title: High volume and low concentration of anaesthetic solution in the perivascular interscalene sheath determines quality of block and incidence of complications.
abstract: OBJECTIVE
  In the perivascular sheath of the brachial plexus, the volume of anaesthetic solution determines the quality of anaesthetic cover. Fibrous septa may divide the perivascular space into compartments, leading to inadequate diffusion of the anaesthetic solution. The aim of our study was to obtain good anaesthesia and less complications using high volume of low concentration anaesthetic solution, overcoming the obstacle of the septa with a double approach to the scalene sheath.
  
  
  METHODS
  Sixty patients scheduled for shoulder capsuloplasty received both Winnie interscalene brachial plexus block and Pippa proximal cranial needle approach. The patients were randomly assigned to two groups. A constant dose of local anaesthetic was administered to each group: Group I (30 patients) received high volume (60 mL of anaesthetic solution) and Group II (30 patients) received low volume of solution (30 mL of anaesthetic solution). Sensory and motor block in the upper limb and complications were evaluated.
  
  
  RESULTS
  In all the patients the quality of anaesthesia obtained at the surgical site was excellent. In Group I also the areas supplied by the medial cutaneous nerves of the arm and forearm, ulnar, median and radial nerves were blocked (P < 0.002). Complications were only observed in Group II and consisted of bradycardia and hypotension (66% of the patients) and phrenic nerve paresis (27% of the patients).
  
  
  CONCLUSIONS
  The lower concentration of the anaesthetic solution avoids complications while increased volume provides good analgesic cover. The combination of the Winnie interscalene plexus block and the Pippa proximal cranial needle approach should contribute to fill up the scalene sheath overcoming the septa obstacles.
authors.affiliation: University of Florence, Department of Anaesthesiology, Florence, Italy.
authors.forename: P
authors.initials: P
authors.lastname: Pippa
authors.forename: P
authors.initials: P
authors.lastname: Cuomo
authors.forename: A
authors.initials: A
authors.lastname: Panchetti
authors.forename: M
authors.initials: M
authors.lastname: Scarchini
authors.forename: G
authors.initials: G
authors.lastname: Poggi
authors.forename: M
authors.initials: M
authors.lastname: D'Arienzo
mesh_terms: D000322:Adrenergic Agonists / Q000008:administration & dosage; D000328:Adult; D000368:Aged; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects*; D001917:Brachial Plexus / Q000098:blood supply / Q000187:drug effects*; D001919:Bradycardia / Q000139:chemically induced; D002045:Bupivacaine / Q000008:administration & dosage / Q000009:adverse effects; D004837:Epinephrine / Q000008:administration & dosage; D005260:Female; D006801:Humans; D007022:Hypotension / Q000139:chemically induced; D008012:Lidocaine / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000009:adverse effects* / Q000379:methods; D010291:Paresis / Q000139:chemically induced; D010791:Phrenic Nerve / Q000187:drug effects; D012785:Shoulder Joint / Q000294:innervation / Q000601:surgery
chemical_list: D000322:Adrenergic Agonists; D000779:Anesthetics, Local; D008012:Lidocaine; D002045:Bupivacaine; D004837:Epinephrine