Infraclavicular Brachial Plexus Research Articles

Comparative Effects of Supraclavicular Perivascular and Infraclavicular Brachial Plexus Block for Upper Limb Surgeries

Comparative Effects of Supraclavicular Perivascular and Infraclavicular Brachial Plexus Block for Upper Limb Surgeries

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.

Thermochromic nail polish as a novel indicator to predict infraclavicular brachial plexus block success: A prospective cohort study.

Skin temperature measurements after peripheral nerve block can be used as an easy and objective method to help predict block success. Thermochromic nail polishes are popular cosmetic products especially among young women. The colour change of nail polish is based on a thermochromic reaction as the temperature changes. The aim of this study was to test the hypothesis that the success of infraclavicular brachial plexus blocks (IBPBs) can be predicted by the colour change in thermochromic nail polish, which depends on skin temperature changes. A prospective cohort study. Training and research hospital from December 2018 to March 2019. A total of 50 patients who received IBPB for forearm, wrist or hand surgery were included. Thermochromic nail polish was applied to the nails of both hands of all patients before the block. Reaction of the nail polish in both hands was photographed immediately after application of nail polish and at 30 min after performing the block. The digital photographs of each patient were evaluated by observers. To evaluate the validity of the colour change in nail polish in predicting a successful IBPB, sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios were estimated. The positive predictive value for colour change in thermochromic nail polish predicting a successful IBPB was 96% [95% confidence interval (CI) 90 to 98] and sensitivity was 94% (95% CI 87 to 97). Fleiss kappa value showed substantial agreement (0.76; 95% CI 0.59 to 0.93) in the assessment of interobserver agreement. The current study demonstrates that the colour change in thermochromic nail polish is a valid and reliable indicator for the prediction of block success. ClinicalTrials.gov identifier: NCT03767868.

The Need for Supplemental Blocks in Infraclavicular Brachial Plexus Blocks

The Need for Supplemental Blocks in Infraclavicular Brachial Plexus Blocks

Randomized comparison between perineural dexamethasone and dexmedetomidine for ultrasound-guided infraclavicular block

BackgroundThis randomized trial compared perineural dexamethasone (5 mg) and dexmedetomidine (100 µg) for ultrasound-guided infraclavicular brachial plexus block. We hypothesized that both adjuvants would result in similar durations of motor...

Comparing Postoperative Analgesic Effect of Dexmedetomidine or Dexamethasone Added to Lidocaine Through Infraclavicular Block in Forearm Surgery.

The objective of this study was to compare the analgesic efficacy of dexamethasone versus dexmedetomidine added to lidocaine using infraclavicular block in patients undergoing forearm fracture surgery. Seventy-five patients aged 20 to 60 years were recruited for a prospective, double-blinded, randomized clinical trial. Ultrasound-guided infraclavicular brachial plexus block was performed in 3 groups by injecting 28 mL lidocaine plus 2 mL distilled water (Lido), 28 mL lidocaine plus 2 mL (8 mg) dexamethasone (Dexa), and 28 mL lidocaine plus 2 mL (1 µg/kg) dexmedetomidine (Dexm). Sensory and motor block onset time and the duration, hemodynamic variables, the time for the first analgesic request, and the total analgesic agents consumed within 6 hours after infraclavicular block were assessed. Sensory block duration in the Dexm group was significantly greater than in the Lido (P=0.019) and Dexa (P=0.046) groups. The mean motor block duration in the Dexm group showed to be significantly longer than that in the Lido group (P=0.009). Pain intensity within 4 hours after block significantly increased in the Lido group compared with that in the Dexa and Dexm groups (P=0.001). Analgesic consumption during 6 hours after the procedure was higher in the Lido group when compared with the other 2 groups (P=0.001). The Dexm group showed the highest reduction in the mean arterial pressure (P=0.006) and heart rate (P=0.001) among the 3 groups. There was no significant difference in postoperative pain intensity between the Dexa and Dexm groups, although DEXm demonstrated a longer sensory block duration in comparison with dexamethasone as a lidocaine adjuvant in infraclavicular block.

Microcirculation and haemodynamics after infraclavicular brachial plexus block using adrenaline as an adjuvant to lidocaine: a randomised, double-blind, crossover study inhealthy volunteers.

We evaluated the effect of adrenaline on human skin microcirculation (nutritive and sub-papillary) and systemic cardiovascular variables after it was added to lidocaine in infraclavicular brachial plexus blocks. Twelve healthy, non-smoking male volunteers were included, each attending two study sessions 2weeks apart, and they were studied using a crossover design. In both sessions, they received an ultrasound-guided infraclavicular brachial plexus block in the non-dominant arm with 0.4ml.kg-1 lidocaine, 15mg.ml-1 with or without adrenaline 5μg.ml-1 . Microcirculation was assessed by laser Doppler fluxmetry (sub-papillary blood flow), capillary video microscopy (nutritive blood flow) and continuous temperature measurements. Heart rate and arterial pressure were recorded continuously and non-invasively. Median (IQR [range]) sub-papillary blood flow increased substantially 30min after the brachial plexus block, from 8.5 (4.4-13.5 [2.9-28.2]) to 162.7 (111.0-197.8 [9.5-206.7]) arbitrary units with adrenaline (p=0.017), and from 6.9 (5.3-28.5 [1.8-42.1] to 133.7 (16.5-216.7 [1.0-445.0] arbitrary units without adrenaline (p=0.036). Nutritive blood flow (functional capillary density, capillaries.mm-2 , measured at the dorsal side of the hand) decreased in the blocked extremity when adrenaline was used as adjuvant, from median (IQR [range]) 45 (36-52 [26-59]) to 38 (29-41 [26-42]), p=0.028, whereas no significant change occurred without adrenaline. Median finger skin temperature (°C) increased by 44% (data pooled) with no significant differences between the groups. No significant changes were found in the systemic cardiovascular variables with or without adrenaline. We conclude that lidocaine infraclavicular brachial plexus blocks caused an increase in skin sub-papillary blood flow. The addition of adrenaline produced stronger and longer lasting blocks, but decreased the nutritive blood flow.

Upper extremity regional anesthesia techniques: A comprehensive review for clinical anesthesiologists.

Surgeries and chronic pain states of the upper extremity are quite common and pose unique challenges for the clinical anesthesiology and pain specialists. Most innervation of the upper extremity involves the brachial plexus. The four most common brachial plexus blocks performed in clinical setting include the interscalene, supraclavicular, infraclavicular, and axillary brachial plexus blocks. These blocks are most commonly performed with the use of ultrasound-guided techniques, whereby analgesia is achieved by anesthetizing the brachial plexus at different levels such as the roots, divisions, cords, and branches. Additional regional anesthetic techniques for upper extremity surgery include wrist, intercostobrachial, and digital nerve blocks, which are most frequently performed using landmark anatomical techniques. This review provides a comprehensive summary of each of these blocks including anatomy, best practice techniques, and potential complications.

Surgical Decompression for Thoracic Outlet Syndrome in Adolescent Patients

Objectives: Thoracic outlet syndrome represents a complex combination of symptoms in the upper extremity that occurs due to compression of the neurovascular structures of the thoracic outlet or subcoracoid space. It can be seen in overhead athletes and is commonly misdiagnosed as other shoulder pathology. This study seeks to highlight patient characteristics, intraoperative findings, and both short term and long term outcomes of thoracic outlet decompression in the adolescent population as well as a comparison of outcomes by mechanism of injury including athletes. Methods: A retrospective chart review was performed of patients between the ages of 13 and 21 with a clinical diagnosis of TOS that were treated surgically by a single surgeon between 2000 and 2015. Data points including preoperative patient characteristics and intraoperative findings were collected. In addition, patient reported outcome scores including quickDASH, CBSQ, VAS, and SANE were obtained for a cohort of patients with long-term follow up ranging from 2 to 15 years. Results: The study population consisted of 54 adolescents (61 extremities) aged 13-21 at the time of presentation. There was a 3:1 female to male ratio. Patients saw an average of 2.08 other healthcare providers before referral to our institution. The most common surgical procedures included neurolysis of the brachial plexus (60; 98.4%), anterior scalenectomy (59; 96.7%), middle scalenectomy (54; 88.5%), excision of the first rib (28; 45.9%), excision of cervical rib (5; 8.2%), and subclavian artery manipulation (50, 81.9%). A second incision in the subcoracoid space was utilized in 28 (45.9%) extremities for exploration of the infraclavicular brachial plexus with release of the coracocostal ligament in 26 of these 28 patients (92.9%). Long-term follow-up data, including patient reported outcomes, was collected for 24/54 patients (44%). In this patient subset, the average follow-up was 69.5 months and ranged from 24 months to 180 months. The average preoperative VAS was recorded at 8.2 with an average postoperative VAS of 2.0, showing an improvement of 6.2 points. The average preoperative SANE score was 28.9 and the average postoperative SANE score was 85.4 with an improvement in 56.5. The average postoperative quickDASH score was 11.4. The average postoperative CBSQ score was 27.4 . The average postoperative NTOS Index score was 17.2. Subgroup analysis was performed analyzing patients having a first rib excision versus patients where their first rib was left intact. There was no difference regarding clinical outcome measures in these groups including CBSQ, VAS, SANE score, quick DASH and NTOS index. An additional subgroup analysis was performed comparing mechanism of injury including overuse from sports, trauma, and idiopathic causes. There was also no difference regarding clinical outcome measures in these groups including CBSQ, VAS, SANE score, quick DASH and NTOS index. Conclusion: We found no difference in clinical outcome scores in patients treated with rib resection versus patients with the first rib left intact. We also found no difference in outcomes with respect to mechanism of injury including overhead sports athletes. Overall, patients did well long-term after decompression of the thoracic outlet. Thoracic outlet syndrome should be considered in the differential diagnosis of athletes with upper extremity pain especially if they have neurologic findings.

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.

Infraclavicular brachial plexus block in adults: a comprehensive review based on a unified nomenclature system.

Over the last decade, considerable progress has been made regarding infraclavicular brachial plexus block (ICB) in adults, especially since the introduction of ultrasound guidance. The advancements in ICB have been attributed to the development of various approaches to improve the success rate and reduce complications. This has also necessitated a unified nomenclature system to facilitate comparison among different approaches. This review aimed to propose an anatomical nomenclature system by classifying ICB approaches into proximal and distal ones to aid future research and provide practice advisories according to recent updates. We also comprehensively discuss various aspects of this nomenclature system. Our review suggests that ultrasound-guided ICB should be categorized as an advanced technique that should be performed under supervision and dual guidance. For one-shot block, the conventional distal approach is still preferred but should be modified to follow ergonomic practice, with the arm in the proper position. For continuous ICB, the proximal approach is promising for reducing local anesthetic volume and increasing efficacy. Nevertheless, further studies are warranted in this direction. We provide practice advisories to maximize safety and minimize adverse events, and recommend designing future studies on ICB according to these findings based on the unified nomenclature system.

Retrospective Analysis of Ultrasound-Guided Infraclavicular Block: Effect of Experience of Anesthesiologists on Volume of Local Anesthetic Administered.

Performing a block under ultrasound guidance effectively requires skill; however, inexperienced anesthesiologists often use high-dose LA to ensure success. We aimed to share our experience with the ultrasound-guided infraclavicular brachial plexus block (USGICB) for upper extremity surgeries and to determine changes in failure rate and local anesthetic dose administered with gaining adequate experience. With approval from the local ethics committee, a retrospective review of records of 2953 patients who underwent USGICB between November 2011 and March 2015 was performed for evaluating the following data: age, sex, height, weight, operation type, American Society of Anesthesiologists physical status score, local anesthetic volume, complications, and success of USGICB. The patients were divided into 4 groups of 10 months each from November 2011 to March 2015: first 10-month period, 628 cases (group I); second 10-month period, 672 (group II); third 10-month period, 720 (group III); and the fourth 10-month period, 933 cases (group IV). Nine anesthesiologists with the same baseline experience in USG performed the blocks. During the initial period, when anesthesiologists had insufficient experience, local anesthetic (LA) dose, success rate, failed blocks, and complications were investigated. The LA volume administered in group I (33.7 ± 4.2 ml) was significantly higher than that in groups II, III, and IV (p < 0.05). Although a reduction in LA volume administered with increasing anesthesiologist experience was not statistically significant, a volume reduction of over 30 ml was observed in groups II, III, and IV compared with group I. Furthermore, in group I, failure rate (3.2%) was higher than that in groups II, III, and IV (p < 0.05). We concluded that sonographic guidance ensures a high success rate and that increased experience of anesthesiologists is associated with reduced complications and failure rate of blocks, in addition to prevention of LA overdose.

Volume mínimo efetivo de bupivacaína a 0,5% para abordagem retroclavicular guiada por ultrassom no bloqueio do plexo braquial por via infraclavicular

Background and objectivesThe current study aimed to determine the minimum effective volume (MEV) of bupivacaine 0.5% in 50% of patients for an ultrasound‐guided retroclavicular approach to infraclavicular brachial plexus block. MethodsA total of 25 adult patients who were scheduled for upper limb surgery received an ultrasound‐guided retroclavicular approach to infraclavicular brachial plexus block with bupivacaine 0.5%. The needle insertion point was posterior to the clavicle and the needle was advanced from cephalad to caudal. Block success was defined as a composite score of 14 at 30min after local anesthetic (LA) injection. The minimum effective volume in 50% of patients was determined using the Dixon‐Massey up‐and‐down staircase method. Minimum effective volume for a successful block in 95% of the patients was also calculated using logistic regression and probit transformation. ResultsThe minimum effective volume of bupivacaine 0.5% resulting in successful block in 50% of patients (MEV50) according to the up‐and‐down staircase method was found to be 9.6mL (95% confidence interval (CI), 5.7–13.4). The calculated minimum effective volume required for a successful block in 95% of patients (MEV95) using the probit transformation and logistic regression analysis was 23.2mL (95% CI, 18.8–36.7). ConclusionsThe MEV50 of bupivacaine 0.5% for US‐guided retroclavicular approach to infraclavicular brachial plexus block was 9.6mL and the calculated MEV95 was 23.2mL. Future studies are required for infraclavicular brachial plexus block with different approaches, other LA agents and different concentrations of bupivacaine.

Comparison of infraclavicular and supraclavicular brachial plexus block in upper extremity surgery

Comparison of infraclavicular and supraclavicular brachial plexus block in upper extremity surgery

Comparison of Infraclavicular and Supraclavicular Brachial Plexus Block in Upper Extremity Surgery

Comparison of Infraclavicular and Supraclavicular Brachial Plexus Block in Upper Extremity Surgery

A study of phrenic nerve paralysis after vertical infraclavicular brachial plexus block

A study of phrenic nerve paralysis after vertical infraclavicular brachial plexus block

Comparative evaluation of two approaches of infraclavicular brachial plexus block for upper-limb surgeries.

Background:Infraclavicular approach is a common technique of brachial plexus block. The main difficulty of ultrasound guided technique is in needle visualization due to deep location of the cords. Hebbard et al described a retroclavicular approach wherein the needle was inserted posteriorly to the clavicle.Materials and Methods:In this prospective randomized controlled study, we have compared the classical technique with the retroclavicular approach in terms of needle visibility, block success rate, number of needle passes, block performance time, procedure-related pain, complications, patient and operator comfort and satisfaction.Results:The rate of block success was similar in both the groups. The needle tip and shaft visibility was more in the retroclavicular group (P < 0.05). The number of needle passes was also less in the retroclavicular group. Time for the block procedure was less in retroclavicular group when compared to the classical coracoid group. The patients reported less pain in retroclavicular group (P < 0.05).Discussion:Retroclavicular approach is a feasible option of infraclavicular brachial plexus block in Indian Subpopulation in terms of needle visibility and block success rate.

Patterns of injury to the infraclavicular brachial plexus following dislocation of the glenohumeral joint

Objectives: Brachial plexus injury (BPI) often results in devastating loss of upper limb function and debilitating neuropathic pain. The medial cord is often damaged following low-energy falls and glenohumeral dislocation. Medial cord injury (MCI) is associated with poor functional hand outcome due to paralysis of intrinsic muscles innervated by median and ulnar nerves, yet management options are limited. Nerve injury severity, demographic factors and concomitant injuries are poorly defined in this group. This study aims to understand patterns of infraclavicular BPI to guide management. Methods: All consecutive cases of infraclavicular BPI presenting to a regional peripheral nerve injury service over a 3-year period were retrospectively analysed. Medical records and neurophysiology reports were reviewed, and demographics and injury details were recorded on a database. Results: Ninety-nine infraclavicular BPI cases were identified. Of these, 34 (34%) were attributed to glenohumeral dislocations sustained in low-energy falls. There were 21 females and 13 males with mean age 62 years and mean body mass index 31. Five (13%) and 11 (29%) patients sustained vascular injuries and rotator cuff tears, respectively. Twelve (35%) patients sustained 13 fractures, of the proximal humerus or greater tuberosity. Review of injury patterns identified MCI in 24 cases (71%), 12 (50%) of which were amenable to nerve transfers. Conclusion: Low-energy falls are often accompanied by glenohumeral dislocation, whereby the medial cord is commonly damaged, resulting in an intrinsic minus hand. This injury subgroup has not been previously described, yet early recognition and referral for novel nerve transfer surgery can improve outcomes for these life-changing injuries.

A comparative study between supraclavicular brachial plexus block and Infraclavicular brachial plexus block for upper limb orthopedic surgeries: A prospective, randomized, double-blind study

Introduction: Supraclavicular brachial plexus block is a common approach as it provides faster and dense blockade. In the past few years, infraclavicular brachial plexus block has become a method of increased interest as it has a lower complication rate and near to equal efficacy. The goal of this study was to compare block performance time, block characteristics, quality of block, patient's satisfaction, and complications between infraclavicular and supraclavicular techniques for brachial plexus block. Patients and methods: 100 subjects were randomized in a double-blind fashion, to receive either an infraclavicular block (Group I, n=50) or supraclavicular block (Group S, n=50) using nerve locator apparatus. Block performance time, onset, peak, duration of sensory and motor blockade, any change in hemodynamics, complications were recorded at scheduled intervals intra-operatively and post-operatively as per study protocol. Data were analyzed using GraphPad INSTAT version 3.06 software by Chi-square test or Mann-Whitney U test to compare categorical variables. Results: The block performance time was faster in the Group S compared to the Group I (4.8±4.4 minutes vs. 6.3±1.39 minutes, p <0.001). The sensory block onset time was faster in Group S compared to the Group I (6.9±1.58 minutes vs. 7.6±1.34 minutes, p=0.019). Other observed variables were considered statistically not significant. Conclusion: From our study, it is inferred that nerve locator guided Infraclavicular block by a vertical coracoid approach using multineurostimulation method is less rapidly executed as nerve locator guided supraclavicular block with a similar degree of surgical anesthesia and lesser complication rate.

A cadaveric feasibility study for a staged musculocutaneous to medial cord nerve transfer for restoration of hand function following infraclavicular brachial plexus injury

A cadaveric feasibility study for a staged musculocutaneous to medial cord nerve transfer for restoration of hand function following infraclavicular brachial plexus injury