Factors associated with failed brachial plexus regional anesthesia for upper limb surgery

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C., Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Professor – Instructor, School of Medicine, Pontificia Universidad Javeriana, Bogotá D. C., Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Anesthesiologist, Pontificia Universidad Javeriana, Bogotá D. C., Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Medical Doctor, Pontificia Universidad Javeriana, Bogotá D. C., Colombia" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Carrera 7 No. 40 – 62, Bogotá, Colombia. Tel.: +57 1 5946161 Ext. 2230." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Factores asociados con anestesia regional fallida de plexo braquial para cirugía de extremidad superior" ] ] "textoCompleto" => "IntroductionRegional anesthesia in the brachial plexus has several clinical applications and multiple advantages over general anesthesia in upper limb surgery, including better postoperative analgesia,<a class="elsevierStyleCrossRefs" href="#bib0195">1,2</a> lower opioid use,<a class="elsevierStyleCrossRefs" href="#bib0205">3–5</a> less postoperative nausea and vomiting<a class="elsevierStyleCrossRefs" href="#bib0220">6–8</a> and, consequently, decreased use of antiemetics, shorter time to ambulation and hospital discharge<a class="elsevierStyleCrossRefs" href="#bib0220">6,9,10</a> and shorter PACU stay.<a class="elsevierStyleCrossRefs" href="#bib0230">8–10</a> These advantages explain the growing interest and use by anesthesiologists around the world.Ultrasonography applied to regional anesthesia has proven to lower the dose and volume of the local anesthetic agent required.<a class="elsevierStyleCrossRefs" href="#bib0245">11,12</a> In other words, there is a lower probability of systemic toxicity from local anesthetic agents, enables real time visualization of the needle with respect to the tissues identified, hence reducing the probability of both mechanical and systemic injury (puncture and vascular injection, pleural puncture, peripheral nerve injury, puncture and visceral injury, etc.),<a class="elsevierStyleCrossRefs" href="#bib0255">13,14</a> decreases the number of punctures and thus improves patient satisfaction and comfort,<a class="elsevierStyleCrossRef" href="#bib0255">13</a> in addition to increasing the success rate for some approaches.<a class="elsevierStyleCrossRef" href="#bib0250">12</a>Observational studies suggest patient and operator-dependent factors and the technique used may impact the success of the brachial plexus bocks. Patients with preoperative anxiety<a class="elsevierStyleCrossRef" href="#bib0265">15</a> and elevated body mass index (BMI)<a class="elsevierStyleCrossRefs" href="#bib0215">5,16,17</a> present more frequent failures. Success may depend on the approach,<a class="elsevierStyleCrossRefs" href="#bib0280">18,19</a> the needle size in the transarterial technique,<a class="elsevierStyleCrossRef" href="#bib0290">20</a> the guide,<a class="elsevierStyleCrossRefs" href="#bib0295">21,22</a> the peripheral nerve stimulation threshold, the volume and total dose of the local anesthetic<a class="elsevierStyleCrossRef" href="#bib0250">12</a> and the number of injections administered.<a class="elsevierStyleCrossRefs" href="#bib0270">16,23,24</a> The operator's training and experience are crucial for the success or failure of the procedure.<a class="elsevierStyleCrossRef" href="#bib0315">25</a>ObjectiveTo identify factors associated with brachial plexus block failure with supraclavicular, infraclavicular, and axillary approach in surgery of the distal humerus, the elbow, the forearm, and hand at the HUSI between 2011 and 2012.Materials and methodsPrevious approval by the Research and Institutional Ethics Committee of the San Ignacio University Hospital (HUSI) (record 2013-57), data of electronic medical records were collected and analyzed of all patients that underwent brachial plexus block using the approaches described for surgeries of the distal humerus, the elbow, the forearm, the hand at the HUSI between 2011 and 2012. This time period was chosen because it represents a stable practice of regional anesthesia based on the guidelines used (neurostimulation, ultrasound or dual) and operators (anesthesiologists with and without additional training in regional anesthesia) at the HUSI.Interscalene blocks and pediatric (<14 years old) patient blocks were excluded because these are usually accompanied by general anesthesia prior to the surgical incision.The definition of failed brachial plexus block is accepted when complying with anyone of the following: (1) Onset of general anesthesia (GA) after the surgical incision; (2) Use of opioid intravenous analgesics greater or equal to 100μg of fentanyl or its equivalent following the surgical incision; (3) Rescue peripheral nerve block (second block after completion of the initial block); or (4) Surgeon infiltration of local anesthetic agents into the surgical site.<a class="elsevierStyleCrossRef" href="#bib0320">26</a> The use of intravenous sedatives or hypnotics was not included since these agents are usually administered during Monitored Anesthesia Care (MAC) and present variable pharmacodynamics responses among patients, hindering the determination of the cut points between GA and MAC. The four criteria comprising our definition of failures were chosen because they are routinely recorded in the electronic medical records at the HUSI and have been accepted in previous research papers.<a class="elsevierStyleCrossRef" href="#bib0320">26</a>Additionally, the patient's demographic data were collected (gender, age, weight, height, and BMI). Medical and anesthetic history (diabetes mellitus, obesity, depression and failed peripheral anesthesia), guided block (ultrasound, neurostimulation and dual stimulation); local anesthetic used (volume, concentration and dose), complementary perineural medications (epinephrine, dexamethasone and others), operator (general anesthesiologist, – GA; Regional anesthesiologist – RA; resident supervised by GA; and resident supervised by RA). RA were the anesthesiologist with a second specialty in Regional Anesthesia endorsed by a university and completed at least 12 months-training (three anesthesiologists for the study period). Residents were classified as with/without regional anesthesia internship (before and after the mandatory two-month training as part of their education as anesthesiologists). These variables were chosen based on their potential association to failure.The criteria for our definition of failure and potentially-associated variables were pooled in the Microsoft Excel 2010 program (license HUSI). The sample size calculation was made based on a pilot recruitment of patients intervened on April 2011 (HUSI, unpublished). 22 brachial plexus block procedures were recorded during this time period, as the single anesthetic technique for the surgical procedures, including 5 failures as per our definition (all as a result of the initial administration of general anesthesia after the surgical incision {first criterion}). Based on this frequency of procedures and failures, it was estimated that data had to be collected for at least 14 months to identify differences of 20% beginning with outcomes (failed block) between the most experienced and trained group (RA and resident supervised by RA) and the less experienced and trained group (GA and resident with no internship supervised by GA or RA); alpha error 0.05 and 80% power. This calculation was done using Epidat 3.1 software (downloaded free of charge – PAHO). However, it may be possible that this month was not necessarily representative of the number of upper limb surgical procedures at the HUSI so the timeframe was extended to 24 months. The associations were measured with Epidat 3.1 (differences in frequency of failures for dichotomous comparisons) and multivariate analysis-based logistical regression was planned for all variables and univariate for statistically significant risk factors, SSPS (version 19) software; percentage differences were calculated, Chi square tests, confidence intervals and p-value analyses to stablish statistically significant differences.ResultsInformation was collected from 202 patients. The mean age was 46 years old; most patients were males (60.9%). There were no records reporting history of anxiety, depression, or previous failed block. 5% of the patients presented with arterial hypertension, diabetes mellitus or obesity. The diagnosis of obesity was based on the medical history and could not be inferred from anthropometric measurements because these were not systematically recorded in the medical records.All blockades were administered for orthopedic surgery, mostly of the forearm (47%), and hand (45%), followed by elbow (4%) and distal humerus (2%). (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>)<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The most frequent approaches were axillary and supreaclavicular. 62.9% were ultrasound guided; 35.14% were neurostimulator guided and 1.98% used a dual technique. 1% or 2% lidocaine and 0.5 bupivacaíne % (combined) were used in 95% of blocks. Most blocks were administered or supervised by GA (119 cases {60%}). Despite being a training institution, in 70% of the cases the operator was not a resident; 20% and 50% were RA and GA, respectively.7.4% of failed blocks (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) were all due to the start of general anesthesia following the surgical incision (first criterion). Of these, 6% of failures were among females and 8% among males. The average age of patients with failed blocks was 41 years (age range 18–62 years) and there were not comorbidities present. 60% of failures occurred in blocks with ultrasound guidance, 40% in blocks guided by nerve stimulator and none used a dual technique (among the neurostimulation and ultrasound-guided blocks, 8.5% and 7% were failed, respectively) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Failed blocks had the following approach distribution: 40% infraclavicular, 33% axillary and 27% supraclavicular. Out of the infraclavicular blocks, 10% failed of which 83% were neurostimulation-guided; no operator differences were identified. 6% of axillary blocks failed, of which 80% were ultrasound guided and 20% were neurostimulation guided. All failed axillary blocks were administered by GA or resident with no regional anesthesia training. 5% of the supraclavicular blocks failed, all were ultrasound-guided and with no operator differences identified.None of the factors potentially associated with failure had a statistically significant relationship with the outcome measured for dichotomous comparisons. The logistic regression was not statically significant either for any of the variables.DiscussionThe clinical definition of brachial plexus regional anesthesia failure for upper extremity surgery may exhibit some variability. Finlayson et al. propose increasingly objective score-based systems to determine the latency of successful sensitive and motor blockade of each peripheral nerve, defining as a failure the inability to reach a minimum score in the sensorial domains and in the sensitive and motor combination within 30min,<a class="elsevierStyleCrossRef" href="#bib0320">26</a> or whenever similar criteria to those of our definition of failure during surgery are presented. The use of this extended, more sensitive failure definition, not systematically registered in the HUSI medical records, may play an important role, not just in research, but in our daily clinical practice, with early identification of failures prior to the start of surgery, avoiding any injuries to the patient and interventions that may be perceived as improvised and stressing for the patient.Our failure frequency is similar to other series simultaneously collected and reported in the literature;<a class="elsevierStyleCrossRefs" href="#bib0325">27,28</a> this may translate into an under-registration of failures in our environment, that may lead to increased registry biases.Our sample size was based on the association of a successful or failed block and operator expertise, based on the frequency of regional procedures and failure in a pilot trial described under materials and methods (not published). The only variable showing a potentially causal relationship with outcome was gender; however, a logistic regression analysis, showed no statistically significant association with this or a different variable analyzed – probably related to the low frequency of failures in our sample. The trends described in the results section are supported by trends in the local anesthetic practices and may represent confounding factors not necessarily associated with true failure associated factors. For instance, the fact that all failed supraclavicular blocks were ultrasound-guided represents a constant in the guidelines for supraclavicular blocks at the HUSI, where none of these blocks is administered via anatomical landmarks or neurostimulation and very few with the dual technique. Likewise, the fact that failed axillary blocks were administered by a GA or a resident who has not done a rotation in regional anesthesia may be explained because less experienced practitioners prefer this approach due to the lower risk of involving structures associated with severe complications (pleural injury, phrenic nerve block, and primary neuronal injury due to the presence of less myelinated fibers). In conclusion, the low frequency of failures in the sample analyzed makes it impossible to develop any solid conclusions or associations from the clinical and statistical point of view.The determining factors of a successful block are controversial.<a class="elsevierStyleCrossRef" href="#bib0335">29</a> It is thought that in order to improve the probability of success of a peripheral nerve block, it is necessary to do a proper identification of the nerve or plexus, to place the needle close to the nerve, and be able to fully encircle the nerve with local anesthetic.<a class="elsevierStyleCrossRefs" href="#bib0250">12,30</a> Direct vision of the nerve and other adjacent structures ensures improved distribution of the local anesthetic, shortens the time to perform the block, reduces the volume of anesthetic agent, reduces the risk of any vascular or neural lesion and the probability of toxicity resulting from local anesthetic agents and the detection of anatomic variants that may impair the effectiveness of the block.<a class="elsevierStyleCrossRefs" href="#bib0335">29,31,32</a> Ultrasound guidance has shown to improve clinical outcomes<a class="elsevierStyleCrossRefs" href="#bib0300">22,33</a> but this trial failed to show any improved outcomes in terms of effectiveness (reductions of failures); this may be explained by the low frequency of failures, in addition to the fact that neurostimulation effectiveness is quite high in experienced hands.<a class="elsevierStyleCrossRef" href="#bib0360">34</a> Neurosmulation-assisted blocks are associated with decreased patient satisfaction. This is important for trauma patients since the electrical stimulus leads to muscle contraction and movement may cause discomfort and paint to the patient.<a class="elsevierStyleCrossRef" href="#bib0365">35</a> Due to the observational, historical, and record-based nature of the trial, patient satisfaction or pain during the administration of the block were not evaluated; however, these are important outcomes from the patient's perspective and may potentially rise the frequency of failures.Though there were very few cases using the dual technique, there were no failures with this technique. The literature recommends its use exceptionally in regional anesthesia resident and training programs, since it reduces the time of administration of the block, the number of punctures needs and the number of complications.<a class="elsevierStyleCrossRef" href="#bib0340">30</a>Our study identified volumes of local anesthetic above the minimum effective volumes reported in other series<a class="elsevierStyleCrossRefs" href="#bib0370">36,37</a> and guide methods. However, when comparing the volumes by subgroups, based on the guides used, these were smaller in the ultrasound-guided blocks versus neurostimulation, (mean volume 33.3ml (95% CI 31.5–35ml) versus 35.1ml (95% CI 33.7–36.4ml), respectively), consistent with the reports from other authors.<a class="elsevierStyleCrossRef" href="#bib0380">38</a>ConclusionsBrachial plexus block failure-associated factors are multifactorial and multidimensional. These may depend on the patient, the operator, the guide, the approach selected, medications, dose, concentration or volume selected. Failure frequency depends on the definition used and the way it is measured. Our study evidences the difficulties to determine these factors associated with failures of a highly effective procedure in the current clinical practice.It is recommended to improve the quality of anesthesiology records and data bases to determine associations measured with less probability of biases, quantifiable and objective of the interventions in patients undergoing procedures under anesthesia and specifically under regional anesthesia in order to estimate the pre-surgical risk of failure with these techniques and establish strategies focused on risk groups that improve the effectiveness of peripheral regional anesthesia.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the responsible Clinical Research Ethics Committee and in accordance with those of the World Medical Association and the Helsinki Declaration.Confidentiality of dataThe authors declare that they have followed the protocols of their work centre on the publication of patient data.Right to privacy and informed consentThe authors must have obtained the informed consent of the patients and/or subjects mentioned in the article. The author for correspondence must be in possession of this document.FinancingThe authors did not receive sponsorship to carry out this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres737128" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Materials and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec741226" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres737127" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Materiales y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec741225" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0060" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 10 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0050" "titulo" => "Financing" ] 12 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-12-14" "fechaAceptado" => "2016-06-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec741226" "palabras" => array:5 [ 0 => "Ultrasonography, interventional" 1 => "Anesthesia, conduction" 2 => "Nerve block" 3 => "Brachial plexus" 4 => "Ultrasonography" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec741225" "palabras" => array:5 [ 0 => "Ultrasonografía intervencional" 1 => "Anestesia de conducción" 2 => "Bloqueo nervioso" 3 => "Plexo braquial" 4 => "Ultrasonografía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionBrachial plexus block as an anesthetic technique for upper limb surgery has some advantages over general anesthesia. The technique is widely used in our practice, with high effectiveness and adequate safety profile. However, the relationship between block failure and failure-determining factors has not been measured. ObjectivesTo identify and quantify brachial plexus block failure-associated factors for upper limb surgery as an initial observation aimed at developing prevention-oriented risk profiles and strategies. Materials and methodsAn analytical observational study was conducted by collecting data from electronic medical records of upper limb surgery using brachial plexus block from the San Ignacio University Hospital between 2011 and 2012. Block failures were identified using standardized clinical criteria, measuring potentially associated factors. Dichotomous comparisons were made and uni-and multivariate logistic regression analysis was performed to identify potential statistically significant variables, based on failed cases and successful controls. ResultsNone of the proposed factors was independently associated with failure of brachial plexus block. A qualitative description of failed cases presented confounding factors associated with local practices and the failure characteristics did not show a clinically plausible trend. ConclusionsThere were no factors determined by patient, anesthetic procedure, surgical procedure and operator that could be independently associated with brachial plexus block failure. The suggestion is to fine-tune the definition of failures, not just in the research environment, but in the current clinical practice; to improve the anesthesia records to rise the numbers and the quality of data bases for a quantitative determination of the risk of peripheral regional anesthesia failure and design prevention strategies focused on risk groups." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Materials and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl bloqueo de plexo braquial como técnica anestésica para cirugía de extremidad superior presenta ventajas sobre la anestesia general. Es ampliamente usada en nuestro medio con alta efectividad y adecuado perfil de seguridad. Sin embargo, no existe la cuantificación de las asociaciones entre fallo del bloqueo y factores determinantes del fallo. ObjetivosIdentificar y cuantificar los factores asociados al fallo del bloqueo de plexo braquial como observación inicial para crear perfiles de riesgo y estrategias para prevenirlo. Materiales y métodosSe realizó un estudio observacional analítico, recolectando los datos de historias clínicas de bloqueos de plexo braquial para cirugía de miembro superior del Hospital Universitario San Ignacio de los años 2011-2012, identificando los bloqueos fallidos con criterios clínicos estandarizados, midiendo los factores potencialmente asociados a estos. Partiendo del grupo de fallos (casos) y grupo exitoso (controles) se establecieron comparaciones dicotómicas y análisis de regresión logística con análisis uni- y multivariado para identificar variables con significancia estadística. ResultadosNinguno de los factores propuestos se asoció de forma independiente al fallo de bloqueo de plexo braquial. La descripción cualitativa de los casos fallidos presenta factores de confusión asociados a prácticas clínicas locales y ninguna tendencia clínicamente plausible en la característica de los fallos. ConclusionesNingún factor determinado por el paciente, procedimiento anestésico, procedimiento quirúrgico, operador se asocia de forma independiente a fallo del bloqueo de plexo braquial. Se propone afinar la definición de fallo, no solo en el contexto investigativo, si no en la práctica clínica actual, mejorar los sistemas de registro en anestesia para ampliar en número y calidad las bases de datos que permitan aproximarse cuantitativamente al riesgo de fallo de anestesia regional periférica y plantear estrategias de prevención enfocadas en grupos de riesgo." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Materiales y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Moreno-Martínez DA, Perea-Bello AH, Díaz-Bohada JL, García-Rodriguez DM, Echeverri-Mallarino V, Valencia-Peña MJ, et al. Factores asociados con anestesia regional fallida de plexo braquial para cirugía de extremidad superior. Rev Colomb Anestesiol. 2016;44:292–298." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: Authors." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total cases \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Failed blocks \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Gender</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Females \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Males \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">123 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Guided block</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ultrasonography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">127 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neurostimulator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Approach</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Supraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Axillary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Surgical site</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Elbow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Distal humerus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1217102.png" ] ] ] ] "descripcion" => array:1 [ "en" => "General description of population and failed block cases." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "M, male; F, female; GA, general anesthesiologist; RA, regional anesthesiologist; RSR, resident no regional anesthesia training; RCR, resident with training.Source: Authors." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Approach \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical site \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Anesthetic volume (ml) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Latency (min) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Operator \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Guide \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurostimulator \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Axillary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Echography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Echography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RCR (GA) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurostimulator \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RCR (RA) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurostimulator \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Supraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RSR (RA) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ecography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Supraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ecography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Supraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ecography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Axillary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RSR (GA) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Echography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Supraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Echography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Axillary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RSR (AG) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Echography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RSR (AR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurostimulator \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Axillary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RSR (AG) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurostimulator \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Axillary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Echography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infraclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RCR (AR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurostimulator \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1217103.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Failed brachial plexus blocks." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does continuous peripheral nerve block provide superior pain control to opioids? 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Scientific and Technological Research

Factores asociados con anestesia regional fallida de plexo braquial para cirugía de extremidad superior

Diego Alberto Moreno-Martíneza,b,

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diegomoreno@javeriana.edu.co

Corresponding author at: Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Carrera 7 No. 40 – 62, Bogotá, Colombia. Tel.: +57 1 5946161 Ext. 2230.

, Ana Helena Perea-Belloa,b, Judy Lorena Díaz-Bohadaa, Diana Margarita García-Rodrigueza, Verónica Echeverri-Mallarinoa, Maury Julieth Valencia-Peñac, Walter Osorio-Cardonaa, Paola Nathaly Silva-Enríquezd

a Anesthesiologist, Hospital Universitario San Ignacio, Bogotá D. C., Colombia

b Professor – Instructor, School of Medicine, Pontificia Universidad Javeriana, Bogotá D. C., Colombia

c Anesthesiologist, Pontificia Universidad Javeriana, Bogotá D. C., Colombia

d Medical Doctor, Pontificia Universidad Javeriana, Bogotá D. C., Colombia

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Regional anesthesia in the brachial plexus has several clinical applications and multiple advantages over general anesthesia in upper limb surgery&#44; including better postoperative analgesia&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;2</span></a> lower opioid use&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3&#8211;5</span></a> less postoperative nausea and vomiting<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#8211;8</span></a> and&#44; consequently&#44; decreased use of antiemetics&#44; shorter time to ambulation and hospital discharge<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;9&#44;10</span></a> and shorter PACU stay&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">8&#8211;10</span></a> These advantages explain the growing interest and use by anesthesiologists around the world&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Ultrasonography applied to regional anesthesia has proven to lower the dose and volume of the local anesthetic agent required&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#44;12</span></a> In other words&#44; there is a lower probability of systemic toxicity from local anesthetic agents&#44; enables real time visualization of the needle with respect to the tissues identified&#44; hence reducing the probability of both mechanical and systemic injury &#40;puncture and vascular injection&#44; pleural puncture&#44; peripheral nerve injury&#44; puncture and visceral injury&#44; etc&#46;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">13&#44;14</span></a> decreases the number of punctures and thus improves patient satisfaction and comfort&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> in addition to increasing the success rate for some approaches&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Observational studies suggest patient and operator-dependent factors and the technique used may impact the success of the brachial plexus bocks&#46; Patients with preoperative anxiety<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> and elevated body mass index &#40;BMI&#41;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;16&#44;17</span></a> present more frequent failures&#46; Success may depend on the approach&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">18&#44;19</span></a> the needle size in the transarterial technique&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> the guide&#44;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">21&#44;22</span></a> the peripheral nerve stimulation threshold&#44; the volume and total dose of the local anesthetic<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> and the number of injections administered&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">16&#44;23&#44;24</span></a> The operator&#39;s training and experience are crucial for the success or failure of the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Objective</span><p id="par0020" class="elsevierStylePara elsevierViewall">To identify factors associated with brachial plexus block failure with supraclavicular&#44; infraclavicular&#44; and axillary approach in surgery of the distal humerus&#44; the elbow&#44; the forearm&#44; and hand at the HUSI between 2011 and 2012&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Previous approval by the Research and Institutional Ethics Committee of the San Ignacio University Hospital &#40;HUSI&#41; &#40;record 2013-57&#41;&#44; data of electronic medical records were collected and analyzed of all patients that underwent brachial plexus block using the approaches described for surgeries of the distal humerus&#44; the elbow&#44; the forearm&#44; the hand at the HUSI between 2011 and 2012&#46; This time period was chosen because it represents a stable practice of regional anesthesia based on the guidelines used &#40;neurostimulation&#44; ultrasound or dual&#41; and operators &#40;anesthesiologists with and without additional training in regional anesthesia&#41; at the HUSI&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Interscalene blocks and pediatric &#40;&#60;14 years old&#41; patient blocks were excluded because these are usually accompanied by general anesthesia prior to the surgical incision&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The definition of failed brachial plexus block is accepted when complying with anyone of the following&#58; &#40;1&#41; Onset of general anesthesia &#40;GA&#41; after the surgical incision&#59; &#40;2&#41; Use of opioid intravenous analgesics greater or equal to 100<span class="elsevierStyleHsp" style=""></span>&#956;g of fentanyl or its equivalent following the surgical incision&#59; &#40;3&#41; Rescue peripheral nerve block &#40;second block after completion of the initial block&#41;&#59; or &#40;4&#41; Surgeon infiltration of local anesthetic agents into the surgical site&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> The use of intravenous sedatives or hypnotics was not included since these agents are usually administered during Monitored Anesthesia Care &#40;MAC&#41; and present variable pharmacodynamics responses among patients&#44; hindering the determination of the cut points between GA and MAC&#46; The four criteria comprising our definition of failures were chosen because they are routinely recorded in the electronic medical records at the HUSI and have been accepted in previous research papers&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Additionally&#44; the patient&#39;s demographic data were collected &#40;gender&#44; age&#44; weight&#44; height&#44; and BMI&#41;&#46; Medical and anesthetic history &#40;diabetes mellitus&#44; obesity&#44; depression and failed peripheral anesthesia&#41;&#44; guided block &#40;ultrasound&#44; neurostimulation and dual stimulation&#41;&#59; local anesthetic used &#40;volume&#44; concentration and dose&#41;&#44; complementary perineural medications &#40;epinephrine&#44; dexamethasone and others&#41;&#44; operator &#40;general anesthesiologist&#44; &#8211; GA&#59; Regional anesthesiologist &#8211; RA&#59; resident supervised by GA&#59; and resident supervised by RA&#41;&#46; RA were the anesthesiologist with a second specialty in Regional Anesthesia endorsed by a university and completed at least 12 months-training &#40;three anesthesiologists for the study period&#41;&#46; Residents were classified as with&#47;without regional anesthesia internship &#40;before and after the mandatory two-month training as part of their education as anesthesiologists&#41;&#46; These variables were chosen based on their potential association to failure&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The criteria for our definition of failure and potentially-associated variables were pooled in the Microsoft Excel 2010 program &#40;license HUSI&#41;&#46; The sample size calculation was made based on a pilot recruitment of patients intervened on April 2011 &#40;HUSI&#44; unpublished&#41;&#46; 22 brachial plexus block procedures were recorded during this time period&#44; as the single anesthetic technique for the surgical procedures&#44; including 5 failures as per our definition &#40;all as a result of the initial administration of general anesthesia after the surgical incision &#123;first criterion&#125;&#41;&#46; Based on this frequency of procedures and failures&#44; it was estimated that data had to be collected for at least 14 months to identify differences of 20&#37; beginning with outcomes &#40;failed block&#41; between the most experienced and trained group &#40;RA and resident supervised by RA&#41; and the less experienced and trained group &#40;GA and resident with no internship supervised by GA or RA&#41;&#59; alpha error 0&#46;05 and 80&#37; power&#46; This calculation was done using Epidat 3&#46;1 software &#40;downloaded free of charge &#8211; PAHO&#41;&#46; However&#44; it may be possible that this month was not necessarily representative of the number of upper limb surgical procedures at the HUSI so the timeframe was extended to 24 months&#46; The associations were measured with Epidat 3&#46;1 &#40;differences in frequency of failures for dichotomous comparisons&#41; and multivariate analysis-based logistical regression was planned for all variables and univariate for statistically significant risk factors&#44; SSPS &#40;version 19&#41; software&#59; percentage differences were calculated&#44; Chi square tests&#44; confidence intervals and <span class="elsevierStyleItalic">p</span>-value analyses to stablish statistically significant differences&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Information was collected from 202 patients&#46; The mean age was 46 years old&#59; most patients were males &#40;60&#46;9&#37;&#41;&#46; There were no records reporting history of anxiety&#44; depression&#44; or previous failed block&#46; 5&#37; of the patients presented with arterial hypertension&#44; diabetes mellitus or obesity&#46; The diagnosis of obesity was based on the medical history and could not be inferred from anthropometric measurements because these were not systematically recorded in the medical records&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All blockades were administered for orthopedic surgery&#44; mostly of the forearm &#40;47&#37;&#41;&#44; and hand &#40;45&#37;&#41;&#44; followed by elbow &#40;4&#37;&#41; and distal humerus &#40;2&#37;&#41;&#46; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The most frequent approaches were axillary and supreaclavicular&#46; 62&#46;9&#37; were ultrasound guided&#59; 35&#46;14&#37; were neurostimulator guided and 1&#46;98&#37; used a dual technique&#46; 1&#37; or 2&#37; lidocaine and 0&#46;5 bupivaca&#237;ne &#37; &#40;combined&#41; were used in 95&#37; of blocks&#46; Most blocks were administered or supervised by GA &#40;119 cases &#123;60&#37;&#125;&#41;&#46; Despite being a training institution&#44; in 70&#37; of the cases the operator was not a resident&#59; 20&#37; and 50&#37; were RA and GA&#44; respectively&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">7&#46;4&#37; of failed blocks &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; were all due to the start of general anesthesia following the surgical incision &#40;first criterion&#41;&#46; Of these&#44; 6&#37; of failures were among females and 8&#37; among males&#46; The average age of patients with failed blocks was 41 years &#40;age range 18&#8211;62 years&#41; and there were not comorbidities present&#46; 60&#37; of failures occurred in blocks with ultrasound guidance&#44; 40&#37; in blocks guided by nerve stimulator and none used a dual technique &#40;among the neurostimulation and ultrasound-guided blocks&#44; 8&#46;5&#37; and 7&#37; were failed&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Failed blocks had the following approach distribution&#58; 40&#37; infraclavicular&#44; 33&#37; axillary and 27&#37; supraclavicular&#46; Out of the infraclavicular blocks&#44; 10&#37; failed of which 83&#37; were neurostimulation-guided&#59; no operator differences were identified&#46; 6&#37; of axillary blocks failed&#44; of which 80&#37; were ultrasound guided and 20&#37; were neurostimulation guided&#46; All failed axillary blocks were administered by GA or resident with no regional anesthesia training&#46; 5&#37; of the supraclavicular blocks failed&#44; all were ultrasound-guided and with no operator differences identified&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">None of the factors potentially associated with failure had a statistically significant relationship with the outcome measured for dichotomous comparisons&#46; The logistic regression was not statically significant either for any of the variables&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The clinical definition of brachial plexus regional anesthesia failure for upper extremity surgery may exhibit some variability&#46; Finlayson et al&#46; propose increasingly objective score-based systems to determine the latency of successful sensitive and motor blockade of each peripheral nerve&#44; defining as a failure the inability to reach a minimum score in the sensorial domains and in the sensitive and motor combination within 30<span class="elsevierStyleHsp" style=""></span>min&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> or whenever similar criteria to those of our definition of failure during surgery are presented&#46; The use of this extended&#44; more sensitive failure definition&#44; not systematically registered in the HUSI medical records&#44; may play an important role&#44; not just in research&#44; but in our daily clinical practice&#44; with early identification of failures prior to the start of surgery&#44; avoiding any injuries to the patient and interventions that may be perceived as improvised and stressing for the patient&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Our failure frequency is similar to other series simultaneously collected and reported in the literature&#59;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">27&#44;28</span></a> this may translate into an under-registration of failures in our environment&#44; that may lead to increased registry biases&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our sample size was based on the association of a successful or failed block and operator expertise&#44; based on the frequency of regional procedures and failure in a pilot trial described under materials and methods &#40;not published&#41;&#46; The only variable showing a potentially causal relationship with outcome was gender&#59; however&#44; a logistic regression analysis&#44; showed no statistically significant association with this or a different variable analyzed &#8211; probably related to the low frequency of failures in our sample&#46; The trends described in the results section are supported by trends in the local anesthetic practices and may represent confounding factors not necessarily associated with true failure associated factors&#46; For instance&#44; the fact that all failed supraclavicular blocks were ultrasound-guided represents a constant in the guidelines for supraclavicular blocks at the HUSI&#44; where none of these blocks is administered via anatomical landmarks or neurostimulation and very few with the dual technique&#46; Likewise&#44; the fact that failed axillary blocks were administered by a GA or a resident who has not done a rotation in regional anesthesia may be explained because less experienced practitioners prefer this approach due to the lower risk of involving structures associated with severe complications &#40;pleural injury&#44; phrenic nerve block&#44; and primary neuronal injury due to the presence of less myelinated fibers&#41;&#46; In conclusion&#44; the low frequency of failures in the sample analyzed makes it impossible to develop any solid conclusions or associations from the clinical and statistical point of view&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The determining factors of a successful block are controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a> It is thought that in order to improve the probability of success of a peripheral nerve block&#44; it is necessary to do a proper identification of the nerve or plexus&#44; to place the needle close to the nerve&#44; and be able to fully encircle the nerve with local anesthetic&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;30</span></a> Direct vision of the nerve and other adjacent structures ensures improved distribution of the local anesthetic&#44; shortens the time to perform the block&#44; reduces the volume of anesthetic agent&#44; reduces the risk of any vascular or neural lesion and the probability of toxicity resulting from local anesthetic agents and the detection of anatomic variants that may impair the effectiveness of the block&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">29&#44;31&#44;32</span></a> Ultrasound guidance has shown to improve clinical outcomes<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">22&#44;33</span></a> but this trial failed to show any improved outcomes in terms of effectiveness &#40;reductions of failures&#41;&#59; this may be explained by the low frequency of failures&#44; in addition to the fact that neurostimulation effectiveness is quite high in experienced hands&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> Neurosmulation-assisted blocks are associated with decreased patient satisfaction&#46; This is important for trauma patients since the electrical stimulus leads to muscle contraction and movement may cause discomfort and paint to the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> Due to the observational&#44; historical&#44; and record-based nature of the trial&#44; patient satisfaction or pain during the administration of the block were not evaluated&#59; however&#44; these are important outcomes from the patient&#39;s perspective and may potentially rise the frequency of failures&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Though there were very few cases using the dual technique&#44; there were no failures with this technique&#46; The literature recommends its use exceptionally in regional anesthesia resident and training programs&#44; since it reduces the time of administration of the block&#44; the number of punctures needs and the number of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Our study identified volumes of local anesthetic above the minimum effective volumes reported in other series<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">36&#44;37</span></a> and guide methods&#46; However&#44; when comparing the volumes by subgroups&#44; based on the guides used&#44; these were smaller in the ultrasound-guided blocks versus neurostimulation&#44; &#40;mean volume 33&#46;3<span class="elsevierStyleHsp" style=""></span>ml &#40;95&#37; CI 31&#46;5&#8211;35<span class="elsevierStyleHsp" style=""></span>ml&#41; versus 35&#46;1<span class="elsevierStyleHsp" style=""></span>ml &#40;95&#37; CI 33&#46;7&#8211;36&#46;4<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; respectively&#41;&#44; consistent with the reports from other authors&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Brachial plexus block failure-associated factors are multifactorial and multidimensional&#46; These may depend on the patient&#44; the operator&#44; the guide&#44; the approach selected&#44; medications&#44; dose&#44; concentration or volume selected&#46; Failure frequency depends on the definition used and the way it is measured&#46; Our study evidences the difficulties to determine these factors associated with failures of a highly effective procedure in the current clinical practice&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">It is recommended to improve the quality of anesthesiology records and data bases to determine associations measured with less probability of biases&#44; quantifiable and objective of the interventions in patients undergoing procedures under anesthesia and specifically under regional anesthesia in order to estimate the pre-surgical risk of failure with these techniques and establish strategies focused on risk groups that improve the effectiveness of peripheral regional anesthesia&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the responsible Clinical Research Ethics Committee and in accordance with those of the World Medical Association and the Helsinki Declaration&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Financing</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors did not receive sponsorship to carry out this article&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2015-12-14"
    "fechaAceptado" => "2016-06-21"
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          "palabras" => array:5 [
            0 => "Ultrasonography&#44; interventional"
            1 => "Anesthesia&#44; conduction"
            2 => "Nerve block"
            3 => "Brachial plexus"
            4 => "Ultrasonography"
          ]
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          "palabras" => array:5 [
            0 => "Ultrasonograf&#237;a intervencional"
            1 => "Anestesia de conducci&#243;n"
            2 => "Bloqueo nervioso"
            3 => "Plexo braquial"
            4 => "Ultrasonograf&#237;a"
          ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brachial plexus block as an anesthetic technique for upper limb surgery has some advantages over general anesthesia&#46; The technique is widely used in our practice&#44; with high effectiveness and adequate safety profile&#46; However&#44; the relationship between block failure and failure-determining factors has not been measured&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To identify and quantify brachial plexus block failure-associated factors for upper limb surgery as an initial observation aimed at developing prevention-oriented risk profiles and strategies&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Materials and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">An analytical observational study was conducted by collecting data from electronic medical records of upper limb surgery using brachial plexus block from the San Ignacio University Hospital between 2011 and 2012&#46; Block failures were identified using standardized clinical criteria&#44; measuring potentially associated factors&#46; Dichotomous comparisons were made and uni-and multivariate logistic regression analysis was performed to identify potential statistically significant variables&#44; based on failed cases and successful controls&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">None of the proposed factors was independently associated with failure of brachial plexus block&#46; A qualitative description of failed cases presented confounding factors associated with local practices and the failure characteristics did not show a clinically plausible trend&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There were no factors determined by patient&#44; anesthetic procedure&#44; surgical procedure and operator that could be independently associated with brachial plexus block failure&#46; The suggestion is to fine-tune the definition of failures&#44; not just in the research environment&#44; but in the current clinical practice&#59; to improve the anesthesia records to rise the numbers and the quality of data bases for a quantitative determination of the risk of peripheral regional anesthesia failure and design prevention strategies focused on risk groups&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objectives"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Materials and methods"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El bloqueo de plexo braquial como t&#233;cnica anest&#233;sica para cirug&#237;a de extremidad superior presenta ventajas sobre la anestesia general&#46; Es ampliamente usada en nuestro medio con alta efectividad y adecuado perfil de seguridad&#46; Sin embargo&#44; no existe la cuantificaci&#243;n de las asociaciones entre fallo del bloqueo y factores determinantes del fallo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Identificar y cuantificar los factores asociados al fallo del bloqueo de plexo braquial como observaci&#243;n inicial para crear perfiles de riesgo y estrategias para prevenirlo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Materiales y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio observacional anal&#237;tico&#44; recolectando los datos de historias cl&#237;nicas de bloqueos de plexo braquial para cirug&#237;a de miembro superior del Hospital Universitario San Ignacio de los a&#241;os 2011-2012&#44; identificando los bloqueos fallidos con criterios cl&#237;nicos estandarizados&#44; midiendo los factores potencialmente asociados a estos&#46; Partiendo del grupo de fallos &#40;casos&#41; y grupo exitoso &#40;controles&#41; se establecieron comparaciones dicot&#243;micas y an&#225;lisis de regresi&#243;n log&#237;stica con an&#225;lisis uni- y multivariado para identificar variables con significancia estad&#237;stica&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ninguno de los factores propuestos se asoci&#243; de forma independiente al fallo de bloqueo de plexo braquial&#46; La descripci&#243;n cualitativa de los casos fallidos presenta factores de confusi&#243;n asociados a pr&#225;cticas cl&#237;nicas locales y ninguna tendencia cl&#237;nicamente plausible en la caracter&#237;stica de los fallos&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ning&#250;n factor determinado por el paciente&#44; procedimiento anest&#233;sico&#44; procedimiento quir&#250;rgico&#44; operador se asocia de forma independiente a fallo del bloqueo de plexo braquial&#46; Se propone afinar la definici&#243;n de fallo&#44; no solo en el contexto investigativo&#44; si no en la pr&#225;ctica cl&#237;nica actual&#44; mejorar los sistemas de registro en anestesia para ampliar en n&#250;mero y calidad las bases de datos que permitan aproximarse cuantitativamente al riesgo de fallo de anestesia regional perif&#233;rica y plantear estrategias de prevenci&#243;n enfocadas en grupos de riesgo&#46;</p></span>"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Materiales y m&#233;todos"
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    "NotaPie" => array:1 [
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Moreno-Mart&#237;nez DA&#44; Perea-Bello AH&#44; D&#237;az-Bohada JL&#44; Garc&#237;a-Rodriguez DM&#44; Echeverri-Mallarino V&#44; Valencia-Pe&#241;a MJ&#44; et al&#46; Factores asociados con anestesia regional fallida de plexo braquial para cirug&#237;a de extremidad superior&#46; Rev Colomb Anestesiol&#46; 2016&#59;44&#58;292&#8211;298&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Failed blocks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Gender</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Females&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Males&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">123&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Guided block</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ultrasonography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neurostimulator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Approach</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Supraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Axillary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Surgical site</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Elbow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Distal humerus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Approach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Anesthetic volume &#40;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Latency &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Operator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Guide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurostimulator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Axillary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Echography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Echography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCR &#40;GA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurostimulator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCR &#40;RA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurostimulator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RSR &#40;RA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ecography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ecography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ecography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Axillary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RSR &#40;GA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Echography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Echography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Axillary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RSR &#40;AG&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Echography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RSR &#40;AR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurostimulator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Axillary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RSR &#40;AG&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurostimulator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Axillary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Echography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infraclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCR &#40;AR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurostimulator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Failed brachial plexus blocks&#46;</p>"
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        0 => array:2 [
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                            1 => "S&#46;S&#46; Liu"
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Article information

ISSN: 22562087
Original language: English

DOI:10.1016/j.rcae.2016.06.006

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Year/Month	Html	Pdf	Total

2024 November	9	0	9
2024 October	40	3	43
2024 September	108	9	117
2024 August	64	3	67
2024 July	59	5	64
2024 June	66	2	68
2024 May	76	9	85
2024 April	75	7	82
2024 March	97	7	104
2024 February	67	14	81
2024 January	75	3	78
2023 December	80	17	97
2023 November	107	16	123
2023 October	94	13	107
2023 September	68	12	80
2023 August	53	10	63
2023 July	89	7	96
2023 June	94	5	99
2023 May	129	15	144
2023 April	104	674	778
2023 March	80	17	97
2023 February	67	8	75
2023 January	70	7	77
2022 December	61	5	66
2022 November	47	4	51
2022 October	37	18	55
2022 September	48	13	61
2022 August	40	13	53
2022 July	34	9	43
2022 June	28	5	33
2022 May	39	11	50
2022 April	25	7	32
2022 March	46	10	56
2022 February	35	6	41
2022 January	55	26	81
2021 December	54	8	62
2021 November	51	11	62
2021 October	61	11	72
2021 September	64	9	73
2021 August	67	11	78
2021 July	56	18	74
2021 June	61	10	71
2021 May	43	8	51
2021 April	71	16	87
2021 March	24	8	32
2021 February	28	8	36
2021 January	17	7	24
2020 December	11	10	21
2020 November	17	7	24
2020 October	16	9	25
2020 September	13	4	17
2020 August	12	11	23
2020 July	11	9	20
2020 June	12	4	16
2020 May	11	7	18
2020 April	9	2	11
2020 March	8	7	15
2020 February	9	2	11
2020 January	10	4	14
2019 December	8	5	13
2019 November	6	3	9
2019 October	13	7	20
2019 September	6	11	17
2019 August	0	0	0
2019 July	3	8	11
2019 June	5	5	10
2019 May	2	15	17
2019 January	2	0	2
2018 December	1	0	1
2018 November	1	0	1
2018 September	2	0	2
2018 July	1	0	1
2018 June	3	4	7
2018 May	24	7	31
2018 April	35	8	43
2018 March	17	10	27
2018 February	17	7	24
2018 January	31	4	35
2017 December	17	7	24
2017 November	20	7	27
2017 October	23	17	40
2017 September	19	8	27
2017 August	10	23	33
2017 July	21	3	24
2017 June	21	9	30
2017 May	33	17	50
2017 April	33	10	43
2017 March	19	7	26
2017 February	17	4	21
2017 January	23	11	34
2016 December	54	18	72
2016 November	54	19	73
2016 October	51	20	71
2016 September	5	4	9

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