Ultrasound guided costoclavicular block in pediatric population: A prospective observational study

BACKGROUND

The costoclavicular space serves as an alternative approach to the infraclavicular brachial plexus block, and numerous studies in adults have demonstrated promising outcomes for distal upper limb surgery. Blocking the brachial plexus at this level is potentially advantageous because the cords are relatively superficial, located in close proximity to each other and easily identified using ultrasound.

AIMS

This study aimed to assess the success rate and feasibility of costoclavicular block in children undergoing unilateral below elbow upper limb surgery.

METHODS

Thirty children aged 2-12 years scheduled for unilateral below elbow surgery under general anesthesia were included. Costoclavicular block was performed under ultrasound and nerve stimulator guidance with 0.5% ropivacaine, 0.5 mL/kg. Success was evaluated based on the absence of significant hemodynamic response to skin incision made 20 min after the block. The sono-anatomy of costoclavicular space, ease of needling, complications, and the post-operative pain scores were assessed.

RESULTS

The mean age and weight of the children were 6.5 ± 3.8 years and 19.7 ± 9.1 kg, respectively. The success rate of costoclavicular block in our cohort is 100%. Sonographic visualization was graded as excellent (Likert Scale 2) in 90% of cases. The plexus was located at a depth of 1.4 ± 0.3 cm from the skin, the lateral extent of cords from the artery was 0.8 ± 0.4 cm and they were observed inferior and lateral to the artery. The mean needling time was 3.6 ± 1.1 min. None of the children experienced complications such as vascular or pleural puncture, hematoma, Horner's syndrome or diaphragmatic palsy. Postoperative pain scores were low, and no rescue analgesia was required.

CONCLUSIONS

In conclusion, the costoclavicular block exhibited a notably high success rate in pediatric population. This study substantiates that the three cords of the brachial plexus are consistently visible and superficial during ultrasound examination using this approach, confirming their separation from vascular structures and the reliable achievement of blockade without observed complications.

A Comparison Between Ultrasound-Guided Supraclavicular and Infraclavicular Approaches to Brachial Plexus Block for Elective Upper Limb Surgery

BACKGROUND

Regional anaesthesia offers the anaesthesiologist, the surgeon, as well as the patient advantages over general anaesthesia such as being conscious through the surgery, avoiding multiple drugs, better haemodynamic stability, excellent postoperative analgesia, and faster per oral consumption post surgery. Compared with the axillary approach, the brachial plexus block at the level of the clavicle can anaesthetize all four distal upper extremity nerve territories without the requirement for a separate block of the musculocutaneous nerve.

AIM

The aim of the study was to compare the effect of both supraclavicular and infraclavicular brachial plexus blocks in terms of time taken for onset, performance, and block success.

MATERIALS AND METHODS

Sixty patients undergoing below-elbow upper limb surgeries were randomized into two groups: (i) supraclavicular (Group S) and (ii) infraclavicular (Group I). All patients received 30ml 0f 0.5% bupivacaine as the local anesthetic of choice. The block performance time, time taken for onset of sensory and motor blockade, total duration of block, and hemodynamic parameters were observed. The block performance times and the onset of the sensory blockade were the primary outcomes while the duration of the block and hemodynamic parameters were secondary outcomes. Two two-tailed independent sample t-tests will be used to compare the variables.

RESULTS

We observed that the block performance time for the infraclavicular block (mean 14.833 minutes) was longer than the supraclavicular block (mean 10.37 minutes). This was statistically significant with p <0.001. In terms of onset of sensory blockade, the infraclavicular group (13.667 minutes) had a quicker onset compared to the supraclavicular group (17.333 minutes). This was also statistically significant with p <0.001. The mean total duration of sensory and motor blockade was similar in both groups (p-value of 0.341 and 0.791 respectively) and there was no statistical difference. There was no hemodynamic instability or complications in our study.

CONCLUSION

Ultrasound-guided infraclavicular block is a relatively safer technique when compared to the supraclavicular technique with faster onset. The time taken for administering the infraclavicular block can be reduced by repeated exposure to the technique.

Ultrasound-guided brachial plexus block at the clavicle level: A review

The supraclavicular block (SCB) and the infraclavicular block (ICB) are introduced to meet upper extremity surgery, where the transducer or the insertion point is placed superiorly and inferiorly at the approximate midpoint of the clavicle, respectively. These two approaches are highly appealing since they clearly exhibited each cord and its associated anatomy. In addition, it directed the needle accurately with real-time imaging by ultrasound guidance. Therefore, it brought higher success rates and fewer complications. Numerous trials have recently been conducted to examine the SCB and ICB regarding the new approach, injection techniques, block dynamics, and complication of hemidiaphragmatic paresis. It was found that both approaches could improve block effectiveness and postoperative analgesia for upper extremity surgery, according to recent studies at the level of the clavicular brachial plexus block. However, there is still a lack of work comparing the clinical performance and effectiveness of both approaches with ultrasonography. This review aims to outline the current available data from clinical trials along with case reports about these two approaches and to describe the findings published in the literature during the previous 5 years. Based on these findings, we attempt to determine whether there exists a one-size-fits-all approach that has the potential to meet upper extremity surgery.

Regional Anaesthesia in the Post-COVID Era

COVID-19 pandemic has changed clinical practice significantly. Trying to avoid airway manipulation to reduce viral transmission favoured regional anaesthesia techniques over general anaesthesia when feasible. In this case report, we share the anaesthetic care of a 45-year-old male with a history of intensive care unit admission due to COVID, positive pressure ventilation, and ECMO support. The patient was diagnosed with cubital tunnel syndrome, and his treatment was successfully applied as surgical release under infraclavicular block. This case is discussed in relation to recent trends in anaesthesiology, regarding patients with COVID-19 history.

A randomized comparison between ultrasound-guided costoclavicular and infraclavicular block for upper extremity surgery

Background/aim

This study compared ultrasound guided costoclavicular (CC) and lateral sagittal infraclavicular (LS) brachial plexus block in patients undergoing upper extremity surgery.

Materials and methods

A total of 80 patients undergoing upper extremity surgery were randomly classified into two groups: Group CC (costoclavicular (n = 40)) and Group LS (lateral sagittal infraclavicular (n = 40)). Both groups received a 25 mL containing a mixture of 1% lidocaine and 0.25% bupivacaine. A blinded observer recorded the block onset time and decided which patients who were admitted to the operation room needed general anesthesia or rescue block or without any iv. narcotics for the surgical procedure.

Results

The sensorimotor onset time was found to be faster in the CC group [(15.95 2.97) min] compared to the LS group [(17.72 4.15)min]. There was a statistically significant difference between two groups in terms of sensorimotor onset time (p = 0.031). There was no difference between two groups in terms of the block performance times and post-block motor block dissolution times.

Conclusion

The CC approach provides faster onset of sensorimotor blockade than LS approach when the 4 major terminal nerves of the brachial plexus were evaluated.

Effect of Added Alpha 2 Agonists with Local Anaesthetic in Infraclavicular Brachial Plexus Block: A Comparative Study between Dexmedetomidine and Clonidine

Background

Many adjuvant drugs are added with local anesthetics to increase the quality of regional blocks.

Aim

To compare the effects of dexmedetomidine and clonidine added to bupivacaine in infraclavicular brachial plexus block in prolonging the duration of analgesia in patients undergoing orthopedic surgery of forearm or hand and also to compare the duration of sensory and motor block, sedation, and hemodynamic changes like bradycardia and hypotension in two groups.

Settings and Design

This was an observational study conducted in a tertiary care hospital.

Materials and Methods

A study was conducted among 60 patients admitted for elective upper limb surgeries under ultrasound-guided infraclavicular block. Patients who received bupivacaine 0.5% (20 mL) + Clonidine 1 μg.kg-1 were classified as Group A and those received bupivacaine 0.5% (20 mL) + dexmedetomidine 1 μg.kg-1 were classified as Group B.

Statistical Analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 25.

Results

Duration of analgesia was significantly higher in Group B as compared to Group A (mean + standard deviation = 764 ± 17.573 min vs. 526 ± 9.958 min, respectively, P = 0.001). The mean time for onset of a sensory block as well as motor block was significantly less in Group B when compared to Group A (P = 0.001). The mean duration of both sensory block and motor block was higher in Group B as compared to Group A (P = 0.001).

Conclusions

The dexmedetomidine group (Group B) provides a quicker and prolonged analgesic action without major adverse effects.

A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series

BACKGROUND

Shoulder arthroplasty is associated with significant post-operative pain. Interscalene plexus block is the gold standard for pain management in patients undergoing this surgery, however, alternatives are currently being developed. We hypothesized that a combination of anterior suprascapular nerve block and lateral sagittal infraclavicular block would provide effective post-operative analgesia. Primary aims for this study were to document numeric rating scale (NRS) pain score and use of oral morphine equivalents (OMEq) during the first 24 hours after surgery. Secondary aim was to determine the incidence of hemidiaphragmatic paralysis.

METHODS

Twenty patients (ASA physical status I-III) scheduled for shoulder arthroplasty were studied. Four mL ropivacaine 0.5% was administered for the suprascapular nerve block and 15 mL ropivacaine 0.75% for the infraclavicular block. Surgery was performed under general anaesthesia. Paracetamol and prolonged-release oxycodone were prescribed as post-operative analgesics. Morphine and oxycodone were prescribed as rescue pain medication. Diaphragm status was assessed by ultrasound.

RESULTS

Median NRS (0-10) at 1, 3, 6, 8 and 24 hours post-operatively were 1, 0, 0, 0 and 3, respectively. NRS at rest during the first 24 post-operative hours was 4 (2.5-4.5 [0-5]), median (IQR [range]). Maximum NRS was 6.5 (5-8 [0-10]) median (IQR [range]). Total OMEq during the first 24 post-operative hours was 52.5 mg (30-60 [26.4-121.5]) median (IQR [range]). Hemidiaphragmatic paralysis was diagnosed in one patient (5%).

CONCLUSIONS

The combination of suprascapular and infraclavicular nerve block shows an encouraging post-operative analgesic profile and a low risk for hemidiaphragmatic paralysis after total shoulder arthroplasty.

Efficacy of a single injection compared with triple injections using a costoclavicular approach for infraclavicular brachial plexus block during forearm and hand surgery: A randomized controlled trial

OBJECTIVES

It was recently proposed that a costoclavicular (CC) approach can be used in ultrasound (US)-guided infraclavicular brachial plexus block (BPB). In this study, we hypothesized that triple injections in each of the 3 cords in the CC space would result in a greater spread in the 4 major terminal nerves of the brachial plexus than a single injection in the CC space without increasing the local anesthetic (LA) volume.

METHODS

Sixty-eight patients who underwent upper extremity surgery randomly received either a single injection (SI group, n = 34) or a triple injection (TI group, n = 34) using the CC approach. Ten milliliters of 2% lidocaine, 10 mL of 0.75% ropivacaine, and 5 mL of normal saline were used for BPB in each group (total 25 mL). Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves was assessed by a blinded observer at 5 minutes intervals for 30 minutes immediately after LA administration.

RESULTS

Thirty minutes after the block, the blockage rate of all 4 nerves was significantly higher in the TI group than in the SI group (52.9% in the SI group vs 85.3% in the TI group, P = .004). But there was no significant difference in the anesthesia grade between the 2 groups (P = .262). The performance time was similar in the 2 groups (3.0 ± 0.9 minutes in the SI group vs 3.2 ± 1.2 minutes in the TI group, respectively; P = .54).

DISCUSSION

The TI of CC approach increased the consistency of US-guided infraclavicular BPB in terms of the rate of blocking all 4 nerves without increasing the procedure time despite administering the same volume of the LA.

Tissue Oxygen Saturation Change on Upper Extremities After Ultrasound-Guided Infraclavicular Brachial Plexus Blockade; Prospective Observational Study

Background and Objective: The aim of this study was to investigate whether tissue oxygen saturation (StO2) is a reliable and objective method for assessing the adequacy of infraclavicular block and to describe the time course of StO2 changes. Materials and Methods: In this prospective observational study, StO2 was measured in 40 patients planned for elective hand surgery under infraclavicular block. Noninvasive StO2 monitoring was used prior to ultrasound-guided infraclavicular brachial plexus block and during the first 30 min of the blockade. Sensory and motor blocks were evaluated every 5 min followed by pinprick testing and Bromage scale. Results: Preanesthetic median StO2 values of the blocked side and nonblocked side were similar (p = 0.532), whereas the postanesthetic values of the blocked side were higher. At the fifth minute and the following minute, measurements compared to the nonblocked side (p < 0.001). The median StO2 values increased significantly, which increased by 4.5% at 5 min, by another 5.5% at 30 min, and by an average of 1% from 5 to 30 min compared to the baseline values in the blocked side. The responses of the patients to the questions probed in the pinprick test and Bromage scale were fully compatible with the data obtained by the near-infrared spectroscopy (NIRS) method. Conclusions: StO2 monitoring may provide a useful instrument for rapid evaluation of the success of regional anesthesia in the upper extremity.

A randomised comparative evaluation of supraclavicular and infraclavicular approaches to brachial plexus block for upper limb surgeries using both ultrasound and nerve stimulator

Background and Aims:

The supraclavicular and infraclavicular brachial plexus blocks have a similar distribution of anaesthesia, and both can be used effectively for surgeries of the upper limb. This study aimed to compare the supraclavicular and infraclavicular approaches of brachial plexus blocks, guided by ultrasound and neurostimulation.

Methods:

Sixty adult patients scheduled for elective upper limb surgery of the elbow and/or below were randomly divided into two groups: infraclavicular Group (I) and supraclavicular Group (S). All the blocks were performed with the aid of ultrasound-guided nerve stimulator confirmation. The two groups were compared with respect to block performance time, onset of sensory and motor blockade, readiness for surgery, success rate and complications. The statistical analysis was performed with Student t-test and Chi-square test.

Results:

The block performance time for the infraclavicular group was 9.57 ± 3.19 min, whereas for supraclavicular group, it was 11.53 ± 2.90 min with similar success rates (93.3%). Onset of sensory blockade was achieved earlier (6.43 ± 2.61 min) in Group I than Group S (8.45 ± 2.87 min, P = 0.006). The onset of motor blockade was similar in Group I (7.32 ± 2.90 min) and Group S (8.68 ± 3.50 min, P = 0.121). The patient satisfaction was similar in both the groups. One patient had a pneumothorax, three patients developed Horner syndrome and another had clinically symptomatic diaphragmatic paresis in Group S.

Conclusion:

The infraclavicular block is more rapidly executed compared to supraclavicular block with similar success rates and fewer complications in the presence of ultrasound and nerve stimulator and hence should be preferred.

Comparison of ultrasound-guided supraclavicular, infraclavicular and below-C6 interscalene brachial plexus block for upper limb surgery: a randomised, observer-blinded study

This prospective, randomised, observer-blinded study was conducted to compare the ease of performance and surgical effectiveness of interscalene block below the C6 nerve root with supraclavicular and infraclavicular techniques of brachial plexus block for upper arm and forearm surgery. Sixty adult patients of American Society of Anesthesiologists grade 1 to 3, undergoing upper limb surgery, were randomly allocated into three groups. Group SC received supraclavicular blockade, group IC received infraclavicular blockade and Group IS received interscalene blockade. All blocks were guided by ultrasound with nerve stimulator confirmation. The anaesthetic mixture consisted of 0.5 ml/kg of equal volumes of 0.75% ropivacaine and 2% lignocaine-adrenaline. The imaging and block performance time, onset time, success rate, duration of block, and duration of postoperative analgesia were recorded by a blinded observer. The onset time was significantly longer in the interscalene group as compared with supraclavicular and infraclavicular approaches. The imaging time and block performance time were comparable between groups. No significant differences were observed between the three groups in terms of block-related pain scores, success rates, duration of block or of postoperative analgesia. Two patients in the interscalene group developed clinically detectable phrenic nerve palsy. Our findings indicate that, although interscalene block below the C6 nerve root can provide surgical anaesthesia for forearm and hand surgery, it appears to have a longer onset time than supra- and infraclavicular approaches and an unacceptable incidence of phrenic nerve palsy.

[Anesthesia for upper limb surgery in a developing country: experience of infraclavicular and axillary blocks under neurostimulation]

ABSTRACT

Despite advances in regional anesthesia under ultrasound guidance, neurostimulation remains the primary technique in underequipped locations.

MATERIAL AND METHODS

We conducted a prospective descriptive study from January to December 2010 and June 2011 to May 2012 with as our main objective the assessment of the practices of infraclavicular and axillary nerve blocks (ICB and AXB, respectively) at Sylvanus Olympio University Hospital.

RESULTS

105 patients (11.8%) received ICB) and 75 patients (8.5%) axillary blocks (AXB). The average minimum intensity of neurostimulation was 0.4 mA (range: 0.25-0.45 mA. The mean volume of 0.5% bupivacaine used was 30 ± 10 mL. The mean onset time of the block was 15 ± 10 min, and the mean duration of action 6 ± 4 hours. Postoperative pain was significantly worse in patients who received ICB compared to AXB [χ(2) = 19.034, p = 0.00001<0.05]. The cost of either type of locoregional anesthesia under neurostimulation compared with general anesthesia was 44 euros versus 105 euros.

CONCLUSION

Peripheral nerve block by ICB and AXB under neurostimulation showed significant difference in terms of postoperative analgesia efficiency. Locoregional anesthesia remains too rarely practiced in underequipped countries despite its benefits and although it is particularly appropriate for these countries.

Role of ultrasound-guided continuous brachial plexus block in the management of neonatal ischemia in upper limb

Neonatal upper limb ischemia due to accidental arterial damage remains a major concern, which can lead to devastating complications if untreated. The primary objective of this case report is to emphasize the role of continuous infraclavicular brachial plexus block, the issues related with block performance in an ischemic hand, and the importance of ultrasound guidance in this particular case scenario. A 1.1 kg infant suffered from distal forearm ischemia due to accidental arterial damage, which was treated with brachial plexus block. An ultrasound-guided single shot block with 0.5 mL/kg of 0.25% bupivacaine was followed by ultrasound-guided catheter placement in the target area. A continuous infusion of 0.03% of bupivacaine at the rate of 0.5 mL/kg/hr (approx. 0.15 mg/kg/h of bupivacaine) was administered for 36 h. This treatment resulted in reversal of ischemia. Permanent ischemic damage was eventually confined to the tips of 4 fingers. We conclude that ultrasound-guided continuous infraclavicular block has a therapeutic role to play in the treatment of hand ischemia due to arterial damage and subsequent arterial spasm in neonates with added benefits.

Ultrasound-guided single injection infraclavicular brachial plexus block using bupivacaine alone or combined with dexmedetomidine for pain control in upper limb surgery: A prospective randomized controlled trial

Background:

Dexmedetomidine, is a selective α2-adrenoceptor agonist that is used as an adjuvant mixed with local anesthetics during regional anesthesia. This study was designed to test the efficacy of adding dexmedetomidine to bupivacaine during placement of infraclavicular brachial plexus blockade (ICB).

Methods:

Sixty adult patients were divided into 2 equal groups of 30 subjects each. Patients in Group I received an ICB using 30 mL of 0.33% bupivacaine and Group II patients received 30 mL of 0.33% bupivacaine mixed with 0.75 μg/kg of dexmedetomidine. The following brachial plexus nerve block parameters were assessed: block success rate, sensory onset time and duration, motor block onset time and duration, analgesic pain scores using the verbal rating scale (VRS) for pain, duration of analgesia, and amount of supplemental intravenous (IV) morphine required.

Results:

There was a statistically significant shorter time to onset of sensory blockade (13.2 vs 19.4 min, P=0.003), longer duration of sensory block (179.4 vs 122.7 min, P=0.002), shorter onset time to achieve motor block (15.3 vs 22.2 min, P=0.003), longer duration of motor block (155.5 vs 105.7 min, P=0.002), lower VRS pain scores, prolonged analgesia (403 vs 233 min, P=0.002), and lower morphine rescue requirements for 48 h after surgery (4.9 (0–8.0) vs 13.6 mg (4.0–16.0) mg, P=0.005). All patients recovered without evidence of sensory or motor deficit.

Conclusion:

Adding dexmedetomidine to bupivacaine during the placement of an ICB provides: (1) enhancement of onset of sensory and motor blockade, (2) prolonged duration of analgesia, (3) increases duration of sensory and motor block, (4) yields lower VRS pain scores, and (5) reduces supplemental opioid requirements.

Ultrasound-guided continuous infraclavicular brachial plexus block using bupivacaine alone or combined with adenosine for pain control in upper limb surgery

Introduction:

The infraclavicular brachial plexus block (ICB) is designed to deposit anesthetic high in the plexus, achieving anesthesia of the hand, forearm, elbow, and distal arm. Adenosine is a metabolic intermediate that is involved in nearly all aspects of cell function, including neurotransmission and signal transduction.This study was aimed to show whether addition of adenosine to bupivacaine in ultrasound-guided ICB had an analgesic effect.

Methods:

Sixty adult patients were divided into two equal groups, each group included 30 patients. Group I received infraclavicular bupivacaine 0.325% in a volume of 30 ml. Group II received 30 ml of 0.325% bupivacaine + 12 mg adenosine. The block was maintained with an infusion of 10 ml/h. The following parameters were assessed: Success rate, time of the sensory onset, motor block, visual analog scale (VAS), and amount of i.v. pethidine needed.

Results:

This study showed an analgesic effect of infraclavicular adenosine as evidenced by a statistically significant shorter mean time of onset of the sensory block (16 vs. 20 min, P < 0.05), lower mean VAS score over 48 h (1.7 vs. 2.7, P < 0.05), longer mean time of first parenteral analgesic requirement (299 vs. 255 min, P < 0.05), and lower mean total dose of pethidine needed over 48 h after surgery (25.5 vs. 56.6 mg, P <0.05). All patients got successful infraclavicular block and recovered uneventfully without any sensory or motor deficit.

Conclusion:

Adenosine may provide valuable addition to the therapeutic options in anesthesia and pain management. Further research is required to figure out its exact role

Comparison of the vertical and the highest point of shoulder methods in brachial plexus block

BACKGROUND AND AIM

Brachial plexus block by the highest point of the shoulder method may decrease the rate of complication in comparing with the vertical method because the needle is more lateral in the former. We aimed to investigate the highest point of the shoulder block technique against the vertical infraclavicular plexus method regarding the success rates and complications.

PATIENTS AND METHODS

Thirty patients with ASA I-III undergoing elective surgery were included in this study. Patients were divided into two groups, randomly. Group 1 was the highest point of the shoulder method (n of 15), and goup 2 was the vertical approach technique (n of 15). The extensor motor response of hand, wrist and elbow (The target nerves in the operation area: n. medianus, n. ulnaris, n. radialis and n. musculocutanaeus) was obtained by neurostimulation technique. Then, 30 ml bupivacaine (0.5%) was used for the initial block. Spread of analgesia and sensory and motor blocks were evaluated every 5 minutes by an anesthesiologist who was blind to the block techniques.

STATISTICAL ANALYSIS

T-test and Mann-Whitney U test were used.

RESULTS

Successful block was achieved in all patients in both groups. There was no difference among the groups for the onset of block and the duration of block (both sensory and motor), the number of attempt, and the depth of the neddle. One patient developed pneumothorax in group 2. Procedure time of the block was longer in group 2 than in group 1 (p<0.05).

CONCLUSIONS

The highest point of shoulder method with a less complication rate and shorter procedure time has a comparable success rate to vertical approach technique.