Abstract
BackgroundThe 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.MethodsThis 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.ResultsWe 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.ConclusionRCB 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 registrationClinicalTrials.gov (NCT02913625), registered 26 September 2016.
Highlights
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
Natural logarithmic average for performance time was 5.6 (SD: 0.4; 95% Confidence Interval [CI] 5.5–5.7) and 5.7 (SD: 0.4; 95% CI 5.6–5.8) for RCB and ICB respectively
Difference between the logarithmic averages was 0.073 (95% IC diff: [− 5.8% - infinity]; p = 0.06) or 7.1% when expressed in percentage change of performance time and was going over the pre-specified non-inferiority margin of 5.0% by 0.8% (Fig. 2)
Summary
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. Regional anesthesia (RA) offers several advantages over general anesthesia (GA) for upper limb orthopedic surgery. Blanco et al BMC Anesthesiology (2019) 19:193 The purpose of this randomized controlled trial was to perform a systematic comparison between these two RA techniques for upper limb surgery. By providing better needle visibility, our main hypothesis is that the total time required to perform RCB will be non-inferior to the time required to perform ICB while providing at least identical block quality and success. Several secondary outcomes were collected and analyzed such as needle visibility, imaging and needling time, depth of sensory and motor blocks, total anesthesia time, block success, angle and number of passes, procedural pain and incidence of complications
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