case report

Ultrasound Guided Brachial Plexus Anaesthesia for Neonatal Ischaemia of the Upper Limb: A Case Report

Peter Marhofer1*, Katharina Goeral2, Katrin Klebermass-Schrehof2

1Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria

2Comprehensive Center for Pediatrics, Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Intensive Care and Pediatric Neurology, Medical University of Vienna, Vienna, Austria

*Corresponding author: Peter Marhofer, Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, A-1090 Vienna, Austria

Received Date: 10 March 2023

Accepted Date: 14 March 2023

Published Date: 16 March 2023

Citation: Marhofer P, Goeral K, Klebermass-Schrehof K (2023) Ultrasound Guided Brachial Plexus Anaesthesia for Neonatal Ischaemia of the Upper Limb: A Case Report. Ann Case Report. 8: 1219. DOI:https://doi.org/10.29011/2574-7754.101219

Abstract

Background: Neonatal limb ischaemia is a rare pathology. The main pathogenetic mechanism is thromboembolism and ultrasound guided regional anaesthesia is one possibility for treatment.

Case Report: We present one case of a multimorbid 770g preterm neonate with postnatal ischaemia of one upper extremity due to thromboembolism of the brachial artery. A series of ultrasound guided infraclavicular brachial plexus blocks reduced the area of ischaemia significantly and only the fingers remained as necrotic areas.

Conclusion: This is the first case of a neonate < 1000g where an ultrasound guided regional anaesthesia technique enables successful therapy of an ischaemic limb. Ultrasound guided regional anaesthesia is a highly precise technique where the local anaesthetic can be exactly administered around nerve structures. Thus, these techniques should be considered as a potential treatment for neonatal limb ischaemia.

Keywords: Infant, Premature (Unique ID: D007234); Upper Extremity (Unique ID: D034941); Ischaemia (Unique ID: D007511); Brachial Plexus Block (Unique ID: D065527); Ultrasonography (Unique ID: D014463)

Introduction

Neonatal limb ischaemia is a rare pathology with an incidence of 1:4.500 births per year [1]. Neonatal limb ischaemia can be divided into pre- and postnatal causes. Thrombosis and embolism are the main reasons due to a hypo fibrinolytic state with an antithrombin III, protein C and S deficiency [2]. In- utero-compression and postnatal iatrogenic causes (e.g. arterial catheterization) are other possibilities causing limb ischaemia. An extremely rare cause is feto-fetal transfusion syndrome with the subsequent high haematocrit induced hypercoagulative state of the donor twin [3]. Treatment of neonatal limb ischaemia can be performed systemically via hyper hydration, anticoagulation, vasodilation or hyperbaric oxygenation [4]. Loco regional thrombolysis with tissue plasminogen activator is a more focused therapeutic option [5]. Nevertheless, all anticoagulatory therapies may be associated with spontaneous intracranial or visceral haemorrhage. Peripheral regional anaesthesia is another therapeutic option, which should be considered in neonatal limb ischaemia. Nerve blockade is associated with sympatholytic effects [6] and provides optimal pain therapy [7]. In addition, local anaesthetics are beneficial in this context due to anti-inflammatory, endothelial protective and antithrombotic effects [8]. Three case reports describe successful axillary brachial plexus blockade in upper limb ischaemia in neonates > 1000g [9–11]. The authors describe the performance of these axillary approaches to the brachial plexus as subcutaneous infiltration in the axillary region. Ultrasound guidance for brachial plexus blockade was used in two cases where additional microsurgery was performed [12], and another publication describes this technique in a term-born infant [13]. In 1994, our scientific task force described the use of ultrasound guidance in regional anaesthesia [14]. Consequently, we redescribed most of paediatric regional anaesthetic techniques with ultrasound guidance [15,16]. The direct visualization of neuronal structures, of the adjacent anatomy, of the tip of the cannula and of the spread of local anaesthetic are the main advantages of ultrasound guidance for regional anaesthesia as compared with landmark-based or nerve stimulator guided techniques. We described ultrasound guided brachial plexus blockade in a large series in trauma surgery [17]. Therefore, with adequate experience, ultrasound guidance of the brachial plexus should be considered as a precise therapeutic option in neonatal upper limb ischaemia.

Case Presentation

A 770g male neonate, born in the 25th week by caesarean section (APGAR 6/7/7), showed signs of ischaemia of the right distal upper arm and forearm (Figure 1) immediately after birth. The child required mechanical ventilation via a nasotracheal tube due to respiratory distress syndrome, hemodynamic therapy with inotropes and developed a grade IV intraventricular haemorrhage. Thromboembolism of the brachial artery was the underlying diagnosis for ischaemia and was confirmed by ultrasound. The initial systemic anticoagulatory therapy with heparin (300 IU/kg/d) i.v. and epoprostenol (Flolanä) was ineffective, and therefore we considered a loco regional sympatholytic therapy. We performed an ultrasound guided infraclavicular brachial plexus block three days after appearance of the symptoms with a transportable high-end ultrasound machine (SonoSite M-Turbo, Fujifilm SonoSite Inc., Bothell, WA, USA) and a 7-15 MHz linear ultrasound probe with an active area of 25 mm and administered 0.5 mL ropivacaine 0.2% via a 25G cannula with a Facette tip and a pre-filled injection line (Figures 2-4). After performance of the 2nd brachial plexus block, ischaemia improved significantly (Figure 5). Three subsequent ultrasound guided brachial plexus blocks (five in total with time intervals of 24 hours) were performed on the following days, and the local blood circulation improved continuously (Figure 6). Figure 7 illustrates the final situs with only distal necroses of the fingers.

 

Figure 1: Postnatal status of the right upper limb.

 

Figure 2: Performance of the ultrasound guided infraclavicular brachial plexus blockade via an out-of-plane needle guidance technique.

 

Figure 3: Ultrasound image of the infraclavicular portion of the brachial plexus. Vertical arrow: the three fascicles of the brachial plexus; horizontal arrow: pleura. Left side = lateral.