Complications of single-injection ultrasound-guided infraclavicular block: a cohort study

Infraclavicular block in children: Is blocking lateral or posterior cord equally successful?

Background and Aims

The most effective approach for infraclavicular brachial plexus block in adults is to target the posterior cord, usually situated posterior to axillary artery. However, we do not know if this can be extrapolated in children. Our primary objective was to compare the clinical success rate of ultrasound guided infraclavicular brachial plexus block in children with local anesthetic injection aimed at two targets. These were posterior to axillary artery (posterior cord) and lateral to axillary artery (lateral cord). The secondary objectives involved need for intraoperative rescue analgesia, evaluation of duration of analgesia, incidence of complications such as pneumothorax and arterial puncture, comparison of postoperative pain scores and fluoroscopic dye spread pattern was also observed.

Material and Methods

It was a randomized, prospective pilot study. Forty children undergoing forearm and hand surgeries were randomized to two groups, in accordance with the target site of the block. Target sites of Group P (20 patients) and Group L (20 patients) were posterior and lateral to the axillary artery, i.e., posterior and lateral cord respectively. Aforesaid objectives were assessed. SPSS (Version 15.0) statistical package was used. Comparison between Group L and P was by using student's unpaired t test for age and weight. Fisher's exact probability test was applied to compare percentages between groups.

Results

Blocks of both groups were equally successful. No patient required intraoperative rescue analgesia. Duration of analgesia was comparable. Both groups had no major complications and similar postoperative pain scores.

Conclusions

The success rate of infraclavicular brachial plexus block by aiming at the lateral and posterior cord was similar.

Postoperative neurological complications after brachial plexus block: a retrospective study conducted at a teaching hospital

PURPOSE

Serious complications after ultrasound-guided regional anaesthesia can be devastating for the patient. The pathogenesis of postoperative neurological complications (PONC) is multifactorial and includes mechanical, vascular and chemical factors besides the nerve puncture itself. The primary aim of this study was to assess the incidence of PONC after brachial plexus block (BPB).

METHODS

This is an observational retrospective single-centre study conducted at the regional anaesthesia unit of a teaching hospital. All BPBs performed from January 2011 to November 2019 were included. The outcomes analysed were the incidence, aetiology and diagnosis of PONCs and the incidence of other postoperative complications such as local anaesthetic systemic toxicity (LAST), pneumothorax, wrong-side block, etc. The performance of trainees and experienced anaesthesiologists was compared across all the outcomes.

RESULTS

From a total of 5340 BPBs included, 15 cases developed PONC, yielding a rate of 2.81:1000 (95% CI 1.70-4.63). Thirteen patients underwent neurophysiological exams which confirmed nine neuropathies. The rate of PONCs for supervised trainees was 1.80:1000 (95% CI 0.701-4.62), not statistically different from that of experienced anaesthesiologists (p = 0.241). Three cases were considered to present with a PONC probably related to BPB [0.562:1,00 (95% CI 0.191-1.65)]. The incidence of long-term PONCs was 1.12:1000 (95% CI 0.515-2.45). Such complications proved irreversible in 2 cases. The incidences of LAST, pneumothorax and other complications observed were 0.749:1000 (95% CI 0.291-1.92), 0.187:1000 (95% CI 0.0331-1.06) and 4.31:1000 (95% CI 2.87-6.46), respectively.

CONCLUSIONS

This survey suggests that complications after ultrasound-guided BPB, including blocks performed by trainees, are uncommon.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT04451642.

Reliability and Quality of YouTube Videos on Ultrasound-Guided Brachial Plexus Block: A Programmatical Review

BACKGROUND

Ultrasound-guided regional anesthesia has gained popularity over the last decade. This study aimed to assess whether YouTube videos sufficiently serve as an adjunctive tool for learning how to perform an ultrasound-guided brachial plexus block (BPB).

METHODS

All YouTube videos were classified, based on their sources, as either academic, manufacturer, educational, or individual videos. The metrics, accuracy, utility, reliability (using the Journal of American Medical Association Score benchmark criteria (JAMAS)), and educational quality (using the Global Quality Score (GQS) and Brachial Plexus Block Specific Quality Score (BSQS)) were validated.

RESULTS

Here, 175 videos were included. Academic (1.19 ± 0.62, mean ± standard deviation), manufacturer (1.17 ± 0.71), and educational videos (1.15 ± 0.76) had better JAMAS accuracy and reliability than individual videos (0.26 ± 0.67) (p < 0.001). Manufacturer (11.22 ± 1.63) and educational videos (10.33 ± 3.34) had a higher BSQS than individual videos (7.32 ± 4.20) (p < 0.001). All sources weakly addressed the equipment preparation and post-procedure questions after BSQS analysis.

CONCLUSIONS

The reliability and quality of ultrasound-guided BPB videos differ depending on their source. As YouTube is a useful educational platform for learners and teachers, global societies of regional anesthesiologists should set a standard for videos.

Ultrasound-Guided Single-Injection Infraclavicular Block Versus Ultrasound-Guided Double-Injection Axillary Block: A Noninferiority Randomized Controlled Trial

BACKGROUND

Single-injection ultrasound-guided infraclavicular block is a simple, reliable, and effective technique. A simplified double-injection ultrasound-guided axillary block technique with a high success rate recently has been described. It has the advantage of being performed in a superficial and compressible location, with a potentially improved safety profile. However, its effectiveness in comparison with single-injection infraclavicular block has not been established. We hypothesized that the double-injection ultrasound-guided axillary block would show rates of complete sensory block at 30 minutes noninferior to the single-injection ultrasound-guided infraclavicular block.

METHODS

After approval by our research ethics committee and written informed consent, adults undergoing distal upper arm surgery were randomized to either group I, ultrasound-guided single-injection infraclavicular block, or group A, ultrasound-guided double-injection axillary block. In group I, 30 mL of 1.5% mepivacaine was injected posterior to the axillary artery. In group A, 25 mL of 1.5% mepivacaine was injected posteromedial to the axillary artery, after which 5 mL was injected around the musculocutaneous nerve. Primary outcome was the rate of complete sensory block at 30 minutes. Secondary outcomes were the onset of sensory and motor blocks, surgical success rates, performance times, and incidence of complications. All outcomes were assessed by a blinded investigator. The noninferiority of the double-injection ultrasound-guided axillary block was considered if the limits of the 90% confidence intervals (CIs) were within a 10% margin of the rate of complete sensory block of the infraclavicular block.

RESULTS

At 30 minutes, the rate of complete sensory block was 79% in group A (90% CI, 71%-85%) compared with 91% in group I (90% CI, 85%-95%); the upper limit of CI of group A is thus included in the established noninferiority margin of 10%. The rate of complete sensory block was lower in group A (proportion difference of 12% [95% CI, 2-22]; P = 0.0091), as was surgical success rate (82% [95% CI, 74%-89%] vs 93% [95% CI, 86%-97%]; proportion difference of 11% [95% CI 1-20]; P = 0.0153). Sensory block onset also was slower in group A (log rank test P = 0.0020). Performance times were faster in group I (231 seconds [95% CI, 213-250]) than in group A (358 seconds [95% CI, 332-387]; P < 0.0001). No statistically significant difference was observed for vascular puncture, paresthesia during block performance, or procedure-related pain. No neurologic complication was noted at follow-up.

CONCLUSIONS

We failed to demonstrate that the rate of complete sensory block of the double-injection axillary block is noninferior to the single-injection infraclavicular block. However, the rate of complete sensory block at 30 minutes is statistically significantly lower with the axillary block. The ultrasound-guided single-injection infraclavicular block thus seems to be the preferred technique over the axillary for upper arm anesthesia.

Evidence-based medicine for ultrasound-guided regional anesthesia

Available evidence favoring the use of ultrasound for regional anesthesia is reviewed, updated, and critically assessed. Important outcome advantages include decreased time to block onset; decreased risk of local anesthetic systemic toxicity; and, depending on the outcome definition, increased block success rates. Ultrasound guidance, peripheral nerve blocks, and central neuraxial blocks are discussed.