Letters to Editor Page | 142
2. 3.
point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med 2005;33:1764-9. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg 1991;72:823-6. Nakayama S, Takahashi S, Toyooka H. Curved-end guidewire for central venous cannulation in neonate. Anesth Analg 2003;97:917-8.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.125980
Anatomical variations of interscalene brachial plexus block: Do they really matter? Sir, Ultrasound inter-scalene brachial plexus block (ISBPB) is one of the most common procedures carried out for upper limb surgery. However, anatomical variations in brachial plexus anatomy with respect to scalene muscles are common.[1] With ultrasound guided interscalene block, the commonly described anatomical position of the brachial plexus lying between the anterior and middle scalene muscle is seen in 60% of cases only. These variations may pose a problem for nerve stimulation-based approaches to brachial plexus blocks above the clavicle. We report a brachial plexus anomaly at inter-scalene level that was uncommon in our experience. A 55-year-old male who presented to our operation theater at Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences with fracture radius was scheduled for open reduction and internal fixation. After patient’s consent, we planned to give ultrasound guided supraclavicular brachial plexus block. Since the brachial plexus imaging is most consistent in supraclavicular region, we routinely practice to scan supraclavicular region first and trace the plexus to inter-scalene groove. In our patient, brachial plexus anatomy at the level of supraclavicular region was near normal, but as we traced the plexus cranially toward inter-scalene groove, we noticed that the plexus was missing from inter-scalene groove. All ventral rami were seen stacked medial to the anterior scalene muscle (ASM) and lateral to internal jugular vein [Figure 1]. We confirmed these roots by stimulating with nerve stimulator. We gave supraclavicular nerve block to patient and surgery was uneventful with no complications and complete paresthesia with motor blockade. Sonography Vol. 8, Issue 1, January-March 2014
of the opposite side of the brachial plexus revealed no such anomaly and the ventral rami were all stacked between the two scalene muscles. The upper nerve roots of the brachial plexus in the interscalene region have been reported with 13-35% anomalies involving their relation to the ASM. The C5 and C6 nerve roots either course through or anterior to the ASM before assuming a normal position in the inter-scalene groove posterolateral to the subclavian artery.[1-3] There have been not many studies and a few case reports only on scalene muscle anomaly. In a study performed on cadavers by Harry et al., it was found that the most common variation was the penetration of the ASM by the C5 and/or C6 ventral rami.[1]
Figure 1: Inter-scalene brachial plexus anomaly (1) Internal jugular vein, (2) roots of brachial plexus, (3) sternocleidomastoid, (4) scalene ant, (5) scalene med
Saudi Journal of Anesthesia
Letters to Editor Page | 143
Chin et al. also reported an anomalous course of the C5 roots located just medial to the ASM. The C6 root lay slightly more lateral, but still inferomedial to the ASM.[4] In our patient, it seemed that most of the roots originating from ventral rami were medial to the ASM. In none of our cases we had encountered an anatomical variation like this. The clinical implications of these anomalies were more when only nerve stimulator is used for ISBPB. These anomalies lead to restriction of the distribution of the local anesthetic injection resulting in inadequate analgesia. The clinical significance of this anomaly is that in landmark guided technique there would have been sparing of the block in this patient. Therefore, in view of such high anatomical anomaly we recommend that ultrasound should be used in ISBPB. Since the anatomical anomaly in supraclavicular region is fewer; therefore, anesthetist should be prefer it in patients. In addition, sonographic assessment of more volunteers is needed so that frequency of this kind of anatomical variation may be assessed in the general population. Naveen Yadav, Nisha Saini, Arshad Ayub Department of Anesthesia, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence: Dr. Naveen Yadav, Department of Anesthesia, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
4.
Harry WG, Bennett JD, Guha SC. Scalene muscles and the brachial plexus: Anatomical variations and their clinical significance. Clin Anat 1997;10:250-2. Kessler J, Gray AT. Sonography of scalene muscle anomalies for brachial plexus block. Reg Anesth Pain Med 2007;32: 172-3. Natsis K, Totlis T, Tsikaras P, Anastasopoulos N, Skandalakis P, Koebke J. Variations of the course of the upper trunk of the brachial plexus and their clinical significance for the thoracic outlet syndrome: A study on 93 cadavers. Am Surg 2006;72:188-92. Chin KJ, Niazi A, Chan V. Anomalous brachial plexus anatomy in the supraclavicular region detected by ultrasound. Anesth Analg 2008;107:729-31.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.125981
Hyperhomocysteinemia: Anesthetic concerns Sir, Homocystinuria is an inherited autosomal recessive metabolic disorder, which occurs due to deficiency of enzymes (methionine synthase, cystathionine β synthase) involved in methionine metabolism.[1] Homocysteinemia, a separate, but related entity, may be due to similar genetic pre-disposition or in association with chronic renal failure, hypothyroidism, malignancies, methotrexate treatment, oral contraceptive use, and smoking. Hyperhomocysteinemia predisposes to coronary and cerebrovascular thrombotic disease.[2] A 28-year-old male patient presented to us with jejunal obstruction and was subsequently posted for laparotomy. He was a known case of coronary artery disease (CAD), but was not receiving any medications and his Echocardiography showed CAD, dilated left ventricle (LV) with regional wall motion abnormalities in left anterior descending Saudi Journal of Anesthesia
and left circumflex territories, severe LV dysfunction with ejection fraction of 30-35%. During investigation, for prothrombotic state following values were noted: Homocysteine levels of 25.37 μmol/l (3.7-13.9 μmol/l), factor VIII levels 396% (70-150%), C-reactive protein levels of 22.5 mg/l (0-5 mg/l), protein C (78.1%), protein S (92%), factor V Leiden (148%), and factor IX (98.4%). Lipid profile, coagulation profile, and lower limb venous Doppler study was normal. Pre-operatively, he was started on aspirin, atorvastatin, carvedilol, folic acid, pyridoxine, methylcobalamin, and enoxaparin. Adequate hydration and ambulation were also assured. In the operation theater, other than routine monitors, invasive blood pressure, and cardiac output monitoring using the flotrac/vigileoTM device (Edwards Lifesciences, Irvine, CA, USA) was carried out continuously. Pneumatic compression devices were applied on both legs. Vol. 8, Issue 1, January-March 2014
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
2. 3.
point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med 2005;33:1764-9. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg 1991;72:823-6. Nakayama S, Takahashi S, Toyooka H. Curved-end guidewire for central venous cannulation in neonate. Anesth Analg 2003;97:917-8.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.125980
Anatomical variations of interscalene brachial plexus block: Do they really matter? Sir, Ultrasound inter-scalene brachial plexus block (ISBPB) is one of the most common procedures carried out for upper limb surgery. However, anatomical variations in brachial plexus anatomy with respect to scalene muscles are common.[1] With ultrasound guided interscalene block, the commonly described anatomical position of the brachial plexus lying between the anterior and middle scalene muscle is seen in 60% of cases only. These variations may pose a problem for nerve stimulation-based approaches to brachial plexus blocks above the clavicle. We report a brachial plexus anomaly at inter-scalene level that was uncommon in our experience. A 55-year-old male who presented to our operation theater at Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences with fracture radius was scheduled for open reduction and internal fixation. After patient’s consent, we planned to give ultrasound guided supraclavicular brachial plexus block. Since the brachial plexus imaging is most consistent in supraclavicular region, we routinely practice to scan supraclavicular region first and trace the plexus to inter-scalene groove. In our patient, brachial plexus anatomy at the level of supraclavicular region was near normal, but as we traced the plexus cranially toward inter-scalene groove, we noticed that the plexus was missing from inter-scalene groove. All ventral rami were seen stacked medial to the anterior scalene muscle (ASM) and lateral to internal jugular vein [Figure 1]. We confirmed these roots by stimulating with nerve stimulator. We gave supraclavicular nerve block to patient and surgery was uneventful with no complications and complete paresthesia with motor blockade. Sonography Vol. 8, Issue 1, January-March 2014
of the opposite side of the brachial plexus revealed no such anomaly and the ventral rami were all stacked between the two scalene muscles. The upper nerve roots of the brachial plexus in the interscalene region have been reported with 13-35% anomalies involving their relation to the ASM. The C5 and C6 nerve roots either course through or anterior to the ASM before assuming a normal position in the inter-scalene groove posterolateral to the subclavian artery.[1-3] There have been not many studies and a few case reports only on scalene muscle anomaly. In a study performed on cadavers by Harry et al., it was found that the most common variation was the penetration of the ASM by the C5 and/or C6 ventral rami.[1]
Figure 1: Inter-scalene brachial plexus anomaly (1) Internal jugular vein, (2) roots of brachial plexus, (3) sternocleidomastoid, (4) scalene ant, (5) scalene med
Saudi Journal of Anesthesia
Letters to Editor Page | 143
Chin et al. also reported an anomalous course of the C5 roots located just medial to the ASM. The C6 root lay slightly more lateral, but still inferomedial to the ASM.[4] In our patient, it seemed that most of the roots originating from ventral rami were medial to the ASM. In none of our cases we had encountered an anatomical variation like this. The clinical implications of these anomalies were more when only nerve stimulator is used for ISBPB. These anomalies lead to restriction of the distribution of the local anesthetic injection resulting in inadequate analgesia. The clinical significance of this anomaly is that in landmark guided technique there would have been sparing of the block in this patient. Therefore, in view of such high anatomical anomaly we recommend that ultrasound should be used in ISBPB. Since the anatomical anomaly in supraclavicular region is fewer; therefore, anesthetist should be prefer it in patients. In addition, sonographic assessment of more volunteers is needed so that frequency of this kind of anatomical variation may be assessed in the general population. Naveen Yadav, Nisha Saini, Arshad Ayub Department of Anesthesia, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence: Dr. Naveen Yadav, Department of Anesthesia, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
4.
Harry WG, Bennett JD, Guha SC. Scalene muscles and the brachial plexus: Anatomical variations and their clinical significance. Clin Anat 1997;10:250-2. Kessler J, Gray AT. Sonography of scalene muscle anomalies for brachial plexus block. Reg Anesth Pain Med 2007;32: 172-3. Natsis K, Totlis T, Tsikaras P, Anastasopoulos N, Skandalakis P, Koebke J. Variations of the course of the upper trunk of the brachial plexus and their clinical significance for the thoracic outlet syndrome: A study on 93 cadavers. Am Surg 2006;72:188-92. Chin KJ, Niazi A, Chan V. Anomalous brachial plexus anatomy in the supraclavicular region detected by ultrasound. Anesth Analg 2008;107:729-31.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.125981
Hyperhomocysteinemia: Anesthetic concerns Sir, Homocystinuria is an inherited autosomal recessive metabolic disorder, which occurs due to deficiency of enzymes (methionine synthase, cystathionine β synthase) involved in methionine metabolism.[1] Homocysteinemia, a separate, but related entity, may be due to similar genetic pre-disposition or in association with chronic renal failure, hypothyroidism, malignancies, methotrexate treatment, oral contraceptive use, and smoking. Hyperhomocysteinemia predisposes to coronary and cerebrovascular thrombotic disease.[2] A 28-year-old male patient presented to us with jejunal obstruction and was subsequently posted for laparotomy. He was a known case of coronary artery disease (CAD), but was not receiving any medications and his Echocardiography showed CAD, dilated left ventricle (LV) with regional wall motion abnormalities in left anterior descending Saudi Journal of Anesthesia
and left circumflex territories, severe LV dysfunction with ejection fraction of 30-35%. During investigation, for prothrombotic state following values were noted: Homocysteine levels of 25.37 μmol/l (3.7-13.9 μmol/l), factor VIII levels 396% (70-150%), C-reactive protein levels of 22.5 mg/l (0-5 mg/l), protein C (78.1%), protein S (92%), factor V Leiden (148%), and factor IX (98.4%). Lipid profile, coagulation profile, and lower limb venous Doppler study was normal. Pre-operatively, he was started on aspirin, atorvastatin, carvedilol, folic acid, pyridoxine, methylcobalamin, and enoxaparin. Adequate hydration and ambulation were also assured. In the operation theater, other than routine monitors, invasive blood pressure, and cardiac output monitoring using the flotrac/vigileoTM device (Edwards Lifesciences, Irvine, CA, USA) was carried out continuously. Pneumatic compression devices were applied on both legs. Vol. 8, Issue 1, January-March 2014
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
