodynamic

instability was not expected in this case, the right sided external jugular vein was cannulated

for intraoperative fluid management.

The surgeons decided to proceed with left side midshaft fracture humerus first, sonographic

guided in plane supraclavicular block was given with 15 mL of local anaesthetic (7 mL of

1.5% lignocaine with adrenaline [1:200000] + 7 mL of 0.25% bupivacaine +1mL normal

saline) by visualization of the adequate and uniform spread of local anaesthetic. The block

was given under all aseptic conditions using linear probe (6-13 MHz frequency) with

sufficient application of sterilized gel and covered with sterile cover under AAP, with

patients in supine position and head tilted to 45 degrees to the opposite side with no head

ring in place. After fifteen minutes the excellent anaesthesia was obtained in the arm, the

surgery was started without the use of tourniquet. The surgery lasted for 2 hrs and the blood

loss was approximately 200 mL. Once the dressing was done on the operated side, we

prepared for the block on the other side and the right axilla was cleaned with betadine

solution and drapped with sterile sheath. We instituted USG guided axillary block utilizing in

plane technique with 20 mL of local anaesthetic (9 mL of 1.5 lignocaine with adrenaline + 10

ml 0.25% of levobupivacaine ) (4 mg) along with 1 mL of dexamethasone for open fracture

distal shaft of humerus .The radial nerve, median nerve and ulnar nerve were blocked with

5mL of LA solution each, whereas the musculocutaneous nerve was blocked by separate

injection into the substance of coracobrachialis muscle. After adequate anaesthesia of the

arm, the surgery lasted for 1.5 h, with approximately 100mL blood loss. The patient was

comfortable during the procedure that lasted for approximately 1.5hr. In the postoperative

period, the patient experienced no pain for approximately 8h after the surgery in left arm,

while she complained of pain (VAS>3) in the right arm just five hours after surgery The

following day, patient was doing well without any residual numbness.
Discussion
In the literature, there is less evidence of bilateral brachial block being used as sole technique

for providing anaesthesia for upper limb procedures. Although, only very few clinical

situations seem amenable to a bilateral block, especially patients of poly trauma sustaining

multiple injuries, making general anaesthesia risky for the patient. Theoretically, it increases

the probability of local anaesthetic systemic toxicity (LAST) in general1 and the potential

adverse effects of specific approach used ie pneumothorax with supraclavicular approach,

hemi diaphragmatic paralysis (HDP) with interscalene and supraclavicular approach etc.

However, the use of peripheral nerve blocks for surgical anaesthesia has increased

significantly with the advent of ultrasound-guided techniques.

We chose to perform a USG guided supraclavicular block on the side where the skin lesions

reached more proximally on the arm because it has the ability to provide reliable anesthesia

of the proximal and midarm and moreover the use of USG has proved to enhance the quality

of block and minimize the complications. The sonographically guided axillary block was

instituted on right side, as distal arm at the level of elbow (medial aspect) was involved in the

fracture. The surgery done was open reduction and fixation using plate and screws on both

sides.

Recent studies,2-3 have shown that volume of local anesthetic can be significantly

reduced when axillary blocks are performed under ultrasound guidance. An ED95-volume of

0.11 mL/mm2 of mepivacaine has been shown to be effective for individual nerves of axillary

block, which translates into 0.7–1 mL of local anesthetic for individual nerves.4 However, in

another study,5 the effective volume of LA was calculated to be 20 ml for axillary block and

therefore it is recommended by the authors to use at least 4-5 mL of local anaesthetic for each
nerve during axillary nerve block. Therefore, we used 5mL of local anaesthetic solution per

nerve for axillary block and it resulted in dense block.

In the study by Gupta et al,6 the authors concluded that the ED50 of bupivacaine 0.5% for

USG guided supraclavicular brachial plexus block is in the range of 8.9 mL to 13.4 mL,

provided the spread of local anaesthetic is well appreciated on USG . As we were able to

visualize the good spread of LA, we didn’t administer the LA beyond 15 mL in

supraclavicular block, however the margin for injecting more local anaesthetic solution was

still with us.

Kim W et al,7 conducted a study comparing the clinical effect of 0.375% levobupivacaine

with 0.5% levobupivacaine for ABPB using USG guidance with nerve stimulation for upper

limb surgery. The authors concluded that when performing ABPB with 0.375% or 0.5%

levobupivacaine, there were no significant differences in the clinical efficacy, including the

time to block onset, quality of block and patient satisfaction. 0.375% levobupivacaine would

be a reliable and safer choice for ABPB aiming to reduce systemic LA toxicity.

Thereby we have used 0.375% of levobupivacaine with 5 ml of drug per nerve (total volume

of drug being 20ml), and in our study to minimize the dose related side effects.

The sequential block on the opposite side after the duration of two hours was in our favour.

We assume that because the total dose of local anesthetic was injected over an extended

period of time, the plasma level of the drug given in supraclavicular block would have been

declined to acceptable levels.

Moreover, we used levobupivacaine in the axillary block by virtue of its better safety profile

as compared to bupivacaine. Similarily in another case report by Bhat Pai et al,8 the authors

employed bilateral brachial block [supraclavicular and axillary] in patient of hypertrophic

obstructive cardiomyopathy patient. However the authors utilized paraesthesia technique and
injected 24 ml of LA in supraclavicular block and 38mL in axillary block sequentially with

uneventful anaesthesia.

Therefore in our opinion USG guided bilateral brachial plexus block if indicated, can be

successfully performed after careful consideration regarding the approach, the total volume of

LA, adjuvants etc . Moreover, thorough preoperative assessment, availability off clinical

expertise, monitoring facilities and strict vigilance are necessary to guarantee an optimal

standard of care in polytrauma patients.

1. Brendan T. Finucane and Ban C.H. Tsui, Complications of Brachial Plexus Anesthesia, in

Brendan T. Finucane (Ed.), Complications of Regional Anesthesia, Chapter 8, second edition,

(New York: Springer, 2007)121-148.

2. O’Donnell BD, Iohom G. An estimation of the minimum effective anesthetic volume of

2% lidocaine in ultrasound-guided axillary brachial plexus block. Anesthesiology

2009;111:25-9

3. Gonzalez AP, Bernucci F. Pham K, et al. Minimum effective volume of lidocaine for

double injection ultrasound-guided axillary block. Reg Anaesth Pain Med 2013;38:16-20.

4. Vastrad VV, Mulimani SM, Talikoti DG, Sorganvi VM. A comparative clinical study of

ultrasonography- guided perivascular and perineural axillary brachial plexus block for upper

limb surgeries. Anesth Essays Res 2019;13:163-8.

5. Eichenberger U, Stoeckli S, Marhofer P et al. Minimal local anesthetic volume for

peripheral nerve block: a new ultrasound guided, nerve dimension-based method. Reg Anesth

Pain Med 2009;34:242-6.

6. Gupta PK, Pace NL, Hopkins PM. Effect of body mass index on the ED50 volume of

bupivacaine 0.5% for supraclavicular brachial plexus block. British J Anaesth 2010;4:490-5.
7. Kim W, Kim YJ, Kim JH, Kim DY, Chung RK, Kim CH. Clinical comparison of 0.5%

and 0.375% levobupivacaine for ultrasound – guided axillary brachial plexus block with

nerve stimulation. Korean J Anesth 2012;62:24-9.

8. BhatPai RV, Hegde HV, Santhosh M, Roopa S, Deshpande SS, Rao PR. Bilateral brachial

plexus blocks in a patient of hypertrophic obstructive cardiomyopathy with hypertensive

crisis. Indian J Anaesth 2013;57:72-75

Pavicic SJ, Vidjak V ,Tomulic K,Zenko J. Effect of age on minimum effective volume of local

anesthetic for ultrasound guided supraclavicular brachial plexus block block. Acta

Anaesthesiol Scand 2013;57:761-6.