الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Since the discovery of regional anaesthesia, there has been considerable interest in regional anaesthetic techniques particularly in peripheral nerve blockade (PNB). PNB can decrease the anaesthetic and analgesic requirements during surgery and reduce the need for opioid analgesics in the postoperative period. More effective pain relief in the early postoperative period from the residual sensory block provided by local anaesthesia can facilitate the recovery process, enabling early ambulation and discharge home.
Good postoperative analgesic management probably carries benefits other than increased patient comfort. The magnitude of the neuro-endocrine stress response, postoperative pulmonary complications and the incidence of myocardial ischemia can be decreased. Early mobilization can be achieved and the patient can be discharged from hospital sooner.
End Stage Renal Disease (ESRD) patients who need arteriovenous hemodialysis shunt which done as brachiocephalic shunt is a surgical procedure done to provide access for dialysis for these patients as renal replacement therapy and those patients are usually have a lot of comorbidities and general anaesthesia carry multiple risks over the patient so, brachial plexus block can be ideal option for these patients.
Ultrasound guidance has resulted in a resurgence of interest in the supraclavicular approach to the brachial plexus. The ability to image the plexus, rib, pleura, and subclavian artery with ultrasound guidance has increased safety due to better monitoring of anatomy and needle placement and so decreasing the risk of pneumothorax.
Of various local anaesthetics used for brachial plexus block, bupivacaine is an amide local anaesthetic with long duration of action. Its mechanism of action is by preventing the generation and conduction of nerve impulses by reducing sodium permeability and increasing action potential threshold.
Adjuncts to brachial plexus block should prolong the analgesic effect without incurring systemic side effects or prolonged motor block and should also reduce the total dose of local anesthetic. Various studies have investigated several adjuncts, including opioids, clonidine, neostigmine, hyaluronidase, and bicarbonate. The results have been inconclusive, because of associated side effects or doubtful efficacy.