Tips and tricks to improve the safety of the retroclavicular brachial plexus block

Ultrasound-Guided Retroclavicular Approach to the Infraclavicular Region (RAPTIR) Brachial Plexus Block for Anterior Shoulder Reduction

BACKGROUND

Shoulder dislocations are a common presenting injury to the emergency department (ED), with anterior dislocations comprising the majority of these cases. Some patients may tolerate gentle manipulation and reduction, but many require analgesia of some type. Oral or parenteral pain medication is often used alone or in combination with procedural sedation if gentle manipulation fails to achieve reduction. Recently, this treatment algorithm has grown to include regional anesthesia as a mode of analgesia for reduction of shoulder dislocations in the form of brachial plexus blocks. It has been well described that the interscalene and supraclavicular approach to the brachial plexus can be used to assist in reduction of anterior shoulder dislocations; however, there has yet to be any published literature regarding the use of ultrasound-guided retroclavicular approach to the infraclavicular region (RAPTIR) brachial plexus blocks for shoulder reduction.

CASE REPORT

We describe three patients who presented to the ED with anterior shoulder dislocations. The RAPTIR block was performed, provided effective analgesia, and facilitated successful shoulder reduction in all three patients.Why Should an Emergency Physician Be Aware of This? The RAPTIR nerve block is a safe and effective option for analgesia in the patient with an anterior shoulder dislocation. It may have advantages over other brachial nerve blocks and avoids the risks and disadvantages of procedural sedation and opioids.

Retroclavicular vs Infraclavicular block for brachial plexus anesthesia: a multi-centric randomized trial

BACKGROUND

The coracoid approach is a simple method to perform ultrasound-guided brachial plexus regional anesthesia (RA) but its simplicity is counterbalanced by a difficult needle visualization. We hypothesized that the retroclavicular (RCB) approach is not longer to perform when compared to the coracoid (ICB) approach, and improves needle visualization.

METHODS

This randomized, controlled, non-inferiority trial conducted in two hospitals, included patients undergoing distal upper limb surgery. Patients were randomly assigned to a brachial plexus block (ICB or RCB). The primary outcome was performance time (sum of visualization and needling time), and was analyzed with a non-inferiority test of averages. Depth of sensory and motor blockade, surgical success, total anesthesia time, needle visualization, number of needle passes and complications were also evaluated. Subgroup analysis restricted to patients with higher body mass index was completed.

RESULTS

We included 109 patients between September 2016 and May 2017. Mean RCB performance time was 4.8 ± 2.0 min while ICB was 5.2 ± 2.3 min (p = 0.06) with a 95% CI reaching up to 5.8% longer. RCB conferred an ultrasound-needle angle closer to 0° and significantly improved needle visibility after the clavicle was cleared and before local anesthetic administration. No differences were found in the secondary outcomes. Similar results were found in the subgroup analysis.

CONCLUSION

RCB approach for brachial plexus anesthesia was similar to ICB approach in terms of time performance. Needle visibility, which represent an important clinical variable, was superior and angle between needle and ultrasound probe was close to 0° in the RCB group.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT02913625), registered 26 September 2016.

Minimum effective volume of bupivacaine 0.5% for ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block

Background and objectives

The current study aimed to determine the minimum effective volume (MEV) of bupivacaine 0.5% in 50% of patients for an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block.

Methods

A total of 25 adult patients who were scheduled for upper limb surgery received an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block with bupivacaine 0.5%. The needle insertion point was posterior to the clavicle and the needle was advanced from cephalad to caudal. Block success was defined as a composite score of 14 at 30 min after local anesthetic (LA) injection. The minimum effective volume in 50% of patients was determined using the Dixon-Massey up-and-down staircase method. Minimum effective volume for a successful block in 95% of the patients was also calculated using logistic regression and probit transformation.

Results

The minimum effective volume of bupivacaine 0.5% resulting in successful block in 50% of patients (MEV50) according to the up-and-down staircase method was found to be 9.6 mL (95% confidence interval (CI), 5.7–13.4). The calculated minimum effective volume required for a successful block in 95% of patients (MEV95) using the probit transformation and logistic regression analysis was 23.2 mL (95% CI, 18.8–36.7).

Conclusions

The MEV50 of bupivacaine 0.5% for US-guided retroclavicular approach to infraclavicular brachial plexus block was 9.6 mL and the calculated MEV95 was 23.2 mL. Future studies are required for infraclavicular brachial plexus block with different approaches, other LA agents and different concentrations of bupivacaine.

[Minimum effective volume of bupivacaine 0.5% for ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block]

BACKGROUND AND OBJECTIVES

The current study aimed to determine the minimum effective volume (MEV) of bupivacaine 0.5% in 50% of patients for an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block.

METHODS

A total of 25 adult patients who were scheduled for upper limb surgery received an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block with bupivacaine 0.5%. The needle insertion point was posterior to the clavicle and the needle was advanced from cephalad to caudal. Block success was defined as a composite score of 14 at 30min after local anesthetic (LA) injection. The minimum effective volume in 50% of patients was determined using the Dixon-Massey up-and-down staircase method. Minimum effective volume for a successful block in 95% of the patients was also calculated using logistic regression and probit transformation.

RESULTS

The minimum effective volume of bupivacaine 0.5% resulting in successful block in 50% of patients (MEV50) according to the up-and-down staircase method was found to be 9.6mL (95% confidence interval (CI), 5.7-13.4). The calculated minimum effective volume required for a successful block in 95% of patients (MEV95) using the probit transformation and logistic regression analysis was 23.2mL (95% CI, 18.8-36.7).

CONCLUSIONS

The MEV50 of bupivacaine 0.5% for US-guided retroclavicular approach to infraclavicular brachial plexus block was 9.6mL and the calculated MEV95 was 23.2mL. Future studies are required for infraclavicular brachial plexus block with different approaches, other LA agents and different concentrations of bupivacaine.