Onset Time Of Block Research Articles

Effects of different approaches of infraclavicular brachial plexus block on perfusion index and tissue perfusion.

Although both the lateral sagittal and costoclavicular approaches are applied at the cord level in the infraclavicular region, there is a major difference between the distributions of the two approaches. We aimed to investigate the effects of this different distribution on tissue perfusion and oxygenation. Sixty patients undergoing elective elbow, forearm, wrist and hand surgery under infraclavicular brachial plexus block were included in the study. Patients were divided into two groups: group CC (costoclavicular approach, n = 30) and group LS (lateral sagittal approach, n = 30). The primary outcomes of this study were increased perfusion index (PI) and tissue oxygen saturation (StO2) rate. Secondary outcomes were the duration of block application, sensory and motor block onset time, time to first analgesic need and duration of motor block. The PI and StO2 increased significantly from baseline to each time point in both groups; however, there were no significant differences between the groups. The time to reach the sensory block stage was shorter with the costoclavicular approach. The duration of block application was shorter when using the costoclavicular approach. There were no differences between the approaches in terms of the time to the first analgesic requirement or need for additional analgesics. The different distributions of the two different approaches to infraclavicular brachial plexus block, costoclavicular and lateral sagittal, did not have an additional effect on tissue perfusion and oxygenation. Both approaches can be preferred especially in surgeries in which an increase in tissue perfusion is desired owing to perfusion-enhancing properties. NCT04764591.

Comparing C3, 4, and 5 nerve root block and interscalene with intermediate cervical plexus block in diaphragmatic motion for clavicle surgery

Regional anesthesia is a popular method for surgical anesthesia in clavicular surgery. Selective blocking of the cervical 3, 4, and 5 nerve roots shows promise in clavicle surgery, with its fast onset, good anesthesia and less complications, necessitating evaluation of its impact on diaphragmatic function. The purpose of this study is to examine the safety of C3, 4, and 5 nerve root block for its application in clavicle surgery. We conducted a pragmatic, randomized trial to evaluate the effect of C3, 4, and 5 nerve root block as compared with interscalene with intermediate cervical plexus block in diaphragmatic motion. This study involved forty patients undergoing right clavicle surgery. Patients were assigned in a 1:1 ratio to either a C345 nerve root block (administered with 2, 3, and 5 ml of 0.5% ropivacaine) or an interscalene with intermediate cervical plexus block (ISB + ICPB, each receiving 10 ml of 0.5% ropivacaine). Diaphragmatic kinetics were quantitatively assessed using sonographic techniques. The primary outcome was the incidence of complete hemi-diaphragmatic paralysis, observed at 30 min post-blockade. Secondary outcomes included the rate of complete hemi-diaphragmatic paralysis at 15 min and the degree of diaphragmatic motion restoration at 2, 4, 6, and 8 h post-blockade, onset time of block, motor block score in upper extremity, and adverse events. Results showed that only one patient (5%) in the C345 group vs. fifteen (75%) in the ISB + ICPB group experienced complete hemi-diaphragmatic paralysis at 30 min during deep breathing (P = 0.001). No patients in the C345 group, compared to five (25%) in the ISB + ICPB group exhibited paradoxical movement at 30 min during voluntary sniffing (P = 0.0471). Additionally, the C345 group demonstrated significantly greater diaphragmatic motion and upper limb strength restoration at all measured intervals post-blockade. Moreover, faster onset time and less adverse events were observed in the C345 group vs. in the ISB + ICPB group. Benefit from low volume of local anesthetics, the C345 nerve root block not only significantly reduces the incidence of complete hemi-diaphragmatic paralysis but also facilitates better recovery from diaphragmatic paralysis compared to the ISB + ICPB. It can be inferred that C345 is a more beneficial anesthesia method for early recovery of clavicular patients.Trial registration number: ChiCTR2300078283 04/12/2023.

The effect of intravenous lidocaine infusion on subarachnoid anesthesia in patients undergoing total knee replacement: a randomised controlled trial.

Intravenous lidocaine is a non-opioid analgesic adjunct for perioperative pain relief. The aim of our study was to explore whether concurrent administration of intravenous lidocaine prolongs the duration of sensory block during total knee replacement (TKR) under spinal anaesthesia. This prospective randomized double blind controlled trial was conducted on 28 patients (14 in lidocaine group and 14 in the control group) undergoing unilateral TKR under spinal anesthesia. In the lidocaine group, intravenous lidocaine 1.5mg·kg-1 followed by an infusion of 1.5mg·kg-1·h-1 was administered intraoperatively after spinal anesthesia. The primary outcome was the duration of sensory block of spinal anesthesia. Secondary outcomes included onset time of sensory and motor block, duration of motor block, time to first postoperative analgesic, postoperative visual analog scale (VAS) scores and postoperative analgesia requirement in 24h after surgery. The duration of sensory and motor block was longer in the lidocaine group (Mean ± SD; 112.50 ± 5.80min versus 78.21 ± 9.12min;p < 0.001 and 237.14 ± 9.14min versus 215.00 ± 10.12min;p < 0.001, respectively). Time to requirement of first rescue analgesia was 184.29 ± 9.38min in the lidocaine group and 127.14 ± 23.35min in the control group (p < 0.001). VAS scores were lower in the lidocaine group at 4, 8, 12 and 24h after surgery (p < 0.00001, p < 0.00001, p < 0.00006, p = 0.032, respectively). Requirement of additional analgesia in the first 24h was higher in the control group. There were no clinical signs to suggest lidocaine toxicity in any patient. During unilateral TKR under spinal anaesthesia, concurrent use of intravenous lidocaine prolonged sensory block and reduced postoperative analgesic requirements.

Ultrasound-guided popliteal sciatic nerve block for surgical anesthesia in wound care patients with ongoing anticoagulant/antiaggregant therapy: A single-center, prospective study.

Ultrasound-guided peripheral nerve blocks may be a good alternative in patients under antithrombotic drugs. We evaluated the efficacy of ultrasound-guided popliteal sciatic nerve block in patients undergoing lower extremity wound debridement of whom antithrombotic drugs could not be stopped. We focused on hemorrhagic complications related to sciatic nerve block. Wound care patients followed by Cardiovascular Surgery Department scheduled for lower extremity wound surgery were included in this prospective observational study. Data was collected between March 2021 and September 2022. All patient were under antithrombotic therapy and discontinuation of anticoagulant drugs were not possible. Single-insertion and multiple-injection sciatic nerve block at popliteal region was applied to all patients under ultrasound guidance. Primary outcome was the rate of hemorrhage. Secondary outcomes were block onset times, block success and postoperative analgesia times. Data of 105 patients was evaluated, 87 were male and 18 were female. Mean patient age was 61.92 ± 10.06, mean patient body mass index was 25.68 ± 6.33. All patients were under 1 or more antithrombotic drugs. Only one minor hematoma was detected by postoperative ultrasonography control in 1 patient. Hemorrhage complication rate was 1 of 105 (% 0.95, 95% CI, 0.00024-0.051). Overall block success rate was 99.05%. Mean block onset time was 16.27 ± 5.69 minutes. Mean postoperative analgesia time was 19.5 ± 11.22 hours. Sciatic nerve block under ultrasound guidance using in-plane technique was safe and provided sufficient surgical anesthesia and postoperative analgesia for lower extremity wound debridement surgery in patients on antithrombotic drugs.

Comparing the Effects of Infusion and Bolus Doses of Bupivacaine Applied with Infraclavicular Catheter on the Duration and Need of Postoperative Analgesia

Objective: This study aimed to evaluate postoperative analgesia duration, analgesic requirements, and patient satisfaction between continuous infusion and bolus injection techniques using an infraclavicular catheter in patients undergoing forearm surgery. Material and Method: We examined 100 patients which were divided into 2 groups to evaluate the data retrospectively. Bolus Injection Group (B): Patients who received 4 mL of bupivacaine (0.5%) from the catheter if the VAS value was &gt; 3. Continuous Infusion Group (C): Patients who received 20 mg bupivacaine (0.02%) infusion via catheter using an infusion pump in 24 hours. Demographic data, American Society of Anesthesiologists (ASA) score, intraoperative and postoperative hemodynamic data, sensory and motor block onset times, postoperative Visual Analogue Scale (VAS) (1-2-6-12-24th hour), postoperative 24th and 48th hour satisfaction score, obtained from anesthesia and algology follow-up forms, were evaluated. Results: When both groups were compared, VAS6 and VAS24 values of Group C were found to be statistically significantly lower than Group B. Satisfaction scores revealed that significantly more patients in Group C reported being very satisfied compared to Group B. Conclusion: Our findings suggest that continuous local anesthetic infusion via catheter offers more sustainable analgesia compared to bolus administration.

A Comparative Study between Ultrasound-guided Concomitant Infraclavicular Plus Distal Median, Radial, and Ulnar Nerve Blockade Versus Infraclavicular Block Alone

Abstract Background: Peripheral nerve blocks can be used alone as the sole “surgical” anesthetic technique as the initial step in providing prolonged postoperative analgesia. There are studies, where accurate deposition of local anesthetic perineurally has the potential to improve the success rate and reduce the incidence of complications of the infraclavicular block. We hypothesized whether a combined block of the infraclavicular brachial plexus and distal median, radial, and ulnar nerves would accelerate upper extremity anesthesia compared with an infraclavicular block alone. Materials and Methods: This study was a prospective randomized control study conducted among 60 patients undergoing elective and emergency wrist and hand surgeries. A group of 30 patients received an infraclavicular block with 30 mL of a local anesthetic mixture containing 1% lignocaine with adrenaline and 0.25% bupivacaine from Group A. Group B received an infraclavicular block with 15 mL of local anesthetic mixture containing 1% lignocaine with adrenaline and 0.25% bupivacaine along with distal median, radial, and ulnar nerve blockade with 5 mL each of local anesthetic mixture containing 1% lignocaine with adrenaline and 0.25% bupivacaine. Pain score, assessment of sensory and motor functions, block performance time, and surgical anesthesia were observed. Results: The mean block performance time of Group A was 10.9 ± 1.1 min and Group B was 14.7 ± 0.5 min. The difference between the two groups’ block performance minutes was statistically significant (P &lt; 0.001). The difference in the onset of the sensory block between the two groups was statistically significant (P &lt; 0.001). The mean onset of motor blockade between the two groups was statistically very highly significant (P &lt; 0.001). The mean of Group A was 5.0 ± 0.2 and Group B was 2.1 ± 0.4. Conclusion: From this study, we conclude that using an approximately equivalent dose of local anesthetics, combining ultrasound-guided infraclavicular block with distal median, radial, and ulnar nerve blockade shortens the onset time of sensory and motor block with improved block consistency compared to infraclavicular block alone.

Ropivacaine and magnesium sulfate in sciatic nerve block at the popliteal level: randomized double-blind study.

Following surgical procedures, over 80% of patients experience acute pain, with half of them expressing dissatisfaction with pain relief. The modern approach to surgical treatment and pain management increasingly relies on implementing multimodal analgesia, which includes the use of adjuvants in addition to long-acting local anesthetics (such as ropivacaine). This double-blind randomized study evaluated the analgesic effect of magnesium sulfate added to ropivacaine in the sciatic nerve block at the popliteal level for bunion correction surgery. In this double-blind study, fifty patients were enrolled and randomized in a 1:1 ratio to receive ropivacaine and MgSO<inf>4</inf> 200 mg or ropivacaine and physiological solution. The primary endpoint was the duration of sensory block. A statistically significant difference was observed in the onset time for sensory block (9.2 minutes vs. 21.8 minutes, P<0.001) and its duration (18.2 hours vs. 13.9 hours, P<0.001) between the two groups. Between 12 and 24 hours postoperatively, the maximum NRS pain scores in the magnesium group were lower than those in the control group (IQR [range]) 2 (2-3.8 [0-6.5]) vs. 6.7 (5.6-7.9 [2.7-9.2], P<0.001). The need for additional opioids after 12-24 hours was significantly higher in patients in the physiological solution group compared to those in the magnesium group. Our results suggest that magnesium added to the local anesthetic extends sensory block duration, reduces postoperative pain, improves the quality of analgesia, decreases the need for additional opioids. Further studies are needed to confirm these preliminary findings.

Impact of Dexamethasone on Lignocaine and Ropivacaine Mixture for supraclavicular Brachial Plexus Block: A Prospective, Randomized, Double Blind Trial

Supraclavicular brachial plexus block is a common regional anesthesia technique used for upper extremity orthopedic surgeries. The addition of adjuvants to local anesthetics can prolong the duration of analgesia and improve the quality of the block. This prospective, randomized, double-blind study aimed to investigate the impact of dexamethasone on the efficacy of a lignocaine and ropivacaine mixture for ultrasound guided supraclavicular block. A total of 80 patients scheduled for major forearm orthopedic surgery were randomly assigned to receive either a mixture of lignocaine 2% and ropivacaine 0.5% (control group) Group A or the same local anesthetic mixture with the addition of dexamethasone 8 mg (dexamethasone group) Group B. The primary outcome was the duration of analgesia, defined as the time from block placement to the first request for rescue analgesia. Secondary outcomes included the onset time of sensory and motor block, the quality of the block, and the incidence of adverse events. The results showed that the addition of dexamethasone significantly prolonged the duration of analgesia compared to the local anesthetic mixture alone (135 ± 10 min vs. 170 ± 15 min, respectively, p &lt; 0.001). Addition of dexamethasone to mixture of lidocaine and ropivacaine in supraclavicular block results in prolonged duration of sensory and motor block and also improves quality of analgesia without affecting its onset.

Comparative evaluation of intrathecal hyperbaric bupivacaine alone versus combined with dexmedetomidine for cesarean sections

Background &amp; Objective: This study examined the use of dexmedetomidine 5 μg as an adjuvant to 10 mg of intrathecal hyperbaric 0.5% bupivacaine in elective cesarean sections and aimed to assess dexmedetomidine’s impact on block characteristics and post-operative pain management. As spinal anesthesia is commonly employed for cesarean deliveries, the study seeks to determine whether the addition of dexmedetomidine as an adjuvant can prolong the duration and enhance the quality of the block, leading to improved post-operative pain relief. Methodology: This randomized controlled trial included 100 parturients undergoing elective cesarean section over a period of six months. Participants were allocated to either Group B or Group D using a non-random consecutive sampling technique. In Group D, 2 mL of 0.5% bupivacaine mixed with 0.05 mL of dexmedetomidine (5µg) was injected intrathecally, while Group B received 2 mL of 0.5% hyperbaric bupivacaine along with an equivalent volume of saline. Sensory and motor block assessments were conducted prior to the start of surgery. Post-operatively, the duration of motor block and post-operative pain relief were assessed. Results: The addition of dexmedetomidine as an adjuvant to intrathecal bupivacaine resulted in significant reductions in the onset time of sensory block (4.22 ± 0.79 min vs 5.66 ± 1.21 min) and motor block (4.20 ± 0.81min vs 6.32 ± 1.20 min) (P &lt; 0.001). Furthermore, the duration of motor block was longer in the dexmedetomidine + bupivacaine group compared to the bupivacaine alone group (7.32 ± 0.95 h vs 4.38 ± 1.27 h). Additionally, patients who received intrathecal dexmedetomidine as an adjuvant to bupivacaine experienced significantly longer durations of post-operative analgesia (7.32 ± 0.95 h) as compared to the bupivacaine alone group (4.38 ± 1.27 h) (P &lt; 0.001). Conclusion: Dexmedetomidine as an intrathecal adjuvant to hyperbaric bupivacaine extends the duration of analgesia and motor block, providing prolonged pain relief. Additionally, it exhibits an early onset of sensory and motor block, ensuring prompt pain relief and rapid anesthesia onset. Clinical Trial Registration: [www.clinicaltrials.gov], identifier: ID NCT05469529 Abbreviations: CS - cesarean section; OT - Operation Theater; SA - Spinal anesthesia; VAS - visual analogue scale; Keywords: cesarean section, dexmedetomidine, bupivacaine, spinal anesthesia Citation: Qureshi RA, Jadoon H, Shabbir M. Comparative evaluation of intrathecal hyperbaric bupivacaine alone versus combined with dexmedetomidine for cesarean sections. Anaesth. pain intensive care 2024;28(5):866−870. DOI: 10.35975/apic.v28i5.2558 Received: December 03, 2023; Reviewed: December 15, 2023; Accepted: August 16, 2024

The median effective concentration of epidural ropivacaine with different doses of dexmedetomidine for motor blockade: an up-down sequential allocation study.

Recent studies have shown that dexmedetomidine can be safely used in peripheral nerve blocks and spinal anesthesia. Epidural administration of dexmedetomidine produces analgesia and sedation, prolongs motor and sensory block time, extends postoperative analgesia, and reduces the need for rescue analgesia. This investigation seeks to identify the median effective concentration (EC50) of ropivacaine for epidural motor blockade, and assess how incorporating varying doses of dexmedetomidine impacts this EC50 value. Prospective, double-blind, up-down sequential allocation study. Operating room, post-anesthesia care unit, and general ward. One hundred and fifty patients were allocated into five groups in a randomized, double-blinded manner as follows: NR (normal saline combined with ropivacaine) group, RD0.25 (0.25 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.5 (0.5 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.75 (0.75 μg/kg dexmedetomidine combined with ropivacaine) group, RD1.0 (1.0 μg/kg dexmedetomidine combined with ropivacaine) group. The concentration of epidural ropivacaine for the first patient in each group was 0.5%. Following administration, the patients were immediately placed in a supine position for observation, and the lower limb motor block was assessed every 5 min using the modified Bromage score within 30 min after drug administration. According to the sequential method, the concentration of ropivacaine in the next patient was adjusted according to the reaction of the previous patient: effective motor block was defined as the modified Bromage score > 0 within 30 min after epidural administration. If the modified Bromage score of the previous patient was >0 within 30 min after drug administration, the concentration of ropivacaine in the next patient was decreased by 1 gradient. Conversely, if the score did not exceed 0, the concentration of ropivacaine in the next patient was increased by 1 gradient. The up-down sequential allocation method and probit regression were used to calculate the EC50 of epidural ropivacaine. Adverse events, hemodynamic changes, demographic data and clinical characteristics. The EC50 of epidural ropivacaine required to achieve motor block was 0.677% (95% CI, 0.622-0.743%) in the NR group, 0.624% (95% CI, 0.550-0.728%) in the RD0.25 group, 0.549% (95% CI, 0.456-0.660%) in the RD0.5 group, 0.463% (95% CI, 0.408-0.527%) in the RD0.75 group, and 0.435% (95% CI, 0.390-0.447%) in the RD1.0 group. The EC50 of the NR group and the RD0.25 group were significantly higher than that of the RD0.75 and the RD1.0 groups, and the EC50 of the RD0.5 group was significantly higher than that of the RD1.0 group. The EC50 of epidural ropivacaine required to achieve motor block was 0.677% in the NR group, 0.624% in the RD0.25 group, 0.549% in the RD0.5 group, 0.463% in the RD0.75 group, and 0.435% in the RD1.0 group. Dexmedetomidine as an adjuvant for ropivacaine dose-dependently reduce the EC50 of epidural ropivacaine for motor block and shorten the onset time of epidural ropivacaine block. The optimal dose of dexmedetomidine combined with ropivacaine for epidural anesthesia was 0.5 μg/kg.

Comparing the clinical features of lateral and medial approaches of costoclavicular technique versus traditional lateral sagittal technique as infraclavicular brachial plexus block methods: a randomized controlled trial

BackgroundIt is aimed to compare the block onset times and performance features of costoclavicular techniques (medial and lateral approach) versus lateral sagittal technique.MethodsPatients were randomized into three groups. For costoclavicular techniques, ultrasound probe was placed parallel to clavicle obtaining nerve cords, axillary artery and axillary vein visual from lateral-to-medial, respectively. The block needle was advanced from lateral (Group CLB) or medial (Group CMB) to perform costoclavicular block. For lateral sagittal technique (Group LSB), ultrasound probe was placed sagittal and perpendicular below the coracoid process to obtain sagittal artery image with the cords around. Total 20 ml of 0.5% bupivacaine and 10 ml of 2% lidocaine were deposited for all groups. Sensory and motor block onset times, block performance properties, complications, and patient/surgeon satisfactions were investigated.ResultsAmong 56 patients, the primary outcome, sensory block onset time was shorter in Group CLB than Group CMB and Group LSB (10 [5–15], 10 [10–20], and 15 [10–15] minutes, respectively, p < 0.05). Motor block onset was also fastest in Group CLB (15 [10–20] mins for CLB, 20 [15–20] mins for LSB, and 22.5 [15–25] mins for CMB, p = 0.004). Block performance properties did not differ between the groups. The only complication observed was vascular puncture with an incidence of 28% in Group CMB.ConclusionsLateral approach costoclavicular technique provides fastest block onset than the other techniques. Considering the success and safety profile, this technique stands as a good alternative in clinical practice.Trial registrationThis study is prospectively registered to clinicaltrials.gov on 20/02/2022 (NCT05260736).

Comparison of Ropivacaine with or without Fentanyl in Spinal Anaesthesia for Lower Limb Surgeries

Introduction: Spinal anaesthesia is a preferred technique used for lower limb orthopaedic surgeries. Ropivacaine with its short duration of motor blockade and provision for early ambulation along with addition of spinal additives has proven beneficial to the patient. This prospective, double-blind, randomized controlled study set out to evaluate the effects of 0.75% isobaric ropivacaine with fentanyl versus 0.75% isobaric ropivacaine during lower limb orthopaedic surgeries performed under spinal anaesthesia. Methods: The study enrolled 74 patients, aged 18-65 years of either sex, ASA PS I and II, planned for lower limb orthopaedic surgeries. Patients were randomly allocated to receive either 2.5 ml of 0.75% isobaric ropivacaine and 0.5ml of normal saline (Group R) or 2.5 ml of 0.75% isobaric ropivacaine and 0.5ml of fentanyl (25mcg) (Group RF). Results: The demographic profile, onset time of sensory block to T10 dermatome, time for complete motor blockade, maximum block height, duration of motor block, and haemodynamic parameters did not significantly differ between the two groups. Group R took 200.27 ± 21.28 minutes for the S2 dermatome segment regression, while Group RF took 284.59 ± 32.88 minutes (p-value&lt;0.001). Group RF experienced analgesia for a longer duration (335.68±22.18 min) than Group R (240.00±28.28 min) (p-value&lt;0.001). Conclusion: Fentanyl greatly extends the duration of S2 segment regression and analgesia when combined with ropivacaine; the effects on haemodynamics and motor blockade is clinically negligible and side effects are minimal.

Comparison of the classical approach and costoclavicular approach of ultrasound-guided infraclavicular block: A systematic review and meta-analysis.

The infraclavicular brachial plexus block (ICB) provides analgesia and anaesthesia of the upper limb. It is given using the classical or the more recently described costoclavicular (CC) approach at the level of cords. This systematic review aimed to assess which approach is better for the ICB in terms of onset, performance, and safety. This PROSPERO (vide registration number CRD42022361636) registered meta-analysis included randomised trials of patients undergoing upper limb surgery in ultrasound-guided ICB from MEDLINE, EMBASE, SCOPUS, and IRCTP from inception to March 2023. The quality of evidence was assessed using GradePro software. The primary outcomes were sensory and motor block onset time and the number of patients having complete block at 30 minutes. Secondary outcomes included block performance time (BPT), number of attempts, duration of the block, and any incidence of complications. Five trials with 374 adult patients (classic = 185, CC = 189) were included. No significant difference was found in the sensory (Mean difference (MD): 1.44 minutes [95% confidence interval (CI): 3.06, 5.95]; I2 = 95%; very low level of evidence (LOE); P = 0.53) and motor block onset times (MD: 0.83 minutes [95% CI: 0.96, 2.62]; I2 = 84%; very low LOE P = 0.36) and BPT (MD: 5.06 seconds [95% CI: 38.50, 48.63]; I2 = 98%; very low LOE; P = 0.82) in classic and CC approach of ICB. Trial sequential analysis revealed our sample size to be 0.65% of the required sample size to achieve 80% power, deeming our study underpowered. Costoclavicular approach was not superior or inferior to the classical technique for infraclavicular brachial plexus block. However, the quality of evidence is low and further studies are needed to corroborate the findings.

Effectiveness of perineural administration of dexamethasone with lidocaine on onset time of sensory block and early postoperative analgesia in axillary brachial plexus block: a prospective cohort study, Ethiopia.

The axillary brachial plexus block is a popular nerve block for forearm, wrist, and hand surgery. The aim of this study was to assess the effectiveness of perineural administration of dexamethasone as an adjunct to lidocaine with adrenaline on the onset of sensory block and early postoperative analgesia in trans-arterial axillary brachial plexus block. This single-centered prospective cohort study recruited 68 adult patients, 34 in each groups. The frequently used 8mg dexamethasone combined with 1% lidocaine and adrenaline was investigated. The normality of the data was checked using the Shapiro-Wilk test. An independent t-test was used to compare the mean values of symmetric numeric data. Categorical variables between the two groups were analyzed using χ2. The Mann-Whitney U test and Kaplan-Meier method using the log-rank test were used to compare asymmetric numeric data, and a P-value of <0.05 was considered as significant. The median onset time of sensory block was comparable between the nonexposed (24(6) min) and exposed group (24(6) min) (P=0.068). However, the duration of sensory block was significantly longer in the exposed group (235.5±37.51min) than the nonexposed group (172.76±28.19min) (P<0.001). The time to the first analgesic request was significantly longer in the exposed than the nonexposed group (P<0.01). Postoperative pain scores were significantly lower at 4 and 8h in the exposed group (P<0.05). The addition of 8mg dexamethasone to 1% lidocaine with adrenaline solution in trans-arterial axillary brachial plexus block for ambulatory elective hand, wrist, and forearm surgeries prolonged the duration of sensory blockade and the first analgesic request time but did not reduce the onset time of sensory block. The authors recommend the addition of 8mg dexamethasone to 1% lidocaine with adrenaline solution to prolong the duration of sensory block and the first analgesic request time.

Novel triple injection technique - Avante garde for costoclavicular block. A Case series

Costoclavicular block has garnered the attention of regional anesthesia enthusiasts because the cords are snuggly packed and consistently arranged in a particular pattern around the first part of the axillary artery. The single injection technique has been widely used conventionally, but the effect is unpredictable. The effect is unpredictable because of the septum that compartmentalizes cords in upper and lower compartments. We propose a triple injection technique targeting the individual cords separately. Onset time of sensory block from 16 min to 7 min. The average time for a complete motor block was 9.6 min. The chances of the median nerve sparing, as has been reported in some cases in previous studies, are almost nil by this technique–the corner pocket injection that involves the medial root of the median nerve and the lateral cord that is specifically blocked separately, covering the lateral root of the median nerve. The costoclavicular block has already carved a niche as an excellent choice for surgeries of the upper limb involving the elbow or below the elbow. The use of the triple injection technique makes the block effect more predictable and reliable.

The Effect of Preoperative Anxiety on Motor and Sensory Block Duration and Effectiveness in Spinal Anesthesia

Introduction. The aim was to evaluate the effect of preoperative anxiety on the sympathetic block that developed after spinal anesthesia and therefore the duration of motor and sensory blockade. Materials and Methods. After the approval of the ethics committee, 90 patients between the ages of 18 and 55 years who were to be operated under spinal anesthesia were included in the study. Preoperative anxiety of the patients was evaluated with the Spielberger trait and State Anxiety Scale and Visual Analog Scale (VAS). The Bromage scores of the patients were followed up intermittently. Onset time of sensory block, onset time of motor block, and motor block recovery time were recorded. Cases with bradycardia and hypotension were noted. Results. No statistically significant correlation was found between the duration of motor block onset (5.81 ± 4 min), the sensory block onset time (0.89 ± 0.4 min), and the motor block recovery time (92.06 ± 36.9 min) with other variables. VAS (5.81 ± 2.5), STAI‐1 (40.4 ± 9.8), and STAI‐2 (41.69 ± 8.2) values had a statistically significant effect on the occurrence of bradycardia (14.4%). The variables of VAS, STAI‐1, STAI‐2, sensory block onset, motor block onset, and motor block recovery time were statistically significantly higher in women (mean 5.24 ± 2.4, 38.97 ± 9.9, 41.43 ± 8.7, 0.89 ± 0.42, 5.64 ± 3.82, and 88.77 ± 38.74 in males and mean 7.15 ± 2.1, 43.74 ± 8.9, 42.30 ± 7.0, 0.88 ± 0.27, 6.20 ± 4.35, and 99.70 ± 31.70 in females, respectively). Conclusion. It was observed that preoperative anxiety had no effect on motor and sensory block onset and duration.

Medial versus lateral approach in ultrasound-guided costoclavicular brachial plexus block for upper limb surgery: a randomized control trial.

Costoclavicular brachial plexus block has become a procedure of choice for surgical anaesthesia or analgesia in upper limb surgery. The technique is not standardised yet, and two approaches are currently employed: the medial and lateral approach. Our study aims to compare the two approaches in terms of performance time and patient-specific clinical outcomes. The primary outcome assessed was performance time. The secondary outcomes were imaging time, needling time, block onset time, total anaesthesia time, anaesthesia success, and performer difficulty score. Of 59 patients, 30 patients were randomized to Group M and 29 patients were randomized to Group L. We conducted statistical analysis using a modified intention-to-treat approach. The mean ± SD for performance time (in minutes) was 11.9 ± 3.8 in Group M and 9.4 ± 4.1 in Group L with a difference between means (95% CI) of 2.4 (0.3 to 4.5) ( P < 0.05). The median (interquartile range) needling time of Group M was 9.5 minutes (5-16) vs. 7 (4-19) in Group L ( P = 0.035). Among patients, 40%, 26.67%, 33.3% in Group M had grade 3, 2, 1 performer difficulty whereas 10.3%, 37.9%, 51.7% in Group L had grade 3, 2, 1 performer difficulty, respectively ( P = 0.032). The mean performance time was 9.95 minutes in patients with body mass index (BMI) 25 ( P = 0.0243). Our study revealed that the medial approach has no significant advantage over the lateral approach with regards to performance time, imaging time, needling time, and performer difficulty. Both performance time and performer difficulty increase with BMI and depth of the cords, with a larger difference in the medial approach.

Costoclavicular block – single to double injection – time to see the premiere of triple injection

Sir,Securing the phrenic nerve when achieving effective anesthesia block for the upper limb has been a topic intriguing regional anesthesia enthusiasts ever since. Interscalene brachial plexus block is known to involve the phrenic nerve in 100% of the cases and costoclavicular block which has gained momentum since 2015 is declared to involve the phrenic nerve in 0% of the cases. Besides this the compact, reliable topography of the cords in the triangular costoclavicular space along with an expedited sensorimotor block with local anesthesia deposited in the center of the three cords makes costoclavicular block an attractive option for elbow and below elbow surgeries. According to the studies, the success rate of the blockade is 92.5% with single injection in the center of the cords. Another study by Sebastian, where apart from classical single injection, another injection was given after redirecting the needle, between the medial cord and subclavian artery (labeling it a corner pocket technique) for costoclavicular block. They concluded that the block’s onset time and total anesthesia-related time were significantly shortened with the double injection technique compared with single injection. The basis of this was explanation laid by Dr. Monzo and Hadzic where they proposed in a series of 40 patients a linear septum arising from the lateral part of axillary artery separating the lateral code from the posterior and the medial code, thus compartmentalizing the costoclavicular space. They reported a success rate of 97.5% in their study on 40 patients.4 Hence,double injection is used to overcome the septum “issue.” Pornpatra is defined a high definition ultrasonographic presence of paraneural sheath and facial compartments surrounding the brachial plexus cords at the lateral infraclavicular fossa and the costoclavicular space. We propose that a triple injection with 3rd injection in the vicinity of the lateral cord just before withdrawing the needle apart from the other two injections significantly shortens the onset time of sensory block from 16 min to 9 min. The various sites for injection are shown in the figure below, but the exact point of injection of the second and third is more prominent after giving the first injection. The chances of the median nerve sparing as has been reported in some cases in previous studies are almost nil by this technique - the corner pocket injection that involves the medial root of the median nerve and the lateral cord that is specifically blocked separately covering the lateral root of the median nerve. CONCLUSIONWe did a case series in 15 cases and although the sample size is small and this is definitely not a randomized control trial, to make such a bold statement, we would like to decipher a positive future of the costoclavicular block with triple injection technique with an RCT already underway.

Do you mind the role of spinal sensory block duration in a crucial endocrine disorder of diabetes mellitus? A prospective observational study.

Diabetes mellitus, per se, is a global health concern, which is often accompanied by complications such as diabetic neuropathy. This prospective observational study purposed to assess the durations of spinal sensory block and motor blocks in individuals with and without diabetes mellitus who had undergone spinal anesthesia. This study incorporated 80 cases, which were evenly divided into spinal sensory block without diabetes mellitus and spinal sensory block with diabetes mellitus. Various parameters were recorded at different time points, including heart rate, mean arterial blood pressure, SpO2, and spinal block characteristics. Notable measures included maximum spinal sensory block onset time, time to reach the 10th thoracic vertebra (T10), maximal spinal sensory block, time for Bromage scores, and block regression while controlling for age-related variations. Patients in the diabetic group exhibited extended block durations, with significant differences in heart rate noted at specific time points. Regarding the spinal block characteristics, the "maximum onset of SSB" and the "time to reach the T10" were more prolonged in the SSBwDM without significance. Maximum sensory spinal sensory block did not differ. However, some cases in the SSBwDM displayed blocks extending up to the T6. The times to achieve Bromage motor block scores 1-3 were shorter in SSBwDM and lost significance regarding age. Notably, the regression time was longer in SSBwDM, which held significance for both parameters. Diabetic cases commonly encounter prolonged block durations post-subarachnoid intervention, potentially linked to nerve sensitivity, age-related changes, and glycemic control. As such, attenuated local doses for diabetic neuropathic cases may enhance early mobilization, attenuate thromboembolic events, and expedite gastrointestinal recovery.

Comparison of Dexmedetomidine and Fentanyl Added to Levobupivacaine in USG-guided Axillary Block for Upper Limb Surgeries: A Randomised Double-blinded Controlled Study

Introduction: Apart from general anaesthesia, brachial plexus block by the axillary approach is one of the reliable sole anaesthetic techniques for patients undergoing upper limb surgeries. In this study, levobupivacaine was chosen due to fewer adverse effects compared to Bupivacaine, and fewer studies were available for the axillary approach to brachial plexus block. Adjuvants were added to hasten the onset and also to prolong their analgesic effect. Aim: To compare the effect of Dexmedetomidine (D) 0.5 mcg/kg and Fentanyl (F) 0.5 mcg/kg when added to 0.5% Levobupivacaine (L) as an adjuvant in brachial plexus block by the axillary approach for upper limb surgeries. Materials and Methods: A randomised double-blind controlled study was carried out at the Department of Anaesthesiology, Sree Balaji Medical College, BIHER, Chennai, Tamil Nadu, India from January 2020 to October 2021 on 60 American Society of Anaesthesiologists (ASA) I and II patients of either sex posted for various types of upper limb surgeries. Subjects were divided into two equal groups by computer-generated randomisation. Group A received 0.5% levobupivacaine and dexmedetomidine 0.5 mcg/kg, and Group B received 0.5% levobupivacaine and Fentanyl 0.5 mcg/kg. Both patients and the evaluator were unaware of the type of adjuvants added to the local anaesthetic. The onset time, duration of sensory and Motor blockade were recorded. Haemodynamic variables and duration of analgesia were recorded for 24 hours postoperatively. The Mann-Whitney U test demonstrated variations in the onset and duration of sensory and motor blocks. Adverse effects, including nausea, vomiting, and hypotension, exhibited significant differences according to Fisher’s-exact test. Results: Age and weight distributions were comparable between groups (mean age: Group A=45.20 years, Group B=44.80 years; mean weight: Group A=74.13 kg, Group B=74.43 kg). Group A exhibited faster sensory and motor block onset times (sensory: Group A=6.20 minutes, Group B=8.63 minutes; motor: Group A=8.27 minutes, Group B=10.00 minutes), longer block durations (sensory: Group A=11.63 hours, Group B=9.53 hours; motor: Group A=9.67 hours, Group B=8.20 hours), and required the first rescue analgesic (Group A=12.57 hours, Group B=10.27 hours) compared to Group B (p&lt;0.05). Similarly, the mean time for the first rescue analgesia for patients among these two groups was also statistically significant (p&lt;0.05). Conclusion: The addition of 0.5 mcg/kg dexmedetomidine to 0.5% levobupivacaine in axillary block was more effective in prolonging the duration of blockade and providing adequate intraoperative analgesia when compared to 0.5 mcg/kg fentanyl with 0.5% levobupivacaine, without producing any adverse events.