Veterinary Anaesthesia and Analgesia, 2010, 37, 154–161
RESEARCH PAPER
Clinical evaluation of the anaesthetic sparing effect of
brachial plexus block in cats
Martina Mosing, Heidi Reich & Yves Moens
Clinic of Anaesthesia and Perioperative Intensive Care, University of Veterinary Medicine, Vienna, Austria
Correspondence: Martina Mosing, Faculty of Veterinary Science, The University of Liverpool, Leahurst, Chester High Road, Neston CH64
7TE, UK. E-mail: mmosing@liverpool.ac.uk
Abstract
Objective To evaluate the isoflurane sparing effect
and the post-surgical analgesia provided by a
brachial plexus block (BPB) in cats undergoing
distal thoracic limb surgery.
Study design Prospective randomized blinded clini-
cal study.
Animals Twenty client-owned cats.
Methods Cats were assigned to receive either no
BPB (group NB) or a nerve stimulator guided BPB
(group BPB) using lidocaine (3.6 mg kg)1) and
bupivacaine (1.2 mg kg)1). Pre-medication con-
sisted of midazolam and ketamine intravenously
(IV). Anaesthesia was induced with propofol IV to
effect and maintained with isoflurane delivered in
oxygen and a continuous rate infusion of fentanyl
(2 lg kg)1 hour)1). End-tidal isoflurane concentra-
tion (FE¢ISO) was adjusted every 3 minutes guided
by changes in cardiorespiratory parameters and
reflexes present, to maintain a stable depth of
anaesthesia. Five time points were chosen to record
all parameters and compare values between groups.
Recovery and post-operative pain assessment were
performed using a visual analogue scale (VAS) at 15
and 45 minutes after extubation and thereafter at
hourly intervals until 5 hours after placement of the
BPB.
Results No clinically significant differences were
seen for heart rate, respiratory rate and non-
154
doi:10.1111/j.1467-2995.2009.00509.
invasive blood pressure between groups. Mean
FE¢ISO was significantly lower in group BPB com-
pared with group NB at all time points. In group NB,
all intraoperative measurements of FE¢ISO were
significantly higher compared with baseline (3 min-
utes before start of surgery) measurements. During
recovery, VAS scores for group BPB were signifi-
cantly lower than for group NB. Additional analge-
sics were needed in all cats within the study period.
Conclusion and Clinical relevance In cats undergo-
ing orthopaedic surgery of the thoracic limb, BPB
reduced intra-operative isoflurane requirement and
pain during the early post-operative period when
compared with procedures without a BPB. BPB is a
useful adjunct to anaesthesia in such cases.
Keywords brachial plexus block, cat, isoflurane spa-
ring effect.
Introduction
The use of a balanced anaesthetic protocol is a
widely used concept in companion animal anaes-
thesia (Ilkiw 1999). Locoregional anaesthetic tech-
niques may provide a useful contribution to such
protocols.
A brachial plexus block (BPB) using local anaes-
thetic drugs provides analgesia of the antebrachium
and is used commonly in human anaesthesia (Neal
et al. 2002). The use of a BPB in dogs has been
described in several studies in both clinical and
experimental settings (Moens & Caulkett 2000;
Futema et al. 2002; Wenger 2004; Wenger et al.

2005). There is limited information on the use of
BPBs in cats. One study documents onset time and
duration of brachial plexus blockade using bupiva-
caine in an experimental setting (Freitas et al.
2002). The use of a nerve stimulator to localize
the nerves of the brachial plexus and therefore
refine the technique otherwise based on anatomical
landmarks has been described in dogs, but not in
cats (Wenger 2004; Wenger et al. 2005). To the
authors’ knowledge, there is no published informa-
tion on the clinical use of BPBs in cats.
This study investigated the efficacy of a BPB as
part of a balanced anaesthetic protocol in feline
patients undergoing orthopaedic surgery of the
distal thoracic limb. The isoflurane sparing effect
and post-operative analgesia were evaluated.
Materials and methods
The study was designed as a blinded prospective
randomized clinical study.
The study procedure was discussed and approved
by the institutional ethics committee of the Univer-
sity of Veterinary Medicine of Vienna and had
governmental approval (GZ 68.205/196-BrGT/
2004).
Animals
Twenty client-owned cats of various breeds pre-
senting for surgery of the thoracic limb distal to the
elbow joint were included initially in the study. The
evening before surgery, cats were assessed and
assigned an American Society of Anesthesiologists
(ASA) grade based on clinical examination, bio-
chemical and haematological analysis and thoracic
radiographs. Cats classified as ASA IV and V were
excluded from the study. Of the 20 cats selected and
assigned to protocol, one cat in group BPB had to be
excluded because of technical problems. Data from
one cat in group NB were excluded retrospectively
as additional pathology was detected post-opera-
tively (traumatic rupture of the urinary bladder)
that could have influenced results. Thirteen of the
remaining 18 cats were classified ASA II and five
ASA III.
Data from the remaining 18 cats were analyzed;
nine cats in each group. Six cats were females and
12 males with a mean ± SD (range) body mass of
4.2 ± 1.4 kg (1.8–7.6 kg), aged 3–170 months.
Fifteen cats had a history of trauma within the
previous week. Surgical procedures in those 15 cats
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Brachial plexus block in cats M Mosing et al.
included fracture repair of the radius and/or ulna
(group BPB/NB: 5/6) or metacarpal bones (group
BPB/NB: 2/2) using plates, external fixators, pins or
screws. Three cats underwent elective surgeries
(group BPB/NB: 2/1); two carpal arthrodeses and
one plate removal and metacarpal fracture repair on
the same leg (fracture without trauma).
Study protocol
Cats were randomly allocated to one of two groups;
group BPB received a BPB whereas group NB
received no block. Randomization was achieved by
writing equal numbers of BPB and NB on 20 pieces
of paper and then blindly selecting one for each cat.
A pain score, using the visual analogue scale (VAS),
was assigned by the anaesthetist/assessor on the
evening before surgery to all cats whilst they were
in their kennels. The anaesthetist was an experi-
enced clinician familiar with pain assessment and
VAS scoring in cats. The same anaesthetist per-
formed all pain assessments. A VAS score (Grue-
nenthal Pharma, Ireland) was used with a scale
between 0 and 100 mm with no pain on the left
and the worst pain possible for this procedure on the
right.
Food was withheld for at least 8 hours before
surgery, but the cats had free access to water until
pre-medication. All cats had a catheter placed in
the cephalic or medial saphenous vein before
further pre-anaesthetic evaluation. Cats were
pre-medicated with 0.3 mg kg)1 midazolam (Mid-
azolam 5 mg mL)1; Mayrhofer Pharmazeutika,
Austria) and 3 mg kg)1 ketamine (Ketasol; Dr E.
Gräub AG, Switzerland) intravenously (IV). Prop-
ofol (Propofol 1% ‘Fresenius’; Fresenius Kabi Aus-
tria GmbH, Austria) IV was given to effect (mean
dose 3.9 ± 2.2 mg kg)1) until endotracheal intu-
bation was possible. Anaesthesia was maintained
with isoflurane (Furane, Baxter, Austria) in oxygen
supplied at a rate of 200 mL kg)1 minute)1 via a
Mapleson D breathing system. Lactated Ringer’s
solution (Ringer Lactat ‘Fresenius’; Fresenius Kabi
Austria GmbH, Austria) was administered IV as a
continuous rate infusion (CRI) of 10 mL kg)1
hour)1 throughout the procedure. A fentanyl CRI
(Fentanyl-Janssen; Janssen-Cilag Pharma, Austria)
was administered IV at a rate of 2 lg kg)1 hour)1.
Heart rate (HR derived from electrocardiogram),
arterial haemoglobin O2 saturation (SpO2 from
pulse oximetry), oesophageal temperature (C),
respiratory rate (fR), end-tidal CO2 partial pressure
155
Brachial plexus block in cats M Mosing et al.
(PE¢CO2) and end-tidal isoflurane concentration
(FE¢ISO%) were monitored using a multi-channel
patient monitor calibrated within the time period
recommended by the manufacturer (HP Omni Care
CMS Patient Monitor; HP GmbH, Germany). Gas
measurement readings were recorded with a min-
imum time gap of 3 minutes between changing
vaporizer setting and recording values or just at the
time point of changing vaporizer setting to adapt
depth of anaesthesia. Non-invasive arterial blood
pressure (NIBP) was measured every 5 minutes
with the Doppler method (Ultrasonic Doppler Flow
Detector Model 811-B; Parks Medical Electronics
Inc., OR, USA). The Doppler probe was placed on
the plantar surface of a distal pelvic limb. A blood
pressure cuff (sized as approximately 40% of the
circumference of the limb) attached to a sphygmo-
manometer was placed proximal to the hock.
Brachial plexus block
Pre-surgical preparation was identical for cats in
both groups and involved a standard pattern of
hair-clipping cranial to the shoulder joint. Cats were
then transferred into the operating theatre where
they were placed in lateral recumbency with the
affected limb uppermost. Depending on their group
allocation, the cat received either a BPB (group BPB)
or a needle stab at the theoretical injection site
(group NB). The same experienced person performed
the BPB in all cats and the anaesthetist/assessor left
the theatre during BPB placement to guarantee
blinding to group allocation.
For patients receiving a BPB, a mixture of
lidocaine 1% (Xylanest purum 1%; Gebro Pharma
GmbH, Austria) and bupivacaine 0.5% (Carbostesin
0.5%; Astra Zeneca GmbH, Austria), 3.6 mg kg)1
and 1.2 mg kg)1 respectively, was used resulting in
a total volume of 0.6 mL kg)1. To ensure accuracy,
both drugs were drawn up in separate syringes and
mixed together in a third syringe.
The block was performed using a nerve stimula-
tor (Stimuplex DIG; B. Braun Melsungen GmbH,
Germany) to locate the nerves of the brachial
plexus. The nerve stimulator delivered electrical
impulses at a frequency of 2 Hz and an impulse
width of 0.1 msecond via an insulated stimulation
needle. A stimulation needle (Stimuplex D; B. Braun
Melsungen GmbH, Germany) with a tube attached
to the hub of the needle was used. The tube prevents
changes in the position of the needle when the
syringe is attached and the drugs are administered.
156  2010 The Authors. Journal compilation  2010 Association of Veterinary Anaesthetists, 37, 154–161
The stimulating needle was introduced through a
small stab puncture at a point craniomedial to the
shoulder joint and advanced in a caudo-dorsal
direction. The current of the nerve stimulator was
initially set at 1 mA. Once evoked movement of the
limb was noted, the current was gradually reduced
(down to 0.3 mA) to allow more precise location of
the nerve. Negative pressure was applied to the
syringe to confirm that the needle was not placed in
a blood vessel or in the thorax. An increment of the
total volume of local anaesthetic was then injected
as slowly as possible until evoked movement was
abolished. An additional volume equal to that
already administered to stop limb movement was
then given at that site. Subsequently, the needle tip
was moved slightly in different directions to see if
other plexus branches could be identified by
twitches, and where this happened, injection was
repeated as described. If no further branches could
be identified, the remaining amount of the total
0.6 mL kg)1 solution was administered at the site of
previous major limb movement. Finally, the tube
and the needle were flushed with the dead space
volume (0.45 mL) using sterile saline. At least
15 minutes were allowed between the BPB and
recording of base line values.
Intraoperative period
Baseline values (TBL) of HR, fR, NIBP and FE¢ISO
were recorded 3 minutes before the start of surgery.
During surgery, four measuring time points were
selected for recording values for HR, fR, NIBP and
FE¢ISO; skin incision (TSI), repositioning of fracture
or time point of maximal stretch of the joint and the
surrounding soft tissue during carpal arthrodeses
(TREP), bone drilling (TBD) and skin suturing (TSS).
During the whole procedure, FE¢ISO was titrated to
maintain an adequate depth of surgical anaesthesia.
Changes in HR, fR, NIBP and reflexes present (pal-
pebral reflex, globe position and movement) were
used to assess depth of anaesthesia. End-tidal iso-
flurane concentration was decreased in steps of
0.1% every 3 minutes if the recorded physiological
parameters remained within a 20% range compared
with base line values; FE¢ISO was increased in steps
of 0.2% up to a maximum of 2.0% when two of the
three parameters suddenly increased more than
20% or a single parameter suddenly increased more
than 30%. If HR, fR and NIBP continued to increase
when FE¢ISO was 2.0%, the cat received a bolus of
2 lg kg)1 fentanyl IV. If NIBP decreased below

80 mmHg, the infusion rate of lactated Ringer’s
solution was increased to 15 mL kg)1 hour)1 and a
bolus of 4 mL kg)1 of hetastarch (HAES-steril 6%
(200/0.5); Fresenius Kabi Austria GmbH, Austria)
was given IV over 5 minutes. If necessary, the bolus
was repeated within the following 10 minutes. If
this failed to increase blood pressure, a dobuta-
mine CRI of 1–5 lg kg)1 minute)1 (Dobutamin
‘Nycomed’; Nycomed Austria GmbH, Austria) was
started and titrated to keep NIBP above 80 mmHg.
Recovery and post-operative pain assessment
Cats were monitored continuously for 2 hours post-
operatively. Pain was assessed using a VAS at 15
and 45 minutes after extubation and thereafter at
hourly intervals until 5 hours after extubation. If
VAS score was >40 mm at any of the preset time
points, the cat received methadone 0.1 mg kg)1
(Heptadon; EBEWE Pharma GesmbH, Unterach,
Austria) IV and carprofen 4 mg kg)1 (Rimadyl;
Pfizer corporation Austria GmbH, Austria) subcu-
taneously (SC).
Administration of rescue analgesia (methadone
0.1 mg kg)1 IV and carprofen 4 mg kg)1 SC,
followed by methadone 0.1 mg kg)1 IV if necessary)
was allowed at any time after extubation whenever
the cats were uncomfortable and the reactions were
likely to be associated with pain.
Data from those cats receiving additional analge-
sia in the post-operative period were excluded from
further evaluation from that time point onward.
Statistics
Statistical analysis was performed using SPSS
v.11.5 (IBM, IL, USA). Normality was tested by use
of the Shapiro–Wilk test. Statistics comparing
treatments and changes over time were analysed
using a General Linear Model with Tukey’s post hoc
test for multiple comparisons. Difference in heta-
starch and dobutamine requirements between
groups was tested using Fisher’s Exact test. Post-
operative pain scores within groups were analysed
via chi-squared test for best fit. Values of p < 0.05
were considered significant.
Results
No significant differences in age, ASA score and
body mass of the cats were detected between
groups. Mean duration of anaesthesia ± SD (range)
 2010 The Authors. Journal compilation  2010 Association of Veterinary Anaesthetists, 37, 154–161
Brachial plexus block in cats M Mosing et al.
in minutes was 162 ± 43 (110–245) and
177 ± 41 (125–240) for group BPB and NB,
respectively, and was not statistically different
between groups.
Isoflurane requirements were significantly higher
in group NB, compared with group BPB at all five
time points (Table 1). Mean FE¢ISO during surgery
ranged from 1.5% to 1.7% and 1.0% to 1.1% for
group NB and BPB, respectively (Table 1). Cats in
group NB required significantly more FE¢ISO at all
time points during surgery compared with base line
values except at TSI. In group BPB, isoflurane
requirements were not significantly different from
baseline at any time point. In group NB, one cat
received three and one cat one rescue boluses of
fentanyl.
No significant differences for HR, fR and NIBP
could be detected between groups with the excep-
tion of HR at TSI and fR at TREP (Table 1). In group
BPB, the HR, fR and NIBP remained clinically stable
throughout the study period and no statistically
significant differences were found in any of the
aforementioned parameters compared with base-
line. HR increased significantly at TSI and TSS
compared with baseline in group NB (Table 1).
Three cats out of nine in group BPB and six out of
nine in group NB required two boluses of hetastach
and a CRI of dobutamine to maintain NIBP
>80 mmHg. The difference was not statistically
significant.
One cat out of group NB and two out of group
BPB showed intermittent cardiac arrhythmias (pre-
mature ventricular contractions), none of which
required treatment. All three of these cats received a
dobutamine CRI during anaesthesia. No adverse
side effects that could be related to BPB were
observed.
Post-operative pain scores (VAS) for both groups
increased significantly compared with pre-operative
scores (Fig. 1). Five cats in group NB received
methadone and carprofen prior to the first pain
evaluation (15 minutes after extubation) as a result
of obvious signs of pain immediately after extuba-
tion. These cats were excluded from further evalu-
ation. For the remaining cats, the mean VAS was
significantly lower for group BPB (54 ± 17 mm,
n = 9) compared with group NB (82 ± 5 mm,
n = 4) 15 minutes after extubation (Fig. 1). How-
ever, the remaining four cats in group NB and five
cats in group BPB required a methadone and
carprofen bolus after the first pain evaluation
15 minutes after extubation. The remaining four
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Brachial plexus block in cats M Mosing et al.

Table 1 Mean value (±SD) for end-tidal Isoflurane (FE¢ISO), heart rate (HR), respiratory rate (fR), non-invasive arterial
blood pressure (NIBP, Doppler measurement) at five measurement time points: baseline values 3 minutes before start of
surgery (TBL), skin incision (TSI), repositioning of fragments (TREP), bone drilling (TBD) and skin sutures (TSS); bpm, beats
minute)1; brpm, breaths minute)1; group NB (n = 9): no brachial plexus block; group BPB (n = 9): brachial plexus block

FE¢ISO (%) HR (bpm) fR (brpm) NIBP (mmHg)

NB BPB NB BPB NB BPB NB BPB

TBL 1.2 ± 0.2* 0.9 ± 0.1 133 ± 19 127 ± 17 16 ± 5 13 ± 4 97 ± 26 88 ± 11

TSI 1.5 ± 0.3*  1.0 ± 0.2 148 ± 23* 123 ± 25 18 ± 7 13 ± 4 113 ± 33 97 ± 17
TREP 1.7 ± 0.3*  1.1 ± 0.3 172 ± 17  149 ± 34 26 ± 7* 15 ± 5 136 ± 45 99 ± 36
TBD 1.6 ± 0.3*  1.0 ± 0.2 159 ± 17 142 ± 16 20 ± 8 16 ± 8 132 ± 35 109 ± 28
TSS 1.6 ± 0.3*  1.0 ± 0.3 163 ± 17  141 ± 25 24 ± 11 18 ± 12 113 ± 35 104 ± 25

*Significant difference between groups;  significant difference with TBL.

100 isoflurane sparing effect. The significant FE¢ISO

90 *
difference between group NB and BPB evident at
80
the baseline measurements, taken 15 minutes after
Pain score (VAS)

70
60
50
40
30
20
n=9 n=9
10
0 groups, although no differences had been found in
VAS pre
Group NB
Figure 1 Pain scores as measured by a Visual analogue
scale (VAS) for nine cats with brachial plexus block (group
BPB) and nine cats without brachial plexus block (group
NB) on the day before surgery (VAS pre) and 15 minutes
after extubation (VAS 15 minutes); *Significant difference
between groups.
cats in group BPB received analgesics 45 (n = 1),
165 (n = 2) and 225 minutes (n = 1) after extuba-
tion.
Discussion
In this study, there was an isoflurane sparing effect
during orthopaedic surgery of the thoracic limb in
cats, which had received a BPB. The time period of
3 minutes allowed between change of vaporizer
setting, equilibration of alveolar and inspiratory
isoflurane concentration and evaluation of the
depth of anaesthesia appeared to be sufficient to
adapt depth of anaesthesia in this clinical setting.
Successful anaesthesia of the brachial plexus
nerves is the most likely reason for the observed
*
the BPB, could be interpreted as a reduction in
nociceptive input to the CNS from traumatized
tissue. This may occur as a result of local blockade
n=4 n=9
or systemic absorption of the local anaesthetic from
the injection site. This difference could also have
resulted from unequal nociceptive input between
VAS 15 minutes
Group BPB pain scores the evening before the procedure.
Baseline measurements immediately prior to per-
forming BPB would have clarified this statement.
The effect of a reduction in FE¢ISO found in this
study could represent a distinct advantage for the
patient since the cardiovascular and respiratory
depressant effects of volatile agents are directly
related to FE¢ISO concentration (Steffey & Howland
1977; Steffey & Mama 2007). Less cardiovascular
support (administration of hetastach and dobuta-
mine CRI) was needed in group BPB (three out of
nine) compared with group NB (six out of nine), but
the difference was not statistically significant. The
fact that none of the cats reacted to volume
expansion by hetastarch could be an indicator of
low myocardial contractility or an insufficient
volume of colloids. However, the (non-significant)
higher need of positive inotropic support in group
NB might be directly related to the higher isoflurane
concentration needed.
A low dose of fentanyl for CRI was chosen to
allow adequate spontaneous ventilation during
surgery. Two cats in group NB and none in group
BPB needed rescue analgesia (2 lg kg)1 fentanyl
bolus IV) in addition to this CRI. Although fentanyl

158  2010 The Authors. Journal compilation  2010 Association of Veterinary Anaesthetists, 37, 154–161

CRI can cause respiratory depression, none of the
cats required intermittent positive pressure ventila-
tion defined by the trend of the measured PE¢CO2.
Two cats in group BPB required an increase in
FE¢ISO of more than 0.3% at TREP. This finding
suggests incomplete block of the brachial plexus
nerves. Incomplete or partial blockade is a well-
described complication in human regional anaes-
thesia and its incidence, depending on the technique
used varies widely from 4% to 100% (De Tran et al.
2007). Complete block may be more difficult to
obtain in animals as the major nerve trunks of the
plexus are loosely arranged and are more separated
by connective tissue than in humans. However, the
incidental need for higher FE¢ISO of more than 0.3%
at TREP in the group BPB is not necessarily related to
incomplete brachial plexus blockade. Extensive
manipulation during repositioning of fractures in
small cats induces nociceptive stress in muscles and
bones situated above the area desensitized by the
BPB. Another potential explanation is that the
duration of block might have been inadequate
although TREP was within an hour after BPB in
both cats.
In this study, muscle contractions were provoked
easily by stimulating the brachial plexus nerves
using electrical nerve stimulation with currents of
0.3–0.5 mA. This is comparable with findings in
dogs where muscle contraction caused by a current
of 0.2–0.4 mA was used to identify individual nerve
branches (Mahler & Adogwa 2008). However,
identification of different nerve branches responsible
for flexion or extension as described in dogs
(Wenger et al. 2005; Mahler & Adogwa 2008)
was not possible in our feline patients. Possible
reasons could include the smaller size of the limb
making differentiation of movement difficult, or that
even low currents stimulate several nerve trunks at
the same time in the small size patient as a result of
the close proximity of these anatomical structures.
A change in chronaxy (duration of the stimulus)
was not possible with the nerve stimulator used in
this study.
Effectiveness and duration of brachial plexus
blockade will be influenced by the nature of the
local anaesthetic, its concentration and the total
volume used. In dogs, a volume of 0.25 mL kg)1
to approximately 1.0 mL kg)1 was used with a
100% success rate (Futema et al. 2002; Wenger
et al. 2005). Skarda & Tranquilli (2007) recom-
mend a volume of 1 mL of either 2% lidocaine or
0.5% bupivacaine for BPB in cats. This volume
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Brachial plexus block in cats M Mosing et al.
would result in a dose of 5 mg kg)1 of lidocaine
and 1.0 mg kg)1 of bupivacaine for a 5-kg cat but
double the dose for a 2.5 kg cat. In this study, the
volume was set at a total of 0.6 mL kg)1 of a
lidocaine–bupivacaine mixture. Doses were based
on clinical experience and the clinical observation
that the effect of the BPB appeared to reduce
intraoperatively (increase in autonomic responses
to surgical stimulus) with volumes described in
dogs (Wenger 2004; Wenger et al. 2005). The
doses for lidocaine and bupivacaine used in this
study are lower than the mean convulsive and
mean cardiotoxic dose of lidocaine (11.7 and
47.3 mg kg)1, respectively) and bupivacaine (3.8
and 18.4 mg kg)1, respectively) described after IV
administration in cats (Chadwick 1985). In Chad-
wick’s (1985) paper, plasma concentrations of
lidocaine and bupivacaine were 140 and 37 lg
mL)1 at time of first recorded electroencephalo-
graphic changes. However, Pypendop & Ilkiw
(2005) demonstrated that concentrations of 7 lg
mL)1 lidocaine in cats were sufficient to result in
significant changes in haemodynamic parameters,
with decreased HR, cardiac index and stroke
index, and therefore suggested that IV lidocaine
should not be used to reduce isoflurane require-
ments in this species. The aim of this study was to
reduce isoflurane requirements using lidocaine in
combination with bupivacaine by reducing noci-
ceptive input because of peripheral local block.
Absorption of drug from a certain tissue and
resulting peak plasma concentrations depend on
the vascularity of the tissue, the protein binding of
the drug and the effect of the drug on the vessels
(Rosenberg et al. 2004). Peak plasma concentra-
tions of lidocaine after BPB is lower compared
with intercostal block or epidural administration
of the same dose (Rosenberg et al. 2004). Plasma
concentrations of lidocaine and bupivacaine were
not evaluated in our study, and further investi-
gations to measure these are required to rule out
any negative effects of systemic absorption of
lidocaine or bupivacaine at the doses (3.6 mg
kg)1 lidocaine and 1.2 mg kg)1 bupivacaine) used
for BPB.
Cardiac arrhythmias (premature ventricular con-
tractions of various degree without obvious clinical
impact on haemodynamics) were observed during
anaesthesia in three cats (one group NB; two group
BPB). Possible explanations for these findings are
myocarditis after thoracic trauma (Otto & Tassani-
Prell 1993), pre-existing cardiac disease or the
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Brachial plexus block in cats M Mosing et al.
arrhythmogenic effect of dobutamine. Toxic side
effect following absorption of bupivacaine, which
has arrhythmogenic properties, although unlikely,
given the previously mentioned cardiotoxic doses, is
still one possible explanation.
The post-operative evaluation of the contribution
of brachial plexus blockade to absence/presence of
pain in a clinical setting relies on pain scoring (VAS)
and on evaluation of BPB-induced sensory and/or
motor block. The latter was not possible because of
the presence of a limb cast after fracture repair or an
external fixator (three cats in group BPB and three
cats in group NB). The relatively frequent and rapid
need for rescue analgesia in cats in both groups
suggests a shorter duration of sensory block com-
pared with dogs. In dogs, duration of action of
brachial plexus blockades was reported to be up to
8 hours using a lidocaine–bupivacaine mixture
with the same amount of bupivacaine kg)1 as used
in this study (Wenger et al. 2005). In one experi-
mental study, 0.25% and 0.75% bupivacaine (1 mg
kg)1) was used for BPBs performed in cats (Freitas
et al. 2002). No surgery was performed on these
cats and the mean duration of the block with both
concentrations was approximately 3 hours. These
results, together with those of this study suggest
that the duration of a brachial plexus blockade in
cats is shorter than in dogs. No obvious explanation
for the longer duration of sensory block was found
for the three cats in this study, which did not
require further analgesia 2 hours after extubation of
the trachea. The nature (one radial and two
metacarpal fractures treated with a plate and
intramedullary pins) or duration of the procedure,
pre-operative pain scoring, surgeon or length of
time since trauma did not differ from those of the
other patients.
The fact that this study was designed as a clinical
study increases the heterogeneity in pre-operative
pain level, nociceptive input from the surgical site,
timing of the stimuli after application of the BPB and
duration of anaesthesia time. A larger number of
animals in the study would have compensated for
some of these factors.
In conclusion, the use of 3.6 mg kg)1 lidocaine
1% and 1.2 mg kg)1 bupivacaine 0.5% for brachial
plexus blockade in cats provides a useful anti-
nociceptive adjunct for balanced anaesthesia, and
allows significant reduction of isoflurane require-
ments. BPBs are occasionally incomplete and addi-
tional analgesic treatments must be available
during and after surgery. Duration of action of
160  2010 The Authors. Journal compilation  2010 Association of Veterinary Anaesthetists, 37, 154–161
brachial plexus blockade appears to be shorter in
feline compared with canine patients necessitating
close monitoring for signs of pain during recovery
from anaesthesia. Further investigation into the
plasma concentrations after BPB in cats is needed to
rule out negative systemic effects, as high doses of
lidocaine and bupivacaine are needed to achieve the
duration of action of brachial plexus blockade
lasting throughout surgery and recovery from
anaesthesia.
References
Chadwick HS (1985) Toxicity and resuscitation in lido-
caine- or bupivacaine-infused cats. Anesthesiology 63,
385–390.
De Tran QH, Clemente A, Doan J et al. (2007) Brachial
plexus blocks: a review of approaches and techniques.
Can J Anaesth 54, 662–674.
Freitas PM, Lima PCA, Mota FCD et al. (2002) Comparison
between the use of 0.25% and 0.75% bupivacaine
solution for the brachial plexus blockade in cats. Ars
Veterinaria 18, 218–222.
Futema F, Fantoni DT, Auler JOC Jr et al. (2002) A new
brachial plexus block technique in dogs. Vet Anaesth
Analg 29, 133–139.
Ilkiw JE (1999) Balanced anesthetic techniques in dogs
and cats. Clin Tech Small Anim Pract 14, 27–37.
Mahler SP, Adogwa AO (2008) Anatomical and experi-
mental studies of brachial plexus, sciatic, and femoral
nerve-location using peripheral nerve stimulation in the
dog. Vet Anaesth Analg 35, 80–89.
Moens NM, Caulkett NA (2000) The use of a catheter to
provide brachial plexus block in dogs. Can Vet J 41,
685–689.
Neal JM, Hebl JR, Gerancher JC et al. (2002) Brachial
plexus anesthesia: essentials of our current under-
standing. Reg Anesth Pain Med 27, 402–428.
Otto K, Tassani-Prell M (1993) Diaphragmatic rupture in
the domestic cat – pathophysiology and anesthesia
complications. Tierarztl Prax 21, 536–539.
Pypendop BH, Ilkiw JE (2005) Assessment of the
hemodynamic effects of lidocaine administered IV in
isoflurane-anesthetized cats. Am J Vet Res 66, 661–
668.
Rosenberg PH, Veering BT, Urmey WF (2004) Maximum
recommended doses of local anesthetics: a multifactorial
concept. Reg Anesth Pain Med 29, 564–575.
Skarda RT, Tranquilli WJ (2007) Local and regional
anesthetic and analgesic techniques: cats. In: Lumb &
Jones’ Veterinary Anesthesia and Analgesia. Tranquilli
WJ, Thurmon JC, Grimm KA (eds). Blackwell Publishing
Ltd, Ames, Iowa. pp. 595–603.
Steffey EP, Howland D Jr (1977) Isoflurane potency in the
dog and cat. Am J Vet Res 38, 1833–1836.
 Brachial plexus block in cats M Mosing et al.

Steffey EP, Mama KR(2007) Inhalation Anesthetics. In:
Lumb & Jones¢Veterinary Anesthesia and Analgesia (4th
edn). Tranquilli WJ, Thurmon JC, Grimm KA (eds).
Blackwell Publishing, Ames, Iowa. pp. 355–393.
Wenger S (2004) Brachial plexus block using electrolo-
cation for pancarpal arthrodesis in a dog. Vet Anaesth
Analg 31, 272–275.
Wenger S, Moens Y, Jaggin N et al. (2005) Evaluation of
the analgesic effect of lidocaine and bupivacaine used to
provide a brachial plexus block for forelimb surgery in
10 dogs. Vet Rec 156, 639–642.
Received 13 November 2008; accepted 10 June 2009.

 2010 The Authors. Journal compilation  2010 Association of Veterinary Anaesthetists, 37, 154–161 161
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