Brachial Plexus Block Anesthesia Research Articles

Effects of Dexamethasone as an adjuvant to local anaesthetic in brachial plexus block through supraclavicular route

Effects of Dexamethasone as an adjuvant to local anaesthetic in brachial plexus block through supraclavicular route

Comparative Evaluation of Different Local Anaesthetics in Supraclavicular Brachial Plexus Block in Pediatric Patients

Comparative Evaluation of Different Local Anaesthetics in Supraclavicular Brachial Plexus Block in Pediatric Patients

Dexmedetomidine combined with local anesthetics in thoracic paravertebral block: A systematic review and meta-analysis of randomized controlled trials.

BackgroundDexmedetomidine (DEX) improves postoperative pain scores and prolongs the duration of blockage when combined with local anesthetics (LAs) for neuraxial and brachial plexus block; however, there is little information about the effectiveness of DEX as an adjuvant to LAs in paravertebral block (PVB). Therefore, a systematic review and meta-analysis were performed to evaluate the safety and efficacy of DEX combined with LAs in PVB.MethodAn electronic database search from inception date to February 2018 was performed. Randomized controlled trials (RCTs) comparing DEX as an adjuvant to LAs with LAs alone for PVB in adult patients were included. Postoperative pain scores, duration of analgesia, cumulative perioperative analgesic consumption, and adverse events were analyzed.ResultWe identified 7 trials enrolling 350 patients and found that DEX reduced pain scores at rest by standardized mean differences (SMD) −0.86 cm (95% confidence interval [CI] [−1.55, −0.17], P = .01) and SMD −0.93 cm (95% CI [−1.41, −0.26], P =.008) at postoperative 12 hours and 24 hours, respectively. DEX reduced pain scores while dynamic by SMD −1.63 cm (95% CI [−2.92, −0.34], P =.01) and SMD −1.78 cm (95% CI [−2.66, −0.90], P =.007) for postoperative 12 hours and 24 hours, respectively. DEX extended the duration of analgesia by weighted mean differences (WMD) 201.53 minutes (95% CI [33.45, 369.61], P =.02); and reduced cumulative postoperative analgesic consumption by WMD −7.71 mg (95% CI [−10.64, −4.78], P <.001) and WMD −45.64 mg (95% CI [−69.76, −21.53], P < .001) for 24 hours morphine and 48 hours tramadol subgroups, respectively. DEX also increased the odds of hypotension by odds ratio (OR) 4.40 (95% CI [1.37, 14.17], P = .01); however, there was no statistically significant difference for intraoperative fentanyl consumption and the incidence of the bradycardia.ConclusionsDEX combined with LAs in PVB significantly improved postoperative pain scores, prolonged the duration of analgesia, reduced postoperative analgesic consumption, and increased the odds of hypotension. However, we cannot neglect the heterogeneity of the included RCTs. More large-scale prospective studies are needed to further clarify the above conclusions.Systematic review registrationPROSPERO registration number CRD42018090251.

Analgesic effect of Ropivacaine combined with Dexmedetomidine on brachial plexus block

BackgroundThis randomized controlled study investigated the analgesic effect of ropivacaine in combination with dexmedetomidine versus ropivacaine alone on brachial plexus block to provide alternative anesthetic means for upper limb trauma surgery.MethodsTotally 114 patients who received upper limb surgeries under brachial plexus block anesthesia in our hospital from February 2013 to July 2015 were enrolled. The patients were randomized to ropivacaine alone (the control group) or ropivacaine combined with dexmedetomidine (the combination group). The blocking effect on sensory and motor neurons, visual analog scale (VAS) score, heart rate (HR), mean arterial pressure (MAP), peripheral capillary oxygen saturation (SPO2) and adverse reactions were compared between the two groups.ResultsThe time to onset of sensory and motor nerve blockade was significantly shorter in the combination group than in the control group (8.9 min vs. 12.4 min for sensation blockade; 7.5 min vs. 12.8 min for motor blockade, P < 0.05 for both comparisons), and the duration of the blockade was significantly longer in the combination group (590.2 min vs. 532.1 min, P < 0.05). There was no significant difference in VAS scores between the two groups immediately and 4 h after surgery; however, 8, 12 and 24 h after surgery, the VAS scores were all significantly lower in the combination group than the control group (2.4 vs. 3.0 for 8 h; 2.2 vs. 4.2 for 12 h, and 2.1 vs. 5.4 for 24 h, respectively, P < 0.05 for all comparisons). There was no statistical difference in HR, MAP and SPO2 between the two groups before anesthesia, but after anesthesia, the MAP and HR were significantly lower, and the SPO2 was significantly higher in the combination group than the control group (78 vs. 84 for MAP; 72 vs. 79 for HR; and 95.1 vs. 88.2 for SPO2, P < 0.05 for all comparisons). The rates of adverse reaction was significantly lower in the combination group than the control group (3.6 vs. 7.2, P < 0.05).ConclusionThe brachial plexus blocking effect of ropivacaine combined with dexmedetomidine was superior to that of ropivacaine alone, mainly intra-operatively and postoperatively.Trial registrationAnalgesic Effect of Ropivacaine Combined with Dexmedetomidine on Brachial Plexus Block, ChiCTR1800017372, retrospectively registered on July 26, 2018.

Comparison of 0.5% Ropivacaine with 0.5% Ropivacaine and Magnesium sulphate in supraclavicular brachial plexus block for forelimb and hand surgeries

Objectives: Supraclavicular Brachial Plexus is commonly used for forelimb and hand surgeries. A lot of research is going on to increase the duration of sensory and motor blockade by the addition of adjuvants with the local anesthetics. We evaluated the effect of adding magnesium sulphate to ropivacaine for supraclavicular brachial plexus blockade. Our primary parameters were the onset and duration of sensory and motor block and duration of analgesia. Methods: 60 patients posted for elective forearm and hand surgeries under supraclavicular brachial plexus block were divided into two equal groups (Group RM and RN) in a double blind fashion. In Group RM 30ml 0.5% ropivacaine plus 150 mg magnesium sulphate in (1 ml 0.9% saline) and in group RN 1ml of normal saline was added to ropivacaine. Results: Both the groups have similar demographic profile and time of onset of senory and motor block but the duration of senory and motor blockade and duration of analgesia were significantly longer in RM group than RN group. Intraoperative hemodynamics were compareable amoung two groups and no considerable side effects were noted in both the groups. Conclusion: It can be concluded from our study that by addition of magnesium sulphate to local anesthetics in supraclavicular brachial plexus block may increase the duration of senory and motor blockade and duration of analgesia with no appreciable side effects, however duration of onset of sensory and motor blockade was more in magnesium sulphate group.

Comparative study between bupivacaine-dexmedetomidine combination and bupivacaine (plain) in brachial plexus block using nerve stimulator

Introduction: Brachial plexus block has evolved into a valuable and safe alternative to general anaesthesia for the upper limb surgeries. It is a great tool in the anaesthetic armamentarium for relief of pain preoperatively, perioperatively and post operatively. It is possible and desirable for patient to remain ambulatory. Adjuvants with local anaesthetics in brachial plexus block are being used to achieve quick, dense and prolonged block. Dexmedetomidine added to local anesthetics prolongs the duration of block and postoperative analgesia in brachial plexus block. Methods and Methodology: It is a prospective, randomised, comparative study of 60 patients admitted in a tertiary hospital for upper limb surgery who were posted under regional anaesthesia during the period of October 2012 to December 2014. The patients taken in this study were allocated into two groups randomly. Group B (n=30) 20millilitres (ml) of 0.5%% bupivacaine +1ml saline and group D (n=30) 20ml of 0.5% bupivacaine +1microgram (mcg)/kilogram (kg) dexmedetomidine was given. Results: There were no clinical or statistically significant differences in the demographic profile of patients in either group. Onset of sensory block in radial, median and ulnar nerve distributions were significantly shorter in group B. Motor onset was also significantly shorter in group B. However rescue time was higher in group D. There were no adverse effects noted in both the groups. There was a significant percentage of GA conversion seen in case of group. B. Discussion: Onset of sensory block was faster in Group B than in Group D, onset of motor block was faster in Group B than in Group D, and the difference was statistically significant. There was significant increase in duration of analgesia in Group D (456.12±97.99 min) as compared with Group B (289.67±62.50 min). The difference was statistically significant No side-effects (nausea, vomiting, dry mouth) were reported during the first 24 h in the post-operative period in both the groups. From this study, we would like to suggest that dexmedetomidine can be safely used with local anaesthetic in peripheral nerve blocks; however, further trials to determine the exact dose and effect of neurotoxicity on the human nerve are required.

Effect of tramadol as an adjuvant to local anesthetics for brachial plexus block: A systematic review and meta-analysis.

BackgroundTramadol, a 4-phenyl-piperidine analog of codeine, has a unique action in that it has a central opioidergic, noradrenergic, serotonergic analgesic, and peripheral local anesthetic (LA) effect. Many studies have reported contradictory findings regarding the peripheral analgesic effect of tramadol as an adjuvant to LA in brachial plexus block (BPB). This meta-analysis aimed to evaluate the effects of tramadol as an adjunct to LA in BPB during shoulder or upper extremity surgery.MethodsWe searched the PubMed, EMBASE, Cochrane, KoreaMed databases, and Google Scholar for eligible randomized controlled trials (RCTs) that compared BPB with LA alone and BPB with LA and tramadol. Primary outcomes were the effects of tramadol as an adjuvant on duration of sensory block, motor block, and analgesia. Secondary outcomes were the effects of tramadol as an adjuvant on time to onset of sensory block and motor block and on adverse effects. We performed the meta-analysis using Review Manager 5.3 software.ResultsWe identified 16 RCTs with 751 patients. BPB with tramadol prolonged the duration of sensory block (mean difference [MD], -61.5 min; 95% CI, -95.5 to -27.6; P = 0.0004), motor block (MD, -65.6 min; 95% CI, -101.5 to -29.7; P = 0.0003), and analgesia (MD, -125.5 min; 95% CI, -175.8 to -75.3; P < 0.0001) compared with BPB without tramadol. Tramadol also shortened the time to onset of sensory block (MD, 2.1 min; 95% CI, 1.1 to 3.1; P < 0.0001) and motor block (MD, 1.2 min; 95% CI, 0.2 to 2.1; P = 0.010). In subgroup analysis, the duration of sensory block, motor block, and analgesia was prolonged for BPB with tramadol 100 mg (P < 0.05) but not for BPB with tramadol 50 mg. The quality of evidence was high for duration of analgesia according to the GRADE system. Adverse effects were comparable between the studies.ConclusionsIn upper extremity surgery performed under BPB, use of tramadol 100 mg as an adjuvant to LA appears to prolong the duration of sensory block, motor block, and analgesia, and shorten the time to onset of sensory and motor blocks without altering adverse effects.

Ultrasound Guidance Versus Peripheral Neurostimulation for Brachial Plexus Block Anesthesia with Axillary Approach and Multiple Injection Technique

Abstract Introduction: There are several approaches for brachial plexus anesthesia: supraclavicular, infraclavicular, interscalenic and axillary. Out of these, the axillary approach is considered to be the safest because of the low risk of lesioning the adjacent structures, low risk of phrenic nerve blockade or of producing an iatrogenic pneumothorax. The block can be performed by one single injection at the site, by two injections or by several injection, among each nerve of the plexus. Ultrasound was introduced in regional anesthesia since 1978, being used initially as an auxiliary method to peripheral neurostimulator. Objectives: The evaluation of ultrasound efficiency as an auxiliary method for brachial plexus block performance, in terms of success rate, vascular punctures. The influence of obesity on performing time, total duration of the block, and success rate of brachial plexus block. Material and method: Prospective, randomized study which enrolled adult patients, scheduled for surgical emergency or elective surgical intervention on upper limb with brachial plexus block by axillary approach, using either the peripheral nerve stimulation or the ultrasound guidance. Results: We enrolled 160 patients, grouped in two sets- the ultrasound group= 82 patients (US) the neurostimulation group = 78 patients (NS). Vascular punctures were statistically significant different p= 0, 04. The success rate was not influenced by the obesity. Conclusions: Ultrasound guidance makes axillary brachial plexus block safer, we can recommend ultrasound guidance as routine for axillary brachial plexus block. The obese patient can beneficiate by both methods of brachial plexus blockage.

Addition ofdexmedetomidinetobupivacainein supraclavicular brachial plexus block.

Research is ongoing to determine the lowest dose of local anesthetics in brachial plexus block that provides adequate anesthesia and postoperative analgesia and reduces complications related to local anesthetics. Patients 18-65 years of age who underwent upper limb surgery and who received ultrasound-guided supraclavicular brachial plexus block at the Erciyes University Faculty of Medicine Hospital between February 2014 and January 2015 were included in the study (n=50). Supraclavicular brachial plexus blocks were performed on Group B cases by adding 30 ml 0.33% bupivacaine and on Group BD cases by adding 15 ml 0.33% bupivacaine and 1 µg / kg dexmedetomidine. Block success was evaluated by the onset and block duration of motor and sensory block and the duration of analgesia. The block success of Group B and Group BD was 92.6% and 89.3%, respectively (P = 1.000). Onset time of sensory block, degree of sensory block, duration of sensory block, onset time of motor block, degree of motor block and duration of motor block were similar in both groups in the intergroup comparison (P > 0.05). Duration of analgesia and the operative conditions of groups were similar (P > 0.05). In the implementation of ultrasound-guided supraclavicular brachial plexus block, block success, sensory and motor block and analgesia duration were similar for patients anaesthetized with 30 ml of bupivacaine in comparison with dexmedetomidine+bupivacaine (when the bupivacaine dose was reduced by 50% by the addition of the adjuvant).

Postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: A randomized prospective trial.

Background:On a pharmacologic basis, levobupivacaine is expected to last longer than ropivacaine. However, most reports of these anesthetics for brachial plexus block do not suggest a difference in analgesic effect. The aim of this study is to compare the postoperative analgesic effects of levobupivacaine and ropivacaine when used for treating ultrasound-guided brachial plexus block.Methods:A total of 62 patients undergoing orthopedic surgery procedures were prospectively enrolled and randomized to receive levobupivacaine (group L, N = 31) or ropivacaine (group R, N = 31). The duration of analgesia, offset time of motor block, need for rescue analgesics, and sleep disturbance on the night of surgery were recorded. Pain score was recorded on the day of surgery, and on postoperative days 1 and 2.Results:There was no difference in the time interval until the first request for pain medication comparing the two groups (group L: 15.6 [11.4, 16.8] hours; group R: 12.5 [9.4, 16.0] hours, P = 0.32). There was no difference in the duration of motor block (group L: 12.2 [7.6, 14.4] hours; group R: 9.4 [7.9, 13.2] hours, P = 0.44), pain score (P = 0.92), need for rescue analgesics (group L: 55%; group R: 65%, P = 0.6), or rate of sleep disturbance (group L: 61%, group R: 58%, P = 1.0) on comparing the two groups.Conclusions:There was no difference in postoperative analgesia comparing levobupivacaine and ropivacaine when used for brachial plexus block.

Comparative study of supraclavicular brachial plexus block with or without dexamethasone

Background: Local anesthetics with various adjuvants are used to increase the duration of postoperative analgesia in supraclavicular brachial plexus block. Perineural injection of steroid is known to influence postoperative analgesia. Materials and Methods: A total of fifty patients of the American Society of Anaesthesiologist Grade I–II undergoing various upper limb surgeries under supraclavicular brachial plexus block were randomly divided into two groups. In Group C, patients received 32 ml of mixture of 1.5% lignocaine–adrenaline 10 ml, 0.5% bupivacaine 20 ml and normal saline 2 ml, whereas in Group D, patients received the same amount of local anesthetics with dexamethasone 2 ml (8 mg). Sensory and motor block were recorded at the regular intervals. Postoperative analgesia was assessed using visual analog scale (VAS) score. Statistical analysis was performed using Student's unpaired t-test. Results: The mean onset time of sensory and motor block was 3.24 ± 1.09 min and 6.2 ± 1.44 min in Group D and 4.24 ± 1.42 min and 7.52 ± 1.50 min in Group C, respectively. There was markedly prolonged duration of analgesia in Group D (12–16 h) compared to Group C (4–5 h). The mean VAS score was 4.16 ± 1.39 at the end of 6 h in Group C, whereas it was 0 (zero) in Group D at the same time. The difference was statistically significant (P Conclusion: Addition of dexamethasone as an adjuvant to local anesthetics in brachial plexus block provides in significantly early-onset and markedly prolonged duration of analgesia without hemodynamic disturbances.

Ultrasound-guided axillary brachial plexus block versus local infiltration anesthesia for arteriovenous fistula creation at the forearm for hemodialysis in patients with chronic renal failure.

Background:The primary failure rate for arteriovenous fistula (AVF) creation under local anesthesia for hemodialysis is about 30%. Axillary brachial plexus block (BPB) may improve blood flow through blood vessels used in fistula creation; it may improve the AVF blood flow and thus may reduce the primary failure rate after 3 months.Methods:Hundred and forty patients with chronic renal failure scheduled for AVF creation for hemodialysis were divided into two equal groups; Group 1 (AxBP-G) received ultrasound (US) guided axillary BPB, and Group 2 (LI-G) received local infiltration. We recorded the measurements of the brachial and radial arteries before and after anesthesia and the AVF blood flow in both groups at three different time points. Furthermore, the primary failure rate was recorded in each group and compared.Results:After anesthesia, the mean radial artery blood flow in the AxBP-group was 3.52 ml/min more than the LI-group, and the brachial artery diameter was also 0.68 mm more than in the LI-group, both differences were statistically significant (P < 0.05). There were significant increases (P < 0.05) in the AVF blood flow in the AxBP-group more than the LI-group with mean differences of 29.6, 69.8, and 27.2 ml/min at 4 h, 1 week, and 3 months, respectively. The overall mean of AVF blood flow was 42.21 ml/min more in the AxBP group than the LI-group a difference which is statistically significant (P < 0.001). The primary failure rate was 17% in the AxBP group versus 30% in the LI-group; however, this difference is not significant statistically (P = 0.110).Conclusion:The US-guided axillary block increases AVF blood flow significantly more than local infiltration and nonsignificantly decreases the primary failure rate of the AVF after 3 months.

The Analgesic Efficacy of Dexmedetomidine as an Adjunct to Local Anesthetics in Supraclavicular Brachial Plexus Block

(Abstracted from Anesth Analg, 121:1655–1660, 2015) Dexmedetomidine is a selective α2-adrenoceptor agonist and has been reported to be safe and effective as an analgesic when administered with peripheral nerve blocks. However, few data are available on the use of dexmedetomidine in brachial plexus blocks.

Supraclavicular Brachial Plexus Block with and without Dexamethasone as an Adjuvant to local anaesthetics: a Comparative Study

Aim and Objectives: To assess the effect of dexamethasone on onset and duration of anaesthesia as well as duration of analgesia when added to local anaesthetic solution for supraclavicular brachial plexus block. Methods: A randomized comparative study included total 60 patients of either sex, age between 18-70 years belonging to ASA Grade I and II undergoing elective or emergency surgeries of upper limb under supraclavicular brachial plexus block. Patients were randomly divided in group A (40 ml volume of lignocaine 2% with adrenaline (1:200000) + 0.5% bupivacaine) and group B (40 ml volume of lignocaine 2% with adrenaline (1:200000) + 0.5% bupivacaine with dexamethasone 8 mg). The onset and duration of sensory and motor block as well as duration of analgesia in the two groups were compared and any complications of the procedure were noted. Result: Group B had early onset and prolonged duration of sensory and motor block as well as prolonged duration of analgesia as compared to group A. None of the patients had bradycardia, hypotension or any other side effects. Conclusion: We concluded that addition of 8 mg dexamethasone to local anaesthetics in supraclavicular brachial plexus block reduces the time to onset of sensory and motor blockage and prolonged duration of postoperative analgesia.

Comparison of Tramadol and Dexamethasone as an adjuvant to Bupivacaine in Supraclavicular brachial plexus block: A Randomised Comparative Study in Patients undergoing Elective Upper limb surgeries

Supraclavicular nerve block is good alternative to general anesthesia for upper limb surgery. This avoids the untoward effects of general anesthetic drugs and upper airway instrumentation. It achieves complete muscle relaxation, intraoperative hemodynamic stability, and postoperative analgesia. The objective is to compare the postoperative analgesia following supraclavicular brachial plexus block with Tramadol or Dexamethasone as an adjuvant to bupivacaine in elective upper extremity surgery. Total 60 patients of ASA I and II undergoing upper extremity surgery under brachial plexus block with Bupivacaine were randomly divided in to two groups; group A received Tramadol (2mg/kg) and group B received Dexamethasone (0.15mg/kg) as an adjuvant to Bupivacaine. The duration of postoperative analgesia was recorded in both groups using pain VAS score which was determined by maximum VAS score of 8-10 and when patient demands for additional analgesics. The mean duration of postoperative analgesia in the Dexamethasone group was 1023.87 ±161.01 minutes while in the tramadol group it was 454.47±44.29 minutes. Dexamethasone with local anaesthetic prolongs postoperative analgesia significantly than Tramadol (P<0.05) when used as admixture to local anaesthetic in brachial plexus block in upper extremity surgery.

Effect of Nalbuphine as Adjuvant to Bupivacaine for Ultrasound-Guided Supraclavicular Brachial Plexus Block

Background: Nalbuphine is a derivative of 14-hydroxymorphine which is a strong analgesic with mixed k agonist and μ antagonist. Nalbuphine was studied several times as adjuvant to local anesthetics in spinal, epidural and local intravenous block. The aim of this study was to evaluate the effect of nalbuphine as an adjuvant to local anesthetics in supraclavicular brachial plexus block. Patients and Methods: Fifty-six patients undergoing elective forearm and hand surgery under supraclavicular brachial plexus block were allocated randomly into one of two groups of 28 patients each to receive either 25 ml (0.5%) bupivacaine with 1 ml of NS or 25 ml (0.5%) bupivacaine with 1 ml (20 mg) nalbuphine. Onset time and duration of both sensory and motor block, and post-operative analgesia were observed. Result: Nalbuphine group showed significant increase in the duration of motor block (412.59 ± 18.63), when compared to control group (353.70 ± 29.019) p-value < 0.001, also, there was significant increase in sensory duration in nalbuphine group (718.14 ± 21.04) when compared to control group (610.18 ± 26.33) p-value < 0.001, without affecting the onset time of the blockade. And also, there was a significant increase in the duration of analgesic effect in nalbuphine group (835.18 ± 42.45) when compared to control group (708.14 ± 54.57) p-value < 0.001. Conclusion: The present study demonstrates that addition of 20 mg nalbuphine to bupivacaine in supraclavicular brachial plexus block is associated with significant increase in the duration of both sensory and motor block and also prolong the duration of analgesia.

Comparative study on the clinical profile of different doses of dexmedetomidine with levobupivacaine in supraclavicular brachial plexus block

Background and aims: Many studies have been conducted using dexmedetomidine as adjuvant to local anaesthetics in peripheral nerve blocks, but few studies compare the effect of different doses of dexmedetomidine. We aimed at comparing the clinical profile of different doses of dexmedetomidine as adjuvant to levobupivacaine in supraclavicular brachial plexus block and finding out the dose which provides maximum improvement in block parameters with minimum undesirable effects. Material and Methods: This double blinded comparative study was conducted in 120 patients belonging to American Society of Anaesthesiologist Physical Status (ASA PS) I or II, undergoing elective upper limb orthopaedic procedures. The subjects were randomly allocated into four groups of 30 each. Supraclavicular brachial plexus blocks were performed in each group. While group LS received plain levobupivacaine, group LD30, LD60 and LD100 received 30 microgram(mcg), 60mcg and 100mcg dexmedetomidine along with levobupivacaine. The primary outcomes studied were block parameters and the secondary outcomes were hemodynamic profile, oxygen saturation and sedation scores. Statistical analysis was done using ANOVA test, chi-square test and Scheffe’s multiple comparison tests. Results: The demographic profile and hemodynamic variables were comparable in all four groups. Increasing doses of dexmedetomidine showed statistically significant improvement in block parameters and increase in sedation score, while significant decrease was found in heart rate and blood pressure. Conclusions: A dose of 60mcg of dexmedetomidine showed clinically significant improvement in block characteristics with minimum undesirable effects like bradycardia, sedation and prolonged motor blockade. Keywords: Dexmedetomidine, Levobupivacaine, Supraclavicular brachial plexus block. Key Messages: A dose of 60mcg dexmedetomidine as adjuvant to local anaesthetics in supraclavicular brachial plexus block provides best block characteristic

Clonidine as an adjuvant to local anesthetic in supraclavicular brachial plexus block: a randomized, double blinded placebo controlled study

Background: Many drugs have been studied as adjuvants to local anesthetic agents with the aim of improving the quality of anesthesia and to provide profound analgesia. Clonidine has also been used as an adjunct to local anesthetic agents in various regional techniques. The studies regarding clonidine in brachial plexus block have given mixed results. Aim was to determine whether addition of clonidine to the local anesthetic solution for brachial plexus block by supraclavicular approach, prolongs sensory and motor blockade and improves postoperative analgesia. Also to observe side effects if any. Methods: 60 patients aged 18-60 years, were randomly allocated into two groups. Group A received 2 µg / kg of Clonidine diluted to 1 ml with saline and group B received 1 ml of saline added to bupivacaine (10 ml 0.5%) and lignocaine (20 ml 2 %) solution, in the supraclavicular block. The onset and duration of sensory and motor block was compared along with the duration of analgesia, sedation in both the groups. Patients’ pulse rate, blood pressure, saturation was also recorded. Results: Addition of clonidine had no effect on the onset of the block, but was found to increase the duration of sensory and motor block along with the increase in the duration of analgesia. Visual analogue score for pain was significantly lower in the group receiving clonidine. Conclusions: Clonidine 2 µg / kg added to 10 ml of 0.5 % Bupivacaine + 20 ml of 2% lignocaine with adrenaline (1:200000) is a good option for improving the quality and duration of supraclavicular brachial plexus block.

The Analgesic Efficacy of Dexmedetomidine as an Adjunct to Local Anesthetics in Supraclavicular Brachial Plexus Block: A Randomized Controlled Trial.

This study was designed to assess the effects of dexmedetomidine on the onset and duration of block and postoperative analgesia during supraclavicular brachial plexus block in patients undergoing upper limb surgeries. Sixty adult patients undergoing upper limb and hand surgeries were randomly allocated into 2 groups. The control group received equal volumes of 0.75% ropivacaine and 2% lidocaine with adrenaline, whereas the dexmedetomidine (dexmed) group received 1 μg/kg dexmedetomidine along with equal volumes of 0.75% ropivacaine and 2% lidocaine with adrenaline. A total volume of 0.5 mL/kg was administered in ultrasound-guided supraclavicular brachial plexus block in both groups. Patients were observed for hemodynamic stability, onset and duration of sensory and motor blockade, duration of analgesia, postoperative pain, and adverse effects. The onset time of motor blockade was shortened and the duration of sensory, as well as motor, block was significantly prolonged in the dexmed group (P < 0.0001). The duration of postoperative analgesia was also longer in the dexmed group compared with the control group (median [interquartile range], 12 [10.5-13.5] hours and 17 [10.5-19.5] hours in control and dexmed group, respectively [95% confidence interval, -5 {-5, -4}, P < 0.0001]). The requirement for rescue analgesic during the 24-hour postoperative period was less in the dexmed group (P < 0.0001). Postoperative pain scores were comparable among groups except at 8 and 10 hours, when pain scores were lower in the dexmed group. Patients receiving dexmedetomidine were more sedated for 2 hours than the control group patients (P < 0.0001). No episode of bradycardia, hypotension, respiratory depression, or dizziness was reported. We conclude that the addition of dexmedetomidine to ropivacaine-lidocaine prolonged the duration of supraclavicular brachial plexus block and improved postoperative analgesia without significant adverse effects in patients undergoing upper limb surgeries.

Reconstruction of Digital Skin Defects with the Free Wrist Crease Flap.

Soft-tissue digital defects frequently need to be covered by a flap rather than a skin graft. In hand surgery, functional preservation and aesthetic appearance are often as important as procedural efficacy. We present our clinical experience with reconstruction of digital skin defects with the free wrist crease flap. From January 2012 to September 2013, 14 digits of 14 patients (10 males, 4 females) were included for evaluation. The procedure was performed with brachial plexus block anesthesia. The superficial palmar branch of the radial artery, a subcutaneous superficial vein, and the palmar cutaneous branch of the median nerve were included in the free wrist crease flap. The flaps were used to reconstruct the skin defect of injured digits through microvascular anastomosis, and donor sites were closed primarily. Postoperative follow-up time ranged from 3 to 25 months. All digital deformities were corrected, all flaps survived completely without ischemia, and none were aesthetically bulky. The area of free wrist crease flaps ranged from 2.5 to 5.0 cm by 2.0 to 3.1 cm. Slight wound infections appeared in two cases. Venous crisis occurred in one case, but it was successfully addressed after vascular exploration and reanastomosis. Sensation determined by static two-point discrimination measured in these flaps 2 months postsurgery was "good" at a mean 9.7 ± 2.1 mm (range, 6-14 mm). The mean motion range of the distal interphalangeal joint and proximal interphalangeal joint was 23.4 ± 6.9 degrees (0-42 degrees) and 75.8 ± 22.1 degrees (0-98 degrees) preoperatively. The mean motion range of the distal interphalangeal joint recovered to 40.3 ± 5.7 degrees (36-42 degrees), and that of the proximal interphalangeal joint was 90.3 ± 15.3 degrees (85-98 degrees) postoperatively. Both joints reached normal motion angle and difference was statistically significant preoperatively and postoperatively (p < 0.05). The mean disabilities of arm and shoulder (DASH) score was 6.8 ± 3.4 (0-15), and there was statistically significant difference when compared with the preoperative score of 13.5 ± 4.3 (3-19) (p < 0.05). We found the free wrist crease flap to be an ideal solution for reconstruction of skin defects of digits.